Occupational hierarchy, economic sector, and mortality from cardiovascular disease among men and women. Findings from the National Longitudinal Mortality Study.

PURPOSE: Although socioeconomic position has been identified as a determinant of cardiovascular disease among employed men and women in the U.S., the role of economic sector in shaping this relationship has yet to be examined. We sought to estimate the combined effects of economic sector-one of the three major sectors of the economy: finance, government and production-and socioeconomic position on cardiovascular mortality among employed men and women. METHODS: Approximately 375,000 men and women 25 years of age or more were identified from selected Current Population Surveys between 1979 and 1985. These persons were followed for cardiovascular mortality through use of the National Death Index for the years 1979 through 1989. RESULTS: In men, the lowest cardiovascular mortality was found for professionals in the finance sector (76/100,000 person/years). The highest cardiovascular mortality was found among male non-professional workers in the production sector (192/100,000 person years). A different pattern was observed among women. Professional women in the finance sector had the highest rates of cardiovascular mortality (133/100,000 person years). For both men and women, the professional/non-professional gap in cardiovascular mortality was lower in the government sector than in the production and finance sectors. These associations were strong even after adjustment for age, race and income. CONCLUSIONS: Characteristics of government, finance and production work differentially influence the risk of cardiovascular disease mortality. Men, women, professionals and non-professionals experience this risk differently.

Marital status and mortality: the national longitudinal mortality study.

PURPOSE: To examine the effect of marital status (married, widowed, divorced/separated, and never-married) on mortality in a cohort of 281,460 men and women, ages 45 years and older, of black and white races, who were part of the National Longitudinal Mortality Study (NLMS). METHODS: Major findings are based on assessments of estimated relative risk (RR) from Cox proportional hazards models. Duration of bereavement for the widowed is also estimated using the Cox model. RESULTS: For persons aged 45-64, each of the non-married groups generally showed statistically significant increased risk compared to their married counterparts (RR for white males, 1.24-1.39; white females, 1.46-1.49; black males, 1.27-1.57; and black females, 1. 10-1.36). Older age groups tended to have smaller RRs than their younger counterparts. Elevated risk for non-married females was comparable to that of non-married males. For cardiovascular disease mortality, widowed and never-married white males ages 45-64 showed statistically significant increased RRs of 1.25 and 1.32, respectively, whereas each non-married group of white females showed statistically significant increased RRs from 1.50 to 1.60. RRs for causes other than cardiovascular diseases or cancers were high (for white males ages 45-64: widowed, 1.85; divorced/separated, 2.15; and never-married, 1.48). The importance of labor force status in determining the elevated risk of non-married males compared to non-married females by race is shown. CONCLUSIONS: Each of the non-married categories show elevated RR of death compared to married persons, and these effects continue to be strong after adjustment for other socioeconomic factors.

Relation between income inequality and mortality: empirical demonstration.

Objective To assess the extent to which observed associations between income inequality and mortality at population level are statistical artifacts. Design Indirect "what if" simulation using observed risks of mortality at individual level as a function of income to construct hypothetical state-level mortality specific for age and sex as if the statistical artifact argument were 100% correct. Method Data from the 1990 census for the 50 US states plus Washington, DC, were used for population distributions by age, sex, state, and income range; data disaggregated by age, sex, and state from the Centers for Disease Control and Prevention were used for mortality; and regressions from the national longitudinal mortality study were used for the individual-level relation between income and risk of mortality. Results Hypothetical mortality, although correlated with inequality (as implied by the logic of the statistical artifact argument), showed a weaker association with the level of income inequality in each state than the observed mortality. Conclusions The observed associations in the United States at the state level between income inequality and mortality cannot be entirely or substantially explained as statistical artifacts of an underlying individual-level relation between income and mortality. There remains an important association between income inequality and mortality at state level above anything that could be accounted for by any statistical artifact. This result reinforces the need to consider a broad range of factors, including the social milieu, as fundamental determinants of health.

A comparison of the relationships of education and income with mortality: the National Longitudinal Mortality Study.

A sample of over 400,000 men and women, ages 25-64, from the National Longitudinal Mortality Study (NLMS), a cohort study representative of the noninstitutionalized US population, was followed for mortality between the years of 1979 and 1989 in order to compare and contrast the functional forms of the relationships of education and income with mortality. Results from the study suggest that functional forms for both variables are nonlinear. Education is described significantly better by a trichotomy (represented by less than a high school diploma, a high school diploma or greater but no college diploma, or a college diploma or greater) than by a simple linear function for both men (p < 0.0001 for lack of fit) and women (p = 0.006 for lack of fit). For describing the association between income and mortality, a two-sloped function, where the decrease in mortality associated with a US$1000 increase in income is much greater at incomes below US$22,500 than at incomes above US$22,500, fits significantly better than a linear function for both men (p < 0.0001 for lack of fit) and women (p = 0.0005 for lack of fit). The different shapes for the two functional forms imply that differences in mortality may primarily be a function of income at the low end of the socioeconomic continuum, but primarily a function of education at the high end.

Relation between income inequality and mortality: empirical demonstration.

OBJECTIVE: To assess the extent to which observed associations at population level between income inequality and mortality are statistical artefacts. DESIGN: Indirect "what if" simulation by using observed risks of mortality at individual level as a function of income to construct hypothetical state level mortality specific for age and sex as if the statistical artefact argument were 100% correct. SETTING: Data from the 1990 census for the 50 US states plus Washington, DC, were used for population distributions by age, sex, state, and income range; data disaggregated by age, sex, and state from the Centers for Disease Control and Prevention were used for mortality; and regressions from the national longitudinal mortality study were used for the individual level relation between income and risk of mortality. RESULTS: Hypothetical mortality, while correlated with inequality (as implied by the logic of the statistical artefact argument), showed a weaker association with states' levels of income inequality than the observed mortality. CONCLUSIONS: The observed associations in the United States at the state level between income inequality and mortality cannot be entirely or substantially explained as statistical artefacts of an underlying individual level relation between income and mortality. There remains an important association between income inequality and mortality at state level over and above anything that could be accounted for by any statistical artefact. This result reinforces the need to consider a broad range of factors, including the social milieu, as fundamental determinants of health.

PIP: The aim of this study is to evaluate the extent to which observed associations at the population level between income inequality and mortality are statistical artifacts. Data from the 1990 census for the 50 American states plus the District of Columbia were used for population distributions by age, sex, state and income range; data disaggregated by age, sex and state from the Centers for Disease Control and Prevention were used for mortality; and regressions from the national longitudinal mortality study were used for the individual level relation between income and risk of mortality. Results revealed that hypothetical mortality, while correlated with inequality, displayed a weaker association with state's levels of income inequality than the observed mortality. The associations seen in the US at the state level between income inequality and mortality cannot be entirely or substantially explained as statistical artifacts of an underlying individual level relation between income and mortality. There is still a significant association between income inequality and mortality at state level over and above anything that could be accounted for by any statistical artifact. This finding reinforces the need to consider a broad range of factors, including the social milieu, as fundamental determinants of health.

The impact of specific occupation on mortality in the U.S. National Longitudinal Mortality Study.

We compare mortality differences for specific and general categories of occupations using a national cohort of approximately 380,000 persons aged 25-64 from the U.S. National Longitudinal Mortality Study. Based on comparisons of relative risk obtained from Cox proportional-hazards model analyses, higher risk is observed in moving across the occupational spectrum from the technical, highly skilled occupations to less-skilled and generally more labor-intensive occupations. Mortality differences obtained for social status groups of specific occupations are almost completely accounted for by adjustments for income and education. Important differences are shown to exist for selected specific occupations beyond those accounted for by social status, income, and education. High-risk specific occupations include taxi drivers, cooks, longshoremen, and transportation operatives. Low-risk specific occupations include lawyers, natural scientists, teachers, farmers, and a variety of engineers.

Mortality effects of community socioeconomic status.

We linked data from the National Longitudinal Mortality Study to census tract information on 239,187 persons to assess 11-year mortality risk among black and white women and women associated with median census tract income, adjusted for individual family income from the Current Population Survey. We stratified Cox proportional hazards models by ages 25-64 years and 65 years and older. We used a robust covariance matrix to obtain standard errors for the model coefficients that account for correlation among individuals in the same census tract. Both income indicators were independently related to all-cause mortality. Among persons age 25-64 years, the rate ratios (RR) for individual family income and the median census tract income, respectively, for low income relative to high income were RR = 2.10 vs. 1.49 for black men, RR = 2.03 vs 1.26 for white men; and RR = 1.92 vs 1.30 for black women and RR = 1.61 vs 1.16 for white women. Among persons age 65 years or greater, only individual family income was associated with mortality, and only for white men. Although family income has a stronger association with mortality than census tract, our results indicate that, more broadly, area socioeconomic status makes a unique and substantial contribution to mortality and should be explored in health policy and disease prevention research.

The shape of the relationship between income and mortality in the United States. Evidence from the National Longitudinal Mortality Study.

A follow-up study based on a large national sample was used to examine differences in the well-established inverse gradient between income and mortality at different income levels. The study showed the income-mortality gradient to be much smaller at high income levels than at low to moderate income levels in the working age (25 to 64 years) and elderly (over 65 years) populations for men and women both before and after adjustment for other socioeconomic variables. In addition, a much larger gradient existed for working age women at extreme poverty levels than for those women at low to moderate income levels. The income-mortality gradient was much smaller in the elderly than in the working age population. The study also examined the ability of several different mathematic functions of income to delineate the relationship between income and mortality. The study suggested that the health benefits associated with increased income diminish as income increases.

US mortality by economic, demographic, and social characteristics: the National Longitudinal Mortality Study.

OBJECTIVES: A large US sample was used to estimate the effects of race, employment status, income, education, occupation, marital status, and household size on mortality. METHODS: Approximately 530,000 persons 25 years of age or more were identified from selected Current Population Surveys between 1979 and 1985. These individuals were followed for mortality through use of the National Death Index for the years 1979 through 1989. RESULTS: Higher mortality was found in Blacks than in Whites less than 65 years of age; in persons not in the labor force, with lower incomes, with less education, and in service and other lower level occupations; and in persons not married and living alone. With occasional exceptions, in specific sex and age groups, these relationships were reduced but remained strong and statistically significant when each variable was adjusted for all of the other characteristics. The relationships were generally weaker in individuals 65 years of age or more. CONCLUSIONS: Employment status, income, education, occupation, race, and marital status have substantial net associations with mortality. This study identified segments of the population in need of public health attention and demonstrated the importance of including these variables in morbidity and mortality studies.

Long-term beneficial effects of adrenal medullary autografts supported by nerve growth factor in Parkinson's disease.

Parkinson's disease has been the object of several therapeutic strategies based upon replacement of the degenerating dopaminergic neurons. Adrenal medullary transplants were tried initially, because of the biochemical relationship between chromaffin cells of the medulla and dopaminergic neurons of the substantia nigra. Compared to transplant of fetal neurons, autologous grafts of adrenal medullary tissue has the advantage of using a readily available source of tissue without the problems of immunosuppression. However, these cells have not proven to be as effective as fetal neurons, probably because they do not fully differentiate into neurons. In animal models, brief treatment with nerve growth factor can facilitate such differentiation. This study is a clinical evaluation of the efficacy of adrenal medullary cell transplantation, combined with nerve growth factor infusion. Two patients were selected who were moderately to severely affected (Hoehn-Yahr stage 2 in on-phase and stage 4 in off-phase). After adrenalectomy, small pieces of medulla were prepared and implanted stereotactically into the dorsal putamen on one side of the brain. A catheter filled with mouse beta-nerve growth factor (NGF) was placed close to the grafts. Infusion of NGF was continued for one month. Despite a progressively deteriorating course prior to surgery, both patients showed improvement on the rating scales postoperatively. There was also significant improvement in timed motor tests. Motor readiness evoked potentials showed increased voltage over the operated hemisphere. The study points to methods and feasibility of supplying nerve growth factor intraparenchymally to the human brain. Possible implications with respect to other growth factors, particularly Glial cell-line Derived Neurotrophic factor (GDNF) are discussed.

Mortality in the uninsured compared with that in persons with public and private health insurance.

OBJECTIVE: To compare mortality in persons with employer-provided health insurance, Medicare, Medicaid, military health benefits, other private health insurance, and no health insurance, before and after adjustment for income and employment status. DESIGN: Cohort study using national survey data containing information on social, economic, and demographic factors and health insurance, with deaths identified through matching to the National Death Index resulting in a mortality follow-up period of 5 years. SETTING: Noninstitutionalized population of the United States. PARTICIPANTS: Approximately 150,000 respondents to national surveys conducted by the US Bureau of the Census (Current Population Surveys), aged 25 to 64 years. RESULTS: After adjustment for age and income, persons with Medicare and Medicaid had the highest mortality in comparison with those with employer-provided insurance, with relative risks generally greater than 2. With adjustment for age and income, persons without insurance had higher mortality than those with employer-provided insurance, with relative risks of 1.2 for white men and 1.5 for white women. These relationships held after adjustment for employment status, with the working uninsured showing mortality between 1.2 and 1.3 times higher than that of the working insured. Mortality was higher in those with lower incomes after adjustment for insurance status. Those with annual income of $10,000 or less per year had mortality about two times that of persons with incomes greater than $25,000 per year. CONCLUSION: Mortality was lowest in employed persons with employer-provided health insurance. The higher mortality in those with public insurance or with no insurance reflects an indeterminate mix of selection on existing health status and access to medical care.

Ethnic differences in stroke mortality between non-Hispanic whites, Hispanic whites, and blacks. The National Longitudinal Mortality Study.

BACKGROUND AND PURPOSE: Although US blacks are known to have an excess stroke mortality compared with US whites, little is known about the stroke burden of the Hispanic white population. This report will provide estimates of the relative burden of stroke mortality in the US black and Hispanic population relative to the white population and examine the consistency of this relation across age. METHODS: Data were from participants aged > 45 years from the National Longitudinal Mortality Study. There were 1844 stroke deaths among 239,734 non-Hispanic whites, 46 deaths among 12,527 Hispanic whites, and 234 deaths among 23,468 black participants. Standard statistical methods were used to examine the ethnic differences in stroke mortality. RESULTS: The hazard ratios for black men and women (relative to non-Hispanic whites) were nearly identical, at > 4.0 at age 45 but marginally < 1.0 by age 85. For both Hispanic men and women, the hazard ratios (relative to non-Hispanic whites) were approximately 1.0 at age 45 but were marginally significantly < 1.0 at older ages. The ethnic differences in stroke death rates reveal differences in age distributions of age at fatal stroke between these groups. Approximately 6% of fatal strokes for non-Hispanic whites occurred before age 60, whereas > 15% occurred in both Hispanic whites and blacks. CONCLUSIONS: These results suggest that (1) for Hispanics, stroke risk is similar to that for non-Hispanic whites at young ages but is marginally lower at older ages, (2) the excess stroke mortality in blacks mainly occurs at younger ages (between 45 and 55 years), and (3) the relation between stroke risk for blacks and Hispanics relative to whites is similar by sex. The impact of age on relative stroke mortality would argue against simple age adjustment for describing ethnic differences in stroke mortality. Finally, proportionally, more strokes occur at older ages in non-Hispanic whites than in either US blacks or Hispanic whites.

Leptomeningeal tissue: a barrier against brain tumor cell invasion.

BACKGROUND: Primary brain tumors are characterized by an extensive infiltrative growth into the surrounding brain tissue. This process is confined to the central nervous system, and tumor cell metastasis to other organs is rare. However, other tumors of non-neural origin may frequently metastasize to the central nervous system. PURPOSE: The purpose of the present study was to examine the invasive behavior of different glioma cells into tissues of neural (brain aggregates) as well as non-neural origin (leptomeningeal tissue). Using the same target tissues, the invasive characteristics of two neural metastatic tumors (one malignant melanoma and one small-cell lung carcinoma) were also studied. This direct comparison of the invasive behavior between tumors of neural and non-neural origin provides valuable information regarding the mechanisms of glioma cell dissemination in the central nervous system. METHODS: The in vitro invasive behavior of human tumors of the central nervous system into human leptomeningeal tissue as well as into normal rat brain tissue was studied. For this purpose, a co-culture system consisting of tumor biopsy specimens, human leptomeningeal cell aggregates, and brain cell aggregates was established. Three glioblastomas, one oligodendroglioma, one meningioma, one small-cell lung carcinoma, and one malignant melanoma were studied. RESULTS: In co-cultures of gliomas and leptomeningeal cell aggregates, a well-defined border between the two tissues was observed. The brain cell aggregates, in contrast, were consistently invaded by the glioma cells. The brain metastases showed a different invasion pattern. The metastatic cells invaded and progressively destroyed leptomeningeal cell aggregates, whereas they did not invade the brain cell aggregates. Upon confrontation of the leptomeningeal tissue with the meningioma, a fusion of the two tissues was observed. Immunostaining of the leptomeningeal tissue showed a strong expression of the basement membrane components fibronectin, collagen type IV, and laminin with no expression of glial fibrillary acidic protein, neuron-specific enolase, or S-100 protein. CONCLUSIONS: The present study indicates that there may be important biologic differences between the invasive behavior of gliomas and non-neuroepithelial tumors. Our co-culture experiments suggest that leptomeningeal cells and associated acellular components may constitute a barrier against glioma cell invasion. However, this barrier may not be functional for metastatic tumors to the brain. The presence of glioma cells within the leptomeninges should not necessarily be taken as evidence of aggressive growth or as an indicator of malignancy.

Treatment of craniopharyngiomas: the multimodality approach.

A Multimodality Protocol for the treatment of craniopharyngiomas, where stereotactic methods are used preferentially, give long-term results not inferior to those reported when microsurgical removal has been the first therapeutic choice. Case material, treated in accordance with this protocol, is presented in a long-term perspective. The features of the protocol are discussed.

Mortality by Hispanic status in the United States.

OBJECTIVE: To compare all-cause and cause-specific mortality rates between Hispanic and non-Hispanic groups and estimate the effect of family income, place of birth, and place of residence on these rates. DESIGN: Cohort study using national survey data matched to the National Death Index, with a mortality follow-up period of 9 years. SETTING: The noninstitutionalized population of the United States. PARTICIPANTS: Approximately 700,000 respondents (aged 25 years or older), including 40,000 Hispanics, to national surveys conducted by the US Bureau of the Census (Current Population Surveys). OUTCOME MEASURES: All causes and underlying cause of death, coded from the death certificate, occurring between 1979 and 1987. RESULTS: Adjusting for age, Hispanics were shown to have lower mortality from all causes compared with non-Hispanics (standardized rate ratio [SRR], 0.74 for men, 0.82 for women), lower mortality from cancer (SRR, 0.69 for men, 0.61 for women), lower mortality from cardiovascular disease (SRR, 0.65 for men, 0.80 for women), higher mortality from diabetes (SRR, 1.86 for men, 2.38 for women), and higher mortality from homicide (SRR, 3.60 for men). After adjusting for differences in annual family income, the relative mortality ratios were even lower for Hispanics than non-Hispanics. CONCLUSIONS: These data describe, in a large national cohort study, a lower mortality in Hispanics than in non-Hispanics. This mortality is particularly low after adjustment for differences in family income.

The results of Gamma Knife surgery of meningiomas, related to size of tumor and dose.

In Bergen, 20 patients with meningiomas have been treated with a follow-up period in excess of 1 year. While this is too short a period to allow more than tentative conclusions to be drawn, some trends can be determined nonetheless. There has been some variation in the reporting of the results of treatment of meningiomas, with one group producing a reduction in size in 7% of patients and another in 34%. In the current material, 10 patients received 10 Gy or less to the edge of the tumor. In 4 of these 12 patients there was increase in the volume of the tumor within 1 year of treatment. Ten of the patients received 12 Gy or more to the edge of the tumor. Of these 10 patients, 4 had tumors which showed a reduction in volume. It is suggested that the difference in the reported rate of tumor volume reduction is related to differences in dose, which is discussed in relation to other treatment parameters.

The effects of Gamma Knife surgery of pituitary adenomas on tumor growth and endocrinopathies.

Fifteen patients were treated in the Gamma Knife Unit and followed for 18 months or longer. Four patients had Cushing's disease, 4 had acromegaly, 3 had Nelson's syndrome and 3 had prolactinomas. One patient had no endocrinopathy. One of the patients with acromegaly and 2 of those with prolactinomas had been operated prior to Gamma Knife treatment. Radiological tumor localization was not an insuperable problem in this series. The effect of Gamma Knife treatment on the anterior pituitary neoplasia, as such, was consistently successful. All the tumors which received 10 Gy or more to the edge showed either a reduction in volume or at least cessation of growth. On the other hand, the effect of the treatment was less consistent in respect to the endocrinopathies. These results are discussed in respect of dose and tumor size. It is suggested that the role of the Gamma Knife in the treatment of pituitary adenomas requires further clarification, based on prospective studies.