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Objectives To conduct the first-ever nationwide, population-based cohort study investigating survival patterns of all patients with incident SSc in Sweden compared with matched individuals from the Swedish general population. Methods We used the National Patient Register to identify patients with incident SSc diagnosed between 2004 and 2015 and the Total Population Register to identify comparators (1:5), matched on sex, birth year and residential area. We followed them until death, emigration or the end of 2016. Follow-up of the general population comparators started the same date as their matched patients were included. We estimated all-cause survival using the Kaplan–Meier method, crude mortality rates and hazard ratios (HRs) using flexible parametric models. Results We identified 1139 incident patients with SSc and 5613 matched comparators. The median follow-up was 5.0 years in patients with SSc and 6.0 years for their comparators. During follow-up, 268 deaths occurred in patients with SSc and 554 in their comparators. The 5-year survival was 79.8% and the 10-year survival was 67.7% among patients with SSc vs 92.9% and 84.8%, respectively, for the comparators (P  < 0.0001). The mortality rate in patients with SSc was 42.1 per 1000 person-years and 15.8 per 1000 person-years in their comparators, corresponding to an HR of 3.7 (95% CI 2.9, 4.7) at the end of the first year of follow-up and 2.0 (95% CI 1.4, 2.8) at the end of the follow-up period. Conclusion Despite advances in understanding the disease and in diagnostic methods over the past decades, survival is still severely impacted in Swedish patients diagnosed with SSc between 2004 and 2015. [ABSTRACT FROM AUTHOR]

Context: The effects of polycystic ovary syndrome (PCOS) on cardiovascular morbidity and mortality are unclear.Objective: This work aims to establish the relative risk of myocardial infarction (MI), stroke, angina, revascularization, and cardiovascular mortality for women with PCOS.Methods: Data were extracted from the Clinical Practice Research Datalink Aurum database. Patients with PCOS were matched to controls (1:1) by age, body mass index (BMI) category, and primary care practice. The primary outcome was the time to major adverse cardiovascular event (MACE); a composite end point incorporating MI, stroke, angina, revascularization and cardiovascular mortality. Secondary outcomes were the individual MACE end points.Results: Of 219 034 individuals with a diagnosis of PCOS, 174 660 (79.7%) met the eligibility criteria and were matched. Crude rates of the composite end point, MI, stroke, angina, revascularization, and cardiovascular mortality were respectively 82.7, 22.7, 27.4, 32.8, 10.5, and 6.97 per 100 000 patient-years for cases, and 64.3, 15.9, 25.7, 19.8, 7.13, and 7.75 per 100 000 patient-years for controls. In adjusted Cox proportional hazard models (CPHMs), the hazard ratios (HRs) were 1.26 (95% CI, 1.13-1.41), 1.38 (95% CI, 1.11-1.72), 1.60 (95% CI, 1.32-1.94), and 1.50 (95% CI, 1.08-2.07) for the composite outcome, MI, angina, and revascularization, respectively. In a time-dependent CPHM, weight gain (HR 1.01; 1.00-1.01), prior type 2 diabetes mellitus (T2DM) (HR 2.40; 1.76-3.30), and social deprivation (HR 1.53; 1.11-2.11) increased risk of progression to the composite end point.Conclusion: The risk of incident MI, angina, and revascularization is increased in young women with PCOS. Weight and T2DM are potentially modifiable risk factors amenable to intervention. [ABSTRACT FROM AUTHOR]

Objective: To investigate the characteristics of hip fractures in patients with rheumatoid arthritis (RA). Methods: Between 2012 and 2015, 789 hip fractures were treated at our hospital. Patients with RA were checked and their characteristics were compared with data recorded 10 years before, and with the general population. Results: There were 11 patients with RA, who were all female, and the mean age was 76 ± 7.0 years. The age at the time of hip fracture was 4 years older than that recorded 10 years before (72 ± 4.5 years, p<.05), but was younger than that of the general population (84 ± 8.0 years, p<.001). The mean prednisolone dose of 2.5 ± 2.6mg/day was lower than that recorded 10 years before (4.8 ± 2.9mg/day, p<.05). The rate of patients treated with anti-osteoporotic medications at fracture (73%) was higher than 10 years before (42%); however, the difference was not significant. The incidence of secondary fracture was not high compared to the general population. No mortality was recorded at 1 year, and no infective complications occurred. Conclusion: The age at the time of hip fracture in RA patients is increasing, but is still younger than that of the general population. [ABSTRACT FROM AUTHOR]

Summary: Forecasts of mortality provide vital information about future populations, with implications for pension and healthcare policy as well as for decisions made by private companies about life insurance and annuity pricing. The paper presents a Bayesian approach to the forecasting of mortality that jointly estimates a generalized additive model (GAM) for mortality for the majority of the age range and a parametric model for older ages where the data are sparser. The GAM allows smooth components to be estimated for age, cohort and age‐specific improvement rates, together with a non‐smoothed period effect. Forecasts for the UK are produced by using data from the human mortality database spanning the period 1961–2013. A metric that approximates predictive accuracy is used to estimate weights for the 'stacking' of forecasts from models with different points of transition between the GAM and parametric elements. Mortality for males and females is estimated separately at first, but a joint model allows the asymptotic limit of mortality at old ages to be shared between sexes and furthermore provides for forecasts accounting for correlations in period innovations. [ABSTRACT FROM AUTHOR]

Introduction: Sickle cell trait (SCT) affects an estimated 5.02% of non-Hispanic blacks, 1.08% of Hispanics, and 0.1% of Whites in the U.S. military. Policies for SCT screening and occupational restrictions vary by service. Population-based studies of SCT with quantification of military-relevant outcomes are lacking.Methods: The study design was a retrospective cohort of 15,081 SCT-positive versus 60,320 SCT-negative U.S. active duty personnel enlisted from 1992 to 2012 and followed through 2013. Military-relevant outcome included number and days of deployment, length of service, and cause of death.Results: SCT-positive versus SCT-negative service members experienced more deployments (p < 0.01) and longer number of days deployed for all services, especially the Army (p < 0.001). The median length of service was longer for SCT-positive service members stratified by service and by gender (p < 0.05). The adjusted risk of length of service greater than 5 yr by SCT status was 1.37 (95% confidence interval 1.31-1.43) with greater than a three-fold higher risk in the Navy and Air Force compared with the Army. Crude mortality rate was not significantly different by SCT status, although deaths due to suicide, self-directed violence, and other non-specific causes were more common in SCT-positive service members.Conclusion: We found that SCT-positive service members deployed more frequently, for greater lengths of time, and remained in service longer. No significant difference in crude mortality ratio was discovered. Additional research on military-relevant outcomes and a cost-effectiveness analysis of SCT screening practices are needed to inform evidence-based SCT enlistment policies. [ABSTRACT FROM AUTHOR]

The standardized mortality rate of rhabdomyolysis (RM) in Active Duty U.S. Army Soldiers is considerably higher than in the civilian population. RM occurs when large amounts of intracellular contents from damaged skeletal muscle escape into circulation, leading to serious sequelae (e.g., acute renal failure, hyperkalemia, compartment syndrome). Extended physical exertion, especially in hot environments, and trauma can precipitate RM. The aim of this study was to identify RM risk factors among U.S. Active Duty Army (ADA) Soldiers.Methods: This nested case-control study used data from the Total Army Injury and Health Outcomes Database (years 2004-2006) to examine RM among ADA male Soldiers. Demographic and occupational variables were identified as potential risk factors. Each RM case was age and date-matched to 4 controls. Adjusted odds ratios (OR) were computed using conditional logistic regression analyses.Results: From years 2004 to 2006, 1,086 Soldiers (0.19%) met the study criteria for clinically diagnosed RM. Three variables were found to increase the odds of acquiring RM: (1) prior heat stroke, OR 4.95 (95% confidence interval [CI] 1.1-21.7); (2) self-reported Black race, OR 2.56 (95% CI 2.2-3.0); and (3) length of service (0-90 days), OR 2.05 (95% CI 1.6-2.7).Conclusion: There is a substantially greater likelihood for male U.S. Army Soldiers to develop RM who: (1) have had a prior heat injury, (2) self-report in the Black racial category, and (3) who are within the initial 90 days of service. Greater awareness of the risk factors associated with RM may improve force health protection and readiness through targeted mitigation strategies. [ABSTRACT FROM AUTHOR]

Aims To investigate the long-term performance of the CONFIRM score for prediction of all-cause mortality in a large patient cohort undergoing coronary computed tomography angiography (CCTA). Methods and results Patients with a 5-year follow-up from the international multicentre CONFIRM registry were included. The primary endpoint was all-cause mortality. The predictive value of the CONFIRM score over clinical risk scores (Morise, Framingham, and NCEP ATP III score) was studied in the entire patient population as well as in subgroups. Improvement in risk prediction and patient reclassification were assessed using categorical net reclassification index (NRI) and integrated discrimination improvement (IDI). During a median follow-up period of 5.3 years, 982 (6.5%) of 15 219 patients died. The CONFIRM score outperformed the prognostic value of the studied three clinical risk scores (c-indices: CONFIRM score 0.696, NCEP ATP III score 0.675, Framingham score 0.610, Morise score 0.606; c-index for improvement CONFIRM score vs. NCEP ATP III score 0.650, P < 0.0001). Application of the CONFIRM score allowed reclassification of 34% of patients when compared with the NCEP ATP III score, which was the best clinical risk score. Reclassification was significant as revealed by categorical NRI (0.06 with 95% CI 0.02 and 0.10, P = 0.005) and IDI (0.013 with 95% CI 0.01 and 0.015, P < 0.001). Subgroup analysis revealed a comparable performance in a variety of patient subgroups. Conclusions The CONFIRM score permits a significantly improved prediction of mortality over clinical risk scores for >5 years after CCTA. These findings are consistent in a large variety of patient subgroups. [ABSTRACT FROM AUTHOR]

In population-based cancer studies, it is often interesting to compare cancer survival between different populations. However, in such studies, the exact causes of death are often unavailable or unreliable. Net survival methods were developed to overcome this difficulty. Net survival is the survival that would be observed if the disease under study was the only possible cause of death. The Pohar-Perme estimator (PPE) is a nonparametric consistent estimator of net survival. In this article, we present a log-rank-type test for comparing net survival functions (as estimated by PPE) between several groups. We put the test within the counting process framework to introduce the inverse probability weighting procedure as required by the PPE. We built a stratified version to control for categorical covariates that affect the outcome. We performed simulation studies to evaluate the performance of this test and worked an application on real data. [ABSTRACT FROM AUTHOR]

Background: Income is not frequently used to monitor health equity on a national level largely due to the lack of public data on income. Information on income allows policy makers to identify the economically disadvantaged population in a country directly. We examined differences in life expectancy (LE) at birth by income and quantified age- and cause-specific contributions to the LE differences using national health insurance data. Methods: Data from a nationally representative sample of 1097 333 South Koreans (2% of the total population) collected between 2002 and 2010 (39 737 deaths) were used. National health insurance premiums were used to estimate income level. Age- and cause-specific contributions to differences in LE at birth by income were estimated using Arriaga's decomposition method. Results: LE at birth gradually increased with income in both genders. Interquintile income LE differences were 7.93 years in males and 3.82 years in females. Most of LE differentials were attributed to differences in mortality in middle-aged and older adults. Suicide and cerebrovascular accidents were the two leading causes of death contributing the most to income LE differences in both males and females. The top 10 causes of death accounted for over 50% of the total LE differences by income in both genders. Alcohol-related causes of death explained the majority of the gender differences in the income LE differentials. Conclusions: Income differentials in LE at birth according to national health insurance premiums and data linkage systems could provide a valuable opportunity for monitoring and prioritizing population health inequalities in South Korea. [ABSTRACT FROM AUTHOR]

Recent epidemiologic evidence suggests that prediagnosis physical activity is associated with survival in women diagnosed with breast cancer. However, few data exist for racial/ethnic groups other than non-Latina whites. To examine the association between prediagnosis recreational physical activity and mortality by race/ethnicity, we pooled data from the California Breast Cancer Survivorship Consortium for 3 population-based case-control studies of breast cancer patients (n = 4,608) diagnosed from 1994 to 2002 and followed up through 2010. Cox proportional hazards models provided estimates of the relative hazard ratio for mortality from all causes, breast cancer, and causes other than breast cancer associated with recent recreational physical activity (i.e., in the 10 years before diagnosis). Among 1,347 ascertained deaths, 826 (61%) were from breast cancer. Compared with women with the lowest level of recent recreational physical activity, those with the highest level had a marginally decreased risk of all-cause mortality (hazard ratio = 0.88, 95% confidence interval: 0.76, 1.01) and a statistically significant decreased risk of mortality from causes other than breast cancer (hazard ratio = 0.63, 95% confidence interval: 0.49, 0.80), and particularly from cardiovascular disease. No association was observed for breast cancer-specific mortality. These risk patterns did not differ by race/ethnicity (non-Latina white, African American, Latina, and Asian American). Our findings suggest that physical activity is beneficial for overall survival regardless of race/ethnicity. [ABSTRACT FROM AUTHOR]

Epidemiologic studies have reported conflicting results on the relationship between daytime napping and mortality risk, and there are few data on the potential association in the British population. We investigated the associations between daytime napping and all-cause or cause-specific mortality in the European Prospective Investigation Into Cancer-Norfolk study, a British population-based cohort study. Among the 16,374 men and women who answered questions on napping habits between 1998 and 2000, a total of 3,251 died during the 13-year follow-up. Daytime napping was associated with an increased risk of all-cause mortality (for napping less than 1 hour per day on average, hazard ratio = 1.14, 95% confidence interval: 1.02, 1.27; for napping 1 hour or longer per day on average, hazard ratio = 1.32, 95% confidence interval: 1.04, 1.68), independent of age, sex, social class, educational level, marital status, employment status, body mass index, physical activity level, smoking status, alcohol intake, depression, self-reported general health, use of hypnotic drugs or other medications, time spent in bed at night, and presence of preexisting health conditions. This association was more pronounced for death from respiratory diseases (for napping less than 1 hour, hazard ratio = 1.40, 95% confidence interval: 0.95, 2.05; for napping 1 hour or more, hazard ratio = 2.56, 95% confidence interval: 1.34, 4.86) and in individuals 65 years of age or younger. Excessive daytime napping might be a useful marker of underlying health risk, particularly of respiratory problems, especially among those 65 years of age or younger. Further research is required to clarify the nature of the observed association. [ABSTRACT FROM PUBLISHER]

Aims Prolonged PR interval, or first degree AV block, has been traditionally regarded as a benign electrocardiographic finding in healthy individuals, until recent studies have suggested that it may be associated with increased mortality and morbidity. The aim of this study was to further elucidate clinical and prognostic importance of prolonged PR interval in a large middle-aged population with a long follow-up. Methods and results We evaluated 12-lead electrocardiograms of 10 785 individuals aged 30–59 years (mean age 44 years, 52% males) recorded between 1966 and 1972, and followed the subjects for 30 ± 11 years. Prolonged PR interval was defined as PR >200 ms, with further analysis performed using PR ≥220 ms. Main endpoints were all-cause mortality, cardiovascular mortality, and sudden cardiac death, and other endpoints included hospitalizations due to cardiovascular causes. During the baseline examination, prolonged PR interval >200 ms was present in 2.1% of the subjects, but PR interval normalized to ≤200 ms in 30% of these individuals during the follow-up. No increase in mortality or in hospitalizations due to coronary artery disease, heart failure, atrial fibrillation, or stroke was associated with prolonged PR interval (P = non-significant for all endpoints). These results were not changed after multivariate adjustment or in several subanalyses. Conclusion In the middle-aged general population, prolonged PR interval normalizes in a substantial proportion of subjects during the time course, and it is not associated with an increased risk of all-cause or cardiovascular mortality. [ABSTRACT FROM PUBLISHER]

The Manhiça Health Research Centre, established in 1996 in a rural area of southern Mozambique, currently follows around 92 000 individuals living in approximately 20 000 enumerated and geo-positioned households. Its main strength is the possibility of linking demographic data and clinical data to promote and conduct biomedical research in priority health areas. Socio-demographic data are updated twice a year and clinical data are collected on a daily basis. The data collected in Manhiça HDSS comprises household and individual characteristics, household socio-economic assets, vital data, migration, individual health history and cause of death, among others. Studies conducted in this HDSS contributed to guide the health authorities and decision-making bodies to define or adjust health policies such as the introduction of Mozambique’s expanded programme of immunization with different vaccines (Haemophilus influenzae type b, Pneumococcus) or the development of the concept of Intermittent Preventive Treatment for Infants (IPTi) that led to the World Health Organization recommendation of this method as best practice for the control of malaria among infants. Manhiça’s data can be accessed through a formal request to Diana Quelhas (diana.quelhas@manhica.net) accompanied by a proposal that will be analysed by the Manhiça HDSS internal scientific and ethics committees. [ABSTRACT FROM AUTHOR]

Background and objective: the data concerning the predictive role of oxidised LDL (ox-LDL) in all-cause mortality are scarce. We investigated whether circulating ox-LDL would stand out as a risk factor of total mortality in the elderly.Study subjects, design and methods: a total of 1,260 elderly inhabitants (533 men, 727 women) aged 64 years or more from Lieto, South-Western Finland participated the study in 1998–99. Medical records were re-examined approximately a decade later in January 2009. Circulating ox-LDL lipids were used as the main outcome measure. The comparisons were obtained by the Cox hazard ratio model.Results: during the 10-year follow-up, 467 participants had died (37%), of whom 36% had died of atherosclerotic cardiovascular diseases. Ox-LDL was a significant predictor of all-cause mortality, when proportioned to low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c) or apolipoprotein A1 (apoA1). These findings were independent of age, sex, body mass index, smoking, blood pressure and diabetes (P < 0.05 for all).Conclusion: circulating ox-LDL lipids, when proportioned to LDL-c, HDL-c or apoaA1, stand out as a risk factor for all-cause mortality independent of major confounding attributes. In the prospective survival and increasing disease burden caused by accumulating age, oxidative stress may have a considerable role. [ABSTRACT FROM PUBLISHER]

Aims Spatial QRS-T angle measured from a 12-lead electrocardiogram (ECG) has been shown to predict cardiac mortality. However, there is a paucity of studies on the prognostic significance of frontal QRS-T angle, which is more readily available from the standard 12-lead ECG. The purpose of the present study was to investigate the importance of wide frontal QRS-T angle, QRS-axis, and T-wave axis as cardiac risk predictors in general population. Methods and results We evaluated the 12-lead ECGs of 10 957 Finnish middle-aged subjects from the general population recorded between 1966 and 1972, and followed them for 30 ± 11 years. QRS-T angle 0 to 90°, QRS-axis −30 to 90°, and T-wave axis 0 to 90° were considered normal. The primary endpoint was death from arrhythmia, and the secondary endpoints were all-cause mortality and non-arrhythmic cardiac mortality. QRS-T angle ≥100° was present in 2.0% of the subjects, and it was associated with an increased risk of sudden arrhythmic death [relative risk (RR) 2.26; 95% confidence interval (CI) 1.59–3.21; P< 0.001) and all-cause mortality (RR 1.57; CI 1.34–1.84; P< 0.001), but not with non-arrhythmic cardiac mortality (RR 1.34; CI 0.93–1.92; P= 0.13). The prognostic significance of wide QRS-T angle was mainly due to abnormal T-wave axis, which predicted death from arrhythmia (RR 2.13; CI 1.63–2.79; P< 0.001), all-cause mortality (RR 1.39; 1.24–1.55; P< 0.001), and non-arrhythmic cardiac death (RR 1.87; CI 1.50–2.34; P< 0.001). Conclusion Frontal QRS-T angle ≥100° increases the risk of arrhythmic death, this being mainly the result of an altered T-wave axis. [ABSTRACT FROM PUBLISHER]

Background. Current US guidelines recommend limiting hepatitis C virus (HCV) screening to high-risk individuals, and 50%-75% of infected persons remain unaware of their status. Methods. To estimate the cost-effectiveness and population-level impact of adding one-time HCV screening of US population aged 20-69 years to current guidelines, we developed a decision analytic model for the screening intervention and Markov model with annual transitions to estimate natural history. Subanalyses included protease inhibitor therapy and screening those at highest risk of infection (birth year 1945-1965). We relied on published literature and took a lifetime, societal perspective. Results. Compared to current guidelines, incremental cost per quality-adjusted life year gained (ICER) was $7900 for general population screening and $4200 for screening by birth year, which dominated general population screening if cost, clinician uptake, and median age of diagnoses were assumed equivalent. General population screening remained cost-effective in all one-way sensitivity analyses, 30 000 Monte Carlo simulations, and scenarios in which background mortality was doubled, all genotype 1 patients were treated with protease inhibitors, and most parameters were set unfavorable to increased screening. ICER was lowest if screening was applied to a population with liver fibrosis similar to 2010 estimates. Approximately 1% of liver-related deaths would be averted per 15% of the general population screened; the impact would be greater with improved referral, treatment uptake, and cure. Conclusions. Broader screening for HCV would likely be cost-effective, but significantly reducing HCV-related morbidity and mortality would also require improved rates of referral, treatment, and cure. [ABSTRACT FROM AUTHOR]

Within-individual consistency and among-individual heterogeneity in fitness are prerequisites for selection to take place. Within-individual variation in productivity between years, however, can vary considerably, especially when organisms become older and more experienced. We examine individual consistency in annual productivity, the covariation between survival and annual productivity, and the sources of variation in annual productivity, while accounting for advancing age, to test the individual-quality and resource-allocation life-history theory hypotheses. We use long-term data from a pedigreed, wild population of house sparrows. Within-individual annual productivity first increased and later decreased with age, but there were no selective mortality due to individual quality and no correlation between lifespan and productivity. Individuals were consistent in their annual productivity ( C = 0.49). Narrow-sense heritability was low ( h2 = 0.09), but maternal effects explained much of the variation ( M = 0.33). Such effects can influence evolutionary processes and are of major importance for our understanding of how variation in fitness can be maintained. [ABSTRACT FROM AUTHOR]

Aims The impact of insulin secretagogues (ISs) on long-term major clinical outcomes in type 2 diabetes remains unclear. We examined mortality and cardiovascular risk associated with all available ISs compared with metformin in a nationwide study. Methods and results All Danish residents >20 years, initiating single-agent ISs or metformin between 1997 and 2006 were followed for up to 9 years (median 3.3 years) by individual-level linkage of nationwide registers. All-cause mortality, cardiovascular mortality, and the composite of myocardial infarction (MI), stroke, and cardiovascular mortality associated with individual ISs were investigated in patients with or without previous MI by multivariable Cox proportional-hazard analyses including propensity analyses. A total of 107 806 subjects were included, of whom 9607 had previous MI. Compared with metformin, glimepiride (hazard ratios and 95% confidence intervals): 1.32 (1.24–1.40), glibenclamide: 1.19 (1.11–1.28), glipizide: 1.27 (1.17–1.38), and tolbutamide: 1.28 (1.17–1.39) were associated with increased all-cause mortality in patients without previous MI. The corresponding results for patients with previous MI were as follows: glimepiride: 1.30 (1.11–1.44), glibenclamide: 1.47 (1.22–1.76), glipizide: 1.53 (1.23–1.89), and tolbutamide: 1.47 (1.17–1.84). Results for gliclazide [1.05 (0.94–1.16) and 0.90 (0.68–1.20)] and repaglinide and [0.97 (0.81–1.15) and 1.29 (0.86–1.94)] were not statistically different from metformin in both patients without and with previous MI, respectively. Results were similar for cardiovascular mortality and for the composite endpoint. Conclusion Monotherapy with the most used ISs, including glimepiride, glibenclamide, glipizide, and tolbutamide, seems to be associated with increased mortality and cardiovascular risk compared with metformin. Gliclazide and repaglinide appear to be associated with a lower risk than other ISs. [ABSTRACT FROM PUBLISHER]

Background: Body mass index (BMI) (kg/m(2)) has a U- or J-shaped relationship with all-cause mortality in Western and East Asian populations. However, this relationship is not well characterized in Bangladesh, where the BMI distribution is shifted towards lower values.Methods: Using data on 11,445 individuals (aged 18-75 years) participating in the Health Effects of Arsenic Longitudinal Study (HEALS) in Araihazar, Bangladesh, we prospectively examined associations of BMI (measured at baseline) with all-cause mortality during approximately 6 years of follow-up. We also examined this relationship within strata of key covariates (sex, age, smoking, education and arsenic exposure). Cox proportional hazards models adjusted for these covariates and BMI-related illnesses were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for BMI categories defined by the World Health Organization.Results: Low BMI was strongly associated with increased mortality in this cohort (P-trend < 0.0001). Severe underweight (BMI < 16 kg/m(2); HR 2.06, CI 1.53-2.77) and moderate underweight (16.0-16.9 kg/m(2); HR 1.39, CI 1.01-2.90) were associated with increased all-cause mortality compared with normal BMI (18.6-22.9 kg/m(2)). The highest BMI category (> or =23.0 kg/m(2)) did not show a clear association with mortality (HR 1.10, CI 0.77-1.53). The BMI-mortality association was stronger among individuals with <5 years of formal education (interaction P = 0.02).Conclusions: Underweight (presumably due to malnutrition) is a major determinant of mortality in the rural Bangladeshi population. [ABSTRACT FROM AUTHOR]

Background: Screening tools to identify persons with high cardiovascular risk exist, but less is known about their validity in different population groups. The aim of this article is to compare the sensitivity and specificity of three different cardiovascular disease risk scores and their ability to detect high-risk individuals in daily practice. Methods: The sensitivity and specificity of risk charts based on Framingham Risk Function, SCORE and cardiovascular disease (CVD) Risk Score were analysed using a large population risk factor survey database in Finland. For different cardiovascular disease end-points in 10-year follow-up true positive, false positive, true negative and false negative cases were identified using different risk charts. Subjects over 40 years (n = 25 059) of the FINRISK Study were used in analyses. Results: Risk scores differed depending on gender, age and cardiovascular outcome. Among men the sensitivity of CVD Risk Score and Framingham Risk Function at risk of ≥10% for each end point was higher than of SCORE or Framingham Risk Function at risk of 20%. The specificity of Framingham Risk Function at risk of 20% was higher than the specificity of other risk charts. Among women in all endpoints the sensitivity was highest in CVD Risk Score and lowest in Framingham Risk Function at risk of ≥20%. Specificity for all different endpoints was highest in SCORE and Framingham Risk Function at risk of 20%. Conclusions: Sensitivity and specificity varied markedly in between three cardiovascular risk evaluation tools. Practitioners should be aware of their limitations especially when estimating risk among women and younger patients. [ABSTRACT FROM PUBLISHER]

Geographical inequalities in mortality across Europe may be influenced by migration between regions. The relationship between age- and sex-standardised death rates, 2008-2010, and population change resulting from migration 2000-2010, was analysed in 250 'Nomenclature of Statistical Territorial Units' (NUTS) level 2 regions in 26 European countries. Across Europe death rates were significantly higher in regions experiencing population loss. This association continued after adjustment for 2005 household income among all regions and Western regions but not among Eastern areas. This analysis suggests migration could contribute to Europe's persistent inequalities in mortality, and highlights the problems of Eastern regions with the highest death rates, lowest incomes and declining populations. [ABSTRACT FROM AUTHOR]

Lifespan variation adds to life expectancy by measuring the inequality surrounding age of death that a population faces. Countries that tackle premature mortality generally have decreasing lifespan variation but this is the first study to compare and statistically assess when and to what extent trends in lifespan variation have changed across Western Europe. Lifespan variation was measured using e+ and joinpoint regression analysed the timing and rate of change. Trends have been mostly downward with the recent exception of men in Scotland, Northern Ireland, Ireland and Finland where trends have flattened or show slight increases. Future research aimed at identifying the ages and causes of death, driving trends in these countries, is key to preventing increasing inequalities. [ABSTRACT FROM AUTHOR]

It is widely believed that influenza (flu) vaccination of the elderly reduces all-cause mortality, yet randomized trials for assessing vaccine effectiveness are not feasible and the observational research has been controversial. Efforts to differentiate vaccine effectiveness from selection bias have been problematic. The authors examined mortality before, during, and after 9 flu seasons in relation to time-varying vaccination status in an elderly California population in which 115,823 deaths occurred from 1996 to 2005, including 20,484 deaths during laboratory-defined flu seasons. Vaccine coverage averaged 63%; excess mortality when the flu virus was circulating averaged 7.8%. In analyses that omitted weeks when flu circulated, the odds ratio measuring the vaccination-mortality association increased monotonically from 0.34 early in November to 0.56 in January, 0.67 in April, and 0.76 in August. This reflects the trajectory of selection effects in the absence of flu. In analyses that included weeks with flu and adjustment for selection effects, flu season multiplied the odds ratio by 0.954. The corresponding vaccine effectiveness estimate was 4.6% (95% confidence interval: 0.7, 8.3). To differentiate vaccine effects from selection bias, the authors used logistic regression with a novel case-centered specification that may be useful in other population-based studies when the exposure-outcome association varies markedly over time. [ABSTRACT FROM PUBLISHER]

Lindgren funnel traps baited with aggregation pheromones are widely used to monitor and manage populations of economically important bark beetles (Coleoptera: Scolytidae). This study was designed to advance our understanding of how funnel trap catches assess bark beetle communities and relative abundance of individual species. In the second year (2005) of a 3-yr study of the bark beetle community structure in north-central Arizona pine (Pinus spp.) forests, we collected data on stand structure, site conditions, and local bark beetle-induced tree mortality at each trap site. We also collected samples of bark from infested (brood) trees near trap sites to identify and determine the population density of bark beetles that were attacking ponderosa pine, Pinus ponderosa Douglas ex Lawson, in the area surrounding the traps. Multiple regression models indicated that the number of Dendroctonus and Ips beetles captured in 2005 was inversely related to elevation of the trap site, and positively associated with the amount of ponderosa pine in the stand surrounding the site. Traps located closer to brood trees also captured more beetles. The relationship between trap catches and host tree mortality was weak and inconsistent in forest stands surrounding the funnel traps, suggesting that trap catches do not provide a good estimate of local beetle-induced tree mortality. However, pheromone-baited funnel trap data and data from gallery identification in bark samples produced statistically similar relative abundance profiles for the five species of bark beetles that we examined, indicating that funnel trap data provided a good assessment of species presence and relative abundance. [ABSTRACT FROM AUTHOR]

Objective To assess the health risk from a medium-sized waste incinerator and develop a single comparable figure to quantify overall risk. [ABSTRACT FROM PUBLISHER]

Background: Mutations in the BRCA genes increase the risk of breast cancer. Valid estimates of the magnitude of the lifetime risk of breast cancer in BRCA gene mutation carriers are needed for genetic counseling. Recent results suggest that penetrance has increased in recent birth cohorts. We examined the cumulative breast cancer incidence and mortality before age 70 over a diagnosis period of 80 years in Icelandic women who carried the BRCA2 founder mutation 999del5. Methods: Information on all breast cancers diagnosed in Iceland since 1911 was obtained from the Icelandic Cancer Registry. Mutation status was determined by molecular analysis of tissue samples for 847 breast cancer probands who were diagnosed from 1921 through 1985 and selected without knowledge of family history of breast cancer. We estimated the cumulative incidence and mortality from breast cancer before age 70 years in BRCA2 mutation carriers from the observed risks in first-degree relatives who were classified according to mutation status of probands and followed-up through 2002. Poisson modeling of these risks was also carried out. All statistical tests were two-sided. Results: Of the 847 probands, 88 carried the BRCA2 999del5 mutation and 759 did not. According to Poisson modeling, the cumulative incidence of breast cancer before age 70 years in mutation carriers increased from 18.6% (95% CI = 11.0% to 29.5%) in calendar year 1920 to 71.9% (95% CI = 45.9% to 100%) in 2002 (P<.001); in relatives of probands who did not carry the BRCA2 mutation and in the general Icelandic population incidence increased over the same period from 2.6% to 10.7% and from 1.8% to 7.5%, respectively (all increases of approximately fourfold). During the same period, the cumulative risk of death from breast cancer before age 70 years for BRCA2 mutation carriers increased from 12.1% (95% CI = 5.3% to 23.9%) to 26.9% (95% CI = 10.9% to 55.5%) (P = .08). However, because the probands were breast cancer patients and not a random sample from the population, some bias in the estimation of time trends in penetrance cannot be ruled out. Conclusions: The results indicate that the penetrance of the Icelandic BRCA2 founder mutation increased nearly fourfold in 80 years, whereas the risk of death from breast cancer before age 70 years increased only approximately twofold. Changes in penetrance with time should be considered when penetrance is estimated. [ABSTRACT FROM AUTHOR]

The United States and other developed countries experienced enormous improvements in population health during tile 20th century. In the context of this dramatic positive change, health disparities by race and socioeconomic status emerged for several potent killers. Any explanation for current health disparities must take these changing patterns into account. Any explanation that ignores large improvements in population health and fails to account for tile emergence of disparities for specific diseases is an inadequate explanation of current disparities. We argue that genetic explanations and sonic prominent social causation explanations are incompatible with these facts. We propose that the theory of "fundamental causes" can account for both vast improvements in population health and the creation of large socioeconomic and racial disparities in mortality for specific causes of death over time. Specifically, we argue that it is our enormously expanded capacity to control disease and death in combination with existing social and economic inequalities that create health disparities by race and socioeconomic stat its: When we develop the ability to control disease and death, the benefits of this new-found ability are distributed according to resources of knowledge, money, power, prestige, and beneficial social connections. We present data on changing mortality patterns by race and socioeconomic status for two types of diseases: those For which our capacity to prevent death has increased significantly and those for which we remain largely unable to prevent death. Time trends in mortality patterns are consistent with the fundamental cause explanation. [ABSTRACT FROM AUTHOR]

There have been suggestions that mortality from cutaneous malignant melanoma (CMM) is starting to level off in the European Union.To analyse changes in CMM mortality trends in Spain during 1975–2001 using joinpoint regression models.Mortality data were obtained from the National Statistics Institute. For each gender, age group-specific and standardized (overall and truncated) rates were calculated by the direct method (using the world standard population). The joinpoint analysis was used to identify the best-fitting points where a statistically significant change in the trend occurred.In women, there was a marked increase from 1975 to 1994 in age-adjusted (overall and truncated) CMM mortality rates[estimated annual percentage change (EAPC) 6·6% and 7·0%, respectively;P < 0·05], followed by a levelling off (EAPC− 0·3% and− 1·3%, respectively; not significant). In men, age-adjusted (35–64 years) mortality rates increased steadily from 1975 to 1991 (EAPC 9·1%,P < 0·05) and then levelled off.We confirmed that CMM mortality rates in Spain rose dramatically from the mid-1970s to the beginning of the 1990s, but we also found that mortality rates are now levelling off in middle-aged adults (35–64 years), following a similar tendency to that observed in other countries. [ABSTRACT FROM AUTHOR]

In its spread west across North America in 2002, West Nile virus (WNV) reached a population of marked American Crows (Corvus brachyrhynchos) in Stillwater, Oklahoma, in late summer. Within two months, 46 of 120 individuals were missing or known to be dead, 39 of which (33% of the population) are estimated to have died for WNV-related reasons. In 2003, 56 of 78 marked crows disappeared or were found dead between June and November. Five of the 28 juvenile losses were possibly unrelated to WNV, thus we estimate that 65% of our population died because of this pathogen in 2003. The total loss of 72% of population members, including 82% of juveniles, in a single year of WNV exposure raises concern for precipitous declines in American Crow populations in coming years. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Validation of EuroSCORE outside the boundaries of the original database has been limited to the additive model and has occasionally shown inconsistencies. Therefore we sought to validate the logistic model and assess its predictive performance compared to the additive approach. Methods: Twenty-four hundred and twenty-six consecutive patients were prospectively assigned individual expected risks of dying calculated by the logistic and the additive EuroSCORE algorithms. Discriminating ability of the two models was tested by Receiver Operating Characteristic (ROC) curves. Calibration was assessed by the Hosmer–Lemeshow (H-T) test and further explored by additional cross-tabulations. A percent difference among the estimates was calculated and plotted across score groups. The series was then sorted by date of operation and split in halves to separately explore the potential effect of variation of performance. Results: Observed mortality (5.6%) was not significantly different from the additive (5.3%) and the logistic estimates (6.9%). Both models satisfactorily discriminated outcomes (ROC areas of 0.80 and 0.79 for the logistic and the additive model, respectively). The H-T test showed that calibration was good for the logistic model (P=0.12) but turned out being inadequate for the additive model (P<0.0001). Further cross-tabulations confirmed a good correlation among observed and predicted death rates by the logistic model across all groups. The additive model, on the other hand, revealed a propensity to over-predict in medium-risk categories and under-predict in the very high-risk cases. Direct comparison of additive vs logistic estimates showed a similar behaviour demonstrating it as an intrinsic property of the additive approach. The split-file analysis revealed a significantly improved outcome for patients treated in the second half of the series though the predictive performance of the two models was unaltered. Conclusions: Logistic EuroSCORE reliably predicted outcomes in our series despite the higher risk profile compared to the reference EuroSCORE sample and the observed variation in clinical performance during the study period. The additive model was less precise, exhibiting a predictive distortion which should be accounted for, particularly when employing it at the individual patient level. [Copyright &y& Elsevier]

Recently, the advantages of self-measurement of blood pressure (BP) at home have been recognized. The same advantages could also be applicable to resting heart rate (HR) values assessed at home using a device designed for home BP measurement. However, there have been no studies investigating whether home HR values predict the risk of cardiovascular disease mortality. We therefore investigated the usefulness of HR values in predicting cardiovascular mortality using a device that allowed self-measurement of BP and HR at home.The association between the home-measured resting HR and the 10-year risk of cardiovascular mortality was examined in 1780 Japanese individuals ≥40 years of age who had no significant arrhythmias. A Cox proportional hazards model that adjusted for major risk factors was used.An increase of 5 beats/min in the morning home HR measurement was associated with a 17% increase in the risk of cardiovascular mortality (95% confidence interval 5% to 30%). This relationship was also statistically significant after adjustment for home BP values. Even when home-measured systolic BP was within the normal range (<135 mm Hg), subjects with HR ≥70 beats/min had a higher risk of cardiovascular mortality (relative hazard 2.16, 95% confidence interval 1.21 to 3.85) than those with normal systolic BP and HR values.Self-measurement of HR at home, together with self-measurement of BP, is a simple method of providing useful clinical information for assessing cardiovascular risk. [Copyright &y& Elsevier]

Background: while mortality among the oldest old has improved over recent decades, these improvements are not reflected in the suicide mortality of this age group. We do not know the reasons why the suicide mortality is still very high among the oldest old. Objective: the aim is to analyse the impact that loss of a partner has on the suicide risks of the oldest old (80+) compared to younger age groups. Subjects: the entire Danish population aged 50 during 1994-1998 (n = 1,978,527). Methods: we applied survival analysis to calculate the changes in relative risk of suicide after a loss by using individual-level data. Results: the majority of older persons who commit suicide are widowed, although only a relatively small proportion of the oldest old who commit suicide have experienced a recent loss of partner (men: 18%, women: 6%). In absolute terms, the oldest old men experience the highest increase in suicide risk immediately after the loss (15-fold; 95% CI 10.2-23.6) compared to middle-aged men who are still married. Oldest old men seem to suffer more from the loss and need longer time to recover than women. Conclusions: although a small proportion of oldest old who commit suicide have experienced a recent bereavement, there is a significant increase in the suicide risk during the first year after a bereavement, especially for men. However, the increased risk of suicide in the oldest old men may only in part be explained by the loss of a partner. [ABSTRACT FROM AUTHOR]

Quantifying the degree of density-dependence in stock–recruit relationships is critical to understanding fish population dynamics. The Shepherd and Cushing (1980) model couples a simple model of density-dependent larval growth with a constant rate of mortality to predict numbers surviving to recruitment. The model has not been evaluated using field data, nor have its predictions been compared with those from other models. Here, the S&C model, an individual-based model (IBM), and a regression model are applied to 8 years of field data for striped bass larvae in the Potomac River, Maryland, USA, to predict larval carrying capacity (K) and percentage of recruitment lost as a consequence of density-dependent growth. The IBM and the regression model were corroborated by comparing their predictions of average growth rates of larvae and relative recruitment strengths to observed values for the 8 years of field data. Although the IBM and the regression model differed in their predictions of several important intermediate variables, both models predicted higher values of K and lower values of density-dependent growth than did the S&C model. Over the 8 years, the IBM and the regression model predicted an average of 0.3 and 1.8% recruitment lost as a result of density-dependent growth, respectively. In contrast, the S&C model predicted much higher recruitment lost (average of 27%). Slight differences in the assumed rate of mortality used in the S&C model resulted in values of carrying capacity similar to those predicted by the IBM and the regression model. Difficulties in estimating parameters of the S&C model from field data are discussed. [Copyright &y& Elsevier]

The Disability Adjusted Life Year (DALY) is a widely used summary measure of population health combining years of life lost due to mortality and years of healthy life lost due to disability. A feature of the DALY is that, in the assessment of morbidity, each health condition is associated with a disability weight. The disability weight lies on a scale between 0 (indicating the health condition is equivalent to full health) and 1 (indicating the health condition is equivalent to death). The disability weight associated with each health condition is currently fixed across all social, cultural and environmental contexts. Thus blindness in the United Kingdom has the same disability weight as blindness in Niger in spite of structural interventions in the UK that make the disability less severe than in Niger. Although the fixed disability weight is defended on grounds that it supports a strongly egalitarian flavour in the DALY, we argue that the lack of consideration of realistic contexts results in a measure that will underestimate the burden associated with morbidity in disadvantaged populations and overestimate the burden in advantaged populations. There is, consequently, a loss of information on possible non-clinical points of intervention. Disaggregated estimates of the burden of disease such as those in the World Health Report 2000 should be interpreted with caution. [ABSTRACT FROM AUTHOR]

Proves that the features characterizing the trends of human mortality rates can be explained by using a model of heterogeneity associated with individual differences in adaptive capacity. Details on the features characterizing mortality rates and survival dynamics in populations; Information on the mixture of two subpopulations of individuals; Description of the model of difference in stress response that produces an intersection of mortality rates.

Background: Research over the past decade has suggested that prenatal and early postnatal nutrition influence the risk of developing chronic degenerative diseases up to 60 years later. We now present evidence that risk of death from infectious diseases in young adulthood is similarly programmed by early life events.Methods: In three rural Gambian villages, affected by a marked annual seasonality in diet and disease, we have kept detailed demographic, anthropometric and health records since 1949. Fate was known with certainty for 3,162 individuals (2,059 alive/1,103 dead, most dying in childhood). For this case-control analysis of antecedent predictors of premature mortality, all adult deaths (n = 61) were paired with two randomly selected controls matched for sex and year of birth.Results: Mean age at death was 25 (SD: 8) years. Adult death was associated with a profound bias in month of birth with 49 cases born in the nutritionally-debilitating hungry season (Jul-Dec) versus 12 in the harvest season (Jan-Jun). Relative to harvest season the hazard ratio for early death in hungry-season births rose from 3.7 (for deaths >14.5 years, P = 0.000013) to 10.3 (for deaths >25 years, P = 0.00002). Anthropometric and haematological status at 18 months of age was identical in cases and controls, indicating an earlier origin to the defect. Most deaths for which cause was known had a definite or possible infectious aetiology; none were from degenerative diseases of affluence.Conclusions: Early life exposures, correlated with season of birth, strongly influence susceptibility to fatal infections in young adulthood. The evidence suggests that nutritionally-mediated intrauterine growth retardation may permanently impair the development of immune function. [ABSTRACT FROM AUTHOR]

Background: The large differences in cardiovascular disease rates between Eastern and Western Europe have largely developed over the last few decades, and are only partly explained by classical risk factors. This study was set up to identify other potential determinants of these differences.Methods: This was an ecological study comparing random samples of men aged 45-64 years selected from three cities representing populations with different rates of cardiovascular mortality: Pardubice (Czech Republic), Augsburg (Bavaria, Germany), and Jerusalem (Israel). In total, 191 (response rate 70%), 153 (70%) and 162 (62%) men, respectively, participated. All centres followed the same study protocol. Lifestyle, anthropometry and biochemical risk factors were assessed by identical questionnaires, standardized medical examination, and central analyses of fasting blood samples.Results: The mortality rates in the study populations, as well as the prevalence of coronary heart disease in study samples, were highest in Czech, intermediate in Bavarian and low in Israeli men. This pattern was replicated across the three samples by mean blood pressure (P < 0.001), cigarette smoking (not significant), triglycerides (P < 0.05), fibrinogen or D-dimer levels (P < 0.05). On the other hand, the prevalence of diabetes and obesity were similar; total and high density lipoprotein (HDL)-cholesterol, apolipoprotein B, lipoprotein (Lp(a)) and glucose did not differ between Czech and Bavarian men; and Czechs had particularly low levels of serum insulin and factor VIIc. Israelis had low fasting glucose and total cholesterol, as well as HDL-cholesterol levels and a high Lp(a) (each P < 0.001) compared with the two other samples. Striking differences were found for plasma homocysteine (10.5 in Czechs versus 8.9 mumol/l in Bavarians, P < 0.001) and for alpha-carotene (geometric mean in Czechs 16, Bavarians 21 and Israelis 30 micrograms/l), beta-carotene (60, 110 and 102 micrograms/l), and lycopene (84, 177 and 223 micrograms/l), respectively; all P-values < 0.001). Adjustment for obesity or smoking did not change these estimates. There were no differences in the levels of tocopherol and retinol.Conclusions: Czech men had high levels of blood pressure, triglycerides, fibrinogen and D-dimer but many other traditional risk factors, as well as indicators of metabolic disorders and vitamins A and E, did not differ between the study samples. The low levels of carotenoids and high concentrations of homocysteine in Czech men seem to reflect their low dietary intakes of fruit and vegetables. The results provide indirect support for the importance of dietary factors in the East-West morbidity and mortality divide. [ABSTRACT FROM AUTHOR]

Examines secular trends in mortality differences among ethnic groups using California population data for 1970, 1980 and 1990. Survival curve analyses; Means and standard deviations analyses; Description of ethnic groups.

Violent deaths, defined as homicides, suicides, and accidents, are leading causes of death among working-age populations. While large-scale population studies and community case studies have established common linkages between race, sex, age, joblessness, and all three forms of violent death, they have tended to be cross-sectional and to be focused on one cause of violent death to the exclusion of others. Utilizing 1970 and 1990 census data and vital records for 75 Chicago community areas, this article examines the relationships between joblessness, family disruption, and all three farms of violent death across the black and nonblack community-area populations of Chicago at two distinct time paints corresponding to William Julius Wilson's theory of the evolution of urban underclass communities. The findings suggest that both homicide rates and accidental death rates are similarly predicted by high rates of joblessness and family disruption, and that these relationships have strengthened in both black and nonblack communities over times. Variations in racial segregation among black community-area populations appeared to have no consistent direct effects on black rates of violent death. We also found that, contrary to historical patterns, suicide rates for young adult black males and young adult nonblack males appear similarly responsive to a secular decline in the economic opportunity structure. Finally, through the use of multiple-decrement life- table analysis techniques across racial communities, we observed a growth trend in the racial disparities between life expectancies of black and nonblack populations that is linked to relative levels of joblessness. [ABSTRACT FROM AUTHOR]

Focuses on the decline of the mortality rate of the population in Europe from the 17th to the 19th century. Role of insects in the transmission of diseases during the pre-decline era; Importance of studying diseases and their modes of transmission; Impact of the discovery of the role of insects in disease transmission on the mortality rate.

Trends in amenable mortality rates for Maori and non-Maori New Zealanders were analysed and compared using regression models. The contribution of medical services to the decline in mortality rates was estimated. Mortality from causes amenable to medical intervention declined at a greater rate than non-amenable mortality for both groups. The proportion of the decline in mortality attributable to improvement in the impact of medical services was greater for non-Maori than for Maori, especially for females. Maori to non-Maori mortality ratios were greater for amenable than for non-amenable causes, indicating a systematic differential between the two groups in the impact of medical services. There was only a small improvement over the 20 years in the excess of amenable mortality suffered by Maori. The results have implications for the provision of medical services to Maori people. [ABSTRACT FROM AUTHOR]

Cohort studies often compare the observed number of cases arising in a group under investigation with the number expected to occur on the basis of general population rates. The general population is taken to represent unexposed persons, but it is almost inevitably biased in that it comprises all types of people including exposed ones. To identify circumstances when this bias matters, the authors modeled its effect in relation to the size of the observed standardized mortality ratio (SMR) and the prevalence of exposed individuals in the general population. The authors found that bias may be a major problem, causing substantial underestimation of the true relative risk, when either the prevalence of exposure in the general population or the SMR are large. The bias can cause an apparent trend in SMRs with age when none exists. It also places a limit on the maximum size of the observed SMR, no matter how large the true relative risk. A table is provided showing the extent of bias in different circumstances. Cohort studies of people with common diseases or exposures, or that find large SMRs, when using general population expectations, need to consider the extent of bias from this source. Am J Epidemiol 1998; 148:1012–17. [ABSTRACT FROM AUTHOR]

Low heart rate variability is associated with high risk of sudden death in myocardial infarction patients. This has been attributed to unfavorable autonomic cardiac control. In the present study, the predictive value of heart rate variability for sudden death, mortality from coronary heart disease, and from all causes was investigated in the general population, using brief electrocardiographic recordings. From 1960 to 1985, 878 middle-aged Dutch men, aged 40–60 years, were followed and repeatedly examined as part of the Zutphen Study. In 1985 the remaining cohort was extended to 885 elderly men, aged 65–85 years, and followed until 1990. Heart rate variability (standard deviation of duration of normal RR intervals) was determined from the resting 12-lead electrocardiogram. The 5-year age-adjusted relative rate of total mortality of men with heart rate variability of <20 milliseconds (msec) compared with men with heart rate variability of 20–39 msec was 2.1 (95 percent confidence interval 1.4–3.0) in middle-aged men and 1.4 (95% confidence interval 0.9–2.2) in elderly men. Death from noncoronary causes, especially cancer, contributed significantly to this elevated risk. The association of low heart rate variability with sudden death or coronary heart disease mortality was less consistent. In conclusion, in middle-aged men and probably in elderly men, low heart rate variability is predictive of mortality from all causes. This suggests that low heart rate variability is an indicator of compromised health in the general population. Am J Epidemiol 1997; 145: 899–908. [ABSTRACT FROM AUTHOR]

Much remains to be understood about how low socioeconomic status (SES) increases cardiovascular disease and mortality risk. Data from the Kuopio Ischemic Heart Disease Risk Factor Study (1984–1993) were used to estimate the associations between acute myocardial infarction and income, all-cause mortality, and cardiovascular mortality in a population-based sample of 2, 272 Finnish men, with adjustment for 23 biologic, behavioral, psychologic, and social risk factors. Compared with the highest income quintile, those in the bottom quintile had age-adjusted relative hazards of 3.14 (95% confidence interval (Cl) 1.77–5.56), 2.66 (95% Cl 1.25–5.66), and 4.34 (95% Cl 1.95–9.66) for all-cause mortality, cardiovascular mortality, and AMI, respectively. After adjustment for risk factors, the relative hazards for the same comparisons were 1.32 (95% Cl 0.70–2.49), 0.70 (95% Cl 0.29–1.69), and 2.83 (95% Cl 1.14–7.00). In the lowest income quintile, adjustment for risk factors reduced the excess relative risk of all-cause mortality by 85%, that of cardiovascular mortality by 118%, and that of acute myocardial infarction by 45%. These data show how the association between SES and cardiovascular mortality and all-cause mortality is mediated by known risk factor pathways, but full “explanations” for these associations will need to encompass why these biologic, behavioral, psychologic, and social risk factors are differentially distributed by SES. Am J Epidemiol 1996; 144: 934-42. [ABSTRACT FROM AUTHOR]

Population is now accorded a central role in the economic history of preindustrial England. The view is widely accepted that population change was the dominant cause of secular variation in the real wage, and perhaps also in rents, terms of trade between industry and agriculture, and other relative prices.' What, then, was the cause of population change? The classical economists emphasized shifts in the demand for labor, coupled with a labor supply that was, in the long run, infinitely elastic at the socially determined living standard, or "natural wage." Demographers and historians, on the other hand, have stressed the importance of exogenous changes in mortality: the Black Death of the fourteenth century is the most famous example, but the low mortality of the sixteenth century and the high mortality of the seventeenth also warrant mention. A third model synthesizes these two, acknowledging the interplay of systematic and accidental forces in the historical movement of population.