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CORK Bibliography: Mortality

99 citations. June 2008 to present

Prepared: March 2009

Ahlm K; Bjornstig U; Ostrom M. Alcohol and drugs in fatally and non-fatally injured motor vehicle drivers in northern Sweden. Accident Analysis and Prevention 41(1): 129-136, 2009. (65 refs.)

Alcohol and drugs are important risk factors for traffic injuries, a major health problem worldwide. This prospective study investigated the epidemiology and the presence of alcohol and drugs in fatally and hospitalized non-fatally injured drivers of motor vehicles in northern Sweden. During a 2-year study period, blood from fatally and hospitalized non-fatally injured drivers was tested for alcohol and drugs. The study subjects were recruited from well-defined geographical areas with known demographics. Autopsy reports, medical journals, police reports, and toxicological analyses were evaluated. Of the fatally injured, 38% tested positive for alcohol and of the non-fatally 21% tested positive; 7% and 13%, respectively, tested positive for pharmaceuticals with a warning for impaired driving; 9% and 4%, respectively, tested positive for illicit drugs. The most frequently detected pharmaceuticals were benzodiazepines. opiates, and antidepressants. Tetrahydrocannabiol was the most frequently detected illicit substance. No fatally injured women had illegal blood alcohol concentration. The relative proportion of positively tested drivers has increased and was higher than in a similar study 14 years earlier. This finding indicates that alcohol and drugs merit more attention in future traffic safety work.

Andreev E; Pridemore WA; Shkolnikov VM; Antonova OI. An investigation of the growing number of deaths of unidentified people in Russia. European Journal of Public Health 18(3): 252-257, 2008. (27 refs.)

Background: We examined mortality among working- age Russian men whose identity could not be determined, focusing on where and how they died. Methods: Employing micro-data from deaths that occurred in Izhevsk (Ural region) between June 2004 and September 2005, we analysed the characteristics of decedent men aged 25-54 (n = 2158). Differences between completely identified (n = 1699) and unidentified deaths (n = 282) were compared via logistic regression. Data on all deaths in Russia in 2002 were used for supplemental comparisons. Results: We found that relative to identified men, unidentified men were at a higher risk of death from exposure to natural cold, violence, alcoholic cardiomyopathy, acute respiratory infections and poisonings. Our results also revealed that alcohol played an important role in the mortality of unidentified men. The places and causes of death among these unidentified men provide substantial evidence of their homelessness and social isolation. Conclusion: The increase in deaths among unidentified men of working- age indicates the emergence of a health threat associated with homelessness and social marginalization. This vulnerable group is exposed to different levels and causes of mortality compared with the larger population and represent a new challenge that requires serious and immediate scholarly attention and policy responses.

Barzi F; Huxley R; Jamrozik K; Lam TH; Ueshima H; Gu D et al. Association of smoking and smoking cessation with major causes of mortality in the Asia Pacific Region: The Asia Pacific Cohort Studies Collaboration. Tobacco Control 17(3): 166-172, 2008. (36 refs.)

Background: Although the dangers of smoking, and the benefits of quitting, are well established and understood in the West, smoking remains popular among Asian men. We investigated the associations between smoking (including ex-smoking) and major causes of mortality in Asian men and women, and compared with Australians and New Zealanders (ANZ). Methods: An overview of 34 cohort studies in the Asia Pacific region involving 512 676 individuals (81% from Asia), followed up for a median of 6.7 years (20 804 deaths). Results: Mortality rates for cause-specific and all causes of mortality were systematically higher for current compared with never smokers. Hazard ratios (HR) for overall and cause-specific mortality comparing current-smokers with never smokers, ex-smokers with current-smokers and comparing numbers of cigarettes smoked per day, were higher for ANZ than Asia (p < 0.001). For overall mortality, the HR (95% CI) comparing current-smoking with not was 1.37 (1.23 to 1.53) and 1.33 (1.26 to 1.40) in Asian men and women respectively. The corresponding figures in ANZ were 1.95 (1.81 to 2.09) and 1.85 (1.69 to 2.02). The HR for quitting in ANZ was 0.67 (0.63 to 0.71) and 0.66 (0.58 to 0.74) in men and women respectively. Quitting smoking had a significant benefit among Asian men, the HR was 0.88 (0.81 to 0.97) after ignoring the first 3 years of follow-up. There was no evidence of benefit for Asian women, for whom ex-smoking is rare. Conclusions: Allowing for the recent uptake of smoking in Asia, its effects are comparable to those observed in ANZ. Stringent tobacco control measures and smoking cessation strategies are urgently required in Asia.

Berg JP; Lynch ME; Coles CD. Increased mortality among women who drank alcohol during pregnancy. Alcohol 42(7): 603-610, 2008. (33 refs.)

Women giving birth to children with fetal alcohol syndrome have a higher risk of early mortality. However, the risk of increased mortality associated with drinking at lower levels during pregnancy has not been evaluated previously. Accordingly, mortality at 20 years post recruitment was examined in a sample (N = 570) of women recruited between 1990 and 1986, who drank more than I ounce of absolute alcohol per week during pregnancy and compared to that in abstainers front the same low socioeconomic, African-American population. Using data from archival information and slate mortality records, Cox proportional hazards survival models were constructed to determine whether alcohol use, cigarette use. infant birth weight, infant dysmorphia, and alcohol use and abuse by the woman's own mother (family history positive) were associated with increased risk for mortality. At follow-up (in 2003), 9.5% of the sample had died, with the rate for controls being 3.6%, for those alcohol users who stopped during pregnancy, 12.7%, and for the alcohol users who continued drinking throughout pregnancy, 12.5%. Thus, women using alcohol in pregnancy, whether they stopped or continued to use, were significantly (chi(2) (2) = 12.1, P < .01) more likely than abstainers to have died before follow-up. Nondrinkers' mortality rate was lower than that of other women from this low-income, high-risk population, whereas the drinkers' rate was 2.7 times higher. In a multivariate analysis, factors contributing to mortality risk included alcohol use and cigarette smoking, but not infant birth weight. Drinking at any level during pregnancy should be regarded as a risk factor for the mother as well as for offspring. Health care professionals working with such women should provide counseling and support for abstinence.

Biecheler MB; Peytavin JF; Facy F; Martineau H. SAM survey on "Drugs and Fatal Accidents": Search of substances consumed and comparison between drivers involved under the influence of alcohol or cannabis. Traffic Injury Prevention 9(1): 11-21, 2008. (29 refs.)

Objectives. A survey was conducted to produce reliable epidemiological data concerning the role played by alcohol and drugs in fatal road accidents in France. The aims are to describe the conduct of the survey, evaluate the overall quality of the findings, and analyze the substances consumed by the involved drivers. A comparison between drivers involved under the influence of alcohol only, cannabis only, or both substances is emphasized. Methods. By a June 1999 law, all drivers in France involved in an immediate fatality accident between October 2001 and 2003 had to undergo a urine test and, if that was not possible or the test proved positive, had a blood sample taken in order to test for drugs ( cannabis, cocaine, heroin, amphetamines). The results were combined with the usual procedures of the police force, which include the results of tests for illegal alcohol levels. A unique and reliable set of accident data on the role of drugs was thus compiled for epidemiological purposes: 10,000 accident reports involving over 17,000 drivers were analyzed. The responsibility level of each driver involved in an accident was determined. Results were generated for a representative sample of about 11,000 drivers. Results. Alcohol levels above the legal limit (0.5 g/L of blood) were found in 21% of all drivers involved in accidents ( killed, injured, or unharmed). Cannabis headed the list of illicit drugs detected, with a prevalence of 6.8% (THC >= 1 ng/mL); it was present in the under-35s and especially the under-25s. About 40% of drivers under the influence of cannabis also had an illegal alcohol level. The other drugs, whether alone or in association with cannabis, are relatively rare. Accident characteristics of drivers detected positive for cannabis only are markedly different from drivers under the influence of alcohol. The overrepresentation of drivers responsible, from 1.7 over the whole population, rises to 2.3 for cannabis alone ( THC >= 1 ng/mL), to 9.4 for alcohol alone (>= 0.5 mg/L), and to 14.1 for the alcohol-cannabis combination. Conclusions. The high incidence (26%) of alcohol or drugs among the population of drivers involved in fatal accidents highlights the importance for road safety of the consumption of these substances. Alcohol remains the major risk at any age. Young drivers consuming alcohol and cannabis represent a priority target for prevention.

Binswanger IA; Takahashi TA; Bradley K; Dellit TH; Benton KL; Merrill JO. Drug users seeking emergency care for soft tissue infection at high risk for subsequent hospitalization and death. Journal of Studies on Alcohol and Drugs 69(6): 924-932, 2008. (41 refs.)

Objective: Although soft tissue infections are common among injection drug users (IDUs), little is known about the health outcomes among those who seek care for these infections. Emergency department visits are an important point-of-health-care contact for IDUs. In this prospective cohort study, we aimed to determine the hospitalization and mortality rates and factors associated with hospitalization or death among IDUs seeking emergency care for soft tissue infection. Method: Participants were English-speaking IDUs, 18 years of age and older. who sought initial care for soft tissue infection in an urban emergency department. We conducted semistructured interviews, identified hospitalizations from hospital records, and identified deaths using the National Death Index. Cox proportional hazards regression was used to investigate associations between baseline characteristics and hospitalizations or death. Results: Of 211 eligible patients, 156 (74%) participated (mean age = 42 years). There were 255 subsequent hospitalizations over a mean of 3.9 years follow-up. The hospitalization rate was 42 hospitalizations per 100 person-years (95% confidence interval [CI]: 38-48). The mortality rate was 2.0 per 100 person-years (95% CI: 1.1-3.7). Factors associated with increased risk for hospitalization or death included living on the street or in a shelter (adjusted odds ratio [AOR] = 1.75, 95% CI: 1.10-2.79), being recently incarcerated (AOR = 1.90, 95% CI: 1.05-3.44), and having insurance (AOR: 1.98, 95% CI: 1.22-3.23), Conclusions: IDUs who sought care in the emergency department for soft tissue infections were at high risk for subsequent hospitalization and death. Visits for soft tissue infections represent missed opportunities for preventive care.

Boyle SH; Mortensen L; Gronbaek M; Barefoot JC. Hostility, drinking pattern and mortality. Addiction 103(1): 54-59, 2008. (23 refs.)

Aims: This study examined the association of hostility to drinking pattern and whether this association mediated the relation of hostility to mortality. Participants and design: Subjects were 3326 current drinkers from the Vietnam Experience Study cohort who were followed for vital status. Setting United States. Measurements: Hostility was measured by an abbreviated version of the Cook-Medley Hostility Scale (ACM). The alcohol variables were total monthly intake of alcohol, drinking frequency, drinks per drinking day and drinking >= 5 drinks on at least one occasion in the past month (i.e. heavy episodic drinking). Findings Regression analyses showed associations between the ACM and total monthly intake of alcohol (P < 0.0001), drinks per drinking day (P < 0.0001) and heavy episodic drinking (P < 0.0001), but not with frequency of drinking days. Hostility, drinks per drinking day, heavy episodic drinking and total monthly alcohol intake were also associated with all-cause mortality (all Ps < 0.0001). Further analyses showed that drinking pattern, particularly drinks per drinking day, may account partially for the relation of hostility to mortality. Conclusions: High hostility is associated with elevated mortality and a deleterious drinking pattern characterized by relatively high intake per drinking occasion. Drinking pattern could help explain the relationships between hostility and health.

Butt AA; Khan UA; Skanderson M. Comorbidities and their impact on mortality in HCV and HCV-HIV-coinfected persons on dialysis. Journal of Clinical Gastroenterology 42(9): 1054-1059, 2008. (37 refs.)

Aim: To determine the rates of non-human immunodeficiency virus (HIV)-related comorbidities and their impact on survival in hepatitis C virus (HCV) and HCV-HIV coinfected persons oil dialysis. Methods: We identified HCV-infected subjects and diagnoses of medical and psychiatric comorbidities in the United States Renal Data System using ICD-9 codes. Logistic regression was used to determine the odds of comorbidities and predictors of mortality. Results: We identified 5310 HCV-infected and 427 HCV-HIV-coinfected subjects. The latter were younger, more likely to be male, black race, and had a lower body mass index. After adjusting for age, race and sex we found that coronary artery disease (CAD), diabetes mellitus (DM) as primary cause of renal failure and cirrhosis were less frequently diagnosed in the HCV- HIV-coinfected subjects, whereas hepatitis B, washing, drug and alcohol abuse, and dependence were more frequently diagnosed. Increasing age. CAD, stroke, DM. cirrhosis, wasting, cancer, and drug abuse and dependence were associated with higher odds of death in the HCV monoinfected subjects, whereas cirrhosis, wasting, and smoking were the only such factors in the HCV-HIV-coinfected subjects. Conclusions: The frequency and patterns of comorbidities and predictors of death differ in HCV-monoinfected and HCV- HIV-coinfected persons on dialysis. These differences should be taken into account when designing future interventions.

Clennell S; Kuh D; Guralnik JM; Patel KV; Mishra GD. Characterisation of smoking behaviour across the life course and its impact on decline in lung function and all-cause mortality: Evidence from a British birth cohort. Journal of Epidemiology and Community Health 62(12): 1051-1056, 2008. (38 refs.)

Objectives: To describe smoking trajectories from early adolescence into mid-life and to examine the effects of these trajectories on health and all-cause mortality. Methods: A nationally representative birth cohort study including 3387 men and women followed up since their birth in 1946 in England, Scotland and Wales. The main outcome measure is all-cause mortality by age 60 years and rate of decline in forced expiratory volume in 1 second (FEV1). Results: Eighteen per cent of the sample were categorised as lifelong smokers (smokers at all six waves at ages 20, 25, 31, 36, 43, 53 years), of whom 90% had begun smoking by age 18 years. By age 60 years, 10% of all lifelong smokers had died. They had a threefold increase in mortality rate compared with never smokers (hazard ratio (HR) 3.2, 95% confidence interval (CI) 2.1 to 4.8). For predominantly smokers ( smokers for at least four of the six data collections), mortality rate remained higher than never smokers (HR 1.6, 95% CI 1.0 to 2.5). Predominantly non-smokers did not differ from those who never smoked (HR 1.3, 95% CI 0.9 to 2.0). Using the most recent smoking status available, current smokers had more than double the risk of mortality compared with never smokers (HR 2.4, 95% CI 1.6 to 3.5). Lifelong smokers and predominantly smokers had a greater rate of decline in lung function than never smokers (regression coefficients 218 ml/year, 95% CI 222 to 213; 26, 95% CI -10.3 to -1.7 respectively). For current smokers, the decline was 8.4 ml/year (95% CI -12.0 to -5.0) faster than never smokers. Conclusions: The strength and differentiation of adverse effects identified by using simplified smoking behaviours has highlighted the advantages of obtaining further information on lifelong smoking behaviour from former smokers, rather than just current smoking status.

Cook JA; Burke-Miller JK; Cohen MH; Cook RL; Vlahov D; Wilson TE et al. Crack cocaine, disease progression, and mortality in a multicenter cohort of HIV-1 positive women. AIDS 22(11): 1355-1363, 2008. (36 refs.)

Background: Longitudinal associations between patterns of crack cocaine use and progression of HIV-1 disease are poorly understood, especially among women. This study explores relationships between crack use and HIV-1 disease outcomes in a multicenter cohort of infected women. Methods: Subjects were 1686 HIV-seropositive women enrolled at six US research centers in the Women's Interagency HIV Study. Approximately 80% were non-white and 29% used crack during the study period. Cox survival and random regression analysis examined biannual observations made April 1996 through September 2004. Outcome measures included death due to AIDS-related causes, CD4 cell count, HIV-1 RNA level, and newly acquired AIDS-defining illnesses. Results: Persistent crack users were over three times as likely as non-users to die from AIDS-related causes, controlling for use of HAART self-reported at 95% or higher adherence, problem drinking, age, race, income, education, illness duration, study site, and baseline virologic and immunologic indicators. Persistent crack users and intermittent users in active and abstinent phases showed greater CD4 cell loss and higher HIV-1 RNA levels controlling for the same covariates. Persistent and intermittent crack users were more likely than non-users to develop new AIDS-defining illnesses controlling for identical confounds. These results persisted when controlling for heroin use, tobacco smoking, depressive symptoms, hepatitis C virus coinfection, and injection drug use. Conclusion: Use of crack cocaine independently predicts AIDS-related mortality, immunologic and virologic markers of HIV-1 disease progression, and development of AIDS-defining illnesses among women.

Cooreman S; De Doncker M; Van Hee P; Uyttenbroeck W; Dits H; Neels H. A case of fatal alcoholic ketoacidosis. Imuno-Analyse & Biolgic Specialisee 23(2): 116-118, 2008. (16 refs.)

Alcoholic ketoacidosis is an acid-base disturbance which is often observed in chronic alcoholic patients when drinking is ceased after a period of excessive alcohol intake. Dehydration and little food intake are frequently present in these patients. It is very important for the treatment of alcoholic ketoacidosis that a distinction with diabetic ketoacidosos is made. The authors present a case of alcoholic ketoacidosis that ended fatally, probably due to pathophysiological conditions induced by tong-term alcohol abuse.

Cruts G; Buster M; Vicente J; Deerenberg I; Van Laar M. Estimating the total mortality among problem drug users. Substance Use & Misuse 43(5): 733-747, 2008. (24 refs.)

This paper's objective is to develop a method to estimate the total mortality among problem drug users. The total mortality is given by a base rate of mortality not related to drugs and the deaths that are directly and indirectly related to drugs. A fatal poisoning by drugs (overdose) is directly related to drugs, whereas a casualty due to a drug-related disease or a drug-related accident is indirectly related to drugs. As an example of a method to estimate the total mortality, the results from a cohort study among methadone patients in Amsterdam were projected on the whole population of problem drug users in The Netherlands. Due to differences between the problem drug users in Amsterdam and the rest of the country, adjustments were required. It was found that an initial estimation did not require adjustment for injection behavior and gender but did require adjustment for age and the percentage of HIV infection. In a first unadjusted estimation, the total number of deaths among problem drug users in The Netherlands in 2001 was estimated at 606 deaths. After adjustment for age, the estimated mortality decreased to 573 deaths, and after adjustment for HIV infection, this estimation again decreased to 479 deaths. From the ultimately estimated mortality, 11% was considered to be not related to drugs, 23% was attributed directly to drugs, and 66% was attributed indirectly to drugs. The number of direct deaths, as estimated by this method, fallows the same order of magnitude as the number extracted from the Causes of Death Statistics, when selecting cases according to the Drug-Related Deaths Standard as established by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Further cross-validation with other measures will be needed to assess the accuracy of the method, the limitations of which are discussed with respect to stipulating directions for future research.

Dias AC; Ribeiro M; Dunn J; Sesso R; Laranjeira R. Follow-up study of crack cocaine users: Situation of the patients after 2, 5, and 12 years. Substance Abuse 29(3): 71-79, 2008

The purpose of this study was to follow-up 131 crack users and examine drug use, treatment experience, employment status, and mortality at 2, 5, and 12 years. Consecutive crack dependent patients were re-interviewed in 1995-1996, 1998-1999, and 2005-2006. Of those subjects not using cocaine at 2 years, 19 (63%) were still abstinent at 5 years. Almost half of the users were abstinent at the same period. The abstinent group was still the most prevalent at 12 years. Twenty-seven (20.6%) patients had died by the 12-year follow-up, with homicide being the most common cause (n = 16). After 2000, however, it declined sharply with only 2 deaths in 7 years. There was a progressive movement toward abstinence over the follow-up period, with the evidence that once abstinence had been achieved it was maintained. On the other hand, the mortality rate was extremely high and probably more related with socioeconomic factors instead of the drug use itself.

Eksborg S; Rajs J. Causes and manners of death among users of heroin, methadone, amphetamine, and cannabis in relation to postmortem chemical tests for illegal drugs. Substance Use & Misuse 43(10): 1326-1339, 2008. (22 refs.)

A 12-year medicolegal investigation of deceased illegal drug users (ILDU) in Stockholm, Sweden, classified on the basis of postmortem chemical tests, showed noticeable variations in causes and manners of death as well as in the distribution of suicide methods. This study offers objective information about connection between the postmortem findings of illegal drugs and the causes and manners of death of their users. However, further studies, comparing prevalence of drug use in general population and at the postmortem tests, are needed for more detailed elucidation of this connection.

Engelfriet PM; Drenthen W; Pieper PG; Tijssen JGP; Yap SC; Boersma E et al. Smoking and its effects on mortality in adults with congenital heart disease. International Journal of Cardiology 127(1): 93-97, 2008. (15 refs.)

Aims: To describe smoking habits in adults with congenital heart disease (ACHD) and to assess the relationship between smoking exposure and cardiovascular mortality. Methods: Data on smoking history and cardiovascular mortality were extracted from the Euro Heart Survey on adult congenital heart disease a retrospective cohort study, that included patients diagnosed with 1 of 8 subgroups of ACHD (Atrial Septal Defects, Ventricular Septal Defects, Marfan Syndrome, Aortic Coarctation, Tetralogy of Fallot (ToF), Transposition of the Great Arteries (TGA), Fontan circulation, and Cyanotic disease). Results: Complete data of 3375 ACHD patients (median age 28 years) were available for analysis. At inclusion, 9.3% (n=314) were current smokers and 4.2% (n=142) of the patients had smoked in the past. During a median follow-up of 5.1 years, 101 patients (3%) died. In the majority of cases the cause of death was cardiovascular (n=81; 80%). Kaplan-Meier and Cox survival analysis for each of the defects separately showed a significantly increased age and sex-adjusted cardiovascular mortality associated with smoking exposure in TGA patients (Hazard ratio 4.2 (95% CI 1.0-16.8); P=0.044). Also in ToF mortality was higher amongst smokers, though not significantly (HR 3.4 (95% CI 0.6-18.5); P=0.15). In the remaining defects no relationship between smoking and cardiovascular mortality was observed. Conclusion: The prevalence of smoking amongst ACHD patients is relatively low. Smoking exposure is associated with increased cardiovascular mortality in patients with TGA. Prospective long-term follow-up studies are necessary.

Fierro I; Ochoa R; Yanez JL; Valderrama JC; Alvarez FJ. Alcohol consumption related mortality in Spain and in the Autonomous Communities in the year 2004. (Spanish). Revista Clinica Espanola 208(9): 455-462, 2008. (33 refs.)

Introduction. Alcohol consumption is associated with great morbidity-mortality rate. The aim of this study is to analyze the mortality that can be attributed to alcohol consumption in Spain and in its different Autonomous Communities during 2004. Method. The records of deaths by cause of death were used, grouped by age, gender and 60 diagnostic categories. The number of deaths attributable to alcohol consumption according to gender and age group in 2004 for Spain and the different Autonomous Communities was calculated by means of the alcohol attributable fractions proposed by the Centers for Disease Control and Prevention for calculating the mortality rates in the U.S.A. in 2001. The raw and adjusted mortality rates attributable to alcohol per 100,000 inhabitants were calculated with respect to the European population standard. Results. Alcohol-related mortality in Spain was 2.3%; 3.2% for men and 1.2% for women. The Community of Murcia, with a mortality rate of 2.9%, together with those of Andalusia, the Canary Islands, the Basque Country and Asturias, had the highest rates of mortality attributable to alcohol in 2004. The highest adjusted mortality rates attributable to alcohol were found in Asturias, Murcia, Galicia and the Basque Country. Conclusions. In the different Autonomous Communities of Spain, alcohol consumption is an important cause of death. This information is of use for identifying priorities and to evaluate intervention programs. Chronic causes, in general, have a greater weight in mortality rates than acute causes, disease of the digestive system having the highest rate of contribution.

Flanagan RJ; Fisher DS. Volatile substance abuse and crime: Data from UK press cuttings 1996-2007. Medicine, Science and the Law 48(4): 295-306, 2008. (24 refs.)

Volatile substance abuse (VSA, solvent abuse, 'glue sniffing'), carries a risk of sudden death (some 700 deaths in the UK, 1996-2006). However, mortality data take no account of the social cost of the habit. From press cuttings we have identified 508 instances (569 individuals: 507 male, median age 25 yr, range 8-51 yr and 62 female, median age 18 yr, range 11-36 yr) where VSA, either alone or together with alcohol/other drugs, was reported in association with criminal or antisocial behaviour that resulted in a criminal conviction or caution. The frequency of reports decreased from 84 per annum (1997 and 1998) to 20 (2007). The agents reported (17 individuals, two agents) were 'glue' (225), LPG/'butane'/aerosol propellants (176), 'solvents' (158), and petrol (gasoline) (27). The offences cited (most serious crime) were: homicide (35), rape or other sexual assault (34), arson (25), assault or serious threat of assault (192), child neglect/cruelty (6), attempting to pervert the course of justice (2), criminal damage (41), burglary/robbery/theft/shoplifting (100), nuisance/ breach of the peace/breach of antisocial behaviour order (104), driving whilst impaired and other vehicle-related offence (22), and supply (non-retail) (8). Thirty offenders were given life sentences or detained indefinitely under mental health legislation. Reports came from all parts of the UK, although most were from Northern England, Northern Ireland, and Scotland. There were many reports of recidivists: one 34-year-old male had made 113 court appearances, and had spent approximately nine years in custody. Although there are severe limitations to data derived from press cuttings and notwithstanding that in some cases VSA may have been raised in mitigation, these data provide an additional insight into the problem posed by VSA in the UK.

Fodale V; Mafrica F; Santamaria LB; Coleman JJ. Killer fentanyl: Is the fear justified? (editorial). Expert Opinion on Drug Safety 7(3): 213-217, 2008. (10 refs.)

Background: Fentanyl-related deaths have created havoc with public health and safety, especially in the United States. With this increasingly apparent role as a drug of abuse in cases of overdose and death, the drug has acquired the reputation of 'killer fentanyl'. Is this fear justified? Objective/methods: Information to clarify some of the present concerns regarding fentanyl abuse based on the review of the scientific literature in major databases and public sourced material available on the internet, followed by a quality assessment of reports. Results/conclusion: The opioid drug, fentanyl, is involved in medical cases of complications, toxic effects, addiction, abuse, overdose and death in patients, as well as abuse among healthcare professionals. The increase of fentanyl abuse is a growing public health problem that may evolve into a global problem. However, abuse patterns of legally and illegally produced fentanyl have produced confusion because media reporters and public officials often ignore important differences in the origins of the drug itself and the people who abuse it. In the light of possible fatal and nonfatal side effects, the use of fentanyl should be reconsidered, especially in view of the new opioid drugs that are now available.

Forrester JE; Tucker KL; Skinner S; Terrin N. Drug use and weight loss in HIV-infected Hispanic men. AIDS Care 20(7): 868-875, 2008. (24 refs.)

Weight loss is an independent risk factor for mortality in HIV but the role of drug use in HIV-related weight loss is not well described. We conducted this study to determine the role of drug use in HIV-related weight loss. Men (n = 304), all of whom were Hispanic, were recruited into one of three groups: HIV-infected drug users; HIV-noninfected drug users; and HIV-infected non-drug users. Bodymass index (BMI) was measured at successive visits. The groups were re-categorized based on self-reported drug use at the current visit into: (1) users of cocaine alone; (2) users of cocaine and opiates; (3) users of opiates alone; (4) former drug users; and (5) those who denied ever using drugs (all HIV-infected). The effect on BMI of the duration of use of the specific drug types was evaluated using repeated-measures analyses. Longer duration of exclusive opiate use or mixed cocaine and opiate use did not affect BMI in the men, regardless of HIV status. Exclusive cocaine use was associated with a decline in BMI among HIV-infected men (-0.070 kg/m(2) per month duration of use; SE = 0.033; p = 0.037) but not among HIV-uninfected men (0.024 kg/m(2) per month; SE = 0.023; p = 0.29). Adjustment for marijuana, cigarette and alcohol use in all men, or for CD4 count, viral load or HIV medication use in the HIV-infected men, did not alter the conclusions. We conclude that the use of opiates or combined opiates and cocaine does not increase the risk of weight loss in the presence or absence of HIV infection. Exclusive cocaine use may exacerbate weight loss in HIV-infection.

Fujisawa K; Takata Y; Matsumoto T; Esaki M; Ansai T; Iida M. Impact of smoking on mortality in 80-year-old Japanese from the general population. Gerontology 54(4): 210-216, 2008. (32 refs.)

Background: It is well known that cigarette smoking is the main health hazard in middle-aged people. However, data regarding smoking and health in old-aged people are limited, especially in the Japanese population. Objective: The present study aimed to investigate the influence of smoking on mortality in the elderly Japanese population. Methods: A cohort of 690 individuals of 80 years of age were categorized into 3 groups: non-smokers, ex-smokers and current smokers. The adjusted mortality after 4 years was compared among the 3 groups. The possible influence of smoking status on the cause of death was also investigated. Results: The overall mortality was significantly higher in males [ relative risk (RR): 2.3, 95% confidence interval (CI): 1.0-5.2] and females ( RR: 4.2, 95% CI: 1.9-9.5) in the current-smoker group than in the non-smoker group. The risk of any-cause mortality in the ex-smoker group was not statistically different from that in the non-smoker group. In males, current smokers died of cancer more frequently than non-smokers ( RR: 10.7, 95% CI: 1.3-90.8). Cardiovascular disease was a significant cause of death in female current smokers ( RR: 5.2, 95% CI: 1.6-16.9). This difference in mortality was not observed between groups of non-smokers and ex-smokers of both genders. In male smokers, there was a positive relationship between the daily amount of consumed cigarettes and overall mortality. Conclusion: Smokers should be encouraged to stop smoking, since habitual smoking increases the risk of mortality even in old age.

Giesbrecht N. Invited Commentary: Is alcohol a risk factor for trauma and chronic disease mortality? Narrowing the gap between evidence and action. (editorial). American Journal of Epidemiology 168(10): 1126-1129, 2008. (34 refs.)

Alcohol has been linked with over 60 chronic diseases and types of trauma, and in developed countries alcohol consumption is ranked third in terms of disability-adjusted life years (of 26 risk factors considered). In this issue of the Journal, two papers from Finland and Canada provide new evidence of the negative effects of alcohol consumption on trauma and mortality. Herttua et al. (Am J Epidemiol. 2008;168(10):1110-1118) used data from a natural experiment involving an increase in access to alcohol and its links to mortality; they offer provocative findings on differential impacts by gender, age, and socioeconomic level. Taylor et al. (Am J Epidemiol. 2008;168(10):1119-1125) focused on lifetime risk of alcohol-related injury mortality, exploring the implications for high-risk drinking patterns. These authors offer agendas for future research on the differential impacts of policy changes according to demographic dimensions, and they highlight the need for a refined measurement of alcohol intake-since the amount of alcohol in a "standard drink" consumed by heavier drinkers is probably not the same as it is for other consumers. There is still a substantial gap between alcohol's position as a significant contributor to mortality and disability and the implementation of effective interventions.

Goodson NJ; Farragher TM; Symmons DPM. Rheumatoid factor, smoking, and disease severity: Associations with mortality in rheumatoid arthritis. (editorial). Journal of Rheumatology 35(6): 945-949, 2008. (51 refs.)

Goy J; Dodds L; Rosenberg MW; King WD. Health-risk behaviours: Examining social disparities in the occurrence of stillbirth. Paediatric and Perinatal Epidemiology 22(4): 314-320, 2008. (25 refs.)

While an association between low socio-economic status (SES) and increased risk of stillbirth has been observed consistently over several decades, the pathways through which SES exerts these effects have not been established. Given that some key health-risk behaviours for stillbirth, including smoking and pre-pregnancy obesity, have strong relationships with SES, health-risk behaviours may serve as a channel through which low SES contributes to stillbirth outcomes. The objective of this study was to estimate the proportion of the relationship between low SES and the occurrence of stillbirth that is explained by health-risk behaviours in populations of Eastern Ontario and Nova Scotia (112 stillbirth cases and 398 controls). Both area and individual level influences of SES were assessed. The study population consisted of 112 cases (women delivering stillborn infants) and 398 controls. Odds ratios and 95% confidence intervals estimated by multivariable logistic regression were used to approximate relative risks. The contribution of health-risk behaviours to relationships between SES and stillbirth was assessed by a change in the relative risk estimate following omission of each health-risk behaviour from the model. Of the three measures of individual level SES examined (household income, education, Blishen occupational index), only household income was a statistically significant predictor of stillbirth. After controlling for individual level SES, no community level SES effects were observed for stillbirth. Adjustments for key health-risk behaviours (smoking) resulted in an 18.5% reduction in the odds ratio estimate for low SES, from 3.31 to 2.79. This large unexplained SES effect that remained highlights the need for research into other potential pathways that may account for increased risk of stillbirth among those of lower SES.

Graham JK; Hanzlick R. Accidental drug deaths in Fulton County, Georgia, 2002: Characteristics, case management and certification issues. American Journal of Forensic Medicine and Pathology 29(3): 224-230, 2008. (12 refs.)

Background and Objectives: Historically, the duty of the medical examiner in assigning cause and manner of death in drug-related death cases has been fraught with controversial challenges. The lack of standardization in certifying drug-related deaths may involve differences among practising forensic pathologists in their approach to such cases. The central objectives of the present study include characterization Of current drug death patterns and the variability among medical examiners with respect to autopsy performance and death certification practices in one County medical examiner's office. Materials and Methods: Death certificates, scene information/investigative reports, autopsy reports, and toxicological laboratory results for each of the 100 cases of drug-related death occurring in 2002 in Fulton County, Georgia were reviewed. Comparison of overall autopsy rates and autopsy rate, in drug-related death cases for each medical examiner individually and for the group collectively was performed. In examining cocaine-related deaths (most common), statistical analysis was performed for comparison of drug concentrations (cocaine and benzoylecgonine) between deaths certified as cocaine toxicity (poisoning) versus cocaine-complicating disease or causing all adverse event such as cerebral hemorrhage. Results: Causes of accidental drug deaths included cocaine 40%, mixed drug intoxication 37%, opioids 10%, ethanol 7%, and prescription medication (nonopioid) 5%. Overall total autopsy rates in 2002 for each of the 6 independent medical examiners ranged from 51% to 69% (mean 64%), whereas autopsy rates in drug-related death ranged from 55% to 91% (mean 81%). In review of the subset of 40 cocaine-related deaths. 25% were certified as cocaine toxicity (poisoning), with the remaining 75% certified as cocaine-complicating disease or causing an adverse event. Autopsy rates in cocaine-related deaths were as follows: cocaine toxicity 80%, cocaine-complicating diseases 77.3%, and cocaine causing adverse event 62.5%. Thirty-eight percent of cocaine-related deaths were considered to be of "low-suspicion" for drug involvement at the time the death was reported to the medical examiner with the remaining 62% being of "high suspicion". Autopsy rates were somewhat lower in the low suspicion group (67%) versus the high suspicion group (72%). Comparison of drug levels between cocaine-related death certification groups was performed. No statistically significant difference was shown in drug levels (cocaine, P > 0.3: benzoylecgonine, P > 0.2) between deaths certified as cocaine toxicity versus those certified as cocaine-complicating disease or causing adverse event. Conclusions: In Fulton County, accidental drug deaths in 2002 most often involved cocaine either alone or in combination with opiates and/or alcohol. Cocaine, opiates, or both were involved in greater than three-fourths (77%) of all drug-related deaths. The majority of all decedents were black (157%) and male (76%) with an average age of 42.2 years. Cocaine and ethanol were more frequently detected in black decedents, whereas opiates and polydrug abuse were more common in white decedents throughout the period studied. Preliminary investigation showed a high index of suspicion for the specific drug involved in virtually all opiate and alcohol cases, and in 62% of cocaine-related cases. Overall, the 100 accidental drug deaths in 2002 accounted for 7.5%, of all deaths investigated and certified by the Fulton County Medical Examiner's Office. Our study provides further evidence to support the lack of correlation between serum drug levels and the mechanism of drug toxicity in cocaine-related deaths. No statistically significant differences were shown in parent cocaine or benzoylecgonine concentrations between those cases certified as toxicities or poisonings versus those cases certified as aggravating underlying disease of causing an adverse event. In addition, 62% of the cocaine-related death cases were considered initially to be of high suspicion for drug-related death, thus emphasizing the strong importance of scene information/investigative reports in evaluating drug-death cases and in formulating plans of action to handle each individual case. Among the drug-death cases handled by 6 staff medical examiners at the Fulton County Medical Examiner's Office, variation existed in autopsy performance and death certification practices. These issues are discussed in the context of the National Association of Medical Examiners' (NAME) Position Paper on Cocaine, NAME Forensic Autopsy Performance Standards, and other relevant literature. Most variations relate to completeness of the cause-of-death statement (whether or not comorbid conditions are included) rather than classification of manner of death within the office. However, specific wording in the cause of death may have significant ramifications regarding drug-related mortality statistics processed by the vital statistics system, with possible under-representation of drug-related deaths in single-cause mortality data.

Graham NA; Merlo LJ; Goldberger BA; Gold MS. Methadone- and heroin-related deaths in Florida. American Journal of Drug and Alcohol Abuse 34(3): 347-353, 2008. (21 refs.)

Methadone is a potent synthetic opioid used for treatment of opioid dependence and chronic pain. Florida Department of Law Enforcement data were analyzed to examine trends in deaths related to or caused by methadone and/or heroin between 2001-2006. Results demonstrated that mortalities associated with methadone use increased steadily as mortalities associated with heroin decreased steadily. Though useful in the treatment of opioid dependence and chronic pain, methadone possesses high abuse potential and documented mortality risks. Treatment with methadone, for both pain and opioid dependence, should be preceded by an abuse liability evaluation. Attempts to minimize diversion should be implemented.

Green TC; Heimer R; Grau LE. Distinguishing signs of opioid overdose and indication for naloxone: An evaluation of six overdose training and naloxone distribution programs in the United States. Addiction 103(6): 979-989, 2008. (42 refs.)

Aims This study assessed overdose and naloxone administration knowledge among current or former opioid abusers trained and untrained in overdose-response in the United States. Design and participants: Ten individuals, divided equally between those trained or not trained in overdose recognition and response, were recruited from each of six sites (n = 62). Setting US-based overdose training and naloxone distribution programs in Baltimore, San Francisco, Chicago, New York and New Mexico. Measurements: Participants completed a brief questionnaire on overdose knowledge that included the task of rating 16 putative overdose scenarios for: (i) whether an overdose was occurring and (ii) if naloxone was indicated. Bivariate and multivariable analyses compared results for those trained to untrained. Responses were also compared to those of 11 medical experts using weighted and unweighted kappa statistics. Findings Respondents were primarily male (72.6%); 45.8% had experienced an overdose and 72% had ever witnessed an overdose. Trained participants recognized more opioid overdose scenarios accurately (t(60) = 3.76, P < 0.001) and instances where naloxone was indicated (t(59) = 2.2, P < 0.05) than did untrained participants. Receipt of training and higher perceived competency in recognizing signs of an opioid overdose were associated independently with higher overdose recognition scores. Trained respondents were as skilled as medical experts in recognizing opioid overdose situations (weighted kappa = 0.85) and when naloxone was indicated (kappa = 1.0). Conclusions: Results suggest that naloxone training programs in the United States improve participants' ability to recognize and respond to opioid overdoses in the community. Drug users with overdose training and confidence in their abilities to respond may effectively prevent overdose mortality.

Gruszecki AC; McGwin G; Robinson CA; Davis GG. The relationship of drug abuse to unexplained sudden death. Archives of Pathology & Laboratory Medicine 132(12): 1903-1906, 2008. (10 refs.)

Context. Forensic pathologists regularly investigate the deaths of individuals with a history of drug abuse. Autopsy, including toxicology testing, reveals no cause for death in a subset of this cohort. Objective. To determine whether deaths with an undetermined cause and manner of death are associated with a history of drug abuse. Design.-Retrospective matched case-control study of 52 decedents whose cause of death remained undetermined following autopsy, matched 1: 2 to a control group of living patients admitted for cholecystectomy according to age and date of death or procedure. Results. Individuals whose cause of death was undetermined were 5.3 times (95% confidence interval, 1.9-14.5) more likely to have a history of drug abuse than were patients with cholecystitis. Conclusions. Decedents with a history of chronic drug abuse appear to be at an increased risk of dying by their chronic drug abuse, even in the absence of any anatomical or toxicologic finding at autopsy to account for death.

Gu DF; Kelly TN; Wu XG; Chen J; Samet JM; Huang JF et al. Mortality attributable to smoking in China. New England Journal of Medicine 360(2): 150-159, 2009. (34 refs.)

Background: Smoking is a risk factor for many diseases and has been increasingly prevalent in economically developing regions of the world. We aimed to estimate the number of deaths attributable to smoking in China. Methods: We conducted a large, prospective cohort study in a nationally representative sample of 169,871 Chinese adults who were 40 years of age or older. Investigators for the China National Hypertension Survey collected data on smoking and other risk factors at a baseline examination in 1991 using a standard protocol. Follow- up evaluation was conducted in 1999 and 2000, with a response rate of 93.4%. We used multivariable- adjusted relative risk, prevalence of smoking, mortality, and population size in each age group, stratified according to sex, to calculate the number of deaths attributable to smoking in 2005. Results: There was a significant, dose - response association between pack- years smoked and death from any cause in both men and women after adjustment for multiple risk factors ( P< 0.001 for trend). We estimated that in 2005, a total of 673,000 deaths ( 95% confidence interval [ CI], 564,700 to 781,400) were attributable to smoking in China: 538,200 ( 95% CI, 455,800 to 620,600) among men and 134,800 ( 95% CI, 108,900 to 160,800) among women. The leading causes of smoking- related deaths were as follows: cancer, 268,200 ( 95% CI, 214,500 to 321,900); cardiovascular disease, 146,200 ( 95% CI, 79,200 to 213,100); and respiratory disease, 66,800 ( 95% CI, 20,300 to 113,300). Conclusions: Our study documents that smoking is a major risk factor for mortality in China. Continued strengthening of national programs and initiatives for smoking prevention and cessation is needed to reduce smoking- related deaths in China.

Hall AJ; Logan JE; Toblin RL; Kaplan JA; Kraner JC; Bixler D et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. Journal of the American Medical Association 300(22): 2613-2620, 2008. (29 refs.)

Context: Use and abuse of prescription narcotic analgesics have increased dramatically in the United States since 1990. The effect of this pharmacoepidemic has been most pronounced in rural states, including West Virginia, which experienced the nation's largest increase in drug overdose mortality rates during 1999- 2004. Objective To evaluate the risk characteristics of persons dying of unintentional pharmaceutical overdose in West Virginia, the types of drugs involved, and the role of drug abuse in the deaths. Design, Setting, and Participants Population- based, observational study using data from medical examiner, prescription drug monitoring program, and opiate treatment program records. The study population was all state residents who died of unintentional pharmaceutical overdoses in West Virginia in 2006. Main Outcome Measures: Rates and rate ratios for selected demographic variables. Prevalence of specific drugs among decedents and proportion that had been prescribed to decedents. Associations between demographics and substance abuse indicators and evidence of pharmaceutical diversion, defined as a death involving a prescription drug without a documented prescription and having received prescriptions for controlled substances from 5 or more clinicians during the year prior to death ( ie, doctor shopping). Results Of 295 decedents, 198 ( 67.1%) were men and 271 ( 91.9%) were aged 18 through 54 years. Pharmaceutical diversion was associated with 186 ( 63.1%) deaths, while 63 ( 21.4%) were accompanied by evidence of doctor shopping. Prevalence of diversion was greatest among decedents aged 18 through 24 years and decreased across each successive age group. Having prescriptions for a controlled substance from 5 or more clinicians in the year prior to death was more common among women (30 [ 30.9%]) and decedents aged 35 through 44 years ( 23 [ 30.7%]) compared with men ( 33 [ 16.7%]) and other age groups ( 40 [ 18.2%]). Substance abuse indicators were identified in 279 decedents ( 94.6%), with nonmedical routes of exposure and illicit contributory drugs particularly prevalent among drug diverters. Multiple contributory substances were implicated in 234 deaths ( 79.3%). Opioid analgesics were taken by 275 decedents (93.2%), of whom only 122 ( 44.4%) had ever been prescribed these drugs. Conclusion: The majority of overdose deaths in West Virginia in 2006 were associated with nonmedical use and diversion of pharmaceuticals, primarily opioid analgesics.

Hart CL; Smith GD. Alcohol consumption and mortality and hospital admissions in men from the Midspan Collaborative Cohort Study. Addiction 103(12): 1979-1986, 2008. (27 refs.)

To investigate the relationships between alcohol consumption and mortality and morbidity risk by specific causes. Prospective cohort study. Twenty-seven work-places in West and Central Scotland. A total of 6000 men aged 21-64 years at screening in 1970-1973, median follow-up 29 years. Relative rates, using Cox's proportional hazard models, by weekly reported units of alcohol consumption for all cause, coronary heart disease (CHD), stroke, respiratory, digestive, liver disease and alcohol-related causes of mortality and for specific causes of acute hospital admissions. Mortality risk was increased for men drinking 15-21 or more units per week for all causes, stroke, liver disease and alcohol-related causes. For respiratory mortality, drinkers of 35 or more units had double the risk compared to non-drinkers. CHD mortality showed increasing trends with consumption when adjusted for age and after full adjustment showed no clear patterns, although the 8-14 units group had a lower risk than non-drinkers [relative rate 0.81 (0.68-0.97)]. Hospital admissions had similar patterns to mortality for stroke and liver disease. Increased risk began at 8-14 units for alcohol-related admissions, and at 15-21 units for respiratory admissions. Non-drinkers had higher risks of having a CHD admission than drinkers and there were decreasing trends with increasing consumption (P = 0.019). Consumption of 15-21 units per week and over was associated with increased mortality from most causes and increased risk of hospital admissions from stroke, liver disease and respiratory diseases. Alcohol-related admissions were raised from 8 to 14 units. Alcohol use may have been under-reported in our study, but it was similar to other studies of the time. The apparent protective effect of alcohol with CHD admissions could be due partly to detrimental effects of heavy drinking causing sudden deaths. The associations, including that with respiratory disease, may arise from inadequate adjustment for confounding by other factors such as smoking.

Haver B; Gjestad R; Lindberg S; Franck J. Mortality risk up to 25 years after initiation of treatment among 420 Swedish women with alcohol addiction. Addiction 104(3): 413-419, 2009. (34 refs.)

Women treated for alcohol addiction have mortality rates three to five times those of women from the general population (GP). However, these figures may be inflated because socially disadvantaged women with advanced drinking careers are over-represented in previous studies. Our aim was to study the long-term mortality of socially relatively well-functioning patients coming to their first treatment, compared to matched GP controls. The mortality rates and causes of death were compared between patients and their matched GP controls, using data from the Causes of Death Register throughout the follow-up period (0-25 years). A specialized treatment programme for women only, called 'Early treatment for Women with Alcohol Addiction' (EWA) at the Karolinska Hospital, Stockholm, Sweden. Subjects (n = 420) receiving their first treatment at the EWA programme, compared to a group of matched GP women (n = 2037). The women patients had significantly higher mortality than matched GP controls throughout the whole follow-up period, with a relative risk of 2.4. However, the younger women had four times higher mortality than their matched controls. The peak of deaths occurred during the first 5 years, and alcohol-related causes of death were highly over-represented, as were uncertain suicides and accidents. First-time-treated women with alcohol addiction have a substantially lower mortality than reported previously from clinical samples, except for the youngest group. Our figures were corrected for confounding factors such as socio-demographic status. We believe our results could apply to broader groups of heavy drinking women, inside or outside specialized treatment settings.

Honkonen H; Mattila AK; Lehtinen K; Elo T; Haataja R; Joukamaa M. Mortality of Finnish acute psychiatric hospital patients. Social Psychiatry and Psychiatric Epidemiology 43(8): 660-666, 2008. (40 refs.)

Objective: The mortality of psychiatric patients is higher than that of the general population. Earlier studies have typically focused on specific diagnostic categories or causes of death. The aim of this study was to assess the overall mortality in acute psychiatric hospital patients covering all diagnostic groups, with special emphasis on substance abuse. Methods The sample consisted of all 18-64-year old patients (n = 3,835) treated or evaluated in the acute wards of the Department of Psychiatry at Tampere University Hospitalital between the years 1999 and 2003, who were followed-up until the end of the year 2005. We assessed the various causes of death according to background variables in bivariate and multivariate analyses and calculated the standardized mortality ratios (SMRs). Results During the study period 379 subjects died (9.9% of the sample). Mortality among men was almost twice as high as among women. Of all deaths, 45.6% were considered to be alcohol or drug related. SMR covering all subjects was 6.55. The SMRs for unnatural causes were higher than those for natural causes. The highest SMRs for unnatural causes of death were found in patients with mood disorders patients with schizophrenia spectrum disorders. Use of coercive measures was associated with increased mortality. Conclusion: Mortality among Finnish psychiatric acute hospital patients is considerably higher than in general population. Excessive alcohol consumption plays a major role in causing excess deaths that could be potentially avoided.

Jenkins AJ; Cone EJ. Time of heroin use. (letter). Journal of Analytical Toxicology 32(6): 454-456, 2008. (13 refs.)

Jessop DC; Wade J. Fear appeals and binge drinking: A terror management theory perspective. British Journal of Health Psychology 13(Part 4): 773-788, 2008. (28 refs.)

Objectives. The aim of the current research was to test the terror management theory-derived hypotheses that exposure to information about the mortality-related risks of binge drinking would make mortality salient (Study 1) and, hence, exacerbate willingness to binge drink amongst those who perceive this behaviour to benefit self-esteem (Study 2). Study 1. Participants (N = 97) were allocated to one of five experimental conditions. Results: confirmed that exposure to information about the mortality-related risks of binge drinking made mortality salient. Study 2. Participants (N = 296) were allocated to one of three experimental conditions. Exposure to mortality-related information about the risks of binge drinking was found to result in greater willingness to binge drink among (i) binge drinkers and (ii) non-binge drinkers who perceived this behaviour to benefit self-esteem. There was no evidence, however, that exposure to such information influenced binge drinking over the following week. Conclusions. Research findings suggest that mortality-related health promotion campaigns might inadvertently make mortality salient, and hence precipitate the very behaviours which they aim to deter among some recipients.

Kalaitzakis E; Wallskog J; Bjornsson E. Abstinence in patients with alcoholic liver cirrhosis: A follow-up study. Hepatology Research 38(9): 869-876, 2008. (40 refs.)

Aim: To investigate the proportion of patients with alcoholic cirrhosis who abstained from alcohol after contact with a hepatology unit, the predictors for abstinence, and the role of clinical and psychosocial factors in short-term mortality in these patients. Methods: Eighty-seven consecutive patients with alcoholic cirrhosis from a transplant center were included. Data on cirrhosis severity and complications, as well as on abstinence and psychosocial factors were collected. Patients were followed up for 19 (12-25) months. Data on abstinence during follow up, alcohol abuse treatment, psychiatric contact, severity of cirrhosis, mortality, and liver transplantation were analyzed. Results: Prior to inclusion, 53/87 (61%) patients had abstained from alcohol for 24 months (interquartile range: 18-33). Twenty percent had a history of other substance abuse, 47% had undergone alcohol abuse treatment, and 21% had a previous psychiatric diagnosis. Forty-eight percent lived with a partner, 23% worked/studied, and 53% were pensioners. During follow up, 26% died, 20% received a liver transplant, 55% abstained from alcohol, 47% received alcohol abuse treatment, and 33% had psychiatric contact. In a multivariate analysis, abstinence during follow up was found to be related to abstinence upon inclusion in the study, to the model for end-stage liver disease (MELD) score at follow up, and to no abuse treatment in a detoxification unit, whereas mortality was related to index MELD and alcohol abuse treatment during follow up. Neither abstinence nor mortality was related to psychosocial factors. Conclusion: More than half of patients with alcoholic cirrhosis were found to abstain from alcohol during follow up, which was related to prior documentation of abstinence and cirrhosis severity. Cirrhosis severity (expressed as the MELD) and alcohol abuse treatment during follow up were related to short-term mortality.

Katanoda K; Marugame T; Saika K; Satoh H; Tajima K; Suzuki T et al. Population attributable fraction of mortality associated with tobacco smoking in Japan: A pooled analysis of three large-scale cohort studies. Journal of Epidemiology 18(6): 251-264, 2008. (40 refs.)

Background: Quantitative measures of the burden of tobacco smoking in Asian countries are limited. We estimated the population attributable fraction (PAF) of mortality associated with smoking in Japan, using pooled data from three large-scale cohort studies. Methods: In total, 296,836 participants (140,026 males and 156,810 females) aged 40-79 years underwent baseline surveys during the 1980s and early 1990s. The average follow-up period was 9.6 years. PAFs for all-cause mortality and individual tobacco-related diseases were estimated from smoking prevalence and relative risks. Results: The prevalence of current and former smokers was 54.4% and 25.1% for males, and 8.1% and 2.4% for females. The PAF of all-cause mortality was 27.8% [95% confidence interval (Cl): 25.2-30.4] for males and 6.7% (95% Cl: 5.9-7.5) for females. The PAF of all-cause mortality calculated by summing the disease-specific PAFs was 19.1% (95% Cl: 16.0-22.2) for males and 3.6% (95% Cl: 3.0-4.2) for females. The estimated number of deaths attributable to smoking in Japan in 2005 was 163,000 for males and 33,000 for females based on the former set of PAFs, and 112,000 for males and 19,000 for females based on the latter set. The leading causes of smoking-attributable deaths were cancer (61% for males and 31% for females), ischemic heart diseases and stroke (23% for males and 51% for females), and chronic obstructive pulmonary diseases and pneumonia (11% for males and 13% for females). Conclusion: The health burden due to smoking remains heavy among Japanese males. Considering the high prevalence of male current smokers and increasing prevalence of young female current smokers, effective tobacco controls and quantitative assessments of the health burden of smoking need to be continuously implemented in Japan.

Kaye S; Darke S; Duflou J; McKetin R. Methamphetamine-related fatalities in Australia: demographics, circumstances, toxicology and major organ pathology. Addiction 103(8): 1353-1360, 2008. (47 refs.)

Aim: To examine the demographic characteristics, circumstances of death, toxicological results and major organ pathology of methamphetamine-related deaths in Australia. Design: Retrospective review of coronial files. Setting: Australia. Methods: Cases in which methamphetamine was listed as a cause of death were identified from the National Coronial Information System (NCIS). Findings A total of 371 cases were identified. The mean age of decedents was 32.7 years; 77% were male and 35% were employed. Route of administration was predominantly by injection (89%). Drugs other than methamphetamine were detected in 89% of cases, most commonly benzodiazepines (41%) and morphine (36%). The median blood methamphetamine concentration was 0.2 mg/l (range 0.02-15.0 mg/l). Deaths were overwhelmingly accidental, with 14% determined to be suicides, and occurred in a private home (71%). Cardiovascular pathology, typically coronary artery atherosclerosis, was detected in 54% of decedents. Cerebrovascular pathology, most commonly cerebral haemorrhage and hypoxia, was present in 20% of cases. Conclusions: Methamphetamine has contributed to a substantial number of deaths in Australia. Users need to be informed of the potential harms of methamphetamine use, particularly those associated with the cardiotoxicity of methamphetamine and the use of methamphetamine in conjunction with other drugs.

Kernbach-Wighton G; Saternus KS. Postmortem biochemical estimations in cases of fatal hypothermia (catecholamines and volatiles). Romanian Journal of Legal Medicine 15(1): 32-38, 2007. (14 refs.)

A hypothermic state represents intense stress accompanied by a massive release of catecholamines. Their estimation can be used to confirm this mechanism of death. We investigated four cases of fatal hypothermia and 12 controls with short and longer agonies on which were performed estimations of adrenaline/noradrenaline and volatile substances (ethanol, methanol, propanol-1, -2, acetone). - In cases of cold death always a predominance of noradrenaline was present (approx. 10-to 32 fold). This corresponds to cases with longer agony. The mean quotients adrenaline/noradrenaline ranged between 0.10 and 0.79. Significant differences were seen especially with cases characterized by short agony in which adrenaline levels were remarkably higher than those of noradrenaline (factor of approx. 4 to 10, quotients varying from 3.8 to 17). Elevated acetone levels were only found in ethanol-free cases while acetone and propanol-2 were both high. In hypothermia with relevant alcoholisation these were within the physiological range what can be due to an anti-lipolytic effect of ethanol. - Therefore, combined estimation of catecholamines and volatile substances in several compartments can have diagnostic value to verify fatal hypothermia.

Kershaw CD; Guidot DM. Alcoholic lung disease. Alcohol Research & Health 31(1): 66-75, 2008. (74 refs.)

In addition to its well-known association with lung infection (i.e., pneumonia), alcohol abuse now is recognized as an independent factor that increases by three- to four-fold the incidence of the acute respiratory distress syndrome, a severe form of acute lung injury with a mortality rate of 40 to 50 percent. This translates to tens of thousands of excess deaths in the United States each year from alcohol-mediated lung injury, which is comparable to scarring of the liver (i.e., cirrhosis) in terms of alcohol-related mortality. Experimental and clinical studies are shedding light on the basic mechanisms by which alcohol abuse predisposes some people to both acute lung injury and pneumonia. At the same time, novel therapeutic targets could be utilized in treating these uniquely vulnerable people. However, there have been no systems biological approaches to the study of the alcoholic lung to date. This is in part because the association between alcohol abuse and acute lung injury was made relatively recently and remains largely unrecognized, even by lung researchers. in parallel, efforts to study complex diseases such as acute lung injury and pneumonia using a genomics and/or proteomics approach, which involves the study of an organism's genes andlor proteins, still are in their infancy. However, the alcoholic lung represents a clear example of environment-host interactions that should be well suited for such applications.

Public Domain

Klys M; Rojek S; Kowalski P; Rzepecka-Wozniak E. Death of a female addict due to heroin and cocaine overdoses: A case report with multiparameter evaluation. Forensic Toxicology 26(1): 36-40, 2008. (20 refs.)

This study undertook a multiparameter evaluation of the death of a 21-year-old woman known to be an abuser of heroin and cocaine. The toxicological analysis of multiple postmortem specimens such as blood and hair was carried out using liquid chromatography atmospheric pressure chemical ionization tandem mass spectrometry (LC-APCI-MS-MS). The blood specimens of the deceased showed the presence of opium components such as morphine and its glucuronides together with cocaine and benzoylecgonine. The detected xenobiotic levels probably explained the cause of her death resulting from combined action of unintentional illicit drug overdose. By analysis of four 2-cm long hair segments, a heroin-cocaine addiction for at least 8 months antemortem was able to be documented; the presence of 6-monoacetylmorphine (6-MAM), cocaine, and benzoylecgonine was demonstrated. The histopathological findings of lesions of the internal organs of the deceased were consistent with long heroin and cocaine abuse. The use of multiple parameters, such as blood and hair segments as matrices and drug metabolites such as 6-MAM, morphine, glucuronides, and benzoylecgonine as target compounds, gave a well-defined outline of her death.

Koster A; Leitzmann MF; Schatzkin A; Adams KF; van Eijk JTM; Hollenbeck AR et al. The combined relations of adiposity and smoking on mortality. American Journal of Clinical Nutrition 88(5): 1206-1212, 2008. (37 refs.)

Background: Smoking and high adiposity are strong independent health risk factors but are also interrelated. Smoking is related to a lower body mass index (BMI) but not necessarily with a smaller waist circumference. Smoking cessation is associated with increased body weight and a substantial increase in waist circumference. How this affects mortality risk is unknown. Objective: This study examined the combined relations of smoking status with BMI and waist circumference and smoking status to all-cause mortality. Design: Data were from 149 502 men and 88 184 women aged 51-72 y participating in the National Institutes of Health-AARP Diet and Health Study. All-cause mortality was assessed over 10 y of follow-up from 1996 to 2006. Results: Current smokers with a BMI (in kg/m(2)) < 18.5 or >= 35 had a mortality risk 6-8 times that of persons within the normal BMI range who never smoked. Current smokers with a large waist circumference had a mortality risk about 5 times that of never smokers with a waist circumference in the second quintile. Conclusion: Both smoking and adiposity are independent predictors of mortality, but the combination of current or recent smoking with a BMI >= 35 or a large waist circumference is related to an especially high mortality risk.

Larm P; Hodgins S; Larsson A; Samuelson YM; Tengstrom A. Long-term outcomes of adolescents treated for substance misuse. Drug and Alcohol Dependence 96(1-2): 79-89, 2008. (62 refs.)

Introduction: Little is known about the long-term outcome of substance misuse by teenagers, this is especially true for gender specific consequences. Objectives: To examine the prevalence of death, physical illnesses related to substance misuse, mental illness, substance misuse, criminality, and poverty in adulthood among two cohorts of individuals who as adolescents had consulted for substance misuse problems, to estimate the effect of sex on adverse outcomes, and to compare cohort effects. Methods: Individuals who had consulted a substance misuse clinic as adolescents during 1968-1971 and 1980-1984 were followed until 2002. Adverse outcomes were documented using information from Swedish national registers. Results: In the older cohort followed to age 50, only one-in-five escaped all six adverse outcomes, while over half of subjects experienced at least two or more. Sex and the severity of adolescent substance misuse and delinquency were predictors of adverse outcomes. More women than men experienced physical illness and poverty in the older cohort while more men than women were convicted of criminal offences in both cohorts and presented continued substance misuse in the younger cohort. Men in the younger as compared to the older cohort had higher rates of substance misuse and criminal convictions. Conclusions: Adolescents seeking help for substance misuse problems are at elevated risk for multiple adverse outcomes later in life. Outcomes differ for women and men and by severity of adolescent misuse and delinquency. Few cohort differences in adult outcomes exist.

Lejckova P; Mravcik V. Mortality of hospitalized drug users in the Czech Republic. Journal of Drug Issues 37(1): 103-118, 2007. (26 refs.)

Drug users are generally thought to experience higher mortality rates than those found among the general population. This study analyzes mortality rates among different subgroups of drug users in the Czech Republic. For this project, a retrospective cohort mortality study was conducted. A cohort of 12,207 persons aged 15 to 49 who had been hospitalized for drug related behavioral disorders was followed from 1997 to 2002. The study findings indicate that direct standardized mortality for the cohort of drug users was 16. 78 per 1000 person-years (PY); 22. 38 for men and 11.18 per 1000 PY for women. After reaching a peak in 1998, mortality rates began to decrease and stabilized around 14 per 1,000 PY from 2000 to 2002. When compared to the rates found in the general population, drug user mortality is eight times higher than nonuser rates (SMR = 8.15; 8.13 for men and 8.22 for women). These mortality rates are highest among polyvalent drug and opiate users and lowest among stimulant users. The authors conclude that the overall mortality of opiate users in the Czech Republic is relatively low when compared with those reported in similar European and non-European studies. There were few overdoses found in the cohort, and in sharp contrast to other available studies, no AIDS related cases were observed.

Lenton S. Case for peer naloxone further strengthened. Commentary. Addiction 103(10): 1658-1659, 2008. (15 refs.)

Lucey MR; Connor JT; Boyer TD; Henderson JM; Rikkers LF. Alcohol consumption by cirrhotic subjects: Patterns of use and effects on liver function. American Journal of Gastroenterology 103(7): 1698-1706, 2008. (20 refs.)

OBJECTIVE: We investigated patterns of use of alcohol and its clinical effects among cirrhotic subjects who participated in a randomized clinical trial comparing the efficacy of transjugular intravenous portosystemic shunt and distal splenorenal shunt. METHODS: There were 132 cirrhotic subjects, 78 with alcoholic liver disease (ALD), who were followed for a median of 49 months (range 2-93 months). Alcohol use was assessed by patient questionnaire, with corroboration by family members. RESULTS: Twenty-eight subjects (21%) were drinking at study entry and 60 subjects (45%) drank during follow-up. Heavy drinking (> 4 drinks/day) was recorded in 25 ALD subjects, but in no non-ALD subjects (P < 0.0001). Drinking by ALD subjects was associated with a 153% increase in gamma-glutamyl transpeptidase (GGT) (P < 0.0001). The frequencies of death (46% vs 30%), ascites (33% vs 20%), encephalopathy (56% vs 42%), and variceal bleeding (11% vs 3%) were greater in the ALD group. In a Cox proportional hazards model only "ever heavy drinking" was associated with death (P = 0.0099), while recent heavy drinking increased the hazard of variceal hemorrhage dramatically (odds ratio 10.85). CONCLUSIONS: Whereas most cirrhotic subjects, alcoholic or not, did not drink during 5 yr of observation, heavy alcohol use occurred exclusively in ALD patients. Alcohol use by ALD subjects was associated with elevations in GGT and was linked to death and with rebleeding from shunt dysfunction.

Lumenta DB; Hautier A; Desouches C; Gouvernet J; Giorgi R; Manelli JC et al. Mortality and morbidity among elderly people with burns: Evaluation of data on admission. Burns 34(7): 965-974, 2008. (47 refs.)

People aged >= 65 years represent a growing population within burns units in the Western world. In 2001, this group was reported to rise to 20% of such admissions. We reviewed the records of 265 burn cases with complete admission and discharge histories, from January 1990 to December 2003 in an A-level regional burns centre. The predictive value of age, gender, total body surface area burned (TBSA), inhalation trauma (IT), premorbid conditions and currently used burn scores (Baux, ABSI, Ryan) for haemodynamic or respiratory complications, mortality and morbidity were analysed. Additionally a subset of patients with diabetes mellitus and >30% total body surface area burned were reviewed. About 16% of all admissions with burns were >65 years of age, with a mortality rate of 30.6% (81/265). Only gender and premorbid conditions did not influence mortality. Haemodynamic and respiratory complications were significantly related to TBSA, presence of I and any of the three scores (all p < 0.001). Among survivors (184/265), the median duration of hospital stay was 26.0 days. Factors contributing to a significantly increased length of stay were, in decreasing order, total body surface area burned, high levels of burn scores, inhalation trauma, flame injury and certain premorbid conditions (cardiovascular disease, alcoholism). About 77.7% of all patients were discharged either to a rehabilitation centre or back to their previous form of housing. This study showed that among burned people aged >65 years a good outcome as evaluated on discharge can be achieved. Studies pooling different centres' results are needed to improve the significance of conclusions drawn from these data.

Mackenbach JP; Stirbu I; Roskam AJR; Schaap MM; Menvielle G; Leinsalu M et al. Socioeconomic inequalities in health in 22 European countries. New England Journal of Medicine 358(23): 2468-2481, 2008. (43 refs.)

Background: Comparisons among countries can help to identify opportunities for the reduction of inequalities in health. We compared the magnitude of inequalities in mortality and self-assessed health among 22 countries in all parts of Europe. Methods: We obtained data on mortality according to education level and occupational class from census-based mortality studies. Deaths were classified according to cause, including common causes, such as cardiovascular disease and cancer; causes related to smoking; causes related to alcohol use; and causes amenable to medical intervention, such as tuberculosis and hypertension. Data on self-assessed health, smoking, and obesity according to education and income were obtained from health or multipurpose surveys. For each country, the association between socioeconomic status and health outcomes was measured with the use of regression-based inequality indexes. Results: In almost all countries, the rates of death and poorer self-assessments of health were substantially higher in groups of lower socioeconomic status, but the magnitude of the inequalities between groups of higher and lower socioeconomic status was much larger in some countries than in others. Inequalities in mortality were small in some southern European countries and very large in most countries in the eastern and Baltic regions. These variations among countries appeared to be attributable in part to causes of death related to smoking or alcohol use or amenable to medical intervention. The magnitude of inequalities in self-assessed health also varied substantially among countries, but in a different pattern. Conclusions: We observed variation across Europe in the magnitude of inequalities in health associated with socioeconomic status. These inequalities might be reduced by improving educational opportunities, income distribution, health-related behavior, or access to health care.

Michel L; Giorgi R; Villes V; Poizot-Martin I; Dellamonica P; Spire B; Protopopescu C et al. Withdrawal symptoms as a predictor of mortality in patients HIV-infected through drug use and receiving highly active antiretroviral therapy (HAART). Drug and Alcohol Dependence 99(1-3): 96-104, 2009. (66 refs.)

Even in the highly active antiretroviral therapy (HAART) era, individuals HIV-infected through injecting, drug use (IDUs) are at increased risk of death due to the burden of competing events such as liver disease, overdose and suicide. The objective of this study was to explore the role which life events' experience, in particular drug-related events such as detoxification or withdrawal symptoms, may play on the risk of death in HIV-infected IDUs. Our analysis was based on longitudinal data of 296 HIV-infected IDUs from when they started HAART Data collection included medical records and patient's self-reports detailing, among other information, life events including drug-related problems. Multiple imputations for missing data in the explanatory variables together with Cox models were used to identify predictors of death. During, HAART follow-up, 26 deaths occurred, corresponding to 1.8 deaths per 100 person-years. The majority (N=8) were attributable to liver disease while 5 were from unknown causes (found deceased at home or in a car). After adjustment for age and time-dependent viral load (>10,000 cp/ml) individuals experiencing withdrawal symptoms had a fivefold increased risk of death with respect to the others. Withdrawal symptoms in IDUs living with HIV reflect physicians' difficulties in managing their patients' opioid dependence. Early detection and increasing substitution dosages or switching to a more adequate treatment could prevent possible drug-related deaths.

Midanik LT; Chaloupka FJ; Saitz R; Toomey TL; Fellows JL; Dufour M et al. Alcohol-attributable deaths and years of potential life lost: United States, 2001. MMWR. Morbidity and Mortality Weekly Report 53(37): 866-870, 2004. (10 refs.)

Excessive alcohol consumption is the third leading preventable cause of death in the United States and is associated with multiple adverse health consequences, including liver cirrhosis, various cancers, unintentional injuries, and violence. To analyze alcohol-related health impacts, CDC estimated the number of alcohol-attributable deaths (AADs) and years of potential life lost (YPLLs) in the United States during 2001. This report summarizes the results of that analysis, which indicated that approximately 75,766 AADs and 2.3 million YPLLs, or approximately 30 years of life lost on average per AAD, were attributable to excessive alcohol use in 2001. These results emphasize the importance of adopting effective strategies to reduce excessive drinking, including increasing alcohol excise taxes and screening for alcohol misuse in clinical settings

Public Domain

Milloy MJS; Kerr T; Mathias R; Zhang R; Montaner JS; Tyndall M et al. Non-fatal overdose among a cohort of active injection drug users recruited from a supervised injection facility. American Journal of Drug and Alcohol Abuse 34(4): 499-509, 2008. (46 refs.)

Non-fatal overdose among injection drug users (IDU) is a source of significant morbidity. Since it has been suggested that supervised injecting facilities (SIF) may increase risk for overdose, we sought to evaluate patterns of non-fatal overdose among a cohort of SIF users. We examined recent non-fatal overdose experiences among participants enrolled in a prospective study of IDU recruited from within North America's first medically supervised safer injecting facility. Correlates of recent non-fatal overdoses were identified using generalized estimating equations (GEE). There were 1,090 individuals recruited during the study period of which 317 (29.08%) were female. At baseline, 638 (58.53%) reported a history of non-fatal overdose and 97 (8.90%) reported at least one non-fatal overdose in the last six months. This proportion remained approximately constant throughout the study period. In the multivariate GEE analysis, factors associated with recent non-fatal overdose included: sex-trade involvement (Adjusted Odds Ratio [AOR]: 1.45 [95% Confidence Interval [CI] 1.07-1.99], p = 0.02) and public drug use (AOR: 1.50 [95% CI 1.09-2.06]; p = 0.01). Using the SIF for = 75% of injections was not associated with recent non-fatal overdose in univariate (Odds Ratio: 1.05, p = 0.73) or multivariate analyses (AOR: 1.01, p = 0.96). The proportion of individuals reporting recent non-fatal overdose did not change over the study period. Our findings indicate that a sub-population of IDU might benefit from overdose prevention interventions. Our findings refute the suggestion that the SIF may increase the likelihood of overdose.

Montisci M; Thiene G; Ferrara SD; Basso C. Cannabis and cocaine: a lethal cocktail triggering coronary sudden death. (editorial). Cardiovascular Pathology 17(5): 344-346, 2008. (5 refs.)

The case of a 31-year-old man who died suddenly, with a history of drug abuse and no risk factors for coronary artery disease, is herein reported. Postmortem examination disclosed critical stenosis due to a fibrocellular atherosclerotic plaque complicated by occlusive thrombosis at the level of the left anterior descending coronary artery. Chemico-toxicological analysis revealed high levels of cocaine, tetrahydrocannabinol, and metabolites. When dealing with an acute coronary syndrome in young people, with or without a history of drug abuse, toxicological examination should always be performed to rule out unnatural causes of myocardial ischemia.

Morgan O; Vicente J; Griffiths P; Hickman M. Trends in overdose deaths from drug misuse in Europe: What do the data tell us? (editorial). Addiction 103(5): 699-700, 2008. (18 refs.)

Murphy JM; Burke JD; Monson RR; Horton NJ; Laird NM; Lesage A et al. Mortality associated with depression: A forty-year perspective from the Stirling County Study. Social Psychiatry and Psychiatric Epidemiology 43(8): 594-601, 2008. (73 refs.)

Background: This report concerns long-term mortality risks associated with depression, and the potentially confounding factors of alcoholism and cigarette smoking, as experienced by a general population assessed at a baseline in 1952, followed for re-assessment of survivors in 1968, and for death by 1992. Methods: Self-report and physician-report information was gathered in 1952 and again in 1968 about a sample of 1,079 adults. At the end of follow-up in 1992, the vital status of all subjects was known. Comorbidity among depression, alcoholism, and smoking was investigated. Cox regression models were employed to estimate hazard ratios (HRs) as indicators of mortality risk. Models including age, gender, and depression were fit for the complete sample at baseline as well as for re-assessed survivors. Models simultaneously controlling for the mortality risks associated with depression, alcoholism, and heavy smoking were fit for men. Results: At the baseline in 1952, depression was somewhat more common among women than men (4% compared to 6%) but was found to carry a significant mortality risk only among men (HR 2.7, 95% CI 1.6-4.7). Based on re-assessments made in 1968, depression was associated with mortality risk among both men (HR 2.2, 95% CI 1.0-4.5) and women (HR 2.1, 95% CI 1.2-3.8). In 1952, more than 20% of men smoked cigarettes excessively and 8% abused alcohol, but very few of these groups of men were also depressed. In the original sample and also among the survivors, depression, alcoholism, and heavy smoking were separately associated with mortality among men. Depression and alcoholism carried a more immediate mortality risk while heavy smoking a more delayed one. Conclusions: At the baseline of the Stirling County Study, the mortality risk associated with depression among men was not enhanced or explained by abuse of alcohol or nicotine, mainly because comorbidity was rare at that time. The longitudinal research of the study has pointed to a number of psychiatrically-relevant time-trends such as the fact that an association between depression and cigarette smoking did not appear until the 1990s. It is hypothesized that a similar trend may emerge over time regarding the comorbidity of depression and alcoholism. A trend reported here was that, while depressed women in the original sample did not carry a significant mortality risk, the surviving women who were depressed at the time of re-assessment exhibited a mortality risk that was as significant as that for men. Such information may provide a useful back-drop for future investigations.

Najman JM; Toloo G; Williams GM. Increasing socio-economic inequalities in drug-induced deaths in Australia: 1981-2002. Drug and Alcohol Review 27(6): 613-618, 2008. (28 refs.)

Introduction and Aims. Since the 1990s illicit drug use death rates in Australia have increased markedly. There is a notable gap in knowledge about changing socio-economic inequalities in drug use death rates. Some limited Australian and overseas data point to higher rates of drug death in the lowest socio-economic groups, but the paucity of available studies and their sometimes conflicting findings need to be addressed. Design and Methods. This paper uses data obtained from the Australian Bureau of Statistics (ABS) to examine changes in age-standardised drug-induced mortality rates for Australian males over the period 1981-2002. Socio-economic status was categorised as manual or non-manual work status. Results. With the rapid increase in drug-induced mortality rates in the 1990s, there was a parallel increase in socio-economic inequalities in drug-induced deaths. The decline in drug death rates from 2000 onwards was associated with a decline in socio-economic inequalities. By 2002, manual workers had drug death rates well over twice the rate of non-manual workers. Discussion. Three factors are identified which contribute to these socio-economic inequalities in mortality. First, there has been an age shift in deaths evident only for manual workers. Secondly, there has been an increase in availability until 1999 and a relative decline in the cost of the drug, which most often leads to drug death (heroin). Thirdly, there has been a shift to amphetamine use which may lead to significant levels of morbidity, but few deaths.

Nakamae T; Shinozuka T; Sasaki C; Ogamo A; Murakami-Hashimoto C; Irie W et al. Case report: Etizolam and its major metabolites in two unnatural death cases. Forensic Science International 182(1-3): E1-E6, 2008. (18 refs.)

A simultaneous analytical method for etizolam and its main metabolites (alpha-hydroxyetizolam and 8-hydroxyetizolam) in whole blood was developed using solid-phase extraction, TMS derivatization and ion trap gas chromatography tandem mass spectrometry (GC-MS/MS). Separation of etizolam, TMS derivatives of alpha-hydroxyetizolam and 8-hydroxyetizolam and fludiazepam as internal standard was performed within about 17 min. The inter-day precision evaluated at the concentration of 50 ng/mL etizolam, alpha-hydroxyetizolam and 8-hydroxyetizolam was evaluated 8.6, 6.4 and 8.0% respectively. Linearity occurred over the range in 5-50 ng/mL. This method is satisfactory for clinical and forensic purposes. This method was applied to two unnatural death cases suspected to involve etizolam. Etizolam and its two metabolites were detected in these cases.

Newman RG. Attributing fatal cardiac effects to methadone: What's the evidence? (editorial). Journal of Addictive Diseases 27(4): 1-4, 2008. (22 refs.)

O'Donnell MP. A billion deaths from tobacco and cuts in tobacco prevention funding. (editorial). American Journal of Health Promotion 22(5): IV-IV, 2008

Ojanpera I; Gergov M; Liiv M; Riikoja A; Vuori E. An epidemic of fatal 3-methylfentanyl poisoning in Estonia. International Journal of Legal Medicine 122(5): 395-400, 2008. (35 refs.)

An exceptional epidemic of poisonings due to the highly potent opioid designer drug 3-methylfentanyl (TMF) was revealed among Estonian drug users in 2005-2006 by post-mortem forensic toxicology. Quantitative analysis of cis-TMF, trans-TMF, and fentanyl was performed by liquid chromatography-tandem mass spectrometry. Comprehensive toxicological analysis was performed using a multi-technique approach. The number of TMF-related fatal accidental poisonings identified was 46 and 71 for 2005 and 2006, respectively. The proportion of male victims was 91.5% and the mean age of all victims was 26 years at death. TMF was used predominantly by intravenous injection. There was no significant difference in the blood concentrations of cis-TMF and trans-TMF between pure TMF poisonings and mixed TMF poisonings. The mean combined concentration of TMF stereoisomers among pure TMF cases (1.9 mu g/l) was more than ten times lower than the mean fentanyl concentration in fentanyl-related fatalities. Concomitant use of other drugs involved alcohol, amphetamines, benzodiazepines, and cannabis, but very rarely other opioids.

Oliveira AF; Valente JG; Leite IC. Aspects of tobacco attributable mortality: systematic review. (review). Revista de Saude Publica 42(2): 335-345, 2008. (68 refs.)

The objective of the article was to assess methodologies published and applied in calculating mortality attributable to smoking. A review of the literature was made for the period 1990 to 2006, in the electronic databases MEDLINE and LILACS. A total of 186 studies were found, which measured mortality based on calculating the smoking-attributable risk. Of these, a total of 41 were selected. The studies that were carried out in the United States and Canada presented a more standard methodology and reported smoking attributable mortality to be 18%-23%, with male mortality being 25%-29% and female mortality 14%-17%. The variations can be attributed to methodological differences and to different estimates of the main tobacco-related illnesses.

Onyesom I; Naiho A. Increasing psychiatric morbidity and mortality rates among 'ozu' addicts in Ika Land, Nigeria. (letter). Substance Abuse 27(1/2): 5-7, 2007
Copyright 2007, Association for Medical Education & Research in Substance Abuse

O'Phelan K; McArthur DL; Chang CWJ; Green D; Hovda DA. The impact of substance abuse on mortality in patients with severe traumatic brain injury. Journal of Trauma, Injury, Infection and Critical Care 65(3): 674-677, 2008. (31 refs.)

Background. Drug and alcohol use are common in neurotrauma patients. Despite growing methamphetamine use there are few studies of the impact of methamphetamine use on outcome after traumatic brain injury (TBI). Methods: We conducted a retrospective review of 5-years of data from a trauma database. Inclusion criteria included severe TBI and diagnosis codes indicating head injury. The entire database was analyzed and then a subset of patients with complete toxicology data were examined separately. Primary outcome was mortality. Results. Four hundred eighty-three patients were included. Toxicology resuits were available for 52.6% of patients. Alcohol, amphetamines, and cannabis were the most commonly detected substances. Overall mortality was 50.9%. When the group with complete tox screen data were analyzed, a toxicology screen that was positive for alcohol or amphetamine was associated with decreased mortality with an odds ratio of 0.23 (CI: 0.10-0.56, p = 0.001) and 0.25 (CI: 0.08-0.79, p = 0.02), respectively. When the subset of patients for whom toxicology data were available was analyzed the amphetamine-positive group was more likely to use cannabis and less likely to use alcohol. Conclusions. We unexpectedly found alcohol and methamphetamine use to be associated with decreased mortality. Neurotoxic and possible neuroprotective mechanisms of these substances are discussed as well as possible interactions between cannabis and methamphetamine. The potential influence of psycho-social factors are also considered. Prospective studies are needed to further investigate the effects of drug and alcohol use on outcome after severe TBI.

Ottaviani G; Lavezzi AM; Matturri L. Sudden unexpected death in young athletes. American Journal of Forensic Medicine and Pathology 29(4): 337-339, 2008. (17 refs.)

A 13-year-old white boy died suddenly and unexpectedly while playing soccer. This case acquires a unique interest because of the coincidence of sudden unexpected death in a 13-year-old boy, anomalous origin of the left coronary artery from the right aortic sinus of Valsalva, anomalous location of the right coronary ostium within proper aortic sinus of Valsalva, hyperacute myocardial infarction, and myocardial fibrosis. The authors are convinced that the cardiovascular evaluation of young athletes needs to be focused on the identification of individuals at high risk of sudden cardiac arrest, paying attention to suggestive symptoms and to a family history of sudden death due to cardiac arrest, particularly at an early age. In addition, enquiry should be made into the concomitant presence of a smoking habit or of passive smoke exposure.

Ozasa K; Katanoda K; Tamakoshi A; Sato H; Tajima K; Suzuki T et al. Reduced life expectancy due to smoking in large-scale cohort studies in Japan. Journal of Epidemiology 18(3): 111-118, 2008. (20 refs.)

Background: To show the reduction in life expectancy due to smoking and the recovery of normal life expectancy by smoking cessation is useful for tobacco control health policy. Methods: This study included 140,026 males and 156,810 females aged 40-79 years, who were participants of large-scale cohort studies in Japan (Japan Health Center-based Prospective Study [JPHC]-I, JPHC-II, Three-Prefecture Study, and Japan Collaborative Cohort [JACC] Study), which commenced around 1990. The mean follow-up period (standard deviation) was 9.6 +/- 2.3 years, during which 16,282 men and 9,418 women died. For persons aged 40-79 years grouped according to each defined smoking status in the baseline questionnaire, sex- and age-specific death rates at attained ages were calculated. The age-specific death rate was calculated by dividing the number of persons who died at the age by the number of persons who were followed-up at the attained age. From these death rates, current life tables were constructed according to the smoking status, and survival curves were plotted. Results: The life expectancy of male smokers, ex-smokers, and never-smokers at age 40 years was 38.5, 40.8, and 42.4 years respectively. In women, the corresponding life expectancies were 42.4, 42.1, and 46.1 years. In both sexes, the age by which half of the current smokers had died was approximately 4 years younger than that for never-smokers. The life expectancies of male ex-smokers who quit smoking before ages 40, 50, 60, and 70 years were 4.8, 3.7, 1.6, and 0.5 years longer than those of smokers, respectively. Conclusion: Smoking considerably reduced the life expectancy, and earlier smoking cessation resulted in a better survival than that seen with continued smoking.

Pampalon R; Hamel D; Gamache P. Recent changes in the geography of social disparities in premature mortality in Quebec. Social Science & Medicine 67(8): 1269-1281, 2008. (67 refs.)

Most recent research reveals that social inequalities in premature mortality are widening. Such findings mainly apply to countries as a whole. In this study, we model recent changes in the association between premature mortality and a deprivation index (a small area-based index) in four geographic settings in Quebec, namely the Montreal metropolitan area, other Quebec metropolitan areas, mid-size cities, and small towns and rural areas. Deaths from all-cause and specific causes of mortality among people under age 75 are considered for the periods 1989-1993 and 1999-2003. Mortality rates are modeled using negative binomial regressions. Models are fitted for the overall population and for men and women, separately, in every geographic setting. Three measures of inequalities are used: mortality rates for different population groups, rate ratios and rate differences. Results show that social inequalities in premature mortality increase everywhere in Quebec except in the Montreal metropolitan area. Presently, the highest mortality rates among deprived groups are found in mid-size cities, small towns and rural areas; the highest rate ratios in the Montreal metropolitan area and other metropolitan areas of Quebec; and the highest rate differences in the Montreal metropolitan area, other metropolitan areas of Quebec and mid-size cities. These results are discussed with reference to possible explanatory factors, namely relative deprivation, smoking, immigration and internal migration. Indications on future research and policy implications are provided.

Paulozzi LJ; Cox CS; Williams DD; Nolte KB. John and Jane Doe: The epidemiology of unidentified decedents. Journal of Forensic Sciences 53(4): 922-927, 2008. (25 refs.)

The number of people who cannot be identified at the time of death, sometimes referred to as John or Jane Does, is unknown, and little is known about them as a group. The study's objectives were to estimate the number of annual unidentified deaths, to identify demographic characteristics associated with dying unidentified, to determine whether the rates of such deaths vary geographically or over time, and to better characterize the causes of death. This was a population-based surveillance study of data collected from death certificates from 1979 to 2004 in the U.S. Subjects were selected by the absence of name, date of birth, and Social Security Number on their certificates. Main outcome measures were distributions by age, sex, and underlying cause of death and rates by sex, race, year, and state of death. An average of 413 unidentified persons died each year. The peak year was 1987 with 691 deaths, a rate of 28.5 per 10 million people. The rate declined to 9.7 per 10 million in 2004. Most unidentified decedents were male (80.6%). Unidentified death rates were highest among black people and in the Southwest. Among deaths for which the cause was known, 82.7% were due to injuries. Among injury deaths, 31.8% were homicides. Improvement in identification technology may have reduced rates of unidentified death since the 1980s. In addition, variations in rates of unidentified decedents may reflect changes in risk factors such as homelessness and substance abuse.

Paulozzi LJ; Xi YL. Recent changes in drug poisoning mortality in the United States by urban-rural status and by drug type. Pharmacoepidemiology and Drug Safety 17(10): 997-1005, 2008. (40 refs.)

Purpose: This study was conducted to determine how the recently reported increase in drug poisoning mortality rates in the United States varied by degree of urbanization. Although drug poisoning is traditionally seen as an urban problem, evidence suggested that at least one component of the recent increase, deaths involving opioid analgesics, was increasing more rapidly in rural areas. Methods: The study compared age-adjusted unintentional and undetermined drug poisoning mortality rates between 1999 and 2004 from the National Vital Statistics System (NVSS) in each of six urban-rural categories. Results: Unintentional and undetermined drug poisoning mortality rates rose 62% from 1999 to 2004. Metropolitan county rates rose 51 %, an increase of 2.66/100 000, while nonmetropolitan county rates rose 159%, an increase of 4.81/100 000. By 2004, metropolitan and nonmetropolitan drug poisoning rates had roughly equalized. In the narcotic drug category, which included heroin, cocaine, and opioid analgesics, the most urban ("large central metro") counties increased only 16% while the most rural ("noncore, nonmetropolitan") counties increased 248%. Heroin rates did not increase significantly for any urban-rural category. Cocaine rate increases were largest in nonmetropolitan counties. Opioid analgesic rate increases ranged from a low of 52% in large central metro counties to an increase of 371% in nonmetropolitan, noncore counties. Conclusions: Prescription drugs have replaced heroin and cocaine as the leading drugs involved in fatal drug overdoses in all urban-rural categories. Fatal drug overdoses are no longer a predominantly urban phenomenon. National prevention efforts will have to shift to address nontraditional populations using nontraditional drugs.

Ponce JD; Andreuccetti G; Jesus MDD; Leyton V; Munoz DR. Alcohol in suicide victims in Sao Paulo. [Portuguese]. Revista de Psiquiatria Clinica 35(Supplement 1): 13-16, 2008. (20 refs.)

Background: A tendency toward violent and impulsive behavior is enhanced following the consumption of alcohol and is important in determining the etiology of deaths by external causes. In this context suicide appears to result from an attitude brought about by alcohol consumption or an expression of that same pathology which leads to substance abuse. Objectives: Considering the inexistence nationwide of data on suicides occurring under the influence of alcohol, the aim of the present study was to analyze the prevalence of alcohol consumption prior to suicide. Methods: Direct analysis of 632 medical examiner's reports on suicide victims autopsied at the Examiner's Office (Instituto Medico-Legal) of the State of Sao Paulo, in the year 2005. Results: Of the 632 cases reviewed, 33,1% presented a positive Blood Alcohol Concentration (BAC), with a higher occurrence in the case of men (37,1%) than that of women (20,156). Hangings presented the highest prevalence of intoxicated victims, at a rate of 38,9% of the cases; intoxications presented the highest BAC mean, at 1,78 g/L. Conclusions: The results demonstrate that roughly speaking, about one third of the suicides in our sample carried out by differing methods were subsequent to alcohol consumption.

Rajab R; Stearns E; Baithun S. Autopsy pathology of cocaine users from the Eastern district of London: A retrospective cohort study. Journal of Clinical Pathology 61(7): 848-850, 2008. (19 refs.)

Aim: To establish the most frequent pathological findings encountered at postmortem examination during the investigation of a fatality with a history of cocaine abuse. Methods: Autopsied deaths investigated by the coroner for the Eastern district of London, between 2004 and 2007, in which the decedent had positive toxicology for cocaine were identified (n = 28). The autopsy records and histology of tissue taken at autopsy were retrieved and reviewed. Pathological findings (gross and microscopic, including cardiac, pulmonary, gastrointestinal, hepatobiliary, renal and neurological) were collated. Results: The main pathological findings at autopsy occurring in this cohort (comprising predominantly men, mean age 31 years), were cardiovascular: left ventricular hypertrophy (46%), multifocal myocardial fibrosis (21%), coronary artery disease (29%), cerebrovascular disease (36%) and pulmonary oedema (71%). Hepatic steatosis (29%) and gastrointestinal haemorrhage (18%), due mostly to gastric erosions/ulceration, were also frequent findings. Conclusions: During a coroner's autopsy of a cocaine user, a thorough cardiac examination combined with cardiac tissue sampling for histology, are valuable investigations, which are most likely to help show pathology relevant to the cause of death.

Ranney DN; Acker WB; Al-Holou SN; Ehrlichman L; Lee DS; Lewin SA et al. Marijuana Use in Potential Liver Transplant Candidates. American Journal of Transplantation 9(2): 280-285, 2009. (36 refs.)

Concern exists that liver transplant center substance abuse policies may have an inappropriate and disproportionate impact on marijuana users. Our hypothesis is that patients with chronic liver disease who were marijuana users will have inferior survival. This is a retrospective (1999-2007) cohort study. The primary outcome measure is time-dependent, adjusted patient survival from the time of liver transplant evaluation. The primary exposure variable is a positive cannabinoid toxicology screen during the liver transplant evaluation period. Overall, 155 patients qualified as marijuana users while 1334 patients were marijuana non-users. Marijuana users were significantly (p < 0.05) younger (48.3 vs. 52.1), more likely to be male (78.1% vs. 63.0%), have hepatitis C (63.9% vs. 40.6%) and were less likely to receive a transplant (21.8% vs. 14.8%). Marijuana users were more likely to use tobacco, narcotics, benzodiazepines, amphetamines, cocaine or barbiturates (p < 0.05). Unadjusted survival rates were similar between cohorts. Upon multivariate analysis, MELD score, hepatitis C and transplantation were significantly associated with survival, while marijuana use was not (HR 1.09, 95% CI 0.78-1.54). We conclude that patients who did and did not use marijuana had similar survival rates. Current substance abuse policies do not seen to systematically expose marijuana users to additional risk of mortality.

Razvodovsky YE. All-cause mortality and fatal alcohol poisoning in Belarus, 1970-2005. Drug and Alcohol Review 27(5): 562-565, 2008. (16 refs.)

Introduction and Aims. Although alcohol appears to be an important contributor to the burden of disease in the countries of eastern Europe, little systematic research has been undertaken on its impact on mortality in the former Soviet republic of Belarus. There may be a number of factors underlying the particularly negative effect of alcohol on mortality in Belarus, including the pattern of drinking and use of surrogates. A solid body of research and empirical evidence suggests that hazardous patterns of alcohol consumption (binge drinking) lead to quicker and deeper intoxication, increasing the propensity for alcohol-related mortality. Design and Method. To estimate the aggregate level effect of binge drinking on the all-cause mortality rate, trends in the all-cause mortality and fatal alcohol poisoning rates (as a proxy for binge drinking) in Belarus from 1970 to 2005 were analysed employing AutoRegressive Integrated Moving Average (ARIMA) time-series analysis in order to assess a bivariate relationship between the two time-series. Results. The results of time-series analysis suggest a close relationship between all-cause mortality and fatal alcohol poisoning rates at the population level. Conclusions. This study supports the hypothesis that alcohol and all-cause mortality are connected closely in countries where the drinking culture is characterised by heavy drinking episodes and adds to the growing body of evidence that a substantial proportion of total mortality in Belarus is due to acute effects of binge drinking.

Redmond G; Spooner C. Alcohol and other drug related deaths among young people in CIS countries: Proximal and distal causes and implications for policy. International Journal of Drug Policy 20(1): 38-47, 2009. (51 refs.)

Background: Although the mortality crisis that followed the break-up of the Soviet Union in 1992 has been well researched, most attention has been paid to mortality among middle-aged men. There has been relatively little analysis of death rates among young people, many of which appear related to alcohol and other drug (AOD) use. Death rates ranged from exceedingly high in some countries (c.g. Russia) to very low in others (e.g. Armenia). This divergence among Commonwealth of Independent States (CIS) countries increased considerably over the 1990s. What caused this divergence in youth deaths and what policy response is needed? Method: An ecological study of country-level data was used to explore the relationships between risk factors, AOD use and youth deaths across time and between countries. Qualitative research literature was used to supplement the statistical data. Results: ACID abuse risk factors were divided into 'proximal causes' (e.g. AOD availability) and 'distal causes' (e.g. social cohesion, welfare, culture). Proximal risk factors appeared to explain some of the AOD use and death data, but they did not explain all of the country differences. Analysis of distal risk factors suggested that family and community strength are important factors in the trends in ACID abuse and youth mortality. Conclusions: The policy response to AOD abuse and mortality among young people needs to attend to both proximal and distal factors. An exclusive focus on proximal risk factors is unlikely to provide a satisfactory solution. Rather, the social determinants of child and Youth development need to be considered. More research is needed on the relationship between ACID abuse and youth mortality, and on the influence of family and community strength on both these outcomes in the region. Useful lessons may be learned from countries such as Armenia, where both AOD abuse and youth mortality have remained low.

Roosaar A; Johansson ALV; Sandborgh-Englund G; Axell T; Nyren O. Cancer and mortality among users and nonusers of snus. International Journal of Cancer 123(1): 168-173, 2008. (46 refs.)

Scandinavian moist snuff (snus) is claimed to be a safer alternative to smoking. We aimed to quantify cancer incidence among male snus users and to shed light on the net health outcome by studying their overall mortality. A cohort, comprised of 9,976 men who participated in a population-based survey, was compiled in 1973-74. Follow-up until January 31, 2002, was accomplished through record-linkages with nation-wide and essentially complete registers of demographics, cancer and causes of deaths. Adjusted relative risks among exposed relative to unexposed men were estimated using Cox proportional hazards regression. The cohort members contributed more than 220,000 person-years at risk for cancer. A statistically significant increase in the incidence of the combined category of oral and pharyngeal cancer among daily users of snus (incidence rate ratio 3.1, 95% confidence interval 1.5-6.6) was found. Overall mortality was also slightly increased (hazard ratio 1.10, 95% confidence interval 1.01-1.21). Although the combined previous literature on snus and oral cancer weigh toward no association, this population-based prospective study provided suggestive evidence of snus-related risks that cannot be lightly ignored.

Sarna L; Bialous SA; Jun HJ; Wewers ME; Cooley ME; Feskanich D. Smoking trends in the Nurses' Health Study (1976-2003). Nursing Research 57(6): 374-382, 2008. (49 refs.)

Background: Smoking trends among nurses are important to monitor as smoking negatively affects their health and decreases their likelihood of providing cessation interventions to patients. Objectives: The objective of the study was to describe the changes in smoking trends in the participants in the Nurses' Health Study (NHS) cohorts over 27 years. Methods: An analysis of biennial changes in smoking status and cigarette consumption within nine 5-year birth cohorts (1920-1924 to 1960-1964) and age-specific mortality rates by smoking status were examined in 237,648 female registered nurses (RNs): NHS (ages of 30-55 years in 1976, followed through 2002) and NHS II (ages of 25-42 years in 1989, followed through 2003). Results: Current smokers constituted 33.2% of NHS in 1976 and 13.5% of NHS II in 1989. Smoking rates declined in all birth cohorts; 8.4% were smoking in 2002/2003. Seventynine percent of nurses who ever smoked had quit. The mean cigarettes per day declined over time but still exceeded half a pack per day (15.1 cigarettes) at the end of follow-up. The mortality rate among current smokers was higher than that of former smokers and was approximately twice that of never smokers in all age categories; those who smoked were more likely to have comorbid conditions. Discussion: This study provides the first report of smoking trends among RNs in the NHS. The decline in smoking rate among female nurses mirrors the decline in smoking rate among women in the United States over the past 25 years. Increased mortality and morbidity rates indicate the devastating cost of smoking to the profession and can provide support for the urgent need for further research to encourage continued smoking cessation efforts for nursing professionals.

Schumann H; Erickson T; Thompson TM; Zautcke JL; Denton JS. Fentanyl epidemic in Chicago, Illinois and surrounding Cook County. Clinical Toxicology 46(6): 501-506, 2008. (28 refs.)

Introduction. Epidemics related to illicit fentanyl abuse have been reported and the potential exists for a national epidemic associated with high mortality. This report describes emergency department visits for opioid toxicity and a recent outbreak of illicit fentanyl fatalities in Chicago, Illinois and surrounding Cook County. Methods. Retrospective chart review of opioid-related overdoses seen in our emergency department and a retrospective review of data from the Cook County Medical Examiner's Office Fentanyl Fatality Database from April 2005 through December 2006. Results. Our emergency department treated 43 patients with a total of 55 emergency department visits during this time. Paramedic transport was utilized for 83.6% of the emergency department visits and naloxone was administered during 80.4% of transports. Naloxone was administered during 47.3% of emergency department visits witwh total doses ranging from 0.4 mg to 12 mg. Eighty percent of cases were treated and discharged from the emergency department. During this same time frame, the Medical Examiner's office identified 342 fentanyl-related fatalities. In 2006, illicit fentanyl fatalities represented 6.9% of all Medical Examiner cases for that year. Approximately 80% of deaths occurred in Chicago. A peak in fentanyl-related deaths occurred in the spring of 2006 and again in the fall of 2006 while the number of emergency department visits peaked during May of 2006. Conclusion. Chicago and surrounding Cook County experienced an outbreak of 342 fentanyl-related deaths between April 2005 and December 2006. The experience demonstrated a clear need for an interdisciplinary approach to identifying, communicating, and managing an outbreak.

Shadnia S; Soltaninejad K; Heydari K; Sasanian G; Abdollahi M. Tramadol intoxication: a review of 114 cases. Human & Experimental Toxicology 27(3): 201-205, 2008. (28 refs.)

Tramadol as a centrally acting analgesic is extensively used in the management of moderate to severe pain. It slightly affects opioid receptors and inhibits the reuptake of norepinephrin and serotonin in the CNS. There are reports about toxicity and abuse of tramadol. The objective of the present study was to evaluate epidemiology of intentional tramadol intoxications. All poisoning cases that admitted to Loghman-Hakim Hospital Poison Center from April to May 2007 were studied. A total of 114 cases (82 men and 32 women) of intentional tramadol intoxications with the median age of 23.66 +/- 6.87 years (range 16-54 years) were identified. Other illicit drugs were found to be used in combination with tramadol in some of the cases, which among them benzodiazepines were the most common. Tramadol overdose has been one of the most frequent causes of drug poisoning in the country in the recent years, especially in male young adults with history of substance abuse and mental disorders. Nausea, vomiting, Central Nervous System (CNS) depression, tachycardia, and seizure are the most common findings in this kind of poisoning. Cardiopulmonary arrest was found as the cause of death in cases who had ingested more than 5000 mg tramadol.

Sharifzadeh GR; Namakin K; Mehrjoofard H. An epidemiological study on infant mortality and factors affecting it in rural areas of Birjand, Iran. Iranian Journal of Pediatrics 18(4): 335-342, 2008. (20 refs.)

Objective: Infant mortality rate is one of the most expressive indicators of development in all countries. The aim of this study was to determine the cause of infant mortality and risk factors in rural areas of Birjand in Iran. Methods: This population based case-control study covered 156 infants who died when aged less than one-year in health houses of Birjand between January 2004 and December 2005. For each case, two controls were selected matching one-to-one to the case considering variables of residency and their date of birth. The data was collected through interview with mothers and reviewing infants' files in health houses. Findings: 57.7 percent of deaths in under one year old infants happened during the first month of their lives. The most important causes of death in neonates were prematurity and low birth weight (44.4%) later gastroenteritis (30.3%). In addition, the study showed that 9.6 percent of infants had died because of narcotic toxicosis. Moreover, the study showed a significant relationship between infant mortality and parents' level of education, mother's addiction, age of mother in the first pregnancy, prematurity, low birth weight, type of delivery and exclusive breast feeding. Conclusion: Special attention to infantile period and special care for infants born to at-risk mothers, as well as providing special health education can cause a dramatic reduction in infants' mortality rate.

Sheron N; Olsen N; Gilmore I. An evidence-based alcohol policy. Gut 57(10): 1341-1344, 2008. (30 refs.)

In the last 30 years of the 20th century deaths from liver cirrhosis steadily increased, in people aged 35 to 44 years the death rate went up 8-fold in men and almost 7-fold in women, in 25�34 year-olds a 4-fold increase was seen over the 30 year period. The UK situation is in stark contrast to the decrease in liver mortality in Mediterranean countries over the same period of time. So why is the UK facing this increase in liver deaths when mortality elsewhere is falling? According to death certification data more than 80% of UK liver deaths are due to alcohol-related cirrhosis. Other causes of liver disease are also increasing; for example, steatosis and viral hepatitis, but only 205 out of 6889 reported liver deaths in 2005 were due to viral hepatitis.2 While viruses and, more importantly, steatosis secondary to obesity may be co-factors in some cases, the evidence suggests that it is our drinking habits that are the problem. Alcoholic drinks have also increased in strength, 5% alcohol by volume (bv) lager has largely replaced 3.5% bv beer, a 40% increase. Similarly, most wine sold at supermarkets is no longer 10�12% but 14�15% bv, the point at which duty increases to the next threshold. Promotion includes �250 million spent on direct alcohol advertising and a greater sum spent on other forms of marketing, much of it directed towards young people. These marketing techniques include the sale of alcohol in larger measures, a large pub measure of wine contains around 3.5 units, an increase of 350%. Similarly, spirits measures in many pubs have gone up from 25 to 35 cl, a 40% increase. Finally, the retail outlets have changed markedly. Pubs, particularly in city centres, have become standing-only (vertical drinking) establishments with extended hours, and off-sales outlets have become dominated by supermarkets, whose purchasing power encourages heavy discounting and loss-leaders. Traditional pubs and independent wine and spirit merchants have struggled against this competition.

Soyka M. Alcohol and the risk of overdose death from heroin. (editorial). Addiction 103(7): 1064-1065, 2008. (7 refs.)

Stevens G; Dias RH; Thomas KJA; Rivera JA; Carvalho N; Barquera S et al. Characterizing the epidemiological transition in Mexico: National and subnational burden of diseases, injuries, and risk factors. PLoS MEDICINE 5(6): 900-910, 2008. (52 refs.)

Background: Rates of diseases and injuries and the effects of their risk factors can have substantial subnational heterogeneity, especially in middle-income countries like Mexico. Subnational analysis of the burden of diseases, injuries, and risk factors can improve characterization of the epidemiological transition and identify policy priorities. Methods and Findings We estimated deaths and loss of healthy life years ( measured in disability-adjusted life years [DALYs]) in 2004 from a comprehensive list of diseases and injuries, and 16 major risk factors, by sex and age for Mexico and its states. Data sources included the vital statistics, national censuses, health examination surveys, and published epidemiological studies. Mortality statistics were adjusted for underreporting, misreporting of age at death, and for misclassification and incomparability of cause-of-death assignment. Nationally, noncommunicable diseases caused 75% of total deaths and 68% of total DALYs, with another 14% of deaths and 18% of DALYs caused by undernutrition and communicable, maternal, and perinatal diseases. The leading causes of death were ischemic heart disease, diabetes mellitus, cerebrovascular disease, liver cirrhosis, and road traffic injuries. High body mass index, high blood glucose, and alcohol use were the leading risk factors for disease burden, causing 5.1%, 5.0%, and 7.3% of total burden of disease, respectively. Mexico City had the lowest mortality rates (4.2 per 1,000) and the Southern region the highest (5.0 per 1,000); under-five mortality in the Southern region was nearly twice that of Mexico City. In the Southern region undernutrition and communicable, maternal, and perinatal diseases caused 23% of DALYs; in Chiapas, they caused 29% of DALYs. At the same time, the absolute rates of noncommunicable disease and injury burdens were highest in the Southern region (105 DALYs per 1,000 population versus 97 nationally for noncommunicable diseases; 22 versus 19 for injuries). Conclusions Mexico is at an advanced stage in the epidemiologic transition, with the majority of the disease and injury burden from noncommunicable diseases. A unique characteristic of the epidemiological transition in Mexico is that overweight and obesity, high blood glucose, and alcohol use are responsible for larger burden of disease than other noncommunicable disease risks such as tobacco smoking. The Southern region is least advanced in the epidemiological transition and suffers from the largest burden of ill health in all disease and injury groups.

Stoove MA; Dietze PM; Aitken CK; Jolley D. Mortality among injecting drug users in Melbourne: A 16-year follow-up of the Victorian Injecting Cohort Study (VICS). Drug and Alcohol Dependence 96(3): 281-285, 2008. (23 refs.)

Multiple factors affect injecting drug-related mortality, many of which will vary over time and between jurisdictions. There are relatively few studies of mortality among injecting drug users (IDU) in Australia. We aimed to provide data comparable to those reported internationally on the rate of mortality among IDU in Australia. We retrospectively examined mortality among participants (N=220) from the first Australian cohort study of IDU by linking coded personal identifier records with a national death register. The overall mortality rate among those followed-up was 0.83 per 100 PY (95% CI, 0.56-1.21 per 100 PY). This rate is lower than those reported internationally but comparable to the limited Australian data from other cohorts of IDU. Mortality was higher among males, most common among those aged in their early thirties and drug-related mortality occurred typically after substantial injecting careers. Extensive experience of incarceration (>= 3 times) was associated with increased risk of mortality. These results suggest that rates of mortality among Australian IDU may be lower than those reported internationally, with low HIV prevalence and Australia's long-held harm reduction framework potentially contributing to this result. Further studies using defined cohorts followed over time are needed to examine long-term outcomes among IDU in Australia.

Strandberg-Larsen K; Tinggaard M; Andersen AMN; Olsen J; Gronbaek M. Use of nicotine replacement therapy during pregnancy and stillbirth: A cohort study. BJOG: An International Journal of Obstetrics and Gynaecology 115(11): 1405-1410, 2008. (21 refs.)

Objective: The objective of this study was to examine whether the use of nicotine replacement therapy (NRT) during pregnancy increases the risk of stillbirth. Design Cohort study with prospective data. Setting: Denmark 1996-2002. Population A total of 87 032 singleton pregnancies enrolled in the Danish National Birth Cohort for which information on NRT use as well as smoking was available. Methods: Outcome of pregnancy was identified by register linkage, with < 1% loss to follow up. We conducted Cox regression analyses to estimate the hazard ratio (HR) and 95% CI of stillbirth according to the use of NRT, type of NRT use and a combination of NRT use and smoking. Main outcome measures Stillbirth, defined as delivery of a dead fetus after 20 completed weeks of gestation. Results A total of 495 pregnancies (5.7 in 1000 births) ended in stillbirth, 8 of which were among NRT users (4.2 in 1000 births). After adjustment for confounders, women who used NRT during pregnancy had a HR of 0.57 (95% CI 0.28-1.16) for stillbirth compared with those who did not use NRT. Smoking during pregnancy was associated with an increased risk of stillbirth (HR 1.46, 95% CI 1.17-1.82), while women who both smoked and used NRT had a HR of 0.83 (95% CI 0.34-2.00) compared with nonsmoking women who did not use NRT. Conclusion: Our study does not indicate that use of NRT during pregnancy increases the risk of stillbirth.

Strang J; Manning V; Mayet S; Best D; Titherington E; Santana L et al. Overdose training and take-home naloxone for opiate users: Prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses. Addiction 103(10): 1648-1657, 2008. (48 refs.)

Aim: To examine the impact of training in overdose management and naloxone provision on the knowledge and confidence of current opiate users; and to record subsequent management of overdoses that occur during a 3-month follow-up period. Design: Repeated-measures design to examine changes in knowledge and confidence immediately after overdose management training; retention of knowledge and confidence at 3 months; and prospective cohort study design to document actual interventions applied at post-training overdose situations. Method: A total of 239 opiate users in treatment completed a pre-training questionnaire on overdose management and naloxone administration and were re-assessed immediately post-training, at which point they were provided with the take-home emergency supply of naloxone. Three months later they were re-interviewed. Results: Significant improvements were seen in knowledge of risks of overdose, characteristics of overdose and appropriate actions to be taken; and in confidence in the administration of naloxone. A 78% follow-up rate was achieved (186 of 239) among whom knowledge of both the risks and physical/behavioural characteristics of overdose and also of recommended management actions was well retained. Eighteen overdoses (either experienced or witnessed) had occurred during the 3 months between the training and the follow-up. Naloxone was used on 12 occasions (a trained client's own supply on 10 occasions). One death occurred in one of the six overdoses where naloxone was not used. Where naloxone was used, all 12 resulted in successful reversal. Conclusions With overdose management training, opiate users can be trained to execute appropriate actions to assist the successful reversal of potentially fatal overdose. Wider provision may reduce drug-related deaths further. Future studies should examine whether public policy of wider overdose management training and naloxone provision could reduce the extent of opiate overdose fatalities, particularly at times of recognized increased risk.

Strasak AM; Kelleher CC; Klenk J; Brant LJ; Ruttmann E; Rapp K et al. Longitudinal change in serum gamma-glutamyltransferase and cardiovascular disease mortality: A prospective population-based study in 76,113 Austrian adults. Arteriosclerosis, Thrombosis, and Vascular Biology 28(10): 1857-1865, 2008. (45 refs.)

Objective: The purpose of this study was to investigate the association of longitudinal change in serum gamma-glutamyltransferase (GGT) with mortality from cardiovascular disease (CVD). Methods and Results: A population-based cohort of 76 113 Austrian men and women with 455 331 serial GGT measurements was prospectively followed-up for a median of 10.2 years after assessment of longitudinal GGT change during an average period of 6.9 years. Cox proportional hazards regression with time-varying covariates was used to evaluate GGT change as an independent predictor for CVD death. Independently of baseline GGT and other classical CVD risk factors, a pronounced increase in GGT (7-year change > 9.2 U/ L) was significantly associated with increased total CVD mortality in men (P = 0.005); the adjusted hazard ratio (95% confidence interval) in comparison to stable GGT (7-year change -0.7 to 1.3 U/L) was 1.40 (1.09 to 1.81). Similarly, total CVD risk was elevated for increasing GGT in women, although effects were less pronounced and statistically significant only in subanalyses regarding coronary heart disease. Age of participants significantly modified the relation between GGT change and CVD mortality, with markedly stronger associations to be observable for younger individuals. Conclusion -Our study is the first to demonstrate that a longitudinal increase in GGT, independently of baseline GGT and even within its normal range, significantly increases risk of fatal CVD.

Suadicani P; Hein HO; Gyntelberg F. Wine intake, ABO phenotype, and risk of ischemic heart disease and all-cause mortality: The Copenhagen Male Study-a 16-year follow-up. Alcohol 42(7): 575-582, 2008. (27 refs.)

The association of alcohol intake with ischemic heart disease (IHD) and all-cause mortality may depend on ABO phenotype. We tested this hypothesis in a 16-year follow-up of 3,022 Caucasian men aged 53-74 years without overt cardiovascular disease. Potential risk factors and confounders included were ABO phenotypes, alcohol intake (wine, beer, and spirits), tobacco smoking history, leisure-time, physical activity, social class, and age. During 16 years, 1985-1986 to end of 2001, 197 subjects (6.5%) died due to IHD, and 1,204 (39.8%) from all causes. Among non-O phenotypes (A, B, and AB) significantly fewer men who died due to IHD were wine consumers, 43.9% versus 55.7%, P < .01: with respect to all-cause mortality corresponding figures were 47.0% versus 60.1%, P < .001. No difference was found among men with phenotype O. Among men with phenotype A, compared to alcohol abstainers, in Cox analysis, the hazard ratio (HR) (95% confidence limit) for men drinking up to 8 beverages/wk was 0.5 (0.3-1.02), and among men consuming > 8 beverages/wk (the highest quintile) the HR was 0.3 (0.2-0.8). P < .01, Among men with phenotype O, the association of wine intake with IHD mortality was slightly and not significantly U-shaped. The difference in the predictive role of wine intake between phenotype O and phenotype A men was supported in a statistical test for interaction. A similar association was found for all-cause mortality. The results suggest that the effect of wine intake on IHD and all-cause mortality among middle-aged and elderly men may depend on ABO phenotypes.

Suchyta MR; Beck CJ; Key CW; Jephson A; Hopkins RO. Substance dependence and psychiatric disorders are related to outcomes in a mixed ICU population. Intensive Care Medicine 34(12): 2264-2267, 2008. (19 refs.)

Objective: Substance dependence disorders are common in hospitalized patients and are associated with poor recovery. We compared mortality and discharge disposition in critically ill patients with and without substance dependence and patients with and without psychiatric disorders. We also compared the prevalence of substance dependence and psychiatric disorders to population data. Methods: All medical records of shock trauma intensive care unit (ICU) patients (mixed medical and surgical) at LDS Hospital were reviewed for pre-critical illness alcohol dependence, drug dependence, and psychiatric disorders. Results: There were 742 critically ill patients of whom 54% were male, acute respiratory distress syndrome developed in 5.5% and hospital mortality was 21%. The mean acute physiology and chronic health evaluation II scores were 16.5 +/- 7.9, sequential organ failure assessment scores were 6.7 +/- 4.2, duration of mechanical ventilation was 5 +/- 6.2 days, ICU length of stay (LOS) was 7.3 +/- 10.1 days, hospital LOS was 12.3 +/- 12.9 days. Multivariable regression analyses found psychiatric disorders predicted higher hospital mortality (Odds ratio = 1.50), but was not statistically significant (p = 0.08); substance dependence predicted shorter hospital LOS (R-2 = 0.08, p = 0.01) after controlling for covariates. There was a higher prevalence of substance dependence compared to Utah (p < 0.001) and US population data (p < 0.001). The prevalence of psychiatric disorders was significantly lower in our patients compared to US population data (19 vs. 26%, p < 0.001). Our data suggest that substance dependence increases hospital LOS and that patients with drug or alcohol dependence are at higher risk for ICU admission compared to the general population.

Tait RJ; Ngo HTT; Hulse GK. Mortality in heroin users 3 years after naltrexone implant or methadone maintenance treatment. Journal of Substance Abuse Treatment 35(2): 116-124, 2008. (39 refs.)

Concerns that treatment for heroin dependence using naltrexone may increase suicide rates during treatment and fatal overdoses posttreatment have been expressed. There is also disquiet about mortality during induction onto methadone. We assessed mortality during specific periods following treatment with naltrexone implants or methadone. Data were assembled using the Western Australian Data Linkage System. The methadone cohort comprised all those who started methadone in Western Australia during 2001-2002: The naltrexone cohort comprised all Western Australian heroin-dependent persons who received their first implant in 2001-2002. There were 15 (2.7%) deaths in the methadone cohort (n = 553) and 6 (1.8%) deaths in the naltrexone cohort (n = 341). Mortality rates for the "initial 14-day period," "stable treatment," and "overall" were 94.47, 0.0, and 5.83 deaths/1,000 person-years for the methadone group. In the naltrexone group, the rates "during first treatment (0-6 months)," "post first treatment," and overall were 0.0, 4.21, and 3.76 deaths/1,000 person-years. The age-standardized mortality rate ratio for naltrexone compared to methadone was 0.645 (95% confidence interval = 0.123-1.17). Increased mortality during induction onto methadone was confirmed. Evidence relating naltrexone to either increased suicide or overdose was not found. Overall mortality rates for naltrexone implant were similar to those for methadone, but increased mortality during methadone induction was avoided.

Taylor B; Rehm J; Room R; Patra J; Bondy S. Determination of lifetime injury mortality risk in Canada in 2002 by drinking amount per occasion and number of occasions. American Journal of Epidemiology 168(10): 1119-1125, 2008. (43 refs.)

Injury is the leading cause of alcohol-attributable mortality in Canada. Risk is determined by amount consumed per occasion and accumulates across drinking episodes. The authors estimated alcohol-attributable injury mortality in Canada for 2002 by combining the absolute risk of injury unrelated to alcohol with relative risks that were specific to gender and consumption per occasion, while taking into account lifetime number of drinking occasions. The absolute risk increased as number of drinking occasions and number of drinks per occasion increased. The absolute risk remained relatively low at fewer than 2 drinking occasions per month, regardless of number of drinks. Absolute risk levels reached 1 in 1,000 at 5 or more drinks once per month for men and at 5-7 drinks once per month for women. The probability of mortality was 1 in 100 for all levels of consumption above 3 drinks 3 times per week for men and above 5 drinks 3 times per week for women. No safe level of consumption is recommended based on these results, although risk is much lower for consuming 3 standard drinks or less fewer than 3 times per week. Absolute risk reflects long-term effects of drinking patterns and is important for risk-communication and alcohol-control policy.

Thomas S; Winecker R; Pestaner JP. Unusual fentanyl patch administration. American Journal of Forensic Medicine and Pathology 29(2): 162-163, 2008. (12 refs.)

Fentanyl is an extremely potent narcotic analgesic that is becoming more popular as a drug of abuse. Because of. the unique way in which the drug is packaged and delivered, the potential for unusual methods of abuse exists. We report the first case of true fentanyl patch ingestion in the medical literature. Initially, though unusual, cases of fentanyl ingestion were thought to have been reported, but further investigation of the literature revealed that in other case reports the patches had been held in the mouth and chewed. Because no reports of swallowing the patch had been published, suicide was initially a strong consideration in this case; however, further investigation showed that the decedent and his brother enjoyed swallowing the patches for quick "highs." Cases such as these serve to remind medical examiners and law enforcement officials of the value of performing thorough death investigations by performing complete autopsies with toxicological testing and correlating with investigation information to form an opinion with regard to the cause and manner of death.

Thomson SJ; Westlake S; Rahman TM; Cowan ML; Majeed A; Maxwell JD et al. Chronic liver disease - An increasing problem: A study of hospital admission and mortality rates in England, 1979-2005, with particular reference to alcoholic liver disease. Alcohol and Alcoholism 43(4): 416-422, 2008. (29 refs.)

Aims: To determine time trends in hospital admissions for chronic liver disease in England between 1989/1990 and 2002/2003, mortality rates in England and Wales between 1979 and 2005, and the influence of alcohol-related disease on these trends. Methods: Hospital episode statistics for admissions in England were obtained from the Information Center for Health and Social Care and mortality data for England and Wales from the Office for National Statistics. Results: Hospital admission rates for chronic liver disease increased by 71% in males and 43% in females over the study period. This increase was largely due to alcoholic liver disease, admission rates for which more than doubled between 1989/1990 and 2002/2003. While there was a smaller rise for chronic viral hepatitis B and C, admission rates declined for hepatitis A, autoimmune hepatitis, and primary biliary cirrhosis. Mortality rates for chronic liver disease more than doubled between 1979 and 2005. Two thirds of these deaths were attributable to alcohol-related liver disease in 2005. The highest rate of alcoholic liver disease mortality was in the 45-64 age group, and the largest percentage increase between 1979 and 2005 occurred in the 25-34 age group. Conclusions: Hospital admissions and mortality in England from chronic liver disease are increasing. The underlying reasons are complex, but alcohol-induced liver disease makes a major contribution. There are clear social and health implications if the trend continues and addressing alcohol-related liver disease should be a public health priority.

Thun MJ; Hannan LM; Stefanek M. Risky business: Tools to improve risk communication in a doctor's office. (editorial). Journal of the National Cancer Institute 100(12): 830-U6, 2008. (22 refs.)

This is a comment on an article in the prior issue -- Woloshin S, Schwartz LM, Welch HG. The risk of death by age, sex, and smoking status in the United States: putting health risks in context. J Natl Cancer Inst (2008) 100(11):1�10 -- on the ability to graphically describe the risk associated with smoking at different ages and by gender, and what might be achieved by posting such material in the physician's office.

Thygesen LC; Johansen C; Keiding N; Giovannucci E; Gronbaek M. Effects of sample attrition in a longitudinal study of the association between alcohol intake and all-cause mortality. Addiction 103(7): 1149-1159, 2008. (45 refs.)

Background and aims Longitudinal studies show higher mortality among abstainers and heavy drinkers than among light and moderate alcohol consumers. The influence on this association of missing information on alcohol intake due to attrition (dropout) has not been examined previously. The aims of this study were to characterize participants who dropped out and to evaluate whether the missing information influenced the association between alcohol intake and all-cause mortality. Design and participants: Data on the 18 974 participants in the Copenhagen City Heart Study, with four measures of alcohol intake and other life-style factors during 28 years of follow-up, were linked with nation-wide registers on socio-economic covariates, mortality and disease incidence. Logistic regression was used to describe life-style and socio-economic determinants of attrition, and Poisson regression was used to evaluate how attrition affected the association between alcohol intake and mortality. The statistical methods used for dealing with missing values were complete case analysis, carry last observation forward, simple imputations, multiple imputation and weighting. Findings: Abstinence and high alcohol intake, current smoking, physical inactivity and high body mass index increased the odds of dropping out, whereas being married, more years of education, skilled occupation, high income and large residential area decreased the odds. Attrition was associated with increased mortality and incidence rates of heart disease, lung and upper digestive tract cancers and alcoholic liver diseases. Increased mortality among abstainers and heavy drinkers was observed with all methods used for handling missing data on alcohol intake. Conclusions: Attrition was non-random, and the observed association between alcohol intake and all-cause mortality did not differ by statistical method for handling missing data.

Valle V; Gosney H; Sinclair J. Qualitative analysis of coroners' data into the unnatural deaths of children and adolescents. Child Care, Health and Development 34(6): 721-731, 2008. (21 refs.)

Introduction: Unintentional injury and suicide are leading causes of death for adolescents, and reducing these is an important health priority. Coroners' records provide a valuable source of information on the events leading up to the death of an individual, and analysis of these records may help our understanding of the causal pathway, and elucidate potential areas for intervention. Method: All cases of unnatural death (poisoning, violence, unintentional injury) in young people aged 8-18 between 1996 and 2002 were identified from the death registers of one region in the UK. Data from Coroners' inquests were analysed to determine cause of death and involvement of professional agencies. A thematic analysis of the transcripts of statements presented at inquests aimed to identify areas of concern in the time immediately prior to death. Results: A total of 77 cases were identified of whom 16 (20.8%) died from alcohol/drug misuse, 20 (26%) by suicide or probable suicide and 41 (53.2%) by other injuries and poisoning. Thematic analysis highlighted: bullying, teenage sexualization and pregnancy, alcohol and substance misuse, reconstituted family difficulties and out of control behaviour as being significant factors on the causal pathway. Conclusion: This study based on comprehensive data from one region highlights some of the difficulties faced by young people as they negotiate how to deal with complex emotions and relationships. It also demonstrates how some parents and carers are uncertain about how to address their concerns. Finally, it shows how mortality among young people could potentially be markedly reduced if availability of alcohol and illicit and prescribed substances were reduced.

Vernacchio L; Kelly JP; Kaufman DW; Mitchell AA. Pseudoephedrine use among US Children, 1999-2006: Results From the Slone Survey. Pediatrics 122(6): 1299-1304, 2008. (13 refs.)

OBJECTIVE. Pseudoephedrine, a decongestant found in many cough-and-cold and allergy medications, has been associated with deaths and adverse events in young children; however, the absolute risks of pediatric pseudoephedrine use are difficult to assess because the number of children exposed on a population basis and typical patterns of use are unknown. In addition, use may be changing because of the Combat Methamphetamine Epidemic Act of 2005, which limited pseudoephedrine availability. We sought to describe the prevalence and patterns of pseudoephedrine use among US children and to assess any change since the 2005 law took effect. METHODS. We analyzed data on pseudoephedrine use among 4267 children who were aged 0 to 17 years and enrolled from 1999 to 2006 in the Slone Survey, a national random-digit-dial telephone survey of medication use in the US population. RESULTS. Overall, 214 children took pseudoephedrine in a given week. Use was highest for children who were younger than 2 years. Sixteen children (7.5% of users) took > 1 pseudoephedrine-containing product within the same week, including 6 children who were younger than 2 years. Of the pseudoephedrine products used, most were multiple-ingredient liquids (58.9%) and multiple-ingredient tablets (24.7%). Fifty-two children (25.0% of users) took pseudoephedrine for > 1 week, including 7 children who were younger than 2 years. Use in 2006 (2.9%) was significantly lower than in 1999-2005 (5.2%). CONCLUSIONS. Pseudoephedrine exposure, mostly in the form of multiple-ingredient products, is common among US children, especially children who are younger than 2 years, who are at the highest risk for toxicity and for whom safe dosing recommendations are lacking. Concerning patterns of use include taking > 1 pseudoephedrine-containing product concurrently and using pseudoephedrine for extended periods. Pediatric pseudoephedrine use seems to be declining since the institution of the 2005 Combat Methamphetamine Epidemic Act.

Vucinovic M; Roje D; Vucinovic Z; Capkun V; Bucat M; Banovic I. Maternal and neonatal effects of substance abuse during pregnancy: Our ten-year experience. Yonsei Medical Journal 49(5): 705-713, 2008. (37 refs.)

Purpose: The aim of the study was to assess perinatal outcome of pregnancy burdened with maternal addiction in comparison with an unselected population from a European transition country. Materials and Methods: Data on pregnancies complicated by illicit drug abuse (n = 85) managed during a 10-year period (1997-2007) at Split University Hospital were analyzed. Data on the type of drug, course of gestation and labor, and on perinatal outcome were considered. Data on all non-dependence pregnancies recorded during the study period were used as a control group. Results: During the study period, there were 85 dependence-complicated pregnancies (0.2%). Use of heroin alone during pregnancy was recorded in 51 women (50%), methadone alone in 6 (7%), and a combination of heroin and methadone in 9 (11%). Premature delivery was significantly more common in the group of pregnant addicts (21% vs. 6%); 49% of pregnant addicts were carriers of hepatitis C virus (HCV) and 14% of hepatitis B virus (HBV). Neonatal abstinence syndrome developed in 61 infants (7%) born to addicted mothers. There were 4 cases (4.6%) of early neonatal death; 7 neonates had 5-minute Apgar score <= 7 (8%); 29 neonates had low birth weight for age (33%); and 7 neonates had congenital anomalies (8%). The risk of various congenital anomalies was 3-fold in the group of children born to addicted mothers. Conclusion: Addiction pregnancies present a small but high-risk group according to perinatal outcome. Appropriate obstetric and neonatal care can reduce the rate of complications in these pregnancies and improve perinatal outcome.

Watterson J; Peaire A; Hinman J. Elevated morphine concentrations determined during infant death investigations: Artifacts of withdrawal of care. Journal of Forensic Sciences 53(4): 1001-1004, 2008. (21 refs.)

Three cases are reported of elevated postmortem blood morphine concentrations (189-3036 ng/mL) that were observed during the course of death investigations involving three children ranging in age from 1 week to 2 years, all of whom underwent withdrawal of life support. In all three cases, the presence of opiates in postmortem blood was indicated by immunoassay (ELISA) and quantitative confirmatory analysis of free morphine concentrations in postmortem blood was performed by solid-phase extraction followed by gas chromatography/mass spectrometry (GC/MS) in the selected ion monitoring mode. While the practice of withdrawing life support from terminally ill patients, with the accompanying administration of narcotics/analgesics has been reported in the medical literature, it has not been adequately described in the forensic literature. The implications of this practice on the forensic toxicological interpretation of morphine findings are discussed. To our knowledge, this is the first report of postmortem morphine concentrations arising directly from administration in conjunction with withdrawal of care in pediatric patients.

Woloshin S; Schwartz LM; Welch HG. The risk of death by age, sex, and smoking status in the United States: Putting health risks in context. Journal of the National Cancer Institute 100(12): 845-853, 2008. (19 refs.)

Background To make sense of the disease risks they face, people need basic facts about the magnitude of a particular risk and how one risk compares with other risks. Unfortunately, this fundamental information is not readily available to patients or physicians. We created simple one-page charts that present the 10-year chance of dying from various causes according to age, sex, and smoking status. Methods We used the National Center for Health Statistics Multiple Cause of Death Public Use File for 2004 and data from the 2004 US Census to calculate age- and sex-specific death rates for various causes of death. We then combined data on smoking prevalence (from the National Health Interview Survey) and the relative risks of death from various causes for smokers vs never smokers (from the American Cancer Society's Cancer Prevention Study-II) to determine age-, sex-, and smoking-specific death rates. Finally, we accumulated these risks for various starting ages in a series of 10-year life tables. The charts present the 10-year risks of dying from heart disease; stroke; lung, colon, breast, cervical, ovarian, and prostate cancer; pneumonia; influenza; AIDS; chronic obstructive pulmonary disease; accidents; and all causes. Results At all ages, the 10-year risk of death from all causes combined is higher for men than women. The effect of smoking on the chance of dying is similar to the effect of adding 5 to 10 years of age: for example, a 55-year-old man who smokes has about the same 10-year risk of death from all causes as a 65-year-old man who never smoked (ie, 178 vs 176 of 1000 men, respectively). For men who never smoked, heart disease death represents the single largest cause of death from age 50 on and the chance of dying from heart disease exceeds the chances of dying from lung, colon, and prostate cancers combined at every age. For men who currently smoke, the chance of dying from lung cancer is of the same order of magnitude as the chance dying from heart disease and after age 50 it is about 10 times greater than the chance of dying from prostate or colon cancer. For women who have never smoked, the magnitudes of the 10-year risks of death from breast cancer and heart disease are similar until age 60; from this age on, heart disease represents the single largest cause of death. For women who currently smoke, the chance of dying from heart disease or lung cancer exceeds the chance of dying from breast cancer from age 40 on (and does so by at least a factor of 5 after age 55). Conclusion The availability of simple charts with consistent data presentations of important causes of death may facilitate discussion about disease risk between physicians and their patients and help highlight the dangers of smoking.

Yang CH; Yang SY; Shen MH; Kuo HS. The changing epidemiology of prevalent diagnosed HIV infections in Taiwan, 1984-2005. International Journal of Drug Policy 19(4): 317-323, 2008. (20 refs.)

By the end of 2005, there were 10,158 reported cases of HIV infections in Taiwan, of them, 2,403 had developed full blown AIDS, and 1,333 had died. It represented an average annual increase of 15% in HIV diagnoses before 2003. The most common route of transmission is through men having sex with men followed by heterosexual contact, while infections through injecting drug use (IDUs) remained low. However, the number of newly reported HIV infections has been rising sharply since 2003, mainly among IDUs. The consequences of this HIV/IDU epidemic include a rapid increase in female HIV/AIDS patients and a decreased mean age of HIV/AIDS cases. Only 2% of patients in the IDU group have been diagnosed with AIDS, suggesting that most IDU cases are in the early stage of HIV infections. HIV/AIDS patients are provided with free medical care by the government in Taiwan, including anti-retroviral treatment. The case fatality rate of AIDS cases declined gradually from 64% in 1996 to 8.9% in 2005. Patients in the IDU group seek medical care less frequently than patients in the sexual contact group. Statistics show that 61.4% of patients in the IDU group did not seek HIV-related medical care, significantly higher compared to the sexual contact group. The Taiwanese government implemented a trial "Harm Reduction Programme," which involved a needle-syringe programme (NSP) and substitution treatment, in August 2005. After I year's pilot study, the HIV incidence in cities with NSP decreased from 13.9 to 13.3 per 100,000 persons compared to an incidence increase from 11.5 to 15.3 per 100,000 persons in cities without NSP. We scaled up the programme to cover the whole of Taiwan in July 2006 and are expecting to see the efficacy in the near future.

Zador D; Rome A; Hutchinson S; Hickman M; Baldacchino A; Fahey T et al. Differences between injectors and non-injectors, and a high prevalence of benzodiazepines among drug related deaths in Scotland 2003. Addiction Research & Theory 15(6): 651-662, 2007. (26 refs.)

Drug related deaths (DRDs) have been increasing in Scotland over at least the past decade. This study aimed to describe the characteristics ( gender, age, ICD10 cause of death), toxicology and circumstances of all Scotland's DRDs in 2003 to help inform a national overdose prevention strategy. Coronial files for 300/317 (95%) DRDs registered with the General Register Office for Scotland (GROS) in 2003 were examined retrospectively ( in 2004). Characteristics: 241/300 (80%) were male. Mean age at death was 32.8 years ( SE 0.63, range 16-82). Route of administration was injecting for 137/268 (51%) who were classifiable. Classified injectors were more likely to be male (91%: 124/137) and younger (mean age of 32 years) than those whose death was by a non-injecting route (male: 87/131 (66%) and mean age of 35 years). Twenty-five to forty-four year olds made up 108/137 DRDs by injecting (79%), but only 62/131 (47%) by non-injecting routes. Cases of intentional self-poisoning (injectors 1; non-injecting 34) and undetermined intent ( injectors 14; non-injecting 26) were infrequent among injectors. Of those who died by the injecting route, 108/137 were known intravenous drug users, but so too were 29/131 DRDs by non-injecting routes. Toxicology: overall 38/300 cases of DRD (13%) were negative for opioid drugs - only 2/137 DRDs by injecting (1%) were negative for opioids compared with 33/131 (25%) by non-injecting route. Methadone was present for 15/137 DRDs by injecting route (11%) and for 57/131 DRDs by non-injecting routes (44%, p < 0.001). Presence of dihydrocodeine, and anti-depressants was about three times and six times respectively, more likely in DRDs by non-injecting routes. Irrespective of route, two-thirds of DRDs tested positive for benzodiazepines (202/300 DRDs). Circumstances: time between overdose and death was within the hour for 61/137 DRDs (45%) by injecting, but rarely by non-injecting routes (3%: 4/131). Three out of four DRDs occurred in a house or flat: 98/137 DRDs (72%) by the injecting route and 101/131 (77%) by non-injecting routes. Interpretation: A relatively high proportion of cases died by non-injecting routes. National mortality databases should separate out cases of injecting-related DRD from non-injecting cases, and public health strategies to reduce DRDs should distinguish between these groups. Widespread availability in Scotland of prescribed and illicit benzodiazepines needs attention.

Zajdow G. Moral panics: the old and the new. Deviant Behavior 29(7): 640-664, 2008. (52 refs.)

The theory of moral panics has been prominent in the sociology of deviance since the 1970s. This article uses this theory to trace the rise of the moral panic around the high number of heroin overdose deaths in Australian in the mid to late 1990s. It argues, however, that much of the panic was generated by groups not traditionally associated with moral panics, but by political progressives in the field of illicit drugs as well as victims, parent groups, and those who work with illicit drug users. In this way it was not a conventional right-wing moral crusade, but it was no less a moral panic.