Alem Mehari

Mortality in adults with sickle cell disease and pulmonary hypertension

To the Editor: Dr Olshansky’s research letter on the accelerated aging of US presidents concluded that presidents do not age faster than other men. That may be true, but this study cannot demonstrate it due to a faulty comparison. Olshansky compared presidents’ actual age at death (adjusted for aging by subtracting 2 days for every day in office) against average life expectancy for men matched to the date of inauguration. However, the correct comparison is with men who have the same profile of risk factors for premature death. For example, as Olshansky notes, education, wealth, and access to medical care strongly influence life expectancy, and these factors undoubtedly contributed to longer lives for many presidents. The real question is if, despite these advantages, presidents’ lives were shortened. That requires comparison with other men of similar education, wealth, and access to medical care, and possibly with similar risk factors, such as smoking and alcohol consumption. Absent data permitting proper restriction, stratification, or control for confounding, the only conclusion that can be drawn is that presidents tend to be blessed with certain advantages that allow them to outlive men without those advantages.

Hemodynamic Predictors of Mortality in Adults with Sickle Cell Disease

BACKGROUND Pulmonary hypertension (PH) in adults with sickle cell disease (SCD) is associated with early mortality, but no prior studies have evaluated quantitative relationships of mortality to physiological measures of pre- and postcapillary PH. OBJECTIVES To identify risk factors associated with mortality and to estimate the expected survival in a cohort of patients with SCD with PH documented by right heart catheterization. METHODS Nine-year follow-up data (median, 4.7 yr) from the National Institutes of Health SCD PH screening study are reported. A total of 529 adults with SCD were screened by echocardiography between 2001 and 2010 with no exclusion criteria. Hemodynamic data were collected from 84 patients. PH was defined as mean pulmonary artery pressure (PAP) ≥ 25 mm Hg. Survival rates were estimated by the Kaplan-Meier method, and mortality risk factors were analyzed by the Cox proportional hazards regression. MEASUREMENTS AND MAIN RESULTS Specific hemodynamic variables were independently related to mortality: mean PAP (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.05-2.45 per 10 mm Hg increase; P = 0.027), diastolic PAP (HR, 1.83; 95% CI, 1.09-3.08 per 10 mm Hg increase; P = 0.022), diastolic PAP - pulmonary capillary wedge pressure (HR, 2.19; 95% CI, 1.23-3.89 per 10 mm Hg increase; P = 0.008), transpulmonary gradient (HR, 1.78; 95% CI, 1.14-2.79 per 10 mm Hg increase; P = 0.011), and pulmonary vascular resistance (HR, 1.44; 95% CI, 1.09-1.89 per Wood unit increase; P = 0.009) as risk factors for mortality. CONCLUSIONS Mortality in adults with SCD and PH is proportional to the physiological severity of precapillary PH, demonstrating its prognostic and clinical relevance despite anemia-induced high cardiac output and less severely elevated pulmonary vascular resistance.

Racial and geographic variation in coronary heart disease mortality trends

BackgroundMagnitudes, geographic and racial variation in trends in coronary heart disease (CHD) mortality within the US require updating for health services and health disparities research. Therefore the aim of this study is to present data on these trends through 2007.MethodsData for CHD were analyzed using the US mortality files for 1999–2007 obtained from the US Centers for Disease Control and Prevention. Age-adjusted annual death rates were computed for non-Hispanic African Americans (AA) and European Americans (EA) aged 35–84 years. The direct method was used to standardize rates by age, using the 2000 US standard population. Joinpoint regression models were used to evaluate trends, expressed as annual percent change (APC).ResultsFor both AA men and women the magnitude in CHD mortality is higher compared to EA men and women, respectively. Between 1999 and 2007 the rate declined both in AA and in EA of both sexes in every geographic division; however, relative declines varied. For example, among men, relative average annual declines ranged from 3.2% to 4.7% in AA and from 4.4% to 5.5% in EA among geographic divisions. In women, rates declined more in later years of the decade and in women over 54 years. In 2007, age-adjusted death rate per 100,000 for CHD ranged from 93 in EA women in New England to 345 in AA men in the East North Central division. In EA, areas near the Ohio and lower Mississippi Rivers had above average rates. Disparities in trends by urbanization level were also found. For AA in the East North Central division, the APC was similar in large central metro (−4.2), large fringe metro (−4.3), medium metro urbanization strata (−4.4), and small metro (−3.9). APC was somewhat higher in the micropolitan/non-metro (−5.3), and especially the non-core/non-metro (−6.5). For EA in the East South Central division, the APC was higher in large central metro (−5.3), large fringe metro (−4.3) and medium metro urbanization strata (−5.1) than in small metro (−3.8), micropolitan/non-metro (−4.0), and non-core/non-metro (−3.3) urbanization strata.ConclusionsBetween 1999 and 2007, the level and rate of decline in CHD mortality displayed persistent disparities. Declines were greater in EA than AA racial groups. Rates were greater in the Ohio and Mississippi River than other geographic regions.

Burden of musculoskeletal disorders in the Eastern Mediterranean Region, 1990-2013: findings from the Global Burden of Disease Study 2013.

Objectives We used findings from the Global Burden of Disease Study 2013 to report the burden of musculoskeletal disorders in the Eastern Mediterranean Region (EMR). Methods The burden of musculoskeletal disorders was calculated for the EMRs 22 countries between 1990 and 2013. A systematic analysis was performed on mortality and morbidity data to estimate prevalence, death, years of live lost, years lived with disability and disability-adjusted life years (DALYs). Results For musculoskeletal disorders, the crude DALYs rate per 100 000 increased from 1297.1 (95% uncertainty interval (UI) 924.3–1703.4) in 1990 to 1606.0 (95% UI 1141.2–2130.4) in 2013. During 1990–2013, the total DALYs of musculoskeletal disorders increased by 105.2% in the EMR compared with a 58.0% increase in the rest of the world. The burden of musculoskeletal disorders as a proportion of total DALYs increased from 2.4% (95% UI 1.7–3.0) in 1990 to 4.7% (95% UI 3.6–5.8) in 2013. The range of point prevalence (per 1000) among the EMR countries was 28.2–136.0 for low back pain, 27.3–49.7 for neck pain, 9.7–37.3 for osteoarthritis (OA), 0.6–2.2 for rheumatoid arthritis and 0.1–0.8 for gout. Low back pain and neck pain had the highest burden in EMR countries. Conclusions This study shows a high burden of musculoskeletal disorders, with a faster increase in EMR compared with the rest of the world. The reasons for this faster increase need to be explored. Our findings call for incorporating prevention and control programmes that should include improving health data, addressing risk factors, providing evidence-based care and community programmes to increase awareness.

Gender and the Association of Smoking with Sleep Quantity and Quality in American Adults

Smoking and gender are known risk factors for sleep disorders. Studies of samples from Norway and Japan have suggested stronger associations between smoking and disrupted sleep in women; therefore, we examined, gender differences in the association in the U.S. population. We analyzed data from the 2005–2006 National Health and Nutrition Examination Survey. We examined the associations between smoking and self-reported measures of sleep disorders (i.e., snoring, short sleep, long sleep, poor sleep, and health care provider diagnosis of sleep disordered breathing) using multivariate logistic regression with odds ratios (OR) and 95% confidence intervals (CI) as measures of association. We also assessed whether the associations varied by gender using a gender x smoking interaction term. Compared to never smokers, current smokers had significantly higher odds of self-reported snoring (OR = 2.0; 95% CI = 1.56–2.56), short sleep (OR 1.68; 95% CI = 1.35–2.10) and poor sleep (OR = 1.38; 95% CI = 1.09–1.74). A dose-response relationship was observed between the amount smoked and sleep symptoms. In multivariate analyses, no significant gender x smoking interaction was observed for snoring, short sleep or poor sleep. Current smoking was independently associated with increased odds of snoring, short sleep, and poor sleep in women and men among U.S. adults.

Trends in Pulmonary Hypertension Mortality and Morbidity

Context. Few reports have been published regarding surveillance data for pulmonary hypertension, a debilitating and often fatal condition. Aims. We report trends in pulmonary hypertension. Settings and Design. United States of America; vital statistics, hospital data. Methods and Material. We used mortality data from the National Vital Statistics System (NVSS) for 1999–2008 and hospital discharge data from the National Hospital Discharge Survey (NHDS) for 1999–2009. Statistical Analysis Used. We present age-standardized rates. Results. Since 1999, the numbers of deaths and hospitalizations as well as death rates and hospitalization rates for pulmonary hypertension have increased. In 1999 death rates were higher for men than for women; however, by 2002, no differences by gender remained because of the increasing death rates among women and the declining death rates among men; after 2003 death rates for women were higher than for men. Death rates throughout the reporting period 1999–2008 were higher for blacks than for whites. Hospitalization rates in women were 1.3–1.6 times higher than in men. Conclusions. Pulmonary hypertension mortality and hospitalization numbers and rates increased from 1999 to 2008.

Obesity and Pulmonary Function in African Americans

Background Obesity prevalence in United States (US) adults exceeds 30% with highest prevalence being among blacks. Obesity is known to have significant effects on respiratory function and obese patients commonly report respiratory complaints requiring pulmonary function tests (PFTs). However, there is no large study showing the relationship between body mass index (BMI) and PFTs in healthy African Americans (AA). Objective To determine the effect of BMI on PFTs in AA patients who did not have evidence of underlying diseases of the respiratory system. Methods We reviewed PFTs of 339 individuals sent for lung function testing who had normal spirometry and lung diffusion capacity for carbon monoxide (DLCO) with wide range of BMI. Results Functional residual capacity (FRC) and expiratory reserve volume (ERV) decreased exponentially with increasing BMI, such that morbid obesity resulted in patients breathing near their residual volume (RV). However, the effects on the extremes of lung volumes, at total lung capacity (TLC) and residual volume (RV) were modest. There was a significant linear inverse relationship between BMI and DLCO, but the group means values remained within the normal ranges even for morbidly obese patients. Conclusions We showed that BMI has significant effects on lung function in AA adults and the greatest effects were on FRC and ERV, which occurred at BMI values < 30 kg/m2. These physiological effects of weight gain should be considered when interpreting PFTs and their effects on respiratory symptoms even in the absence of disease and may also exaggerate existing lung diseases.

The Burden of Mental Disorders in the Eastern Mediterranean Region, 1990-2013.

The Eastern Mediterranean Region (EMR) is witnessing an increase in chronic disorders, including mental illness. With ongoing unrest, this is expected to rise. This is the first study to quantify the burden of mental disorders in the EMR. We used data from the Global Burden of Disease study (GBD) 2013. DALYs (disability-adjusted life years) allow assessment of both premature mortality (years of life lost–YLLs) and nonfatal outcomes (years lived with disability–YLDs). DALYs are computed by adding YLLs and YLDs for each age-sex-country group. In 2013, mental disorders contributed to 5.6% of the total disease burden in the EMR (1894 DALYS/100,000 population): 2519 DALYS/100,000 (2590/100,000 males, 2426/100,000 females) in high-income countries, 1884 DALYS/100,000 (1618/100,000 males, 2157/100,000 females) in middle-income countries, 1607 DALYS/100,000 (1500/100,000 males, 1717/100,000 females) in low-income countries. Females had a greater proportion of burden due to mental disorders than did males of equivalent ages, except for those under 15 years of age. The highest proportion of DALYs occurred in the 25–49 age group, with a peak in the 35–39 years age group (5344 DALYs/100,000). The burden of mental disorders in EMR increased from 1726 DALYs/100,000 in 1990 to 1912 DALYs/100,000 in 2013 (10.8% increase). Within the mental disorders group in EMR, depressive disorders accounted for most DALYs, followed by anxiety disorders. Among EMR countries, Palestine had the largest burden of mental disorders. Nearly all EMR countries had a higher mental disorder burden compared to the global level. Our findings call for EMR ministries of health to increase provision of mental health services and to address the stigma of mental illness. Moreover, our results showing the accelerating burden of mental health are alarming as the region is seeing an increased level of instability. Indeed, mental health problems, if not properly addressed, will lead to an increased burden of diseases in the region.

Elevated Transpulmonary Gradient and Cardiac Magnetic Resonance-Derived Right Ventricular Remodeling Predict Poor Outcomes in Sickle Cell Disease

Adults with sickle cell disease have a high prevalence of pulmonary hypertension. This picture is often complicated by concurrent left ventricular diastolic dysfunction and anemia-related changes in hemodynamics. The change in pressure across the pulmonary circulation reflected by the transpulmonary gradient is less clouded by anemia-related adaptations. We characterized the association of elevated transpulmonary gradient with right ventricular structure and function, exercise capacity and mortality. Data from 84 patients (age 41+/-13 years, 55% female [n=46], 82% hemoglobin SS [n=69]) with right heart catheterization from the Bethesda Sickle Cell Cohort were analyzed. Of the 84 patients, forty-one underwent cardiac magnetic resonance imaging within two days of right heart catheterization. Patients with a catheterization-derived transpulmonary gradient ≥12mmHg had more severe symptoms (p=0.013), shorter 6-minute walk distance (p=0.006), lower cardiac index (p<0.001), reduced right ventricular ejection fraction (p=0.002) and cardiac magnetic resonance imaging markers of adverse morphologic adaptation. An RVEF <32% derived from cardiac magnetic resonance predicted decreased survival (HR 3.70, 95% CI 1.04-13.12, p=0.030) and higher New York Heart Association classification (OR 9.29, p=0.018). In a multivariate model controlling for age and phenotype, transpulmonary gradient ≥12mmHg and right ventricular ejection fraction <32% were independently predictive of increased mortality (HR 5.47, 95% CI 1.13-26.42, p=0.035 and HR 5.11, 95% CI 1.13-23.13, p=0.034). Patients with sickle cell disease and elevated transpulmonary gradient have findings of maladaptive RV remodeling on cardiac magnetic resonance imaging. Elevated transpulmonary gradient and cardiac magnetic resonance-derived RV dysfunction independently predict higher mortality in sickle cell disease. Cardiac magnetic resonance may have a useful role in the clinical evaluation and non-invasive prognostication of adults with sickle cell disease and suspected pulmonary hypertension. This clinical trial was registered at clinicaltrials.gov identifier: [NCT00011648][1] NCT00081523, [NCT00023296][2], and [NCT00352430][3]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00011648&atom=%2Fhaematol%2Fearly%2F2015%2F11%2F13%2Fhaematol.2015.125229.atom [2]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00023296&atom=%2Fhaematol%2Fearly%2F2015%2F11%2F13%2Fhaematol.2015.125229.atom [3]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00352430&atom=%2Fhaematol%2Fearly%2F2015%2F11%2F13%2Fhaematol.2015.125229.atom

Trends in Hospitalization Associated with Alzheimer's Disease in the United States

This study compared the effectiveness of guided balance and strength training with that of self-administered training in institutionalized elderly adults. Residents with moderate to severe dementia could perform exercises in a five-person group under the supervision of one physiotherapist. As an outcome variable, falls occurring within the 3 years were evaluated. The results showed that, in institutionalized elderly adults, guided balance training can prevent falls. There was no difference between strength training and combined balance and strength training, which leads to the conclusion that rehabilitation with balance or strength training or both is useful but that other preventive measures should be included for institutionalized elderly adults to improve quality of life or prevent early death. In the present study, the residents were assessed for vertigo symptoms, gait problems, memory, and fear of falling. Whether any of these variables would be a significant risk factor for a fall in institutionalized elderly adults was also analyzed. Thus, influencing a single factor such as gait problems, postural instability, vertigo, or dizziness may not be enough to prevent accidental falls in institutionalized elderly people with several simultaneous health problems and taking medications.