No abstract

If people stopped smoking, there would be a savings in health care costs, but only in the short term. Eventually, smoking cessation would lead to increased health care costs.

Objectives: To determine the demands on healthcare resources caused by different types of illnesses and variation with age and sex.

Abstract-Limited information exists about the consequences of hypertension during adulthood on residual life expectancy with cardiovascular disease. We aimed to analyze the life course of people with high blood pressure levels at age 50 in terms of total life expectancy and life expectancy with and without cardiovascular disease compared with normotensives. We constructed multistate life tables for cardiovascular disease, myocardial infarction, and stroke using data from 3128 participants of the Framingham Heart Study who had their 50th birthday while enrolled in the study. For the life table calculations, we used hazard ratios for 3 transitions (healthy to death, healthy to disease, and disease to death) by categories of blood pressure level and adjusted by age, sex, and confounders. Irrespective of sex, 50-year-old hypertensives compared with normotensives had a shorter life expectancy, a shorter life expectancy free of cardiovascular disease, myocardial infarction, and stroke, and a longer life expectancy lived with these diseases.Normotensive men (22% of men) survived 7.2 years (95% confidence interval, 5.6 to 9.0) longer without cardiovascular disease compared with hypertensives and spent 2.1 (0.9 to 3.4) fewer years of life with cardiovascular disease. Similar differences were observed in women. Compared with hypertensives, total life expectancy was 5.1 and 4.9 years longer for normotensive men and women, respectively. Increased blood pressure in adulthood is associated with large reductions in life expectancy and more years lived with cardiovascular disease. This effect is larger than estimated previously and affects both sexes similarly. Our findings underline the tremendous importance of preventing high blood pressure and its consequences in the population. Key Words: blood pressure Ⅲ cardiovascular diseases E levated blood pressure (BP) is a major modifiable risk factor for cardiovascular disease (CVD) and mortality. 1,2 Suboptimal BP (Ͼ115 mm Hg systolic BP [SBP]) is estimated to be responsible for 62% of cerebrovascular disease and 49% of coronary heart disease. 3 The relationship between BP and CVD risk is continuous and independent of other risk factors. 1,4,5 BP control has been shown to be effective in reducing CVD and mortality, although below expectations from observational evidence. 1,6,7 However, few studies have looked at the impact of BP on life expectancy (LE), 8,9 and none have evaluated its effects on LE with and without CVD. Therefore, whether improving the level of BP in the population will lead to more or fewer years lived with CVD remained uncertain.The answer to this question might seem obvious, but examples from other risk factors such as smoking or obesity show that results can be counterintuitive. Obesity is associated with a shorter LE and an increase in LE with CVD. Therefore, control of obesity would lead to less cardiovascular morbidity (M. Pardo Silva, unpublished data, 2003). Smoking is also associated with shorter LE but with fewer years lived with CVD because smokers, o...

OBJECTIVES. Many developed countries have seen declining mortality rates for heart disease, together with an alleged decline in incidence and a seemingly paradoxical increase in health care demands. This paper presents a model for forecasting the plausible evolution of heart disease morbidity. METHODS. The simulation model combines data from different sources. It generates acute coronary event and mortality rates from published data on incidences, recurrences, and lethalities of different heart disease conditions and interventions. Forecasts are based on plausible scenarios for declining incidence and increasing survival. RESULTS. Mortality is postponed more than incidence. Prevalence rates of morbidity will decrease among the young and middle-aged but increase among the elderly. As the milder disease states act as risk factors for the more severe states, effects will culminate in the most severe disease states with a disproportionate increase in older people. CONCLUSIONS. Increasing health care needs in the face of declining mortality rates are no contradiction, but reflect a tradeoff of mortality for morbidity. The aging of the population will accentuate this morbidity increase.

One of the applications of the multi-state life table is in the field of Public Health, with states defining various levels of health or functional ability. Another approach is to model Public Health by looking at the impact of individual diseases, but, unfortunately, then two practical problems arise: there are many diseases, and due to comorbidity people may be in several diseases states simultaneously. Both problems tend to make the number of states in the life table unpractically large. In this paper we introduce the proportional multi-state life table. It is especially designed to cope relatively easily with a large number of diseases simultaneously, while allowing for comorbidity. We provide proof of validity and an example implementation for cardiovascular disease.Multi-state life table, Illness-death processes, Comorbidity Submitted by C. M. Suchindran,

Ivermectin is an effective drug for the treatment of human onchocerciasis, a disease caused by the parasitic filarial nematode Onchocerca volvulus. When humans are treated, the microfilariae normally found in the skin are rapidly and very nearly completely eliminated. Nonetheless, after a delay, microfilariae gradually reappear in the skin. This study is concerned with the causes of this delay. Hypotheses are tested by comparing the results of model calculations with skin microfilaria counts collected from 114 patients during a trial of five annual treatments in the focus area of Asubende, Ghana. The results obtained strongly suggest that annual treatment with ivermectin causes an irreversible decline in microfilariae production of~30%/treatment. This result has important implications for public health strategies designed to eliminate onchocerciasis as a significant health hazard.The registration ofthe anthelminthic drug ivermectin (Mectizan; Merck, Rahway, NJ) in 1987 was a landmark in the control of human onchocerciasis or river blindness, a parasitic disease caused by the filarial nematode Onchocerca volvulus. Oral administration in a standard dose of 150-200 j.Lg/kg of body weight is followed by rapid elimination of microfilariae (Mf) from the skin and gradual reduction of ocular Mf levels [1]. Side effects are generally mild. This makes ivermectin a better therapeutic option than diethylcarbamazine, which is often accompanied by severe Mazotti reactions and ocular damage. Ivermectin also produces a longer suppression ofMfrepopulation of the skin [2,3]. To explain this difference, which was obvious in all studies done so far, the effects of ivermectin on adult parasites were studied.Adult female parasites in treated persons show an interruption of the normal embryogenesis, but after a single treatment, this appears to be reversible for most of the worms [4,5]. Excess worm mortality was not observed after a single treatment [1, 2, 6], although significant numbers of dead and mori-

Original participants and at 20 years of follow-up for 2268 Offspring participants. We measured the odds of disability in the Original cohort after 46 years follow-up, and we estimated life expectancy with and without disability from age 50. Two disability measures were used, one representing limitations with mobility only and the second representing limitations with activities of daily living (ADL). Results: Obesity at ages 30 to 49 years was associated with a 2.01-fold increase in the odds of ADL limitations 46 years later. Nonsmoking adults who were obese between 30 and 49 years lived 5.70 (95% confidence interval, 4.11 to 7.35) (men) and 5.02 (95% confidence interval, 3.36 to 6.61) (women) fewer years free of ADL limitations from age 50 than their normal-weight counterparts. There was no significant difference in the total number of years lived with disability throughout life between those obese or normal weight, due to both higher disability prevalence and higher mortality in the obese population. Discussion: Obesity in adulthood is associated with an increased risk of disability throughout life and a reduction in the length of time spent free of disability, but no substantial change in the length of time spent with disability.