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1.  Life expectancy in relation to cardiovascular risk factors: 38 year follow-up of 19 000 men in the Whitehall study 
Objective To assess life expectancy in relation to cardiovascular risk factors recorded in middle age.
Design Prospective cohort study.
Setting Men employed in the civil service in London, England.
Participants 18 863 men examined at entry in 1967-70 and followed for 38 years, of whom 13 501 died and 4811 were re-examined in 1997.
Main outcome measures Life expectancy estimated in relation to fifths and dichotomous categories of risk factors (smoking, “low” or “high” blood pressure (≥140 mm Hg), and “low” or “high” cholesterol (≥5 mmol/l)), and a risk score from these risk factors.
Results At entry, 42% of the men were current smokers, 39% had high blood pressure, and 51% had high cholesterol. At the re-examination, about two thirds of the previously “current” smokers had quit smoking shortly after entry and the mean differences in levels of those with high and low levels of blood pressure and cholesterol were attenuated by two thirds. Compared with men without any baseline risk factors, the presence of all three risk factors at entry was associated with a 10 year shorter life expectancy from age 50 (23.7 v 33.3 years). Compared with men in the lowest 5% of a risk score based on smoking, diabetes, employment grade, and continuous levels of blood pressure, cholesterol concentration, and body mass index (BMI), men in the highest 5% had a 15 year shorter life expectancy from age 50 (20.2 v 35.4 years).
Conclusion Despite substantial changes in these risk factors over time, baseline differences in risk factors were associated with 10 to 15 year shorter life expectancy from age 50.
PMCID: PMC2746269  PMID: 19762417
2.  Effect of influenza vaccination on excess deaths occurring during periods of high circulation of influenza: cohort study in elderly people 
BMJ : British Medical Journal  2004;329(7467):660.
Objective To estimate the protection against death provided by vaccination against influenza.
Design Prospective cohort follow up supplemented by weekly national counts of influenza confirmed in the community.
Setting Primary care.
Participants 24 535 patients aged over 75 years from 73 general practices in Great Britain.
Main outcome measure Death.
Results In unvaccinated members of the cohort daily all cause mortality was strongly associated with an index of influenza circulating in the population (mortality ratio 1.16, 95% confidence interval 1.04 to 1.29 at 90th centile of circulating influenza). The association was strongest for respiratory deaths but was also present for cardiovascular deaths. In contrast, in vaccinated people mortality from any cause was not associated with circulating influenza. The difference in patterns between vaccinated and unvaccinated people could not easily be due to chance (P = 0.02, all causes).
Conclusions This study, using a novel and robust approach to control for confounding, provides robust evidence of a protective effect on mortality of vaccination against influenza.
PMCID: PMC517645  PMID: 15313884
3.  Vulnerability to winter mortality in elderly people in Britain: population based study 
BMJ : British Medical Journal  2004;329(7467):647.
Objective To examine the determinants of vulnerability to winter mortality in elderly British people.
Design Population based cohort study (119 389 person years of follow up).
Setting 106 general practices from the Medical Research Council trial of assessment and management of older people in Britain.
Participants People aged ≥ 75 years.
Main outcome measures Mortality (10 123 deaths) determined by follow up through the Office for National Statistics.
Results Month to month variation accounted for 17% of annual all cause mortality, but only 7.8% after adjustment for temperature. The overall winter:non-winter rate ratio was 1.31 (95% confidence interval 1.26 to 1.36). There was little evidence that this ratio varied by geographical region, age, or any of the personal, socioeconomic, or clinical factors examined, with two exceptions: after adjustment for all major covariates the winter:non-winter ratio in women compared with men was 1.11 (1.00 to 1.23), and those with a self reported history of respiratory illness had a winter:non-winter ratio of 1.20 (1.08 to 1.34) times that of people without a history of respiratory illness. There was no evidence that socioeconomic deprivation or self reported financial worries were predictive of winter death.
Conclusion Except for female sex and pre-existing respiratory illness, there was little evidence for vulnerability to winter death associated with factors thought to lead to vulnerability. The lack of socioeconomic gradient suggests that policies aimed at relief of fuel poverty may need to be supplemented by additional measures to tackle the burden of excess winter deaths in elderly people.
PMCID: PMC517639  PMID: 15315961
4.  Screening older people for impaired vision in primary care: cluster randomised trial 
BMJ : British Medical Journal  2003;327(7422):1027.
Objective To determine the effectiveness of screening for visual impairment in people aged 75 or over as part of a multidimensional screening programme.
Design Cluster randomised trial.
Setting General practices in the United Kingdom participating in the MRC trial of assessment and management of older people in the community.
Participants 4340 people aged 75 years or over randomly sampled from 20 general practices, excluding people resident in hospitals or nursing homes.
Intervention Visual acuity testing and referral to eye services for people with visual impairment. Universal screening (assessment and visual acuity testing) was compared with targeted screening, in which only participants with a range of health related problems were offered an assessment that included acuity screening.
Main outcome measures Proportion of people with visual acuity less than 6/18 in either eye; mean composite score of 25 item version of the National Eye Institute visual function questionnaire.
Results Three to five years after screening, the relative risk of having visual acuity < 6/18 in either eye, comparing universal with targeted screening, was 1.07 (95% confidence interval 0.84 to 1.36; P = 0.58). The mean composite score of the visual function questionnaire was 85.6 in the targeted screening group and 86.0 in the universal group (difference 0.4, 95% confidence interval -1.7 to 2.5, P = 0.69).
Conclusions Including a vision screening component by a practice nurse in a pragmatic trial of multidimensional screening for older people did not lead to improved visual outcomes.
PMCID: PMC261660  PMID: 14593039
6.  Randomised comparison of three methods of administering a screening questionnaire to elderly people: findings from the MRC trial of the assessment and management of older people in the community 
BMJ : British Medical Journal  2001;323(7326):1403.
To compare three different methods of administering a brief screening questionnaire to elderly people: post, interview by lay interviewer, and interview by nurse.
Randomised comparison of methods within a cluster randomised trial.
106 general practices in the United Kingdom.
32 990 people aged 75 years or over registered with participating practices.
Main outcome measures
Response rates, proportion of missing values, prevalence of self reported morbidity, and sensitivity and specificity of self reported measures by method of administration of questionnaire for four domains.
The response rate was higher for the postal questionnaire than for the two interview methods combined (83.5% v 74.9%; difference 8.5%, 95% confidence interval 4.4% to 12.7%, P<0.001). The proportion of missing or invalid responses was low overall (mean 2.1%) but was greater for the postal method than for the interview methods combined (4.1% v 0.9%; difference 3.2%, 2.7% to 3.6%, P<0.001). With a few exceptions, levels of self reported morbidity were lower in the interview groups, particularly for interviews by nurses. The sensitivity of the self reported measures was lower in the nurse interview group for three out of four domains, but 95% confidence intervals for the estimates overlapped. Specificity of the self reported measures varied little by method of administration.
Postal questionnaires were associated with higher response rates but also higher proportions of missing values than were interview methods. Lower estimates of self reported morbidity were obtained with the nurse interview method and to a lesser extent with the lay interview method than with postal questionnaires.
What is already known on this topicThe optimum method of administering a brief multidimensional screening assessment to elderly people is not knownWhat this study addsPostal questionnaires produce a higher response rate than interviews by nurses or lay interviewers but also higher proportions of missing dataInterview by nurses and to a lesser degree by lay interviewers is associated with lower levels of self reported morbidity than are postal questionnaires
PMCID: PMC60986  PMID: 11744565

Results 1-8 (8)