BIRTHRATE IN THE PHILIPPINES
The Philippines, a
staunchly Catholic country, has the highest population
growth rate in the region despite being one of the first
to implement a population control policy in the 1970s.
The growth rate currently is 2.3% per year compared with
India, which is 1.9%; Indonesia, 1.5%; China, 1.3%; and
Thailand, 0.9% (2). All efforts at population control in
the Philippines have been thwarted by the influential
Catholic church. Last year the archbishop of Manila said
that condoms were “evil” and “fit only for
animals.” Also, family planning is usually available
only for 6-month periods and abortion is illegal. But the
number of abortions is increasing, and some politicians
have suggested making abortion punishable by death.
Population growth targets were not met by the previous
administration, and the current president, Joseph
Estrada—who has at least 11 children by 4 different
women—has yet to tackle the population issue despite
his electoral pledges to wipe out poverty. Of a
population of 74 million, 22 million Filipinos are
malnourished, including nearly 4 million children aged 1
to 5 years, and nearly 11,000 children die each year in
the Philippines from malnutrition. As pleasurable as it
is, sex can be devastating to some societies.
MALARIA AND TOBACCO AND
WHO'S RESPONSE
According to the 1999 World
Health Organization Report, about 1 million people in the
world die each year from malaria, most of them
sub-Saharan African children (3). And malaria may be a
cause, not just a consequence, of underdevelopment
because it hits hardest during times of planting and
harvesting. The report also calls for action on smoking,
proposing a worldwide ban on all tobacco advertising and
promotion, sustained tax increases on cigarettes, wider
access to tobacco substitutes, increased public health
information on smoking, and the establishment of
tobacco-controlled coalitions. As many as 1 in 2
long-term smokers die from their habit.
SMOKING AND HIP FRACTURE
Cornuz and colleagues (4) from
Boston, Massachusetts, studied 116,229 female nurses aged
34 to 59 years at baseline in 1980 and followed them for
12 years. Hip fracture was 30% more common among the
smokers than the nonsmokers, and the risk of hip fracture
increased with greater cigarette consumption. There was
no apparent benefit from quitting smoking until 10 years
after cessation. After 10 years, former smokers had a
reduced risk of hip fractures.
INJURIES AND DEATHS FROM
FALLS IN PERSONS AGED 50 YEARS OR OLDER
Fall-induced injuries and deaths
among older adults are major public health problems,
especially in developed societies that have aging
populations. About one third of persons >=65 years of
age living in the community and more than half of those
living in institutions fall every year, and about half of
those who fall do so repeatedly. Both the incidence of
falls and the severity of complications increase with
age. Not all falls of older persons, of course, are
injurious and life threatening, but about 5% of them
result in a fracture, and other serious injuries occur in
5% to 10% of falls. Injury is the fifth leading cause of
death in older adults, and most of these fatal injuries
are related to falls. In the USA, falls, occurring
primarily among older adults, were the second leading
cause of deaths due to unintentional injuries in 1994.
Kannus and colleagues (5)
obtained data on fall-induced injuries from the National
Hospital Discharge Register of Finland for all persons
aged >=50 years admitted to Finnish hospitals for
primary treatment of a first fall-induced injury or
death. For the 25-year period of 1970 to 1995, the number
of fall-induced injuries increased from 5622 in 1970 to
21,574 in 1995, a 284% increase, and the rate increased
from 494/100,000 persons to 1398/100,000, a 183%
increase. The increase occurred in both men and women.
Moreover, the number of deaths due to falls in the
overall population increased from 441 in 1971 to 793 in
1995, an 80% increase, and the rate increased from
38/100,000 in 1971 to 51/100,000 in 1995, a 34% increase.
Thus, in a well-defined white population, the number of
older persons with fall-induced injuries is increasing at
a rate that cannot be explained simply by aging changes.
More preventive measures need to be adopted to control
the increasing burden of these injuries.
GENETICS OF ALCOHOLISM
Schuckit (6) from San Diego,
California, reviewed recent research on the importance of
genetic influences on alcohol abuse and dependence. The
contribution of genetic influence to alcoholism is
supported by the 3- to 4-fold higher prevalence of
alcoholism in first-degree relatives of alcoholics, a
rate that increases another 2-fold in identical twins of
alcoholics. Studies reveal that the increased risk
remains strong for children of alcoholics adopted and
raised by nonalcoholics. The genetic influences appear to
be in large part separate from a generic predisposition
toward dependence on other drugs.
The intensity of response to
most drugs has genetic components. Many alcoholics, for
example, report an ability to consume large amounts of
alcohol with relatively little effect from early in their
drinking careers. Identical twins are more similar on
level of response than are fraternal twin pairs, and
level of response is also genetically influenced in
animals. A lower level of response (or a need for higher
levels of alcohol to produce an effect) is associated
with high levels of alcohol intake in some murine lines.
Relatively low intensities of reaction to alcohol have
been found in about 40% of the children of alcoholics
compared with <10% of controls. A low level of
response at age 20 years predicted alcoholism by age 35
years, thus explaining most of the relation between
family history and alcohol abuse and dependence. No
specific gene has been identified as responsible for this
relatively low intensity of response to alcohol. Thus,
our genes appear to play a role in maybe half of us in
determining whether or not we drink certain liquids and
how much of them we consume.
CESAREAN SECTION FOR
PREVENTION OF HIV IN INFANTS OF MOTHERS WITH HIV
Recently I learned that cesarean
sections are performed in approximately 70% of deliveries
in some private hospitals in Mexico. (In the USA it is
20%.) A major reason for the high frequency is that
insurance companies in Mexico pay the physicians for
performing a cesarean section but do not pay for a normal
vaginal delivery. I noted recent studies comparing
elective cesarean section delivery versus vaginal
delivery in preventing HIV in the newborn infant of
mothers with confirmed HIV infection (7, 8). Three (2%)
of 170 infants born to women assigned cesarean-section
delivery were infected compared with 21 (10%) of 200
infants born to women assigned to vaginal delivery. These
findings provide evidence that elective cesarean-section
delivery significantly lowers the risk of mother-to-child
transmission of HIV infection without significantly
increasing risk of complications for the mother.
POLICE SUICIDE
Suicide rates are most frequent
among dentists, physicians, entrepreneurs, and police
officers, in that order. Fields and Jones (9) reviewed
the suicide rate in the nation's 10 largest police
departments and found that suicide is among the most
serious problems facing law enforcement today. Most
police departments in the USA lose more officers to
suicide than to violence in the course of their
jobs—a total of about 300 officers dying by suicide
a year. If a jumbo jet with 300 people went down every
year, the Federal Aviation Administration would make some
prompt changes.
The nation's largest police
organization, the Fraternal Order of Police, studied
suicides among 38,800 of its 270,000 members in 1995 and
found a suicide rate of 22/100,000 officers. The national
rate in contrast is 12/100,000 people according to the
Centers for Disease Control and Prevention. The USA
Today survey included the nation's largest law
enforcement agencies and found equally disturbing
numbers. In New York City, for example, 36 officers have
been killed in violent confrontations with suspects while
on the job since 1985; during the same period, 87
officers have taken their own lives, a suicide rate of
15/100,000. In Los Angeles, 11 officers have been slain
on duty since 1989; 20 have killed themselves, yielding a
suicide rate of 21/100,000. In Chicago, 12 officers have
been slain while on duty since 1990; 22 have killed
themselves, a rate of 18/100,000 officers. The Federal
Bureau of Investigation, which would be the third largest
police agency in the country if it were a police
department, has lost 4 special agents in the line of duty
since 1993; 18 special agents have killed themselves
during that period, a rate of 26/100,000. The US Customs
Service lost 7 agents to suicide in 1998 alone, a rate of
45/100,000; none were slain that year in the line of
duty.
Suicide has been a chronic
problem among law enforcement officers for years, a
silent killer largely hidden from public view by a police
culture that jealously guards its image of strength. Its
causes are widespread, ranging from the stresses of a job
that requires split-second decisions with life-and-death
consequences to the normal human struggles with family,
career, alcoholism, and depression that can be
exacerbated by the isolation from society many law
enforcement officers feel.
In many police departments an
officer who is known to have contemplated suicide or who
is depressed finds it next to impossible to progress
through the ranks. Because of the negative effect it can
have on their careers, officers are extremely reluctant
to identify others who need help and will go to great
lengths to hide the fact that somebody needs help rather
than help the person get it. The stress that often leads
an officer to commit suicide is at least partially the
result of unrealistically high expectations of being a
successful cop. If a police officer drops a gun during a
bank robbery or misspeaks during a trial, that is a bit
different from a carpenter dropping a hammer. Officers
have to always be in control, and they learn early that
they have to always be right.
Many police departments are
reluctant to discuss the subject of suicide, and it is
difficult to get an accurate tally of suicides because
many departments do not keep official statistics. Some
believe that incidences, such as officers accidentally
killing themselves when cleaning their guns, may actually
be efforts to mask suicides.
Because those who commit suicide
are not killed in the line of duty, they are not given an
official departmental funeral. Their families also are
not entitled to various benefits such as the $144,000
each family of an officer slain in the line of duty
receives from the Justice Department. Many relatives of
suicide victims also lament that they are suddenly
ignored by their loved one's colleagues, unceremoniously
banished from the law enforcement fraternity.
There is no particular profile
of the officer who will attempt suicide. He or she may be
just a few years out of the academy or at the end of a
career, and personal crises run the gamut. Divorce and
the breakup of relationships are common problems. But
those who kill themselves also may be suffering from
stagnated careers, be under investigation for alleged
misconduct, or drink alcohol heavily. Throw the
ever-present firearm into the cauldron and the mix is
deadly. Having the means readily available to commit
suicide is important. The suicide rate among British
police officers who do not carry guns is much lower than
in the USA. And it is not just having the means. It is
the intimate familiarity and comfort with a gun.
Experts on this subject say an
officer who may be contemplating suicide often lacks
energy or motivation, becomes withdrawn, and may actually
talk about suicide. Troubled officers also sometimes
become accident prone or targets of numerous citizen
complaints. Officers are often isolated, distrustful of
anyone outside law enforcement, and the hostility they
sometimes bring home after a day of dealing with
antagonistic situations can erode the one solid safety
net the officers have, namely their family. It is
difficult to go from an almost combat situation to home
life.
At any rate, a number of the
larger police departments are now increasing the number
of police psychologists they have in the department, and
many departments have counselors available for everything
from marital problems to alcohol abuse to depression.
Nevertheless, only about 1% of the officers who need help
seek counseling.
SUICIDES IN JAPAN
The Health and Welfare Ministry
of Japan reported in May that 27,102 Japanese committed
suicide in the first 10 months of 1998 (10). The number
soared by >60% in teenagers, who tend to internalize
their anger and frustration. Young people in Japan also
face diminishing employment prospects because many
companies are cutting recruitment. The suicide rate in
Japan is 17/100,000 people, one of the highest rates in
the world.
LITTLETON, COLORADO, AND
GUNS
On April 20, 1999, in Littleton,
2 heavily armed students, one aged 17 and the other aged
18, killed 12 students and 1 teacher at Columbine High
School (11, 12). Many victims were shot at point-blank
range. After shooting the others, the 2 killers took
their own lives.
Littleton has 40,000 people and
is 93% white. The median household income is
approximately $45,000, 25% higher than the national
average. Its Columbine High School, 1 of 3 in the city,
has 1800 students in grades 9 through 12 and is a sports
powerhouse. Its students score higher than the national
norms in the SAT and ACT college aptitude examinations.
Since that day, there has been
much debate about making the gun laws more stringent. I
am not a gun person, and I tend to believe that it is
more dangerous to possess a gun than to not possess one.
When the Second Amendment to the Constitution was
instituted in 1780, the entire US population was <5
million and the people were more homogenous than today.
Now the USA contains 272 million people and is probably
the most heterogeneous society in the world. The USA now
has 67 greater metropolitan areas with >1 million
inhabitants. Other than Australia, the USA is the only
country in the world that allows its citizens to purchase
guns virtually at will. Despite the preachings of the
National Rifle Association, it is the gun that kills. If
there were no guns there would be no bullets and no
triggers to pull. These Littleton teenagers had
semiautomatic assault weapons! Surely we could start by
getting rid of them. Nonhuman animals kill to survive.
Some human animals kill, it seems, just for fun.
INMATES
At the end of 1985, the number
of inmates in US prisons was just under 750,000. By June
30, 1998, that number had more than doubled to 1.8
million, and the USA may soon surpass Russia as the
country with the highest rate of incarceration (13).
Today in the USA there are 668 inmates for every 100,000
US residents, and in Russia that number is 685 for every
100,000 Russians. The increased number of inmates has
been helped by increased drug prosecutions and a general
get-tough policy on all classes of offenders.
Prisons generally hold
convicted criminals sentenced to terms >1 year whereas
jails typically keep those awaiting trial and
those sentenced to <=12 months. Although the federal
prison population is increasing more rapidly than the
state prison and local jail numbers, state prisons still
hold 1.1 million inmates and dwarf the federal prison
population of slightly <120,000. Local jails held just
under 600,000 inmates as of June 30, 1998.
The incarceration rates in some
states are much higher than in others. The incarceration
rates (sentenced prisoners per 100,000 state residents)
are highest in Louisiana (709), Texas (700), Oklahoma
(629), Mississippi (547), and South Carolina (543). The 5
lowest incarceration rates are in Minnesota (117), Maine
(121), North Dakota (126), Vermont (170), and New
Hampshire (183). There are a lot more guns in the 5
states with the highest incarceration rates than in the 5
states with the lowest rates. Whether this fact makes a
difference is unclear.
TRUCKS, TRUCKS, TRUCKS
Although fatal road accidents
are down, those involving heavy trucks are not, and they
produce about 5000 road fatalities yearly (14). About a
decade ago, industry produced 130,000 new trucks a year;
now that number is up to 220,000 heavy trucks annually.
Indeed, the number of miles traveled by trucks has
increased 25% in the past 4 years, and that mileage could
increase 15% this year alone. Large trucks were involved
in fatal crashes at a rate of 2.5 for every 100 million
miles traveled in 1997, the most recent year for which
full statistics are available. That is down by more than
half from 20 years earlier when the rate was 5.4 for each
100 million miles. (In comparison, the rate for cars in
that period fell to 1.9 from 3.5.) But truck miles
traveled more than doubled in that period to 191 billion
miles from 95 billion miles, so the absolute number of
fatalities did not change much. In 1997, heavy truck
accidents produced 5400 fatalities, of whom nearly all
were in a car, van, pickup, or light vehicle, not in a
heavy truck.
The relatively higher frequency
of heavy truck accidents compared with car-to-car
accidents is believed to be related to fatigue of the
driver. There are limits on how many hours a trucker can
drive and how many he or she can be on duty, including
loading time, but they are widely flouted, partly because
drivers are paid by the mile. Be careful of the
18-wheelers because regulations are poorly observed,
particularly with smaller companies, and there are
317,000 companies with 6 or fewer tractors and only 2800
companies with >100 tractors among the 500,000 or so
registered trucking companies.
SLEEP APNEA AND TRAFFIC
ACCIDENTS
Drowsiness and lack of
concentration contribute to traffic accidents.
Teran-Santos and colleagues (15) examined 102 drivers who
received emergency treatment at hospitals in Burgos or
Santander, Spain, after highway traffic accidents in
1995. Respiratory polygraphy was used to screen the
patients for sleep apnea at home, and conventional
polysomnography was used to confirm the diagnosis. The
drivers who received emergency treatment at the hospitals
were far more likely to have sleep apnea than the control
population of patients randomly selected from primary
health care centers and matched with the patients for age
and sex. The relation between sleep apnea and traffic
accidents remained significant after adjustment for many
potential confounding factors, including alcohol
consumption, age, body mass index (BMI), driving
experience, sleep schedule, use of drugs causing
drowsiness, and history of traffic accidents.
Sleep apnea is a common but
underdiagnosed problem, with an estimated 80% of cases
undiagnosed. Among working people between the ages of 30
and 60, 25% of men and 10% of women have more than 5
episodes of apnea or hypopnea per hour of sleep—a
rate that has been associated with a high risk of traffic
accidents. Although a precise estimate is not available,
sleep apnea is most likely a factor in a substantial
number of accidents. Treatment decreases the risk of
falling asleep while driving, improves performance on
simulated driving tests, and decreases the number of
accidents reported by people with sleep apnea.
Sleep apnea, of course, is not
the only condition causing sleepiness that increases the
risk of traffic accidents. Consumption of alcohol, sleep
deprivation, working at night, driving between the house
of midnight and 6:00 am or for long periods without a
break, narcolepsy, and the use of sedating drugs all
cause sleepiness and have been implicated in traffic
accidents. The presence of any combination of these
factors also substantially increases the risk of a
traffic accident.
The message that it is dangerous
and irresponsible to drive when one is sleepy should be
emphasized in all driver-education courses and publicized
by state regulatory agencies. In many states drivers with
known but untreated sleep apnea who have an accident may
be liable for negligence. Identifying people with sleep
apnea and providing treatment and education may be a good
way to prevent some accidents.
VITAL SIGNS AND BODY
WEIGHT AND HEIGHT
In clinical presentations, blood
pressure, heart rate, respiratory rate, and temperature
are included as the vital signs. I have been surprised at
times to hear a patient's story presented without mention
of body weight or height. Some of the first things
measured in a physician's office are body weight and
height. Some case descriptions include the phrase
“mildly obese” and “moderately
obese.” I rarely know what those phrases mean.
The biggest health hazard in
America is overweightness. Sixty percent of adults over
age 18 years in the USA are overweight. Because there are
approximately 170 million Americans over age 18, that
amounts to at least 100 million people, and of that
number 50% are obese, that is, >20% over ideal body
weight. In recent years BMI (body weight in kilograms
divided by height in meters squared) has been the most
common measure of overweightness and obesity. I have
found few physicians who know their own BMI. Good weights
by some investigators are those considered to be a BMI
<25; overweightness, BMI 25–30; and obesity, BMI
>30. Class I obesity is considered BMI 30–35;
class II, >35–40; and class III obesity, >40.
The Department of Agriculture in 1995 defined healthy
weights for men and women as BMI from 19 to 25 and
overweightness as >27.3 in women and >27.8 in men.
Although many of us do not think in terms of BMI, this
measurement was originally proposed by Quetelet >150
years ago. It correlates more closely with body fat
content than other anthropometric relations of height and
weight and thus is the preferred measure in epidemiologic
and population studies. Its advantages are ease of
determination and the accuracy in measuring both height
and weight. Its chief limitation is that BMI <25
correlates poorly with actual body fat content, but for
BMI values >25, especially >30, it correlates
better with the degrees of excessive fat and risk to
health than do other measurements of overweightness.
If for some reason body weight
and height cannot be measured, waist circumference alone,
circumference of the waist divided by the circumference
of the hips, and sagittal diameter (measured as the
diameter from the abdomen to the back) have all been used
in some excellent studies showing the importance of
central fat distribution and the risk of certain
diseases.
The single most important thing
any individual can do to foster healthfulness is to
maintain an ideal body weight. If body weight is
increased, the most healthful thing one can do is to lose
weight. In my view, physicians and medical personnel need
to set the example or otherwise we have no credibility in
advising others to lose weight.
RELATION OF LEVEL OF
FITNESS TO CARDIOVASCULAR MORTALITY
Recently I gave the Joseph B.
Wolffe Memorial Lecture at the annual Scientific Sessions
of the American College of Sports Medicine and, of
course, had to work into my presentation some discussion
on exercise and fitness. After studying a number of
articles I have come to realize the importance of
fitness. One of the best articles on this subject was one
written by Pate and colleagues (16), representing views
of the Centers for Disease Control and Prevention and the
American College of Sports Medicine. In this splendid
article the authors discuss, among other things, the
relation between level of physical activity and coronary
artery disease mortality. They provide strong evidence
that not only do fit persons live longer than unfit
persons, but the level of fitness or level of activity
also is directly proportional to cardiovascular
mortality. Their conclusion was that every US adult
should accumulate at least 30 minutes of
moderate-intensity physical activity on most, and
preferably all, days of the week. For some of us 30
minutes every day might be a bit difficult, but I find
that even 10 minutes of vigorous physical activity daily
makes an enormous difference in the way I feel and the
amount of energy I have compared to days when I neglect
even those 10 minutes.
A number of studies have shown
that the more we weigh the sooner we die! Until
relatively recently I have thought that leanness was more
important than fitness and have stated that the
nonexercising vegetarian is healthier than the
meat-eating exerciser. Although there are not data to
prove or disprove this thesis, investigators at the
Cooper Clinic here in Dallas have provided some very
useful data on the importance of fitness in any weight
category. Lee and colleagues (17) have followed 21,856
men aged 30 to 83 years who had a complete preventive
medical examination, including a maximal treadmill
exercise test and body composition assessment. During the
18-year period of the study (1971–1989) there were
427 deaths (144 from cardiovascular disease, 143 from
cancer, and 140 from other conditions) during an average
of 8.1 years of follow-up. After adjustment for age,
examination year, cigarette smoking, and alcohol intake,
they observed that men with a BMI of 19 to <25 who
were unfit had 2.3 times the risk of all-cause mortality
compared with fit men in the same BMI group. Unfit men
with a BMI of 25 to <27.8 also had a greater risk of
all-cause mortality than did fit men in the same BMI
group. Fit but overweight men (BMI >=27.8) had a
similar rate of all-cause mortality as physically fit men
of normal weight (BMI 19–<25) and a lower risk of
all-cause mortality than unfit and normal weight men. Fit
men of normal weight had the lowest cardiovascular
mortality, while unfit and overweight men had the highest
cardiovascular mortality. Unfit men had substantially
higher cardiovascular mortality than fit men in each BMI
group.
Several observations may explain
these findings. Of the variables analyzed, the unfit in
each of the 3 weight categories had higher blood
pressures, serum total cholesterol levels, serum
triglyceride levels, and blood glucose levels than the
unfit in each of the 3 BMI categories, and the men with
the higher BMIs, irrespective of being fit or unfit, had
a higher frequency of these risk factors than the men of
lower BMI categories. Thus, unfit men have higher
all-cause and cardiovascular mortality than fit men. The
health benefits of normal weights are greatest in men who
have moderate or high levels of cardiorespiratory
fitness. Since studying this article, I have gotten back
to more regular use of my NordicTrack, stationary
bicycle, and rowing machine.
DEPRESSION, ERECTILE
DYSFUNCTION, AND CARDIOVASCULAR DISEASE
On June 4, 1999, I served as one
of the moderators of a course entitled “Sexual
activity and cardiac risk” held in Princeton, New
Jersey. I certainly learned more information at the
conference than I brought to the conference. The speakers
included cardiologists, psychiatrists, and internists.
I had not realized the close
connection between major depression and erectile
dysfunction. Major depression occurs in about 10% of
adults without coronary artery disease and in at least
20% of patients with coronary disease. Some investigators
have estimated the latter to be as high as 40%.
Depression is 2 times more common in those with erectile
dysfunction as in those without erectile dysfunction. The
predictors of depression are the same as the predictors
of erectile dysfunction, including sedentary lifestyle,
coronary artery disease, older age, physical inactivity,
systemic hypertension, and diabetes mellitus. Exercise is
the best preventer of erectile dysfunction. One speaker
did a Medline search and found 65,000 references to
coronary artery disease, 10,000 references to sexual
dysfunction, and only 26 references with an overlap
between the two. Approximately 50% of patients after
acute myocardial infarction have either depression, panic
disorder, or generalized anxiety disorder. Erectile
dysfunction was observed in at least 40% of patients
having thallium stress tests in the outpatient department
in one institution.
Acute myocardial infarction or
sudden coronary death within 2 hours of sexual
intercourse is of course a very rare but dramatic event.
Sexual activity increases the risk of acute myocardial
infarction by 2.5 times compared with baseline risk, but
the baseline risk is so low—approximately
1/million/hour—that the absolute risk of
coition-induced acute myocardial infarction amounts to a
little over 1% per year even among patients with
symptomatic myocardial ischemia. The low absolute risk
reflects the low frequency of sexual activity. Moreover,
for most individuals the physical exertion associated
with sexual intercourse is modest. Only among patients
with angina pectoris does the heart rate during sexual
activity exceed that during moderate customary physical
activity.
Established trigger mechanisms
for acute cardiac events include the early hours of the
day (diurnal variation), exercise, anger, and sexual
activity. Together these may account for as many as 50%
of acute myocardial infarcts, of which approximately 1%
overall are attributable to sexual activity. Exercise
testing may be useful in stratifying the risk of acute
coronary events among patients with symptomatic
myocardial ischemia. Patients able to achieve a peak
exercise workload of 5 or more METS (multiple of resting
energy expenditure) can generally tolerate sexual
activity that imposes a physical workload of only 3 to 4
METS and only for >2 minutes following orgasm. Among
older individuals, the physical workload of sexual
activity is even less.
Although sexual activity may be
a short-term trigger to coronary events, it is a
long-term protector from these events. Roman Catholic
priests have a higher frequency of cardiovascular disease
than similar-aged nonpriests. Early cessation of sexual
activity in men increases cardiovascular death rates.
Sexual activity in men aged 60 to 94 increases survival.
Sexually frigid women have an increased mortality. After
coronary events, the best ways to keep sexual activity
from being a trigger to another cardiac event are being
physically fit, taking aspirin, and taking a
beta-blocker.
DEMENTIA AND ISOLATED
SYSTOLIC HYPERTENSION
It is well established that
lowering hypertensive blood pressures sharply reduces the
frequency of strokes and aortic dissection. Forette and
colleagues (18) in the Systolic Hypertension in Europe
Trial asked if reducing systolic blood pressures in
patients with isolated systolic hypertension reduced the
frequency of dementia. They studied 2470 patients >=60
years of age who had systolic blood pressures of 160 to
219 mm Hg and diastolic blood pressures <95 mm Hg. Of
the 1238 patients allocated to antihypertensive treatment
after a median follow-up of 2 years, 11 new cases of
dementia (8 Alzheimer and 3 mixed) occurred in the
antihypertensive treatment group, the goal of which was
to reduce systolic blood pressure >=20 mm Hg or to
achieve systolic blood pressure <150 mm Hg. Among the
1238 patients receiving placebo during the same period,
21 new cases (15 Alzheimer, 4 mixed, and 2 vascular)
occurred. Thus, antihypertensive treatment may lead to a
reduction in the frequency of dementia.
ANEMIA IN PERSONS AGED
>=85 years
Recently, Shirani and I
summarized our experience studying hearts at necropsy in
octogenarians, nonagenarians, and centenarians. Among the
490 cases analyzed, 391 were in their 80s, 93 were in
their 90s, and 6 were >=100 (19). Well over 90% had
been anemic during their last month of life. According to
Wintrobe, the normal hematocrit in men is 47% ? 5% and
in women, 42% ? 5%. In the above-mentioned study, anemia
was defined as a hematocrit of <37% in women and
<42% in men.
A recent study by Izaks and
colleagues (20) from Leiden, the Netherlands,
investigated the association between hemoglobin
concentration and cause-specific mortality among 1016
community residents aged 85 years and older. The blood
hemoglobin concentration was measured in 755 persons
(74%). Anemia was defined as a hemoglobin concentration
<7.5 mmol/L (120 g/L) in women and <8.1 mmol/L (130
g/L) in men. Compared with persons with a normal
hemoglobin concentration, the mortality risk was 1.60 in
women with anemia and 2.29 in men with anemia. In both
sexes, the mortality risk increased with lower hemoglobin
concentrations. Mortality from malignant and infectious
diseases was higher in persons with anemia at baseline.
These death rates were calculated up to 5 years after the
baseline blood hemoglobin level was measured. Thus,
anemia is associated with an increased mortality risk in
persons aged 85 years and older. The authors concluded
that a low hemoglobin concentration in the very elderly
signifies the presence of disease and is not due to aging
itself.
BETA-BLOCKERS, CALCIUM
ANTAGONISTS, OR NITRATES FOR STABLE ANGINA PECTORIS
It is estimated that >7
million persons in the USA have stable angina pectoris
and that there are an estimated 350,000 new cases each
year. To prevent anginal symptoms, beta-blockers, calcium
antagonists, and long-acting nitrates or their
combinations have been used. The choice of a first-line
agent has been controversial. Heidenreich and colleagues
(21) from Stanford, California, recently did a
meta-analysis of 90 trials comparing 2 or 3 of the above
agents for stable angina. Rates of cardiac death and
acute myocardial infarction were not significantly
different for treatment with beta-blockers versus calcium
antagonists, but there were 0.31 fewer episodes of angina
per week with beta-blockers than with calcium
antagonists. Beta-blockers were discontinued because of
adverse events less often than calcium antagonists. The
differences between beta-blockers and calcium antagonists
were most striking for nifedipine. Too few trials
compared nitrates with calcium antagonists or
beta-blockers to draw firm conclusions about relative
efficacy. Thus, beta-blockers provide similar clinical
outcomes and are associated with fewer adverse events
than calcium antagonists in randomized trials of patients
with stable angina pectoris.
RELATION OF HOSPITAL
VOLUME TO SURVIVAL AFTER ACUTE MYOCARDIAL INFARCTION
Thiemann and colleagues (22)
from Maryland studied the relation between the number of
Medicare patients with acute myocardial infarction
treated at each hospital in the study (hospital volume)
and long-term survival among 98,898 Medicare patients
(aged >=65 years). The patients in the quartile
admitted to hospitals with the lowest volume were 17%
more likely to die within 30 days after admission than
patients in the quartile admitted to hospitals with the
highest volume. The mortality rate at 1 year was 30%
among the patients admitted to the lowest-volume
hospitals compared with 27% among those admitted to the
highest-volume hospitals. The availability of coronary
angioplasty and coronary bypass surgery was not
independently associated with overall mortality. Thus,
patients with acute myocardial infarction admitted
directly to hospitals that have more experience treating
this condition as reflected by their case volume are more
likely to survive than are patients admitted to
low-volume hospitals. The closest hospital is not always
the best!
ACRONYMS OF CLINICAL
TRIALS IN CARDIOLOGY
Cheng (23) of Washington, D.C.,
recently published a 39-page article listing the 2300
acronyms for clinical trials in cardiology in 1998. In
1992, there were just over 200 acronyms of clinical
trials in cardiology, so the increase has been 10-fold in
just a 6-year period. It's simply dizzying to look at
page after page of these acronyms.
THE MOST COMMON
WORLDWIDE CANCERS
The most common fatal cancers
worldwide as of 1990 on an age-standardized death
rate/100,000 for men is lung (34), stomach (19), and
liver (14); for women it is breast (13), lung (10),
stomach (9), and liver (5) (24). The lung cancer rates
are following the marketing of tobacco products around
the world. As restrictions on tobacco advertising have
tightened in western countries, lung cancer rates have
declined, but in developing countries and in areas where
women previously did not smoke, lung cancer is taking
off. The highest lung cancer rates are in Eastern Europe
and Russia in men, because they have had the highest
smoking prevalence for the longest time. Rates have begun
to fall in North America and in northern Europe, but are
rising rapidly in southern Europe, Asia, and developing
countries and among women. Meanwhile, stomach cancer
rates have declined dramatically in recent years,
reflecting less consumption of smoked and salted foods
and greater consumption of fresh fruits and vegetables.
In addition, better sanitation has reduced the incidence
of childhood infection with Helicobacter pylori
bacteria, which causes chronic inflammation of the
stomach. Cervical cancer has become uncommon among women
in wealthy countries, but it is still common in parts of
Africa, South and Central America, and the Caribbean
where human papillomavirus is common. Sadly, most of
these cancers are preventable.
HEPATITIS C AND BLOOD
TRANSFUSIONS
Between 1988 and 1992, 300,000
Americans received blood transfusions contaminated by
hepatitis C, a deadly virus that can reside in the
bloodstream for years without symptoms (25). Most of
those who received the bad blood have since died. But up
to 100,000 are still alive and infectious, unwittingly
able to spread the virus to lovers and strangers alike. A
test made it possible to track down those victims in
1992, and a report by the Institute of Medicine in 1995
detailed the extent of the infection. The first
coordinated effort to notify patients began in late March
1999 and won't be finished until at least 2001. The
100,000 persons who may still be traceable using old
medical records represent just the tip of a much larger
public health hazard. Nationwide, 4 million Americans
carry hepatitis C virus (HCV), and most of them may not
be identified and diagnosed until the infection becomes
acute. And liver cancer, closely associated with HCV, has
risen 71% since the late 1970s. It is estimated that up
to 20% of all those with HCV—800,000 or
more—were infected through sexual contact and not
through elicit intravenous drug use. Tracking down blood
recipients from 11 years ago based on data collected 7
years ago is a daunting chore, of course.
INCREASING
HEPATOCELLULAR CANCER
El-Serag and Mason (26) from
Albuquerque, New Mexico, determined the age-adjusted
incidence of hepatocellular carcinoma in the USA from
1976 to 1995. The incidence of histologically proved
hepatocellular carcinoma increased from 1.4/100,000
population for the period 1976 to 1980 to 2.4/100,000 for
the period 1991 to 1995. Among black men, the incidence
was 6.1/100,000 for the period 1991 to 1995, and among
white men, it was 2.8/100,000.
The major causes of
hepatocellular cancer worldwide are known and preventable
(27). Hepatitis B virus (HBV) and HCV exist only in
humans, and transmission of the viruses can be
interrupted by vaccination against HBV. No vaccine has
been developed for HCV. The rise in hepatocellular
carcinoma in the USA may continue for many years. There
is a large pool of persons infected with HCV, HBV, or
both, in whom the cancer is in the latency period. In
addition, immigration from areas where hepatocellular
carcinoma is endemic, such as Southeast Asia and parts of
Africa where perinatal HBV infection and exposure to
environmental carcinogens are common, is a factor.
Cirrhosis is estimated to develop during the first 10
years after transfusion in at least 20% of patients with
posttransfusion chronic HCV infection. Once cirrhosis is
established, carcinoma develops at a rate of 1% to 4% per
year, which means that after 20 years hepatocellular
carcinoma will develop in 2% to 7% of all patients with
chronic HCV infection. These projections are obviously
important because approximately 4 million persons in the
USA are infected with HCV. In contrast, the
seroprevalence of HBV in the USA is low, with an
estimated 1 million persons or 0.9% of blacks and 0.2% of
whites harboring a silent HBV infection.
INCREASING RENAL CANCER
Malignant tumors of the kidney
account for about 2% of cancer incidence and mortality in
the USA, with nearly 30,000 new cases and 12,000 deaths
estimated for 1998. More than 80% of renal cancers arise
in the renal parenchyma and the remainder in the renal
pelvis. Nearly all kidney cancers originating in the
renal parenchyma are adenocarcinomas, whereas most renal
pelvis cancers are transitional cell carcinomas. Recent
clinical surveys have revealed that incidental detection
of renal cell carcinomas is rising. Chow and colleagues
(28) from the National Cancer Institute in Bethesda,
Maryland, surveyed patients diagnosed as having kidney
cancer from 1975 through 1995 in the 9 geographic areas
covered by tumor registries in the National Cancer
Institute's Surveillance, Epidemiology, and End Results
(SEER) program. Renal cell cancer incident rates steadily
increased between 1975 and 1995 by 2.3% annually among
white men, 3.1% among white women, 3.9% among black men,
and 4.3% among black women. In contrast, the incidence
rate for renal pelvis cancer declined among white men and
remained stable among white women and blacks. Kidney
cancer mortality rates also increased during this period.
The factors contributing to the rapidly increasing
incidence of renal cell cancer in the USA, particularly
among blacks, is unclear. Better diagnostic tools are not
the explanation.
SYMPTOMATIC
GASTROESOPHAGEAL REFLUX AND ESOPHAGEAL ADENOCARCINOMA
Lagergren and associates (29)
from 3 cities in Sweden interviewed 189 patients with
esophageal adenocarcinoma and 262 with adenocarcinoma of
the cardia of the stomach. Among persons with recurrent
symptoms of reflux, compared with persons without such
symptoms, the odds ratios were 7.7 for esophageal
adenocarcinoma and 2.0 for adenocarcinoma of the cardia.
The more frequent, more severe, and longer lasting the
symptoms of reflux, the greater the risk. Among persons
with long-standing and severe symptoms of reflux, the
odds ratios were 44 for esophageal adenocarcinoma and 4
for adenocarcinoma of the cardia. The risk of esophageal
squamous cell carcinoma was not associated with reflux.
Thus, there is a strong and probably causal relation
between gastroesophageal reflux and esophageal
adenocarcinoma. The relation between reflux and
adenocarcinoma of the gastric cardia is relatively weak.
ASSOCIATION BETWEEN BODY
WEIGHT AND CANCER OF THE ESOPHAGUS AND STOMACH
The incidence of esophageal and
gastric cardia adenocarcinoma is increasing dramatically
in the USA. Lagergren and colleagues (30) examined data
of all Swedish residents who had been born in Sweden,
were <80 years of age, and had lived in Sweden from
1995 through 1997. They studied all persons who developed
new esophageal or cardia adenocarcinomas and persons who
developed esophageal squamous cell carcinomas and were
born on even dates during the 3-year period. The
proportions of men among patients with esophageal
adenocarcinoma, cardia adenocarcinoma, and esophageal
squamous cell carcinoma were 87%, 85%, and 72%,
respectively. The median ages for both sexes in the 4
groups were 69, 66, 67, and 68 years, respectively. A
strong relation was found between BMI and esophageal
adenocarcinoma. Persons in the highest BMI quartile had a
7 times more frequent occurrence of esophageal
adenocarcinoma than persons in the lowest BMI quartile.
Persons with a BMI >30 had a 16 times greater
frequency of esophageal adenocarcinoma compared with
persons with a BMI <22. The odds ratio for patients
with cardia adenocarcinoma was 2.3 in those in the
highest BMI quartile compared with those in the lowest
BMI quartile and 4.3 among obese persons. Esophageal
squamous cell carcinoma was not associated with BMI.
Thus, the association between BMI and esophageal
adenocarcinoma is strong, although the carcinogenic
mechanism is unclear. This article provides another
reason to keep our body weight down. Esophageal cancer is
one of the worst cancers, and it looks like we all can do
something to help prevent it.
MEDICAL MARIJUANA
On March 17, 1999, the
prestigious Institute of Medicine issued a report of an
18-month study on marijuana commissioned by the White
House, concluding that marijuana may indeed be useful for
treating some patients with chronic pain from cancer and
other diseases, as well as some patients with
AIDS-related weight loss (31–33). And the Family
Research Council has released a survey of voters, in
which 60% say they believe the debate over medical
marijuana has “fueled teen use.” The Institute
of Medicine's report noted that questions about
marijuana's role in increasing drug abuse “should
not be a factor in evaluating therapeutic
potential.” As medication, can marijuana do more
good than harm? The answer, quite likely, is yes.
Marijuana smoke is not healthy, but the report concluded
that it can relieve pain, stimulate appetite, and reduce
nausea. Other drugs do those things but not all at once
and not by inhalation. Therefore, marijuana is especially
useful for patients unable to keep other medicines down.
Ideally, what is needed is a purified form of marijuana's
active ingredients that can be inhaled in some measurable
way. But that technology is not now available. Six
western states have passed ballot measures approving its
use, but federal law conflicts with those initiatives,
and there are no research programs currently examining
the drug's effectiveness one way or the other. The
Institute of Medicine proposes short-term clinical trials
to test smoked marijuana's effectiveness.
The other camp believes that
medical marijuana laws are not about relieving suffering
but about decriminalizing pot and ultimately other elicit
drugs. The worry by some is that legalizing smoked
marijuana for medicinal purposes could boost the use of
pot by teenagers. Apparently, 1 in 10 teenagers now
regularly smokes marijuana, and since 1991
marijuana-related visits to emergency rooms have
increased 360%. This issue is a long way from over.
CENTENARIANS
The number of centenarians in
the world is exploding (34). By the year 2000, there may
be 100,000 centenarians on planet Earth. Since 1960, the
number of centenarians has increased at least 10-fold. I
read somewhere that 10,000 people have to reach age 85
for 1 to reach age 100.
Intriguing findings are
emerging. For example, the widely held belief that if you
live long enough you will become demented is not true.
About 30% of centenarians worldwide arrive at age 100
cognitively intact. In Sweden about 50% of centenarians
manage activities of daily living with little, if any,
assistance. In France, where there were 3853 centenarians
in 1990, clinical examination of 700 of them found that
nearly 60% were in good or very good health. About a
third of the centenarians in Denmark are relatively
independent and cognitively intact. The oldest recorded
human longevity was that of the French woman Jeanne
Clament who died in 1997 at age 122. Studies of French
and Swedish centenarians have shown that they tend to be
“calm, communicative, cheerful, optimistic, . . .
more responsible, capable, easygoing and less prone to
anxiety.”
JAPAN'S COMING HEALTHFUL
TOILET
One of the Japanese electronic
companies (Matsushita) has developed a high-tech model
home, which it plans to put on the market by the year
2003 (35). Although the Japanese toilet is already famous
for having elevated the humble water closet into a
technological marvel that warms the buttocks while
washing and blow-drying everything in between, the modern
latrine is not only paperless, it is also made of
bacteria-resistant materials. The new toilet also becomes
an on-line health-monitoring system. Thanks to microchips
and medical equipment installed with the plumbing, the
intelligent toilet can measure the user's weight, fat
content, and urine sugar. The toilet records data onto a
graph and, if requested, sends it to the family doctor or
life insurance company.
In the new future house, the
bedroom contains an electrocardiometer, a blood sugar
meter, a thermometer, a tonometer, and an electronic
scoop. Readings from these devices are automatically
stored in the home computer for personal reference,
remote consultations with specialists, or looking up
advice on exercise or diet via the Internet. The
information can even be linked with the refrigerator and
microwave oven to prepare healthy meals.
These developments, in part, are
due to the fact that Japan has the fastest aging
population in the world, with 1 in 4 people projected to
be older than 65 by the year 2020. Worried that medical
institutions will not be able to cope, the government is
promoting care in the home and in the community. There
are also signs of a growing awareness of health issues as
Japan shifts from a production-oriented society to one in
which individuals focus more on the quality of their
lives. Even the traditional world of sumo is not immune.
Recently, the sports authorities warned wrestlers that
they were overweight and ordered them to pay greater
attention to their health.
THE MERCK
MANUAL
The first Merck Manual
appeared in 1899, contained 192 pages, weighed 119 grams,
and sold for $1 (36). It consisted almost entirely of a
list of the materia medica of the day and their
therapeutic indications. No descriptions of diseases or
their means of diagnosis appeared in this initial manual.
The 17th centennial edition of the Merck Manual
appeared in 1999, contained 2833 pages, weighed 1265
grams, and sells for $35. The newest edition is
unquestionably the best medical book for the price ever
published.
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