Related Articles

Background:

Little is known about psychological risk factors in cerebrovascular disease. We examined the association between psychological distress and risk of death due to cerebrovascular disease.

Methods:

We obtained data from 68 652 adult participants of the Health Survey for England (mean age 54.9 [standard deviation 13.9] yr, 45.0% male sex) with no known history of cardiovascular diseases at baseline. We used the 12-item General Health Questionnaire (GHQ-12) to assess the presence of psychological distress. We followed participants for eight years for cause-specific death using linkage to national registers.

Results:

There were 2367 deaths due to cardiovascular disease during follow-up. Relative to participants with no symptoms of psychological distress (GHQ-12 score 0) at baseline, people with psychological distress (GHQ-12 score ≥ 4, 14.7% of participants) had an increased risk of death from cerebrovascular disease (adjusted hazard ratio [HR] 1.66, 95% confidence interval [CI] 1.32–2.08) and ischemic heart disease (adjusted HR 1.59, 95% CI 1.34–1.88). There was also evidence of a dose–response effect with increasing GHQ-12 score (p for trend < 0.001 in all analyses). Associations were only marginally attenuated after we adjusted for possible confounders, including socioeconomic status, smoking and use of antihypertensive medications.

Interpretation:

Psychological distress was associated with increased risk of death due to cerebrovascular disease in a large population-representative cohort. These data suggest that the cardiovascular effects of psychological distress are not limited to coronary artery disease.

Context

Previous studies have suggested that subclinical abnormalities in TSH levels are associated with detrimental effects on the cardiovascular system.

Objective

To determine the relationship between baseline thyroid status and incident atrial fibrillation, incident cardiovascular disease, and mortality in older men and women not taking thyroid medication.

Design, Setting, and Patients

Participants were 3,233 US community-dwelling individuals aged 65 or over with baseline serum TSH levels who were enrolled in 1989–1990 in the Cardiovascular Health Study (CHS), a large, prospective cohort study.

Main Outcome Measures

Incident atrial fibrillation, coronary heart disease, cerebrovascular disease, cardiovascular death, and all-cause death assessed through June, 2002.

Results

Analyses are reported for four groups defined according to thyroid function test results: subclinical hyperthyroidism, euthyroidism, subclinical hypothyroidism, and overt hypothyroidism. Individuals with overt thyrotoxicosis were excluded due to small numbers. Eighty-two percent of participants were euthyroid, 15% had subclinical hypothyroidism, 1.6% were overtly hypothyroid, and 1.5% had subclinical hyperthyroidism. After exclusion of those with prevalent atrial fibrillation, individuals with subclinical hyperthyroidism had a greater incidence of atrial fibrillation compared to the euthyroid group (67 events vs. 31 events per 1,000 person-years; p<.001, and an adjusted hazard ratio [AHR] of 1.98; 95% confidence interval [CI] 1.29–3.03). No differences were seen between the subclinical hyperthyroidism group and euthyroid group for incident coronary heart disease, cerebrovascular disease, cardiovascular death, or all-cause death. Likewise, there were no differences between the subclinical hypothyroidism or overt hypothyroidism groups and the euthyroid group for cardiovascular outcomes or mortality. Specifically, individuals with subclinical hypothyroidism had an AHR of 1.07 (95% CI, 0.90–1.28) for incident coronary heart disease.

Conclusions

Our data show an association between subclinical hyperthyroidism and the development of atrial fibrillation, but do not support the hypothesis that unrecognized subclinical hyperthyroidism or subclinical hypothyroidism is associated with other cardiovascular disorders or mortality.

Background

Self-reported health perceptions such as physical distress and quality of life are suggested independent predictors of mortality and morbidity in patients with established cardiovascular disease. This study examined the associations between these factors and three years incidence of cardiovascular events in a population of elderly men with long term hyperlipidemia.

Methods

We studied observational data in a cohort of 433 men aged 64–76 years from a prospective, 2 × 2 factorial designed, three-year interventional trial. Information of classical risk factors was obtained and the following questionnaires were administered at baseline: Hospital Anxiety and Depression Scale, Physical Symptom Distress Index and Life Satisfaction Index. The occurrence of cardiovascular death, myocardial infarction, cerebrovascular incidences and peripheral arterial disease were registered throughout the study period. Continuous data with skewed distribution was split into tertiles. Hazard ratios (HR) were calculated from Cox regression analyses to assess the associations between physical distress, quality of life and cardiovascular events.

Results

After three years, 49 cardiovascular events were registered, with similar incidence among subjects with and without established cardiovascular disease. In multivariate analyses adjusted for age, smoking, systolic blood pressure, serum glucose, HADS-anxiety and treatment-intervention, physical distress was positively associated (HR 3.1, 95% CI 1.2 – 7.9 for 3rd versus 1st tertile) and quality of life negatively associated (HR 2.6, 95% CI 1.1–5.8 for 3rd versus 1st tertile) with cardiovascular events. The association remained statistically significant only for physical distress (hazard ratio 2.8 95% CI 1.2 – 6.8, p < 0.05) when both variables were evaluated in the same model.

Conclusion

Physical distress, but not quality of life, was independently associated with increased risk of cardiovascular events in an observational study of elderly men predominantly without established cardiovascular disease.

Trial Registration

Trial registration: NCT00764010

Objective To evaluate the association of kidney function with cardiovascular disease and mortality among apparently healthy women.

Design Prospective cohort study.

Setting Women’s Health Study, United States.

Participants 27 939 female health professionals aged ≥45 who were free of cardiovascular disease and other major disease and who provided a blood sample at study entry.

Main outcome measures Time to cardiovascular disease (non-fatal stroke, non-fatal myocardial infarction, coronary revascularisation procedures, or death from cardiovascular cause), specific cardiovascular disease events, and all-cause mortality. End points were confirmed after review of medical records and death certificates.

Results Glomerular filtration rate (GFR) was estimated with the abbreviated Modification of Diet in Renal Disease Study equation. At baseline, 1315 (4.7%) women had GFR <60 ml/min/1.73 m2. During 12 years of follow-up, 1199 incident cardiovascular disease events and 856 deaths (179 from cardiovascular disease) occurred. Compared with women with GFR ≥90 ml/min/1.73 m2, the multivariable adjusted hazard ratios for any first cardiovascular disease were 0.95 (95% CI 0.83 to 1.08), 0.84 (0.70 to 1.00), and 1.00 (0.79 to 1.27) among women with GFR of 75-89.9, 60-74.9, and <60 ml/min/1.73 m2, respectively; the equivalent hazard ratios for all cause mortality were 0.93 (0.79 to 1.09), 1.03 (0.85 to 1.26), and 1.09 (0.83 to 1.45). Similar null findings were observed for myocardial infarction, stroke, coronary revascularisation, and non-cardiovascular death. However, an increased risk of death from cardiovascular disease was found among women with GFR <60 ml/min/1.73 m2 (hazard ratio 1.68 (1.02 to 2.79)).

Conclusions In this large cohort of women, a glomerular filtration rate <60 ml/min/1.73 m2 was associated with increased risk of cardiovascular disease death but not other cardiovascular disease events or non-cardiovascular disease mortality. We observed no increase in risk of any of the outcomes among women with less severe impairment of kidney function.

OBJECTIVES--(a) To determine the excess mortality from all causes and from coronary heart disease in patients with familial hypercholesterolaemia; (b) to examine how useful various criteria for selective measurement of cholesterol concentration in cardiovascular screening programmes are in identifying these patients. DESIGN--Prospective cohort study. SETTING--Eleven hospital outpatient lipid clinics in the United Kingdom. PATIENTS--282 men and 244 women aged 20-74 with heterozygous familial hypercholesterolaemia. MAIN OUTCOME MEASURE--Standardised mortality ratio, all adults in England and Wales being taken as standard (standardised mortality ratio = 100 for standard population). RESULTS--The cohort was followed up for 2234 person years during 1980-9. Fifteen of the 24 deaths were due to coronary heart disease, giving a standardised mortality ratio of 386 (95% confidence interval 210 to 639). The excess mortality from this cause was highest at age 20-39 (standardised mortality ratio 9686; 3670 to 21,800) and decreased significantly with age. The standardised mortality ratio for all causes was 183 (117 to 273) and also was highest at age 20-39 (standardised mortality ratio 902; 329 to 1950). There was no significant difference between men and women. Criteria for measurement of cholesterol concentration in cardiovascular screening programmes (family history, presence of myocardial infarction, angina, stroke, corneal arcus, xanthelasma, obesity, hypertension, diabetes, or any of these) were present in 78% of patients. CONCLUSIONS--Familial hypercholesterolaemia is associated with a substantial excess mortality from coronary heart disease in young adults but may not be associated with a substantial excess mortality in older patients. Criteria for selective measurement of cholesterol concentration in cardiovascular screening programmes identify about three quarters of patients with the clinically overt condition.

Does psychological distress increase mortality risk? If it does, are women more vulnerable than men to the effect of distress on mortality? Drawing from cumulative disadvantage theory, these questions are addressed with data from a 20-year follow-up of a national sample of adults ages 25−74. Event history analyses were performed to examine mortality from general and specific causes for men and women. Findings reveal that the effect of psychological distress on all-cause mortality was nonlinear for men. Moderate amounts of distress were associated with lower mortality risk, but high levels of distress raised men's mortality risk. Moreover, the curvilinear relationship between distress and mortality varied by cause of death for men and women. Men with high levels of psychological distress were more vulnerable to ischemic heart disease mortality. Women with high levels of distress were more vulnerable to cancer mortality.

Background

The course of major depressive disorder is often characterized by progressing chronicity, but whether this applies to the course of self-reported psychological distress remains unclear. We examined whether the risk of self-reported psychological distress becomes progressively higher the longer the history of distress and whether prolonged history of distress modifies associations between risk markers and future distress.

Methods

Participants were British civil servants from the prospective Whitehall II cohort study (n=7934; 31.5% women, mean age 44.5 years at baseline) followed from 1985 to 2006 with repeat data collected in 7 study phases. Psychological distress was assessed with the 30-item General Health Questionnaire (GHQ). Sex, socioeconomic status, marital status, ethnicity, physical activity, alcohol consumption, smoking, and obesity were assessed as risk markers.

Results

Recurrent history of psychological distress was associated with a progressively increasing risk of future distress in a dose-response manner. Common risk markers, such as low socioeconomic status, non-White ethnicity, being single, and alcohol abstinence were stronger predictors of subsequent distress in participants with a longer history of psychological distress. Sex differences in psychological distress attenuated with prolonged distress history.

Limitations

The participants were already adults in the beginning of the study, so we could not assess the progressive chronicity of psychological distress from adolescence onwards.

Conclusions

These data suggest that self-reported psychological distress becomes more persistent over time and that a longer prior exposure to psychological distress increases sensitivity to the stressful effects of certain risk markers.

Background

This study examined whether psychological distress might be a predictor of chronic obstructive pulmonary disease (COPD).

Method

The relation between psychological distress at baseline, measured by the general health questionnaire (GHQ), and chronic bronchitis three years later, as measured by the Medical Research Council (MRC) bronchitis questionnaire and forced expiratory flow in one second (FEV1), was examined in 1682 men and 2203 women from the Renfrew and Paisley (MIDSPAN) study. The analyses were run on men and women separately and adjustments were made for age, socioeconomic position, and lung function at baseline (FEV1). People with chronic diseases at baseline were then excluded to give a “healthy” baseline cohort. The effect of psychological distress on individual components of the MRC bronchitis questionnaire and FEV1 was also assessed.

Results

In multivariate analyses of the whole cohort baseline psychological distress in women was associated with reduced FEV1 at follow up (OR 1.31 95% CI 1.0 to 1.73) after adjustment. In women, in the healthy cohort, psychological distress was associated with chronic bronchitis (OR 2.00, 95% CI 1.16 to 3.46), symptoms of bronchial infection (OR 2.14, 95% CI 1.44 to 3.19), symptoms of breathlessness (OR 3.02, 95% CI 1.99 to 4.59), and reduced FEV1 (OR 1.62, 95% CI 1.13 to 2.32). In men psychological distress predicted symptoms of bronchial infection (OR 2.09, 95% CI 1.28 to 3.42).

Conclusion

This study supports research suggesting that psychological distress is associated with COPD and shows that psychological distress predicts COPD in women. The robustness of the association and the exact mechanism requires further investigation.

STUDY OBJECTIVES—To examine the association between perceived psychological stress and cause specific mortality in a population where perceived stress was not associated with material disadvantage.
DESIGN—Prospective observational study with follow up of 21 years and repeat screening of half the cohort five years from baseline. Measures included perceived psychological stress, coronary risk factors, and indices of lifecourse socioeconomic position.
SETTING—27 workplaces in Scotland.
PARTICIPANTS—5388 men (mean age 48 years) at first screening and 2595 men at second screening who had complete data on all measures.
MAIN OUTCOME MEASURES—Hazard ratios for all cause mortality and mortality from cardiovascular disease (ICD9 390-459), coronary heart disease (ICD9 410-414), smoking related cancers (ICD9 140, 141, 143-9, 150, 157, 160-163, 188 and 189), other cancers (ICD9 140-208 other than smoking related), stroke (ICD9 430-438), respiratory diseases (ICD9 460-519) and alcohol related causes (ICD9 141, 143-6, 148-9, 150, 155, 161, 291, 303, 571 and 800-998).
RESULTS—At first screening behavioural risk (higher smoking and alcohol consumption, lower exercise) was positively associated with stress. This relation was less apparent at second screening. Higher stress at first screening showed an apparent protective relation with all cause mortality and with most categories of cause specific mortality. In general, these estimates were attenuated on adjustment for social position. This pattern was also seen in relation to cumulative stress at first and second screening and with stress that increased between first and second screening. The pattern was most striking with regard to smoking related cancers: relative risk high compared with low stress at first screening, age adjusted 0.64 (95% CI 0.42, 0.96), p for trend 0.016, fully adjusted 0.69 (95% CI 0.45, 1.06), p for trend 0.10; high compared with low cumulative stress, age adjusted 0.69 (95% CI 0.44, 1.09), p for trend 0.12, fully adjusted 0.76 (95% CI 0.48, 1.21), p for trend 0.25; increased compared with decreased stress, age adjusted 0.65 (95% CI 0.40, 1.06), p for trend 0.09, fully adjusted 0.65 (95% CI 0.40, 1.06), p for trend 0.08.
CONCLUSIONS—This implausible protective relation between higher levels of stress, which were associated with increased smoking, and mortality from smoking related cancers, was probably a product of confounding. Plausible reported associations between psychosocial exposures and disease, in populations where such exposures are associated with material disadvantage, may be similarly produced by confounding, and of no causal significance.


Keywords: socioeconomic differentials; psychosocial factors; mortality

The Whitehall Study is a prospective epidemiological study of cardiovascular risk factors in healthy members of the British Civil Service, which has identified psychological distress as a major risk factor for coronary heart disease. The levels of circulating Hsp60 in 860 participants from the Whitehall cohort and 761 individuals diagnosed with diabetes have been measured and related to psychological, biological, and genetic factors. In the Whitehall participants, concentrations of Hsp60 ranged from undetectable to mg/mL levels. Circulating Hsp60 correlated with total and low-density lipoprotein (LDL) cholesterol and was positively associated with a flattened slope of cortisol decline over the day. Levels of this stress protein also correlated with measures of psychological stress including psychological distress, job demand, and low emotional support. Mass spectrometric analysis of circulating immunoreactive Hsp60 reveal that it is predominantly the intact protein with no mitochondrial import peptide, suggesting that this circulating protein emanates from mitochondria. The Hsp60 is stable when added to plasma and the levels in the circulation of individuals are remarkably constant over a 4-year period, suggesting plasma levels are partly genetically controlled. Sequence analysis of the HSP60-HSP10 intergenic promoter region identified a common variant 3175 C>G where the G allele had a frequency of 0.30 and was associated with higher Hsp60 levels in 761 type 2 diabetic patients. The extended range of plasma Hsp60 concentrations in the general population is genuine and is likely to be related to genetic, biological, and psychosocial risk factors for coronary artery disease.

STUDY OBJECTIVE: To determine whether ethnic differences in cardiovascular disease mortality persist in people with non-insulin-dependent diabetes mellitus. DESIGN: This was an ecological study in which routine mortality data from 1985-86, which coded all mentioned causes of death, provided the numerator. The UK population derived from 1981 census formed the denominator. SETTING: United Kingdom. PARTICIPANTS: Records of all deaths in people aged 45 years and above were extracted if diabetes was mentioned anywhere on the death certificate. The denominator was aged five years to approximate to the 1986 population. Mortality rates where a cardiovascular underlying cause was given were compared between South Asians, African-Caribbeans, and those born in England and Wales. The latter group formed the standard for directly standardised rate ratios. MAIN RESULTS: Mortality from heart disease was approximately three times higher in diabetic South Asian born men and women than in those with diabetes born in England and Wales. This ethnic difference was greatest in the younger age group. Conversely, stroke mortality rates in African-Caribbeans were 3.5-4 times higher than those in the England and Wales population. Despite this high mortality from stroke, ischaemic heart disease death rates were not high in African-Caribbean men. CONCLUSIONS: Ethnic differences in cardiovascular mortality persisted and were greater in those with diabetes. Thus the high risk of heart disease should be targeted for intervention in South Asians, and the high rates of stroke targeted in African-Caribbeans.

Aims

To examine the changes in coronary, all-cause, and cancer mortality in patients with heterozygous familial hypercholesterolaemia (FH) before and after lipid-lowering therapy with statins.

Methods and results

A total of 3382 patients (1650 men) aged <80 years were recruited from 21 lipid clinics in the United Kingdom and followed prospectively between 1980 and 2006 for 46 580 person-years. There were 370 deaths, including 190 from coronary heart disease (CHD) and 90 from cancer. The standardized mortality ratio (compared with the population in England and Wales) was calculated before and from 1 January 1992. In patients aged 20–79 years, CHD mortality fell significantly by 37% (95% CI = 7–56) from 3.4- to 2.1-fold excess. Primary prevention resulted in a 48% reduction in CHD mortality from 2.0-fold excess to none, with a smaller reduction of nearly 25% in patients with established disease. Coronary mortality was reduced more in women than in men. In patients without known CHD at registration, all-cause mortality from 1992 was 33% (21–43), lower than in the general population, mainly due to a 37% (21–50) lower risk of fatal cancer.

Conclusion

The results emphasize the importance of early identification of FH and treatment with statins.

Objectives

To examine the association between self perceived psychological stress and cardiovascular disease in a population where stress was not associated with social disadvantage.

Design

Prospective observational study with follow up of 21 years and repeat screening of half the cohort 5 years from baseline. Measures included perceived psychological stress, coronary risk factors, self reported angina, and ischaemia detected by electrocardiography.

Setting

27 workplaces in Scotland.

Participants

5606 men (mean age 48 years) at first screening and 2623 men at second screening with complete data on all measures

Main outcome measures

Prevalence of angina and ischaemia at baseline, odds ratio for incident angina and ischaemia at second screening, rate ratios for cause specific hospital admission, and hazard ratios for cause specific mortality.

Results

Both prevalence and incidence of angina increased with increasing perceived stress (fully adjusted odds ratio for incident angina, high versus low stress 2.66, 95% confidence interval 1.61 to 4.41; P for trend <0.001). Prevalence and incidence of ischaemia showed weak trends in the opposite direction. High stress was associated with a higher rate of admissions to hospital generally and for admissions related to cardiovascular disease and psychiatric disorders (fully adjusted rate ratios for any general hospital admission 1.13, 1.01 to 1.27, cardiovascular disease 1.20, 1.00 to 1.45, and psychiatric disorders 2.34, 1.41 to 3.91). High stress was not associated with increased admission for coronary heart disease (1.00, 0.76-1.32) and showed an inverse relation with all cause mortality, mortality from cardiovascular disease, and mortality from coronary heart disease, that was attenuated by adjustment for occupational class (fully adjusted hazard ratio for all cause mortality 0.94, 0.81 to 1.11, cardiovascular mortality 0.91, 0.78 to 1.06, and mortality from coronary heart disease 0.98, 0.75 to 1.27).

Conclusions

The relation between higher stress, angina, and some categories of hospital admissions probably resulted from the tendency of participants reporting higher stress to also report more symptoms. The lack of a corresponding relation with objective indices of heart disease suggests that these symptoms did not reflect physical disease. The data suggest that associations between psychosocial measures and disease outcomes reported from some other studies may be spurious.

What is already known on this topicHigher psychological stress has predicted coronary heart disease in several observational studiesExposure to stress and heart disease outcomes were often based on self report so that a general tendency to negative perceptions may have generated a spurious association between higher perceived stress and heart disease symptomsWhat this study addsPerceived stress was strongly related to subjective symptoms of heart disease, including those leading to hospital admissionHowever, stress showed a weakly inverse relation to all objective indices of heart disease: socially advantaged men perceived themselves to be most stressed, and the “protective” effect of stress was probably attributable to residual confoundingSuggestions that psychological stress is an important determinant of heart disease may be premature

Objective

Studies suggest that impaired kidney function is associated with cardiovascular disease (CVD) and mortality, particularly CVD death, among patients with existing kidney disease or CVD. Data in primary prevention are sparse. We aimed to evaluate the association of kidney function with CVD and mortality among apparently healthy women.

Design

Prospective cohort study among 27,939 female health professionals aged ≥45 who were free of CVD and provided a blood sample at study entry.

Setting

Women's health study, United States.

Main outcome measures

Time to CVD (nonfatal stroke, nonfatal myocardial infarction, coronary revascularization procedures, or death from cardiovascular cause), specific CVD events, and all-cause mortality. Endpoints were confirmed after medical record and death certificate review.

Results

We estimated glomerular filtration rate (GFR) using the abbreviated Modification-of-Diet-in-Renal-Disease-Study equation. At baseline, 1,315 (4.7%) women had GFR <60 ml/min/1.73m2. During 12 years of follow-up, 1,199 incident CVD events and 856 deaths (179 from CVD) occurred. Compared with women with GFR ≥90 ml/min/1.73m2, the multivariable-adjusted hazard ratios (HRs) (95% confidence intervals) were 0.95 (0.83−1.08), 0.84 (0.70−1.00), and 1.00 (0.79−1.27) for any first CVD and 0.93 (0.79−1.09), 1.03 (0.85−1.26), and 1.09 (0.83−1.45) for all-cause mortality among women with GFR levels of 75−89.9, 60−74.9, and <60 ml/min/1.73 m2, respectively. Similar null findings were observed for myocardial infarction, stroke, coronary revascularization, and non-cardiovascular death. In contrast, we observed an increased risk of CVD death (HR=1.68; 1.02−2.79) for women with GFR <60 ml/min/1.73m2.

Conclusions

In this large cohort of women, GFR <60 ml/min/1.73m2 appeared to be associated with increased risk of CVD death but not other CVD events or non-CVD mortality. We observed no increase in risk of any of the outcomes among women with less severe impairment of kidney function.

Objective To assess the temporal trends in occupation specific all causes and cause specific mortality in Japan between 1980 and 2005.

Design Longitudinal analysis of individual death certificates by last occupation before death. Data on population by age and occupation were derived from the population census.

Setting Government records, Japan.

Participants Men aged 30-59.

Main outcome measures Age standardised mortality rate for all causes, all cancers, cerebrovascular disease, ischaemic heart disease, unintentional injuries, and suicide.

Results Age standardised mortality rates for all causes and for the four leading causes of death (cancers, ischaemic heart disease, cerebrovascular disease, and unintentional injuries) steadily decreased from 1980 to 2005 among all occupations except for management and professional workers, for whom rates began to rise in the late 1990s (P<0.001). During the study period, the mortality rate was lowest in other occupations such as production/labour, clerical, and sales workers, although overall variability of the age standardised mortality rate across occupations widened. The rate for suicide rapidly increased since the late 1990s, with the greatest increase being among management and professional workers.

Conclusions Occupational patterns in cause specific mortality changed dramatically in Japan during the period of its economic stagnation and resulted in the reversal of occupational patterns in mortality that have been well established in western countries. A significant negative effect on the health of management and professional workers rather than clerks and blue collar workers could be because of increased job demands and more stressful work environments and could have eliminated or even reversed the health inequality across occupations that had existed previously.

Background

Psychological factors associated with low social status have been proposed as one possible explanation for the socio-economic gradient in health. The aim of this study is to explore whether different indicators of psychological distress contribute to socio-economic differences in cause-specific mortality.

Methods

The data source is a nationally representative, repeated cross-sectional survey, "Health Behaviour and Health among the Finnish Adult Population" (AVTK). The survey results were linked with socio-economic register data from Statistics Finland (from the years 1979-2002) and mortality follow-up data up to 2006 from the Finnish National Cause of Death Register. The data included 32451 men and 35420 women (response rate 73.5%). Self-reported measures of depression, insomnia and stress were used as indicators of psychological distress. Socio-economic factors included education, employment status and household income. Mortality data consisted of unnatural causes of death (suicide, accidents and violence, and alcohol-related mortality) and coronary heart disease (CHD) mortality. Adjusted hazard ratios were calculated using the Cox regression model.

Results

In unnatural mortality, psychological distress accounted for some of the employment status (11-31%) and income level (4-16%) differences among both men and women, and for the differences related to the educational level (5-12%) among men; the educational level was associated statistically significantly with unnatural mortality only among men. Psychological distress had minor or no contribution to socio-economic differences in CHD mortality.

Conclusions

Psychological distress partly accounted for socio-economic disparities in unnatural mortality. Further studies are needed to explore the role and mechanisms of psychological distress associated with socio-economic differences in cause-specific mortality.

Study objective: To assess total and cause specific mortality among participants and non-participants of large population based health surveys.

Design: A prospective follow up study. Baseline surveys were conducted in 1972, 1977, 1982, 1987, and 1992. Study end points were overall, cardiovascular, cancer and violent mortality, and deaths related to smoking and alcohol. Study cohorts were followed up until the end of 2000 through computerised record linkage. All analyses were adjusted for age.

Setting: Finland.

Participants: Participants and non-participants of five population based risk factor surveys. The samples included 54 372 men and women aged 25 to 64 years at baseline.

Main results: The average participation rate was 81.7% among men and 87% among women. At eight year follow up, the non-participating men had twice and non-participating women 2.5-fold higher overall mortality than the participating men and women. Non-participants had also significantly higher cause specific mortality, except cancer and smoking related mortality among women. Relative differences in mortality were largest in violent and alcohol related deaths. Non-participants had considerably higher overall mortality than smoking participants, and their mortality was threefold compared with non-smoking participants.

Conclusions: Observed differences in mortality show that health behaviour and health status substantially differ between non-participants and participants. Low participation rate may considerably bias the results of population based health surveys.

Background & Aims

Gallstones are common and contribute to morbidity and health-care costs, but their effects on mortality are unclear. We examined whether gallstone disease was associated with overall and cause-specific mortalities in a prospective national population-based sample.

Methods

We analyzed data from 14,228 participants in the third U.S. National Health and Nutrition Examination Survey (20–74 years old) who underwent gallbladder ultrasonography from 1988 to 1994. Gallstone disease was defined as ultrasound-documented gallstones or evidence of cholecystectomy. The underlying cause of death was identified from death certificates collected through 2006 (mean follow up=14.3 years). Mortality hazard ratios (HR) were calculated using Cox proportional hazards regression analysis, to adjust for multiple demographic and cardiovascular-disease risk factors.

Results

The prevalence of gallstones was 7.1% and of cholecystectomy was 5.3%. During a follow-up period of 18 years or more, the cumulative mortality was 16.5% from all causes (2,389 deaths), 6.7% from cardiovascular disease (886 deaths), and 4.9% from cancer (651 deaths). Participants with gallstone disease had higher all-cause mortality in age-adjusted (HR, 1.3; 95% confidence interval [CI], 1.2–1.5) and multivariate-adjusted analysis (HR, 1.3; 95% CI, 1.1–1.5). A similar increase was observed for cardiovascular disease mortality (multivariate-adjusted HR, 1.4; 95% CI, 1.2–1.7) and cancer mortality (multivariate-adjusted HR, 1.3; 95% CI, 0.98–1.8). Individuals with gallstones had a similar increase in risk of death as those with cholecystectomy (multivariate-adjusted HR, 1.1; 95% CI, 0.92–1.4).

Conclusions

In the U.S. population, persons with gallstone disease have increased mortality, overall, and mortalities from cardiovascular disease and cancer. This relationship was found for both ultrasound-diagnosed gallstones and cholecystectomy.

STUDY OBJECTIVE: Previous studies have established a relationship between low levels of social networks and total mortality, but few have examined cause specific mortality or disease incidence. This study aimed to examine prospectively the relationships between social networks and total and cause specific mortality, as well as cardiovascular disease incidence. DESIGN: This was a four year follow up study in an ongoing cohort of men, for whom information on social networks was collected at baseline. The main outcome measures were total mortality, further categorised into deaths from cardiovascular disease (stroke and coronary heart disease), total cancer, accidents/suicides, and all other causes; as well as stroke and coronary heart disease incidence. PARTICIPANTS: Altogether 32,624 US male health professionals aged 42 to 77 years in 1988, who were free of coronary heart disease, stroke, and cancer at baseline. RESULTS: A total of 511 deaths occurred during 122,911 person years of follow up. Compared with men with the highest level of social networks, socially isolated men (not married, fewer than six friends or relatives, no membership in church or community groups) were at increased risk for cardiovascular disease mortality (age adjusted relative risk, 1.90; 95% CI 1.07, 3.37) and deaths from accidents and suicides (age adjusted relative risk 2.22; 95% CI 0.76, 6.47). No excess risks were found for other causes of death. Socially isolated men were also at increased risk of stroke incidence (relative risk, 2.21; 95% CI, 1.12, 4.35), but not incidence of non-fatal myocardial infarction. CONCLUSIONS: Social networks were associated with lower total mortality by reducing deaths from cardiovascular disease and accidents/suicides. Strong social networks were associated with reduced incidence of stroke, though not of coronary heart disease. However, social networks may assist in prolonging the survival of men with established coronary heart disease.

Background

Little is known about the impact of life-threatening obstetric complications (‘near miss’) on women's mental health in low- and middle-income countries.

Aims

To examine the relationships between near miss and postpartum psychological distress in the Republic of Benin.

Method

One-year prospective cohort using epidemiological and ethnographic techniques in a population of women delivering at health facilities.

Results

In total 694 women contributed to the study. Except when associated with perinatal death, near-miss events were not associated with greater risk of psychological distress in the 12 months postpartum compared with uncomplicated childbirth. Much of the direct effect of near miss with perinatal death on increased risk of psychological distress was shown to be mediated through wider consequences of traumatic childbirth.

Conclusions

A live baby protects near-miss women from increased vulnerability by giving a positive element in their lives that helps them cope and reduces their risk of psychological distress. Near-miss women with perinatal death should be targeted early postpartum to prevent or treat the development of depressive symptoms.

Background

Little is known about the impact of life-threatening obstetric complications (‘near miss’) on women’s mental health in low- and middle-income countries.

Aims

To examine the relationships between near miss and postpartum psychological distress in the Republic of Benin.

Method

One-year prospective cohort using epidemiological and ethnographic techniques in a population of women delivering at health facilities.

Results

In total 694 women contributed to the study. Except when associated with perinatal death, near-miss events were not associated with greater risk of psychological distress in the 12 months postpartum compared with uncomplicated childbirth. Much of the direct effect of near miss with perinatal death on increased risk of psychological distress was shown to be mediated through wider consequences of traumatic childbirth.

Conclusions

A live baby protects near-miss women from increased vulnerability by giving a positive element in their lives that helps them cope and reduces their risk of psychological distress. Near-miss women with perinatal death should be targeted early postpartum to prevent or treat the development of depressive symptoms.

Objective

The authors evaluated the burden of smoking on six causes of death in women using various novel modeling approaches.

Design

A prospective US-based nationwide cohort study.

Participants

102,635 women in the Nurses’ Health Study followed biennially from 1980–2004.

Methods

The authors compared the relationship between cigarette-smoking and cause-specific death using baseline versus biennially-updated smoking status. They used competing risk survival analysis to formally compare associations of smoking-related variables on risk of death due to coronary heart disease (CHD), cerebrovascular diseases, lung cancer, other respiratory diseases, other smoking-caused cancers, and other causes.

Results

The associations of current and former smoking were stronger with most cause-specific mortality when using updated information. The effect of each smoking-related variable differed significantly (ph < 0.0001) across some causes of death. For example, risks increased by 5% for death due to other causes up to 37% for lung cancer death for a 5-year earlier age at initiation. Compared with continuing to smoke, former smokers with 5 to 10 years of cessation had a 25% reduction in risk of dying from other causes of death up to a 61% reduction in risk of dying from CHD and cerebrovascular diseases.

Conclusions

The risks of smoking and the benefits from quitting are greater than previously reported, when utilizing repeated measures of smoking data collected during follow-up, and vary by cause of death. Focused efforts to communicate the benefits of quitting to smokers and to prevent smoking initiation among children and youth should remain top public health priorities to reduce the worldwide mortality burden due to smoking.

Objective To develop and validate version two of the QRISK cardiovascular disease risk algorithm (QRISK2) to provide accurate estimates of cardiovascular risk in patients from different ethnic groups in England and Wales and to compare its performance with the modified version of Framingham score recommended by the National Institute for Health and Clinical Excellence (NICE).

Design Prospective open cohort study with routinely collected data from general practice, 1 January 1993 to 31 March 2008.

Setting 531 practices in England and Wales contributing to the national QRESEARCH database.

Participants 2.3 million patients aged 35-74 (over 16 million person years) with 140 000 cardiovascular events. Overall population (derivation and validation cohorts) comprised 2.22 million people who were white or whose ethnic group was not recorded, 22 013 south Asian, 11 595 black African, 10 402 black Caribbean, and 19 792 from Chinese or other Asian or other ethnic groups.

Main outcome measures First (incident) diagnosis of cardiovascular disease (coronary heart disease, stroke, and transient ischaemic attack) recorded in general practice records or linked Office for National Statistics death certificates. Risk factors included self assigned ethnicity, age, sex, smoking status, systolic blood pressure, ratio of total serum cholesterol:high density lipoprotein cholesterol, body mass index, family history of coronary heart disease in first degree relative under 60 years, Townsend deprivation score, treated hypertension, type 2 diabetes, renal disease, atrial fibrillation, and rheumatoid arthritis.

Results The validation statistics indicated that QRISK2 had improved discrimination and calibration compared with the modified Framingham score. The QRISK2 algorithm explained 43% of the variation in women and 38% in men compared with 39% and 35%, respectively, by the modified Framingham score. Of the 112 156 patients classified as high risk (that is, ≥20% risk over 10 years) by the modified Framingham score, 46 094 (41.1%) would be reclassified at low risk with QRISK2. The 10 year observed risk among these reclassified patients was 16.6% (95% confidence interval 16.1% to 17.0%)—that is, below the 20% treatment threshold. Of the 78 024 patients classified at high risk on QRISK2, 11 962 (15.3%) would be reclassified at low risk by the modified Framingham score. The 10 year observed risk among these patients was 23.3% (22.2% to 24.4%)—that is, above the 20% threshold. In the validation cohort, the annual incidence rate of cardiovascular events among those with a QRISK2 score of ≥20% was 30.6 per 1000 person years (29.8 to 31.5) for women and 32.5 per 1000 person years (31.9 to 33.1) for men. The corresponding figures for the modified Framingham equation were 25.7 per 1000 person years (25.0 to 26.3) for women and 26.4 (26.0 to 26.8) for men). At the 20% threshold, the population identified by QRISK2 was at higher risk of a CV event than the population identified by the Framingham score.

Conclusions Incorporating ethnicity, deprivation, and other clinical conditions into the QRISK2 algorithm for risk of cardiovascular disease improves the accuracy of identification of those at high risk in a nationally representative population. At the 20% threshold, QRISK2 is likely to be a more efficient and equitable tool for treatment decisions for the primary prevention of cardiovascular disease. As the validation was performed in a similar population to the population from which the algorithm was derived, it potentially has a “home advantage.” Further validation in other populations is therefore advised.

Background

Rural Australians face a higher mental health and lifestyle disease burden (obesity, diabetes and cardiovascular disease) than their urban counterparts. Our ongoing research reveals that the Australian farming community has even poorer physical and mental health outcomes than rural averages. In particular, farm men and women have high rates of overweightness, obesity, abdominal adiposity, high blood pressure and psychological distress when compared against Australian averages. Within our farming cohort we observed a significant association between psychological distress and obesity, abdominal adiposity and body fat percentage in the farming population.

Presentation of hypothesis

This paper presents a hypothesis based on preliminary data obtained from an ongoing study that could potentially explain the complex correlation between obesity, psychological distress and physical activity among a farming population. We posit that spasmodic physical activity, changing farm practices and climate variability induce prolonged stress in farmers. This increases systemic cortisol that, in turn, promotes abdominal adiposity and weight gain.

Testing the hypothesis

The hypothesis will be tested by anthropometric, biochemical and psychological analysis matched against systemic cortisol levels and the physical activity of the subjects.

Implications of the hypothesis tested

Previous studies indicate that farming populations have elevated rates of psychological distress and high rates of suicide. Australian farmers have recently experienced challenging climatic conditions including prolonged drought, floods and cyclones. Through our interactions and through the media it is not uncommon for farmers to describe the effect of this long-term stress with feelings of 'defeat'. By gaining a greater understanding of the role cortisol and physical activity have on mental and physical health we may positively impact the current rates of psychological distress in farmers.

Trial registration

ACTRN12610000827033

This study examined the relation between immune response to cytomegalovirus (CMV) and all-cause and cardiovascular disease (CVD) mortality, and possible mediating mechanisms. Data were derived from the Sacramento Area Latino Study on Aging, a population-based study of older Latinos (aged 60–101 years) in California followed in 1998–2008. CMV immunoglobulin G (IgG), tumor necrosis factor, and interleukin-6 were assayed from baseline blood draws. Data on all-cause and CVD mortality were abstracted from death certificates. Analyses included 1,468 of 1,789 participants. For individuals with CMV IgG antibody titers in the highest quartile compared with lower quartiles, fully adjusted models showed that all-cause mortality was 1.43 times (95% confidence interval: 1.14, 1.79) higher over 9 years. In fully adjusted models, the hazard of CVD mortality was also elevated (hazard ratio = 1.35, 95% confidence interval: 1.01, 1.80). A composite measure of tumor necrosis factor and interleukin-6 mediated a substantial proportion of the association between CMV and all-cause (18.9%, P < 0.001) and CVD (29.0%, P = 0.02) mortality. This study is the first known to show that high CMV IgG antibody levels are significantly related to mortality and that the relation is largely mediated by interleukin-6 and tumor necrosis factor. Further studies investigating methods for reducing IgG antibody response to CMV are warranted.