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Background: The incidence of colorectal cancer in North America is rising among patients younger than 50 years. Available data are conflicting regarding presentation and outcomes in this population. This review aimed to synthesize literature regarding young patients with colorectal cancer with respect to patient demographics, disease extent and survival, compared with patients older than 50 years. Methods: We searched Medline, Embase, the Cochrane Central Register of Controlled Trials and PubMed for articles published between 1990 and the time of search. Articles comparing North American patients with colorectal cancer younger and older than 50 years were eligible for inclusion. We used a random-effects model to pool odds ratios. Results: Eight retrospective studies were eligible for inclusion (n = 790 959). Mean age was 42.6 years (standard deviation [SD] 5.07) in the younger group, and 69.1 years (SD 9.25) in the older group. Young patients were more likely to present with regional (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.16-1.40) and distant disease (OR 1.47, 95%CI 1.30-1.67). Considering patients at all stages of disease, differences in 5-year overall survival (OR 1.54, 95%CI 0.96-2.47) and cancer-specific survival (OR 1.01, 95%CI 0.91-1.13) were not statistically significant between groups. However, when controlling for disease extent, 5-year cancer-specific survival was significantly higher among young patients with local (OR 1.69, 95%CI 1.43-1.99), regional (OR 1.37, 95%CI 1.16-1.63) and distant disease (OR 1.79, 95%CI 1.45-2.21). Conclusion: North American patients presenting with colorectal cancer before the age of 50 years are more likely to have advanced disease. Although overall and cancer-specific survival is not significantly different between these groups, younger patients have improved survival when controlling for cancer stage. Contexte : L'incidence du cancer colorectal en Amérique du Nord est en hausse chez les patients de moins de 50 ans. Les données disponibles quant à la présentation et aux issues de la maladie dans cette population sont contradictoires. La présente revue systématique vise à synthétiser les données de la littérature sur les jeunes patients atteints d'un cancer colorectal, entre autres les caractéristiques démographiques des patients, le stade de la maladie et le taux de survie, et à les comparer aux données des patients de plus de 50 ans. Méthodes : Nous avons interrogé les bases de données Medline, Embase, PubMed et le Cochrane Central Register of Controlled Trials pour repérer les articles publiés entre 1990 et le moment de la recherche. Les études comparants les patients nord-américains atteints d'un cancer colorectal de moins de 50 ans et ceux de plus de 50 ans ont été incluses. Nous avons utilisé un modèle à effets aléatoires pour regrouper les rapports de cotes. Résultats : Huit études rétrospectives ont été retenues (n = 790 959). L'âge moyen était de 42,6 ans (écart type [É. T.] 5,07) pour le groupe des moins de 50 ans, et de 69,1 ans (É.-T. 9,25) pour l'autre groupe. Les jeunes patients étaient plus susceptibles de présenter un cancer régional (rapport de cotes [RC] 1,27; intervalle de confiance [IC] à 95% 1,16-1,40) ou un cancer à distance (RC 1,47; IC à 95% 1,30-1,67). Si on ne tenait pas compte du stade de la maladie, la différence entre le taux de survie globale à 5 ans (RC 1,54; IC à 95% 0,96-2,47) et le taux de survie au cancer à 5 ans (RC 1,01; IC à 95% 0,91-1,13) n'était pas statistiquement significative. Toutefois, si on tenait compte de l'étendue de la maladie, le taux de survie lié au cancer à 5 ans était significativement plus élevé chez les jeunes patients ayant un cancer localisé (RC 1,69; IC à 95% 1,43-1,99), régional (RC 1,37; IC à 95% 1,16-1,63) ou à distance (RC 1,79; IC à 95% 1,45-2,21). Conclusion : Les patients nord-américains de moins de 50 ans présentant un cancer colorectal sont plus susceptibles d'être à un stade avancé de la maladie. Bien que le taux de survie globale et le taux de survie au cancer ne diffèrent pas de manière significative entre les 2 groupes, les jeunes patients présentaient un meilleur taux de survie lorsqu'on tenait compte du stade de la maladie., Colorectal cancer remains the second most common cancer and third highest cause of cancer-related death in Canada. (1) Screening programs across the country have contributed to earlier diagnoses and a [...]

Byline: W. C. Chie (1), R. S. Yang (2), J. P. Liu (3), K. S. Tsai (4) Keywords: Hip fracture; Incidence; Nationwide database Abstract: The objective of this study was to describe the incidence rate of hip fracture from 1996 to 2000 in Taiwan, based on an inpatient database of the National Health Insurance Program. A total of 54,199 patients, who had a first-time admission for a diagnosis of hip fracture (ICD9 code 820.0 through 820.9, 820.21, 820.22, and 820.31) on discharge from January 1996 through December 2000 and aged 50 to 100 years, were identified and included in the study. The results showed that the age-specific incidence rates of hip fractures were higher with increasing age in both genders, in an exponential manner after 65 years of age. The incidence was 1.6 times higher and rose about 5 years earlier among women than among men. Thus in these 5 years the age-adjusted incidence rates (95% confidence interval) of hip fracture in Taiwan were 225 (95% CI, 188--263) per 100,000 in men and 505 (95% CI, 423--585) per 100,000 in women (adjusted to US white population of 1989), as compared with US white rate of 187 in men and 535 in women. More than half of the fractures were peritrochanteric, and the recorded cause in most cases was a fall on the same level, from slipping, tripping, or stumbling (ICD9 E885). A total of 37.8% patients had hip hemiarthroplasty, 51.2% had open reduction of fracture with internal fixation, and 10.5% had closed reduction of fracture with internal fixation. We concluded that, using the data from a nationwide health insurance database of Taiwan, we found a high annual incidence rate of hip fracture for both men and women in 5 consecutive years. These incidence rates were higher than other reports on Chinese populations reported in the past 10 years and similar to that of Western countries. With the rapid aging of the populations of Taiwan and other Asian countries in the years to come, our results clearly demonstrated the impact of osteoporosis and hip fracture in this region. Author Affiliation: (1) School of Public Health, College of Public Health, College of Medicine, National Taiwan University, Taipei, Taiwan (2) Department of Orthopedics, College of Medicine, National Taiwan University, Taipei, Taiwan (3) Division of Biostatistics, National Health Research Institutes, Taipei, Taiwan (4) Departments of Laboratory Medicine and Internal Medicine, College of Medicine, National Taiwan University, 7 Chung-Shan South Road, 100, Taipei, Taiwan Article History: Registration Date: 19/04/2004 Received Date: 04/07/2003 Accepted Date: 08/04/2004 Online Date: 20/05/2004

The impact of respiratory disease during a 150-d feedlot finishing period on daily gain, carcass traits, and longissimus tenderness was measured using 204 steer calves. Feedlot health status was monitored in two ways. First, clinical signs of respiratory infection were evaluated each day; treatment with antibiotic was based on degree of fever (if rectal temperature exceeded 40oC then calves were treated). Steers that were treated (n = 102) had lower (P < .05) final live weights, ADG, hot carcass weights (HCW), less external and internal fat, and more desirable yield grades. Steers that were treated had a higher prevalence of carcasses that graded U.S. Standard than steers that were never treated. Second, as an alternative index of health status, lungs of all steers were evaluated at the processing plant using a respiratory tract lesion classification system; this health index included presence or absence of preexisting pneumonic lesions in the anterioventral lobes plus activity of the bronchial lymph nodes (inactive vs active). Lung lesions were present in 33% of all lungs and were distributed almost equally between treated (37%) and untreated cattle (29%). Steers with lesions (n = 87) had lower (P < .05) daily gains, lighter HCW, less internal fat, and lower marbling scores than steers without lesions. Compared to steers with lesions but inactive bronchial lymph nodes (n = 78), steers with lung lesions plus active lymph nodes had lower (P < .01) ADG and dressing percentage. Longissimus shear force values for steaks aged 7 d were lower (P = .05) from steers without lung lesions than those for steaks from steers with lung lesions. Overall, morbidity suppressed daily gains and increased the percentage of U.S. Standard carcasses. Compared to health assessment by clinical appraisal (based on elevated body temperature), classification based on respiratory tract lesions at slaughter proved more reliable statistically and, thereby, more predictive of adverse effects of morbidity on production and meat tenderness. Key Words: Steers, Feedlots, Morbidity, Health, Performance, Carcass Composition

Injury surveillance data are drawn from hospital morbidity data, but the accuracy and reliability of these data are often questioned. The reliability of the injury surveillance data in the Victorian inpatient minimum database was examined, and although there are problems with the hospital morbidity data, the database is sttill an valuable source for injury surveillance.

Physicians should take individual patient characteristics into account when recommending whether the patient should be treated with drugs or surgery. Many cardiovascular diseases can be treated with either drugs or surgery and many studies have compared the two approaches. However, comparing the two treatments is difficult because surgical patients may have increased mortality in the short run from the operation, but reduced mortality in the long run. Many statistical tests used to evaluate outcomes are based on averages, which could be skewed in one direction or another based on how long patients were followed., The statement of hypotheses and choice of statistical tests in clinical trials that compare surgical with nonsurgical treatment are complicated by the likelihood of excess risk in the surgical group during the perioperative period but lower risk after that compared with the more uniform risk in the nonsurgical group. Commonly used statistical survival analyses implicitly assume a constant ratio of risks in the 2 groups during the follow-up period. However, the changing pattern of risk for one treatment but not the other implies that the assessment of the relative efficacy of the treatments varies with the length of the follow-up. As such, determining whether survival curves for the 2 groups are different may not translate easily into selecting the best treatment. Alternative statements of the hypothesis based on consideration of the time horizon of patients and on clinical judgment may be more consistent with the goals of the study. Regardless of the choice of a statistical test, the choice of treatment is a decision specific to the individual patient and should be influenced by the patient&apos;s life expectancy, attitude toward taking risks, quality of life, and cost considerations. When the survival curves cross, there is a trade-off between the risk of surgery and the increase in life expectancy among the survivors of surgery. Accordingly, assessment of differences in outcomes in clinical trials comparing surgical vs nonsurgical therapy should provide both a conclusion about whether 1 treatment can reasonably be considered best for most patients and should provide information to the individual patient and physician on the expected outcome to aid in the decision-making process. JAMA. 1997;278:1432-1436

Reasonably large increases in intervention coverage do not necessarily result in large decreases in mortality. This was gleaned from a macro model developed to assess the impact of health interventions on infant and child mortality in developing countries in the 1990s. For instance, an increase of oral rehydration therapy coverage from 57% to 80% reduced diarrheal mortality by a mere two deaths per thousand. While the macro model was found to be a useful tool for an examination of the effects of health interventions on child mortality, it was found that the quantitative effects of various interventions in lowering childhood mortality are hard to estimate.

Statements that so many people are killed by smoking use the term 'kill' in a very unusual manner which is easily misunderstood by people not expert in epidemiology. In addition, the usual calculations leave out of account the fact that smoking interacts synergistically with other risk factors, so that it is a combination of risk factors rather than any specific one that is likely to have a causal influence on mortality. Strictly speaking it is quite inappropriate to state that smoking kills anybody, if we use the term 'kill' in a meaningful fashion.

Priority health risk behaviors that contribute to the leading causes of mortality, morbidity, and social problems among youth and adults often are established during youth, extend into adulthood, and are interrelated. The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority health risk behaviors among youth and youth adults: behaviors that contribute to unintentional and intentional injuries, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical activity. The YRBSS includes a national, school-based survey conducted by CDC and state and local school-based surveys conducted by state and local education agencies. This report summarizes results from the national survey, 24 state surveys, and nine local surveys conducted among high school students during February through May 1993. In the United States, 72% of all deaths among school-age youth and young adults are from four causes: motor vehicle crashes, other intentional injuries, homicide, and suicide. Results from the 1993 YRBSS suggest many high school students practice behaviors that may increase their likelihood of death from these four causes: 19.1% rarely or never use a safety belt, 35.3% had ridden during the 30 days preceding the survey with a driver who had been drinking alcohol, 22.1% had carried a weapon during the 30 days preceding the survey, 80.9% ever drank alcohol, 32.8% ever used marijuana, and 8.6% had attempted suicide during the 12 months preceding the survey. Substantial morbidity and social problems among adolescents also result from unintended pregnancies and sexually transmitted diseases including HIV infection, YRBSS results indicate that in 1993, 53% of high school students had experienced sexual intercourse, 52.8% of sexually active students had used a condom during last sexual intercourse, and 1.4% ever injected an illegal drug. Among adults, 67% of all deaths are from three causes: heart disease, cancer, and stroke. In 1993, many high school students practiced behaviors that may increase the risk for these health problems: 30.5% of high school students had smoked cigarettes during the 30 days preceding the survey, only 15.4% had eaten five or more servings of fruits and vegetables during the day preceding the survey, and only 34.3% had attended physical education class daily. YRBSS data are being used nationwide by health and education officials to improve school health policies and programs designed to reduce risks associated with the leading causes of mortality and morbidity. At the national level, YRBSS data are being used to measure progress toward achieving 26 national health objectives and one of eight National Education Goals. (J Sch Health. 1995;65(5):163-171), In the United States, 72% of all deaths among school-age youth and young adults ages 5-24 are from only four causes: motor vehicle crashes (30% of all deaths in this [...]

This paper compares total outpatient health care utilization of residents of the Labrador community of Sheshatshit, a predominantly native Innus settlement, with those for the adjacent and predominantly caucasian, community of Northwest River for 1986. In lieu of a community survey, these data provide an approximation of the morbidity patterns within the populations. Findings indicate that the native population experiences proportionately more infectious diseases (39.3% of all visits compared to 12.5% of all visits for the non-native community). While residents of the Innu community utilize health services primarily for curative care, residents of Northwest River sought services for both curative and preventive care. It is concluded that inequalities in material wellbeing may underlie the morbidity in Sheshatshit. While desirable in light of the WHO Ottawa Charter, any modification of the health services on account of these morbidity patterns will have only modest effect until policy-based initiatives to reduce material inequalities are implemented.

Data furnished by the Regie de l'Assurance Automobile du Quebec (RAAQ) were used to describe the geography of motor vehicle accidents in the province of Quebec for the period 1983-1988. These were also used to evaluate the risk factors associated with zones of high risk with regards to accidents for the 97 Municipalites Regionales de Comte (MRC). The results demonstrate that non-severe accidents are more frequent in the urban context. On the other hand, severe accidents are more frequent in the rural context. The Standard Morbidity Ratio (SMR) highlights those MRC's with the risk of severe or non-severe accidents, where risks are twice that of Quebec as a whole. The demographic characteristics (age, sex) of the driver and passengers and the place of the accident (region, density) were used in the model LOGIT to evaluate risk factors associated with high risk zones. Results of the model for those severely injured are different from those for non-severely injured people. This holds true for the location of accidents as well as for demographic characteristics. In both models, women and people over 65 years of age are low-risk groups for accidents. The authors indicate certain action to be undertaken in Quebec by the Government to improve this situation.

The General Household Survey data file for 1982 was examined to identify variations in self-reported morbidity and health service use between socio-economic groups and geographical areas in Great Britain. Both acute and chronic morbidity varied with socio-economic status. Morbidity was more strongly related to housing tenure and car availability than to occupational class. A north-west to south-east gradient in sickness was observed, although morbidity was comparatively high in Wales and comparatively low in Scotland, taking mortality differences into account. The highest age-adjusted morbidity ratios were for females in multiple occupancy inner city areas. Service use rates in relation to reported sickness showed little systematic variation. There was an indication that lack of car transport was an inhibiting factor for the sick in rural areas.

Questions regarding the clinical relevancy of medical research have recently received a great deal of attention. As a part of this, focus has been placed on sample size requirements in medical research. Statistical power analysis has also has played a significant role in the development of methods of comparison and quality control. An approach has been developed to determine the sample size requirement for test performance characteristics. Analysis of these characteristics allow assessment of the clinical usefulness of laboratory tests and provide a basis of comparison for different tests. Statistical comparisons are only useful if they can provide enough statistic power to make the sample size important in assessing performance characteristics. To avoid fewer tests with meaningless negative results and to allow a better quality of the evaluation of laboratory tests, tables have been designed to provide appropriate sample size requirements using standard formulas. Definitions of sensitivity, positive and negative predictive values, and Type I and II errors have been provided. Sample problems are given and the determination of meaningful confidence intervals are discussed. Assumptions must be stated that are inexact, but at the same time not completely arbitrary in determining proportional sample sizes. Estimates of observed proportions prior to the study and assignment of power and type I error may affect the accuracy of the calculated sample size.

The Health Care Financing Administration (HCFA) publishes an annual report that compares predicted and actual rates of hospital mortalities. Much controversy has been generated by these reports and the accuracy of the results has been questioned, based on the assertion that the HCFA uses a flawed prediction model. A quantitative comparison was made of the methodology used by the HCFA and a similar model which also includes severity of illness as a measure. Thirteen hospitals were used to obtain data on 34,252 Medicare patients who fell into one of five diagnostic categories and who had various risk statuses. The severity measure used was the Severity of Illness Index from which a Stage of Principal Diagnosis at Admission was derived. Use of this measure significantly changed the results of predicted mortality rates; it was capable of differentiating among patients based on their health status at the time of admission, which the HCFA model could not do. In addition, the HCFA report did not differentiate between hospitals that had high percentages of low-severity admissions and those that had many high-severity admissions. The HCFA has provided momentum toward the goal of developing accurate measures for the quality of hospital care. However, their yearly mortality study does not utilize a model that provides for wide variations in the conditions of patients and is not sensitive enough to be considered an accurate representation of the quality of hospital care in this country.

ALTHOUGH THERE is a growing body of literature criticizing the use of mere statistical significance as a measure of clinical impact, we submit that this concept has not been widely [...]

Science teaches us to doubt and, in ignorance, to refrain. Claude Bernard (1) The beginning of wisdom is to recognize our own ignorance. We psychiatrists, like other physicians, do not [...]

The opinions of hospital leaders were surveyed for their reactions to a study conducted by the Health Care Financing Administration (HCFA) on hospital mortalities. The HCFA publishes an annual report that compares predicted and actual rates of hospital mortalities. Much controversy has been generated by these reports and the results have been questioned, based on the assertion that the HCFA uses a flawed prediction model. A nationwide survey was distributed and 195 hospital executives participated. No correlations were found between the HCFA rating of specific hospitals and the opinions of these hospitals; all respondents reported negative views on the results of this study. Generally, hospital leaders found the HCFA report to be inaccurate, flawed in interpretation, and useless. Seventy percent of the respondents felt the data obtained was of no use to the hospital, 54 percent felt the accuracy was poor, and 85 percent believed the data was also useless to the consumer. The hospitals with the highest mortality rates (according to the HCFA report) were more likely to utilize the data and reported the highest rates of problems generated from the report. This response reflects the high degree of mistrust of the HCFA by hospital leaders. Efforts towards mutual cooperation and better communication should be encouraged. It is probable that the attitudes of these hospital leaders indicate resistance against efforts to report hospital mortalities and monitor the quality of patient care in this country's hospitals.

Abstract Background and aims--Controversy surrounds the risk of colorectal cancer (CRC) in ulcerative colitis (UC). Many studies have investigated this risk and reported widely varying rates. Methods--A literature search using [...]

Ohtsuka, Yoshinori, Robert W. Clarke, Wayne Mitzner, Kiana Brunson, George J. Jakab, and Steven R. Kleeberger. Interstrain variation in murine susceptibility to inhaled acid-coated particles. Am. J. Physiol. Lung Cell. Mol. Physiol. 278: L469-L476, 2000.--Epidemiologic studies have demonstrated a positive correlation between concentration of acid aerosol and increased morbidity and mortality in many urban environments. To determine whether genetic background is an important risk factor for susceptibility to the toxic effects of inhaled particles, we studied the interstrain (genetic) and intrastrain (environmental) variance of lung responses to acid-coated particle (ACP) aerosol in nine strains of inbred mice. A flow-past nose-only inhalation system was used to expose mice to ACPs produced by the cogeneration of a carbon black aerosol-sulfur dioxide ([SO.sub.2]) mixture at high humidity. Three days after a single 4-h exposure to ACPs or filtered air, mice underwent bronchoalveolar lavage, and cell differentials and total protein were determined as indexes of inflammation and epithelial permeability, respectively. To determine the effect of ACPs on alveolar macrophage (AM) function, lavaged AMs were isolated from exposed animals and Fc receptor-mediated phagocytosis was evaluated. Compared with air-exposed animals, there was a slight but significant exposure effect of ACPs on the mean number of lavageable polymorphonuclear leukocytes in C3H/HeJ and C3H/HeOuJ mice. ACP exposure also caused a significant decrease in AM phagocytosis. Relative to respective air-exposed animals, Fc receptor-mediated phagocytosis was suppressed in eight of nine strains. The order of strain-specific effect of ACPs on phagocytosis was C57BL/6J [is greater than] 129/J [is greater than] SJL/J [is greater than] BALB/cJ [is greater than] C3H/HeOuJ [is greater than] A/J [is greater than] SWR/J AKR/J. There was no effect of ACP exposure on AM phagocytosis in C3H/HeJ mice. The significant interstrain variation in AM response to particle challenge indicates that genetic background has an important role in susceptibility. The effects of ACPs on AM function, inflammation, and epithelial hyperpermeability were not correlated (i.e., no cosegregation). This model may have important implications concerning interindividual variation in particle-induced compromise of host defense. inbred mice; sulfate; air pollution; phagocytosis; alveolar macrophage; morbidity; host defense

One of the pleasures of working as an applied statistician is the awareness it brings of the wide diversity of scientific fields to which our profession contributes critical concepts and [...]