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This study investigated associations between chest computed tomography (CT) pulmonary opacity score on admission and clinical features and outcomes in COVID-19 patients. The retrospective multi-center cohort study included 496 COVID-19 patients in Jiangsu province, China diagnosed as of March 15, 2020. Patients were divided into four groups based on the quartile of pulmonary opacity score: ≤ 5%, 6-20%, 21-40% and 41% +. CT pulmonary opacity score was independently associated with age, single onset, fever, cough, peripheral capillary oxygen saturation, lymphocyte count, platelet count, albumin level, C-reactive protein (CRP) level and fibrinogen level on admission. Patients with score ≥ 41% had a dramatic increased risk of severe or critical illness [odds ratio (OR), 15.58, 95% confidence interval (CI) 3.82-63.53), intensive care unit (ICU)] admission (OR, 6.26, 95% CI 2.15-18.23), respiratory failure (OR, 19.49, 95% CI 4.55-83.40), and a prolonged hospital stay (coefficient, 2.59, 95% CI 0.46-4.72) compared to those with score ≤ 5%. CT pulmonary opacity score on admission, especially when ≥ 41%, was closely related to some clinical characteristics and was an independent predictor of disease severity, ICU admission, respiratory failure and long hospital stay in patients with COVID-19.

Background and aims Systemic immune-inflammation index (SII) has been recently investigated as a novel inflammatory and prognostic marker. SII may be used as an indicator reflecting the progressive inflammatory process in atherosclerosis, although its link to incident cardiovascular disease (CVD) has not been examined in previous studies. This study aims to prospectively assess the association of SII with incident CVD and its main subtypes in Chinese adults. Methods Using data from the Dongfeng-Tongji cohort study, 13,929 middle-aged and older adults with a mean age of 62.56 years (range 35–91 years), who were free of CVD and cancer, were included for analysis. The baseline study was conducted in Shiyan city, Hubei province from 2008 to 2009. The SII was calculated as platelet count (/L) × neutrophil count (/L)/lymphocyte count (/L). Cox regression models were used to examine the associations of SII with incident CVD, including stroke and coronary heart disease (CHD). Results Over a median 8.28 years (maximum 8.98 years) of follow-up, 3386 total CVD cases, including 801 stroke cases and 2585 total CHD cases, were identified. In multivariable Cox regression analyses, higher levels of log-transformed SII were significantly associated with total stroke (HR 1.224, 95% CI 1.065–1.407) and ischemic stroke (HR 1.234, 95% CI 1.055–1.442). For those participants with the highest quartiles of SII versus the lowest quartiles of SII, the HRs were 1.358 (95% CI 1.112–1.658) for total stroke, 1.302 (95% CI 1.041–1.629) for ischemic stroke, and 1.600 (95% CI 1.029–2.490) for hemorrhagic stroke. Conclusions SII may serve as a useful marker to elucidate the role of the interaction of thrombocytosis, inflammation, and immunity in the development of cerebrovascular diseases in the middle-aged and elderly population.

Background : Adverse childhood experiences (ACEs) are associated with increased suicidal behaviors in adolescents and most research has been restricted to certain types of or cumulative exposure to ACEs. Few studies have examined the association between patterns of ACEs and suicidal behaviors. Objective : To identify the contributions of type and pattern of exposure to ACEs to suicidal behaviors and their gender differences among middle school students in China. Methods : A school-based health survey was conducted in four provinces in China between 2017 and 2018. 14 500 students aged 10–20 years completed standard questionnaires, to record details of ACEs, suicide ideation, suicide plan, and suicide attempt. Results : Latent class analysis indicated four distinct patterns of ACEs exposure: high ACEs (6.3%), high abuse and neglect (21.4%), high neglect (45.5%), and low ACEs (26.8%). Logistic analyses showed that, compared with low ACEs, the high ACEs were more likely to report suicidal behaviors. No gender differences were found in the independent effects of ACEs type or pattern on suicidal behaviors, except for the emotional neglect associated with suicidal behaviors in girls than boys. Limitations : The study was cross-sectional and used self-reported questionnaires. Thus, it is difficult to establish a causal relationship between patterns of ACEs and suicidal behaviors. Conclusion : Our findings addressed the need for a comprehensive consideration of ACEs in preventive healthcare work to identify children exposed to the most problematic ACE patterns. The study provided the evidence of targeted intervention to preempt the emergence of suicide behavior in at-risk students in adolescents.

Periodontal disease (PD) is common and increases cardiovascular diseases. However, it is unclear whether PD is associated with increased risk of dementia. We carried out a systematic review and meta-analysis to investigate the influence of PD on dementia. We projected the number of dementia cases to be saved by reducing PD prevalence in the world. We searched cohort and case-control studies reporting the association of PD with all dementia (or any specific type of dementia) through PubMed, MEDLINE, PsycINFO, SocINDEX, CINHAL, and CNKI until 7th November 2018. Five cohorts and seven case-control studies were identified for review. We pooled eligible data to calculate relative risk (RR) of dementia in relation to PD and computed the number of dementia cases saved through reducing PD prevalence. Of 12 studies, six were undertaken in Asia, four in Europe and two in America. Eleven studies showed a positive association between PD and the risk of dementia, of which 10 were significant, and one reported a non-significant inverse association. Overall their quality was good. Pooled RR of dementia in relation to PD from all high quality studies was 1.38 (95%CI 1.01-1.90); in the five cohorts was 1.18 (1.06-1.31) and in the two case-control studies 2.25 (1.48-3.42). A 50% reduction in the current prevalence of 20% of PD in the population could save 850,000 (630,000-1,420,000) patients with dementia in the world. PD could increase the risk of incident dementia. Preventing and treating PD could contribute to controlling the global epidemic of dementia.

IntroductionAssociations of pre-pregnancy impaired fasting glucose (IFG) and body mass index (BMI) with large for gestational age (LGA) and preterm birth (PTB) have been poorly understood. We aimed to investigate the associations of maternal BMI, separately and together with pre-pregnancy IFG, with LGA and PTB in Chinese population. We also aimed to quantify these associations by maternal age.Research design and methodsThis was a retrospective cohort study of women from the National Free Preconception Health Examination Project with singleton birth from 121 counties/districts in 21 cities of Guangdong Province, China, from January 1, 2013 to December 31, 2017. Women were included if they did not have pre-existing chronic diseases (diabetes, hypertension, etc). Participants were divided into eight groups according to their BMI (underweight (BMI 2), normal weight (18.5–23.9 kg/m2), overweight (24.0–27.9 kg/m2), and obesity (≥28.0 kg/m2)) and pre-pregnancy fasting glucose status (normoglycemia (fasting glucose concentration ResultsWe included 634 030 women. The incidences of LGA, severe LGA, PTB and early PTB for the study population were 7.1%, 2.5%, 5.1% and 1.1%, respectively. Compared with normal weight mothers with normoglycemia, overweight and obese mothers irrespective of IFG had a higher risk of LGA (eg, obesity with IFG aIRR 1.85 (1.60–2.14)) and severe LGA (eg, obesity with IFG 2.19 (1.73–2.79)). The associations of BMI and pre-pregnancy fasting glucose status with LGA were similar found among women of all age groups. Underweight with normoglycemia had 6.0% higher risk of PTB (1.06 (1.03–1.09)) and 8.0% higher risk of early PTB (1.08 (1.02–1.17)), underweight with IFG had 14.0% higher risk of PTB (1.14 (1.02–1.27)), and obese mothers with IFG had 45.0% higher risk of PTB (1.45 (1.18–1.78)). The associations of BMI and pre-pregnancy fasting glucose status with PTB differed by maternal age.ConclusionOverweight and obesity regardless of IFG were associated with an increased risk of LGA, and these associations were similarly observed among mothers of all age groups. Underweight regardless of IFG, and obesity with IFG were associated with an increased risk of PTB, but the associations differed by maternal age. Findings from this study may have implications for risk assessment and counselling before pregnancy.

This study investigated the association between pre-pregnancy body mass index (BMI) and adverse pregnancy outcomes among women participated in the National Free Preconception Health Examination Project in Guangdong Province, China, and explored these associations according to maternal age. Pre-pregnancy BMI was classified into underweight (BMI 2), healthy weight (18.5–23.9 kg/m2), overweight (24.0–27.9 kg/m2), and obesity (≥ 28.0 kg/m2) according to Chinese criteria. Outcomes were preterm birth (PTB, delivery before 37 weeks of gestation), large for gestational age (LGA, birthweight above the 90th percentile for gestational age by infants’ sex), small for gestational age (SGA, birthweight below the 10th percentile for gestational age by infants’ sex), primary caesarean delivery, shoulder dystocia or birth injury, and stillbirth. Adjusted incidence risk ratios (aIRR) were calculated for underweight, overweight and obesity, respectively. Compared with healthy weight, underweight was associated with increased risk of PTB (aIRR 1.06, 95%CI 1.04–1.09) and SGA (1.23, 1.22–1.26) but inversely associated with LGA (0.83, 0.82–0.85), primary caesarean delivery (0.88, 0.87–0.90) and stillbirth (0.73, 0.53–0.99). Overweight was associated with increased risk of LGA (1.17, 1.14–1.19), primary caesarean delivery (1.18, 1.16–1.20) and stillbirth (1.44, 1.03–2.06), but inversely associated with SGA (0.92, 0.90–0.95) and shoulder dystocia or birth injury (0.86, 0.79–0.93). Obesity was associated with increased risk of PTB (1.12, 1.05–1.20), LGA (1.32, 1.27–1.37), primary caesarean delivery (1.45, 1.40–1.50), but inversely associated with SGA (0.92, 0.87–0.97). The aIRRs for underweight, overweight and obesity in relation to these adverse pregnancy outcomes ranged from 0.65 to 1.52 according to maternal age. In Chinese population, maternal pre-pregnancy BMI was significantly associated with the risk of adverse pregnancy outcomes and the risk differs according to maternal age. Further investigation is warranted to determine whether and how counselling and interventions for women with low or increased BMI before pregnancy can reduce the risk of adverse pregnancy outcomes.

Background and Purpose— The association of socioeconomic status (SES) with quality of stroke care is not well understood, and few studies have examined the association with different indicators of SES simultaneously. We assessed the impacts of low levels of education, occupation, and income on the quality of stroke care. Methods— We examined data from the China National Stroke Registry recording consecutive stroke patients between September 2007 and August 2008. Baseline low SES was measured using educational level Results— Among 12 270 patients with ischemic stroke, 38.6% had Conclusions— There was a social gradient in the quality of stroke care. Continuous efforts of socioeconomic improvement will increase the quality of acute stroke care.

We conducted a systematic review and meta-analysis to evaluate the effect of Berberine on glucose in patients with type 2 diabetes mellitus and identify potential factors may modifying the hypoglycemic effect. We searched PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, and Wanfang Database to identify randomized controlled trials that investigated the effect of Berberine. We calculated weighted mean differences (WMD) and 95% confidence interval (CI) for fasting plasma glucose (FPG), postprandial plasma glucose (PPG) and glycated haemoglobin (HbA1c) levels. Twenty-eight studies were identified for analysis, with a total of 2,313 type 2 diabetes mellitus (T2DM) patients. The pool data showed that Berberine treatment was associated with a better reduction on FPG (WMD = -0.54 mmol/L, 95% CI: -0.77 to -0.30), PPG (WMD = -0.94 mmol/L, 95% CI: -1.27 to -0.61), and HbA1c (WMD = -0.54 mmol/L, 95% CI: -0.93 to -0.15) than control groups. Subgroup-analyses indicated that effects of Berberine on blood glucose became unremarkable as the treatment lasted more than 90 days, the daily dosage more than 2 g/d and patients aged more than 60 years. The efficiency of Berberine combined with hypoglycaemics is better than either Berberine or hypoglycaemic alone. The dosage and treatment duration of Berberine and patients' age may modify the effect.

ObjectiveTo assess the impact of heart disease (HD) combined with depression on all-cause mortality in older people living in the community.DesignA population-based cohort study.ParticipantsWe examined the data of 1429 participants aged ≥60 years recruited in rural areas in Anhui province, China. Using a standard method of interview, we documented all types of HD diagnosed by doctors and used the validated Geriatric Mental Status-Automated Geriatric Examination for Computer Assisted Taxonomy algorithm to diagnose any depression for each participant at baseline in 2003. The participants were followed up for 8 years to identify vital status.MeasurementsWe sought to examine all-cause mortality rates among participants with HD only, depression only and then their combination compared with those without these diseases using multivariate adjusted Cox regression models.Results385 deaths occurred in the cohort follow-up. Participants with baseline HD (n=91) had a significantly higher mortality (64.9 per 1000 person-years) than those without HD (42.9). In comparison to those without HD and depression, multivariate adjusted HRs for mortality in the groups of participants who had HD only, depression only and both HD and depression were 1.46 (95% CI 0.98 to 2.17), 1.79 (95% CI 1.28 to 2.48) and 2.59 (95% CI 1.12 to 5.98), respectively.ConclusionOlder people with both HD and depression in China had significantly increased all-cause mortality compared with those with HD or depression only, and without either condition. Psychological interventions should be taken into consideration for older people and those with HD living in the community to improve surviving outcome.

Background Previous findings of the association between socioeconomic deprivation and mortality after ischemic stroke are inconsistent. There is a lack of data on the association with combined low education, occupational class, and income. We assessed the associations of three indicators with mortality. Methods We examined data from the China National Stroke Registry, recording all stroke patients occurred between September 2007 and August 2008. Baseline socioeconomic deprivation was measured using low levels of education at Results In a 12-month follow-up 1640 patients died. After adjustment for age, sex, cardiovascular risk factors, severity of stroke, and prehospital medications, odds ratio for mortality in patients with low education was 1.25 (95%CI 1.05–1.48), manual laboring 1.37 (1.09–1.72), and low income 1.19 (1.03–1.37). Further adjustment for acute care and medications in and after hospital made no substantial changes in these odds ratios, except a marginal significant odds ratio for low income (1.15, 0.99–1.33). The odds ratio for low income was 1.27 (1.01–1.60) within patients with high education. Compared with no socioeconomic deprivation, the odds ratio in patients with socioeconomic deprivation determined by any one indicator was 1.33 (1.11–1.59), by any two indicators 1.36 (1.10–1.69), and by all three indicators 1.56 (1.23–1.97). Conclusions There are significant inequalities in survival after ischemic stroke in China in terms of social and material forms of deprivation. General socioeconomic improvement, targeting groups at high risk of mortality is likely to reduce inequality in survival after stroke.

ObjectivesPrevious studies suggested the association of air pollution with initial Mycobacterium tuberculosis infection and the disease development. However, few studies have been conducted on air pollution and initial tuberculosis (TB) consults using short-interval data. We investigated the weekly association between air pollution and initial TB outpatient visits.MethodsWe used a Poisson regression model combined with a distributed lag non-linear model to conduct a time-series study with weekly air pollution data and TB cases during 2014–2017 in Wuhan, China.ResultsA 10 µg/m3 increase in NO2 (nitrogen dioxide) was associated with 11.74% (95% CI: 0.70 to 23.98, lag 0–1 weeks), 21.45% (95% CI: 1.44 to 45.41, lag 0–2 weeks) and 12.8% (95% CI: 0.97 to 26.02, lag 0–1 weeks) increase in initial TB consults among all patients with TB, old patients (≥60 years old) and male ones, respectively. A 10 µg/m3 increase in SO2 (sulfur dioxide) was associated with −22.23% (95% CI: −39.23 to −0.49, lag 0–16 weeks), −28.65% (95% CI: −44.3 to −8.58, lag 0–16 weeks), −23.85 (95% CI: −41.79 to −0.37, lag 0–8 weeks) and −23.82% (95% CI: −41.31 to −1.11, lag 0–16 weeks) increase in initial TB consults among the total, young (aged 15–59 years old), old and male patients, respectively. In old patients, a 0.1 mg/m3 increase in CO (carbon monoxide) and a 10 µg/m3 increase in PM2.5 (particulate matter) were separately associated with 42.32% (95% CI: 1.16 to 100.22, lag 0–16 weeks) and 17.38% (95% CI: 0.28 to 37.38, lag 0–16 weeks) increases in TB consults.ConclusionOur study first highlighted the importance of weekly association between air pollution and the risk of initial TB consults, which is helpful for the arrangements of TB screening and medical assistance.

Background and Purpose— Previous findings of the association between socioeconomic deprivation and functional impairment after stroke are inconsistent. There is a lack of data on long-term association. We assessed the association and differences by age, sex, prestroke comorbidities, and stroke phenotypes. Methods— We examined data from the South London Stroke Register cohort of 1995 to 2011, recording all first-ever strokes in patients of all ages in South London. A total of 2104 patients were alive at 3 months after stroke. Socioeconomic deprivation was measured using the index of multiple deprivation based on patient postcodes, and functional impairment after stroke was defined as a Barthel index of Results— At 3 months after stroke, 643 patients had functional impairment (30.6%; 95% confidence interval, 28.6%–32.5%). Compared with the first quartile of index of multiple deprivation (the least deprived), multivariate-adjusted odds ratios for functional impairment in patients with the second, third, and fourth quartiles were 1.29 (95% confidence interval, 0.94–1.76), 1.33 (0.97–1.82), and 1.78 (1.31–2.43), overall P =0.004. The association was significant in patients aged ≥65 years (corresponding odds ratios were 1.49 [1.02–2.17], 1.21 [0.83–1.75], and 1.94 [1.34–2.81]; P =0.003); in women, P =0.008, in patients who do not have prestroke comorbidities, P =0.009, and in patients with ischemic stroke, P Conclusions— There are significant inequalities in short- and long-term functional recovery after stroke. General socioeconomic improvement, targeting groups at high risk of functional impairment is likely to reduce inequality in functional recovery after stroke.

ObjectivesChina carries the greatest burden of stroke given its largest volume of people with hypertension. This study assessed the impacts of suboptimal controls of hypertension on incident stroke and projected the number of patients with stroke saved after the control of blood pressure improved in population.SettingAnhui, China.ParticipantsWe examined data from the Anhui cohort of 2001–2011, consisting of 3336 participants aged ≥60 years who were randomly recruited from the urban and rural Anhui. 2852 participants had hypertensive status measured and no stroke at baseline, and were followed up until 2011 in three surveys using a standard method of interview.ResultsAt baseline, 1646 participants (57.7%) were identified to have hypertension, among whom 912 (55.4%) were previously undetected, 115 (7.0%) detected but not treated, 452 (27.5%) treated but not controlled and only 127 (7.7%) controlled. During the 10-year follow-up, 211 incident stroke cases (12.8/1000 person-years) occurred. Compared with normotensive individuals at baseline, multivariate adjusted HR for having stroke increased in those with undetected hypertension by 1.63 (95%CI 1.15 to 2.32), untreated by 2.21 (1.26–3.85) and uncontrolled hypertension by 3.34 (2.28–4.88), but did not differ from those with controlled hypertension (1.34; 0.60–2.99). Based on a two-fold increase in the detection and management of current levels of hypertension and algorithms on the current situation in China, approximately 250 000 incident stroke cases could be prevented annually.ConclusionsIn China, hypertension is frequently undetected or inadequately treated. With appropriate management of hypertension, a substantial number of people could be saved form stroke.

Background To investigate the impact of low socioeconomic status (SES), indicated by low level of education, occupation and income, on 3 months functional outcome after ischemic stroke. Methods We analyzed data from the China National Stroke Registry (CNSR), a multicenter and prospective registry of consecutive patients with acute cerebrovascular events occurred between September 2007 and August 2008. 11226 patients with ischemic stroke had SES and clinical characteristics data collected at baseline and mRS measured as indicator of functional outcome in 3 months follow up. Multinomial and ordinal logistic regression models were performed to examine associations between SES and the functional outcome. Results At 3 months after stroke, 5.3% of total patients had mRS scored at 5, 11.3% at score 4, 11.1% at score 3, 14.4% at score 2, 34.2% at score 1 and 23.7% at score 0. Compared to patients with educational level of ≥ 6 years and non-manual laboring, those < 6 years and manual laboring tended to have higher mRS score (P

BackgroundDeterminants for undetected dementia and late-life depression have been not well studied.AimsTo investigate risk factors for undetected dementia and depression in older communities.MethodUsing the method of the 10/66 algorithm, we interviewed a random sample of 7072 participants aged ⩽60 years in six provinces of China during 2007–2011. We documented doctor-diagnosed dementia and depression in the interview. Using the validated 10/66 algorithm we diagnosed dementia (n= 359) and depression (n= 328).ResultsWe found that 93.1% of dementia and 92.5% of depression was undetected. Both undetected dementia and depression were significantly associated with low levels of education and occupation, and living in a rural area. The risk of undetected dementia was also associated with ‘help available when needed‘, and inversely, with a family history of mental illness and having functional impairment. Undetected depression was significantly related to female gender, low income, having more children and inversely with having heart disease.ConclusionsOlder adults in China have high levels of undetected dementia and depression. General socioeconomic improvement, associated with mental health education, targeting high-risk populations are likely to increase detection of dementia and depression in older adults, providing a backdrop for culturally acceptable service development.

Objective To determine whether the effect of South Asian ethnicity differs between studies of incidence and prognosis of coronary disease. Design Systematic literature review and meta-analysis, and cohort analysis from a national acute coronary syndrome (ACS) registry linked to mortality (National Institute of Cardiovascular Outcomes Research/Myocardial Infarction National Audit Project). Setting International for the review, and England and Wales for the cohort analysis. Patients The numbers of South Asians included in the meta-analysis were 111 555 (incidence) and 14 531 (prognosis) of whom 8251 were from the ACS cohort. Main outcome measures Incidence studies: non-fatal myocardial infarction or fatal coronary heart disease; prognostic studies: mortality; HRs for 1-year all-cause death in ACS cohort. Results South Asians had higher incidence of coronary disease compared with white subjects (HR 1.35 95% CI 1.30 to 1.40) based on meta-analysis of nine studies. Among 10 studies on prognosis, South Asians had better prognosis compared with white subjects (HR 0.78 95% CI 0.74 to 0.82). In the ACS cohort, the impact of diabetes (42.4% of South Asians, 16.9% of white subjects) on 1-year mortality was stronger in South Asians than white subjects (age-adjusted HR 1.83 95% CI 1.59 to 2.11 vs 1.53 95% CI 1.49 to 1.57). However, prognosis was better in South Asians even among diabetics, older people and those living in areas of the highest social deprivation. Conclusions South Asian ethnicity is associated with higher incidence of coronary disease, but lower mortality once coronary disease is manifest. The dissociation between effects on incidence and prognosis suggests that public health initiatives to reduce inequalities in mortality between South Asian and white populations should focus on primary prevention. This is a CALIBER study with ClinicalTrials.gov Identifier: NCT01163513.

Booster influenza vaccination has been recommended for patients with chronic renal disease in order to enhance the immune response to the influenza vaccine; however, the efficacy of a booster influenza vaccination is a matter of controversy. Therefore, we made a meta-analysis to determine the efficacy in patients with hemodialysis (HD), peritoneal dialysis (PD) and renal transplant recipient (RT). The sero-protection rate was used as a serologic parameter to describe the immune response to the vaccine. Statistical analysis was performed to calculate the pooled rate difference (RD) and 95% confidence interval (CI). The pooled RD for the H1N1, H3N2 and B influenza vaccines was 0.02 (95% CI: -0.02-0.06), 0.05 (95% CI: -0.01-0.11), 0.04 (95% CI: -0.02-0.10), respectively. We concluded that a booster dose of the influenza vaccine did not effectively enhance immunogenicity. Therefore, a booster dose of vaccine is not recommended for patients with hemodialysis, peritoneal dialysis and renal transplant recipients.

Background Dementia is a major public health challenge and China has the largest population with dementia in the world. However, dementia care and caregivers for Chinese are less investigated. Objectives and design To evaluate demographic and socio-economic influences on dementia care, management patterns and caregiver burden in a household community-dwelling-based survey, using participants’ care receipts and Zarit scale. Setting and participants Rural and urban communities across six provinces of China comprising 4837 residents aged ≥60 years, in whom 398 had dementia and 1312 non-dementia diseases. Results People with dementia were less likely to receive care if they were living in rural compared to urban areas (Odd ratio (OR) = 0.20; 95%CI: 0.10–0.41), having education level below compared to above secondary school (OR = 0.24; 95%CI: 0.08–0.70), manual labourer compared to non-manual workers (OR = 0.27; 95%CI: 0.13–0.55), having personal annual income below RMB 10,000 yuan (£1000) compared to above (OR = 0.37; 95%CI: 0.13–0.74) or having four or more than compared to less four children (OR = 0.52; 95%CI: 0.27–1.00). Caregivers for dementia compared with those for non-dementia diseases were younger and more likely to be patients’ children or children in-law, had lower education and spent more caring time. Caregiver burden increased with low education, cutback on work and caring for patients who were younger or living in rural areas, and this caregiver burden was three-fold greater than that for non-dementia diseases. Conclusions There are a number of inequalities in dementia care and caregiver burden in China. Reducing the socio-economic gap and increasing education may improve community care for people with dementia and preserve caregivers’ well-being.

Background and Purpose— Rates of stroke incidence and mortality vary across populations with important differences between socioeconomic groups worldwide. Knowledge of existing disparities in stroke risk is important for effective stroke prevention and management strategies. This review updates the evidence for associations between socioeconomic status and stroke. Summary of Review— Studies were identified with electronic searches of MEDLINE and EMBASE databases (January 2006 to July 2011) and reference lists from identified studies were searched manually. Articles reporting the association between any measure of socioeconomic status and stroke were included. Conclusions— The impact of stroke as measured by disability-adjusted life-years lost and mortality rates is >3-fold higher in low-income compared with high- and middle-income countries. The number of stroke deaths is projected to increase by >30% in the next 20 years with the majority occurring in low-income countries. Higher incidence of stroke, stroke risk factors, and rates of stroke mortality are generally observed in low compared with high socioeconomic groups within and between populations worldwide. There is less available evidence of an association between socioeconomic status and stroke recurrence or temporal trends in inequalities. Those with a lower socioeconomic status have more severe deficits and are less likely to receive evidence-based stroke services, although the results are inconsistent. Poorer people within a population and poorer countries globally are most affected in terms of incidence and poor outcomes of stroke. Innovative prevention strategies targeting people in low socioeconomic groups are required along with effective measures to promote access to effective stroke interventions worldwide.

Background Environmental tobacco smoke (ETS) is known to be harmful; however, its association with dementia remains controversial and with Alzheimer's disease (AD) is unknown. Methods Using a standard interview method, the author carried out a multicenter cross-sectional study of dementia in China by examining 2692 never-smoking people aged ≥60 years. Relative risks (RRs) of AD and all dementia, as diagnosed by psychiatrists, in relation to ETS were calculated in a multivariate regression model. Results The adjusted RR for all dementia was 1.78 (95% confidence interval [CI]: 1.18–2.68). The increased risk was mainly from exposure to ETS at home (1.87, 95% CI: 1.19–2.93), and it was associated with exposure duration. The adjusted RR for AD was 2.28 (95% CI: 1.82–2.84); the matched figure for ETS exposure at home, at work, and at other places was 2.15 (95% CI: 1.69–2.74), 2.04 (95% CI: 1.72–2.42), and 1.80 (95% CI: 0.96–3.38), respectively. The association of the increased risk with a total cumulative exposure dose was at borderline significance. Conclusions The risk of dementia and AD increased with ETS exposure. Banning smoking in public areas may help reduce a dementia epidemic worldwide.

Objectives To determine whether coronary angiography for suspected stable angina pectoris is underused in older patients, women, south Asian patients, and those from socioeconomically deprived areas, and, if it is, whether this is associated with higher coronary event rates. Design Multicentre cohort with five year follow-up. Setting Six ambulatory care clinics in England. Participants 1375 consecutive patients in whom coronary angiography was individually rated as appropriate with the Rand consensus method. Main outcome measures Receipt of angiography (420 procedures); coronary mortality and acute coronary syndrome events. Results In a multivariable analysis, angiography was less likely to be performed in patients aged over 64 compared with those aged under 50 (hazard ratio 0.60, 95% confidence interval 0.38 to 0.96), women compared with men (0.42, 0.35 to 0.50), south Asians compared with white people (0.48, 0.34 to 0.67), and patients in the most deprived fifth compared with the other four fifths (0.66, 0.40 to 1.08). Not undergoing angiography when it was deemed appropriate was associated with higher rates of coronary event. Conclusions At an early stage after presentation with suspected angina, coronary angiography is underused in older people, women, south Asians, and people from deprived areas. Not receiving appropriate angiography was associated with a higher risk of coronary events in all groups. Interventions based on clinical guidance that supports individualised management decisions might improve access and outcomes.

Purpose Socioeconomic deprivation (SED) has an effect on many health outcomes, including ischaemic stroke; however, its impact on mortality after haemorrhagic stroke remains unclear, particularly in the long run. We examined this association in a multiethnic population in the UK. Design We examined data from 782 patients with first-ever haemorrhagic stroke, collected by the South London Stroke Register from 1995 to 2011. SED was defined as the quartile with the highest Carstairs scores, and was analysed in relation to mortality after stroke in a multivariate-adjusted Cox regression model. Results In a follow-up of 17 years, 498 patients died. Compared with the first quartile of Carstairs score (the least deprived), the multivariate-adjusted HRs for 17-year mortality in patients in the second, third and fourth quartiles were 0.94 (95% CI 0.72 to 1.23), 1.17 (95% CI 0.90 to 1.52) and 1.36 (95% CI 1.04 to 1.78), overall p=0.04. The SED gradient association remained in patients with intracerebral haemorrhagic stroke, while in patients with subarachnoid haemorrhagic stroke the corresponding HRs were 2.62 (95% CI 1.22 to 5.64), 3.03 (95% CI 1.49 to 6.18) and 1.83 (95% CI 0.87 to 3.83), respectively. Results of 10-year mortality showed similar patterns, although the association of deprivation with 1-year mortality was not significant. Conclusions There is a significant impact of SED on long-term mortality after haemorrhagic stroke. The reasons for this survival inequality must be explored to reduce mortality in patients with haemorrhagic stroke.

Hypercholesterolemia is common in older adults and less treated, but little is known about correlates of untreated hypercholesterolemia. Using a standard interview method we examined a random sample of 7,572 participants aged ≥60 years in a community-based household survey across 7 provinces of China during 2007-2012, and documented 328 cases of hypercholesterolemia from self-reported doctor diagnosis. Compared to participants with normal cholesterol, older adults with hypercholesterolemia had higher socioeconomic position and larger body mass index. In patients with hypercholesterolemia, 209 were not treated using lipid-lowering medications (63.7%, 95% confidence interval (CI) 58.5%-68.9%). Untreated hypercholesterolemia was significantly associated with female sex (adjusted odds ratio 2.13, 95%CI 1.17-3.89), current smoking (3.48, 1.44-8.44), heavy alcohol drinking (3.13,1.11-8.84), chronic bronchitis (2.37,1.14-4.90) and high level of meat consumptions (2.85,1.22-6.65). Although having coronary heart disease exposed participants for treatment, half of participants with coronary heart disease did not receive lipid-lowering medications. Among hypercholesterolemia participants with stroke, hypertension or diabetes, more than half of them did not receive lipid-lowering medications. The high proportion of untreated hypercholesterolemia in older, high-risk Chinese adults needs to be mitigated through multi-faceted primary and secondary prevention strategies to increase population opportunities of treating hypercholesterolemia.

Delayed response to a mail survey is related to age, lifestyle and socioeconomic status, and may provoke bias in epidemiological study. We investigated whether delayed respondents were associated with their personality traits and neuropsychological symptoms. Two hundred and ninety-eight painters from a Scottish dockyard cohort and their 571 male controls (general subjects) randomly recruited from the local residents completed a questionnaire, which included 24 statements of the Eysenck personality scales and 22 questions of neuropsychological symptoms. There was a similar distribution of delayed response between general subjects and painters, with a total of 55.6% early (returning questionnaires within 4 weeks), 33.4% intermediate (within 8 weeks) and 11.0% late respondents (after 8 weeks). The delayed response was related to only a few individual statements or symptoms, which varied between general subjects and painters. There were no significant differences in scores in statements of personality traits and neuropsychological symptoms among the three respondent groups, except for the late respondents in painters having an increased score of total neuropsychological symptoms at borderline significance. After adjustment for confounding the case-control analysis showed no significant association of the high scores of social conformity, neuroticism and symptoms with a delayed response. This study suggests that response to a postal health survey may not be influenced or biased by personality traits and neuropsychological symptoms.

Background and aims Socioeconomic deprivation (SED) is associated with increased mortality after stroke, however, its associations with stroke care remains uncertain. We assessed the SED impacts on acute and long-term stroke care, and examined their ethnic differences and secular trends. Methods We used data from 4202 patients with first-ever stroke (mean age 70.1 years, 50.4% male, 20.4% black), collected by a population-based stroke register in South London, England from 1995 to 2010. Carstairs deprivation score was measured for each patient, taking the 1st as the least deprived and the 2nd to 5th quintiles as SED, and was related to 20 indicators of care in multivariate logistic regression models. Results Patients with SED had 29% and 35% statistically significant reductions in odds of being admitted to hospital and having swallow tests, respectively. The multivariate adjusted odds ratio (OR) for receiving five indicators of acute stroke care was 0.81 (95% CI 0.72 to 0.92). It was 0.76 (0.58 to 0.99) in black patients and 0.82 (0.71 to 0.96) in white patients; and 0.70 (0.58 to 0.84) in patients with stroke occurring before 2001 and 0.89 (0.75 to 1.05) since 2001. SED was further associated with receipt of some stroke care during 5 years of follow-up, including atrial fibrillation medication (0.63, 0.48 to 0.83), and in black patients physiotherapy and occupational therapy (0.32, 0.11 to 0.92). Conclusions Stroke healthcare inequalities in England exist for some important indicators, although overall it has improved over time. The impact of SED may be stronger in black patients than in white patients. Further efforts are required to achieve stroke care equality.

Background and Purpose Fatigue after stroke is common and has a negative impact on rehabilitation and survival. However, its pathogenesis and contributing factors remain unclear. The purpose of this study was to identify factors influencing the occurrence of fatigue after first-ever ischemic stroke in acute phase. Methods We examined 265 consecutive patients with first-ever ischemic stroke during acute phase (within 2 weeks) in two tertiary stroke care hospitals in Henan, China. We documented patients’ demographic and clinical characteristics through face-to-face interviews using structured questionnaires and reviews of medical records. Post-stroke fatigue was defined as a score of ≥4 using the Fatigue Severity Scale. Multivariate logistic regression was used to examine post-stroke fatigue in relation to socio-demographic, lifestyle, clinical characteristics and family function. Results About 40% first-ever ischemic stroke patients experienced post-stroke fatigue in acute phase. Post-stroke fatigue was associated with lack of exercise before stroke (adjusted odds ratio 4.01, 95% CI 1.95–8.24), family dysfunction (2.63, 1.20–5.80), depression (2.39, 1.02–5.58), the presence of pre-stroke fatigue (4.89, 2.13–11.21), use of sedative medications (4.14, 1.58–10.88), coronary heart disease (3.38, 1.46–7.79) and more severe Modified Rankin Scale (2.55, 1.65–3.95). Conclusions The causes of post-stroke fatigue are multifaceted. More physical exercise, improving family function, reducing depression and appropriate use of sedative medications may be helpful in preventing post-stroke fatigue.

Dietary antioxidants, waist circumference, and pulmonary function were measured in the Fourth Scottish MONICA cross-sectional survey of 865 men and 971 women aged 25-64 years. Waist circumference was inversely related to forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC), even after adjustment for age, height, weight, working status, energy intake, and smoking variables in a multiple linear regression model (men: beta = -0.017 for FEV1 l/cm, p < 0.01 and beta = -0.008 for FVC, p = 0.04; women: beta = -0.009 for FEV1, p < 0.01 and beta = -0.007 for FVC, p = 0.01). After additional adjustment for waist circumference, estimated vitamin C and beta-carotene intakes were positively associated with lung function in men (vitamin C: beta = 0.102 for FEV1 l/mg/day, p = 0.03; beta-carotene: beta = 0.073 for FVC l/g/day, p = 0.02). Retinol and vitamin E were not significantly related to lung function for either sex. A case-control study of airway obstruction showed that waist circumference was significantly associated, while vitamin C could be protective. The study suggests that adequate intake of antioxidants and avoidance of increasing girth could help to preserve lung function.

Background and Purpose— Previous findings of the association between socioeconomic deprivation (SED) and survival after stroke are inconsistent. There is less investigation on long-term survival. We assessed the associations in a multi-ethnic population in England. Methods— We examined data from 4398 patients (3103 whites, 932 blacks, and 253 Asians/others) with first-ever stroke, collected by a population-based stroke register in South London from 1995 to 2011. SED was measured using the Carstairs index score—the higher score, the more deprived. It was analyzed in multivariate Cox regression models in relation to survival after stroke. Results— During 17-year follow-up 2754 patients died. The quartile data of Carstairs score showed no significant association of SED with survival in patients, except for black Caribbeans and Africans. Black patients with the fourth quartile SED had a multivariate adjusted hazard ratio of 1.76 (95% confidence interval, 1.06–2.94) for 3-month mortality and 1.54 (1.00–2.37) for 1-year mortality. After adjustment for acute stroke care provisions, these were no longer significant. However, the sextile data of Carstairs score showed a consistent association of SED with survival after stroke; all patients with the sixth sextile had a fully adjusted hazard ratio of 1.23 (1.05–1.44) for 3-month mortality and 1.13 (1.01–1.25) for 17-year mortality. Conclusions— There is a weak but significant association of SED with reduced survival after stroke in England. SED in blacks may have a stronger impact on short-term survival when compared with white patients. Further efforts are required to achieve equality in survival among patients with stroke of different socioeconomic groups.

Background There has been little information about depression in Chinese elderly people. In order to investigate whether or not there is an excess of depression among the Chinese elderly, we have performed a meta-analysis of the published epidemiological studies. Methods Papers published in the literature from The People's Republic of China included in the Chinese medical databases were obtained. Some additional papers collected from other sources were also included. The fixed/random effects model and Poisson model were employed for data analysis. Results There were 10 cross-sectional studies (23 samples divided according to men/women and urban/rural subjects) giving sufficient prevalence data on depression (13 565 subjects) or depressive mood (8476 subjects). The pooled prevalence of depression was 3.86% (95%CI 3.37–4.42%), while that of depressive mood was 14.81% (14.20–15.64%). The risk of depression in the rural communities (5.07%, 3.61–7.13%) was higher than in the urban (2.61%, 2.22–3.08%). The same trends were observed for depressive mood. The patterns of risk factors were similar to those in western countries. Conclusions Chinese tradition and culture may be explanatory factors for the low prevalence, provided the methodological issues have not seriously biased the results. Copyright © 1999 John Wiley & Sons, Ltd.

Background The prevalence of obesity is increasing rapidly in low- and middle-income countries (LMICs) as their populations become exposed to obesogenic environments. The transition from an agrarian to an industrial and service-based economy results in important lifestyle changes. Yet different socioeconomic groups may experience and respond to these changes differently. Investigating the socioeconomic distribution of obesity in LMICs is key to understanding the causes of obesity but the field is limited by the scarcity of data and a uni-dimensional approach to socioeconomic status (SES). This study splits socioeconomic status into two dimensions to investigate how educated women may have lower levels of obesity in a context where labour market opportunities have shifted away from agriculture to other forms of employment. Methods The Four Provinces Study in China 2008/09 is a household-based community survey of 4,314 people aged ≥60 years (2,465 women). It was used to investigate an interaction between education (none/any) and occupation (agricultural/non-agricultural) on high-risk central obesity defined as a waist circumference ≥80 cm. An interaction term between education and occupation was incorporated in a multivariate logistic regression model, and the estimates adjusted for age, parity, urban/rural residence and health behaviours (smoking, alcohol, meat and fruit & vegetable consumption). Complete case analyses were undertaken and results confirmed using multiple imputation to impute missing data. Results An interaction between occupation and education was present (P = 0.02). In the group with no education, the odds of central obesity in the sedentary occupation group were more than double those of the agricultural occupation group even after taking age group and parity into account (OR; 95%CI: 2.21; 1.52, 3.21), while in the group with any education there was no evidence of such a relationship (OR; 95%CI: 1.25; 0.92, 1.70). Health behaviours appeared to account for some of the association. Conclusion These findings suggest that education may have a protective role in women against the higher odds of obesity associated with occupational shifts in middle-income countries, and that investment in women’s education may present an important long term investment in obesity prevention. Further research could elucidate the mechanisms behind this association.

Background Following the development of intravenous thrombolysis as a successful treatment for ischaemic stroke, advances in neurointerventional radiology have facilitated endovascular approaches to treatment. This article reviews the available endovascular therapeutic options and their evidence-base. Summary Initial studies demonstrated that endovascular treatment of ischaemic stroke with intra-arterial thrombolysis and/or the use of clot-retrieval, thrombus aspiration and stent-retriever devices produced early recanalisation and reperfusion and improved neurological outcome. More recent randomised trials, however, have failed to show translation of recanalisation into successful clinical outcome with ‘time to treatment’ proving crucial. In this rapidly evolving field, combined therapy incorporating intravenous and intra-arterial thrombolysis in combination with endovascular clot-retrieval has been developed and further studies are expected to yield better evidence to guide the optimal treatment of acute cerebral ischaemia.

To the Editor: In a recent study published in Stroke , Kokubo et al1 reported that consumption of green tea and coffee could significantly reduce the risk of stroke; compared with no tea drinking, participants drinking ≥4 cups/d had a 20% reduction in incidence of all strokes, and a similar reduction was found for those drinking coffee ≥2 cups/d compared with no coffee drinking. It would be interesting to see whether or not there were any significant differences in incidence of stroke between participants with drinking tea or coffee as a whole and those that are nondrinkers. The large data from the Japan Public Health Center (JPHC)–Based …

Purpose: Despite the known association of second hand smoke (SHS) with increased risk of ill health and mortality, the effects of SHS exposure on cognitive functioning in children and adolescents are unclear. Through a critical review of the literature we sought to determine whether a relationship exists between these variables. Methods: The authors systematically reviewed articles (dated 1989e2012) that investigated the association between SHS exposure (including in utero due to SHS exposure by pregnant women) and performance on neurocognitive and academic tests. Eligible studies were identified from searches of Web of Knowledge, MEDLINE, Science Direct, Google Scholar, CINAHL, EMBASE, Zetoc, and Clinicaltrials.gov. Results: Fifteen articles were identified, of which 12 showed inverse relationships between SHS and cognitive parameters. Prenatal SHS exposure was inversely associated with neurodevelopmental outcomes in young children, whereas postnatal SHS exposure was associated with poor academic achievement and neurocognitive performance in older children and adolescents. Furthermore, SHS exposure was associated with an increased risk of neurodevelopmental delay. Conclusions: Recommendations should be made to the public to avoid sources of SHS and future research should investigate interactions between SHS exposure and other risk factors for delayed neurodevelopment and poor cognitive performance.

BACKGROUND: With growing recognition of the social determinants of health, social capital is an increasingly important construct in international health. However, the application of social capital discourse in response to HIV infection remains preliminary. The aim of this study was to assess the impact of social capital on quality of life (QoL) among adult patients with acquired immune deficiency syndrome (AIDS). METHODS: A convenient sample of 283 patients receiving antiretroviral treatment (ART) was investigated in Anhui province, China. QoL data were collected using the Medical Outcomes Study HIV Survey (MOS-HIV) questionnaire. Social capital was measured using a self-developed questionnaire. Logistic regression models were used to explore associations between social capital and QoL. RESULTS: The study sample had a mean physical health summary (PHS) score of 50.13 ± 9.90 and a mean mental health summary (MHS) score of 41.64 ± 11.68. Cronbach's α coefficients of the five multi-item scales of social capital ranged from 0.44 to 0.79. When other variables were controlled for, lower individual levels of reciprocity and trust were associated with a greater likelihood of having a poor PHS score (odds ratio [OR] =2.02) or PHS score (OR=6.90). Additionally, the factors of social support and social networks and ties were associated positively with MHS score (OR=2.30, OR=4.17, respectively). CONCLUSIONS: This is the first report to explore the effects of social capital on QoL of AIDS patients in China. The results indicate that social capital is a promising avenue for developing strategies to improve the QoL of AIDS patients in China, suggesting that the contribution of social capital should be fully exploited, especially with enhancement of QoL through social participation. Social capital development policy may be worthy of consideration.

Objectives Environmental tobacco smoke (ETS) has a range of adverse health effects, but its association with dementia remains unclear and with dementia syndromes unknown. We examined the dose–response relationship between ETS exposure and dementia syndromes. Methods Using a standard method of GMS, we interviewed 5921 people aged ≥60 years in five provinces in China in 2007–2009 and characterised their ETS exposure. Five levels of dementia syndrome were diagnosed using the Automated Geriatric Examination for Computer Assisted Taxonomy instrument. The relative risk (RR) of moderate (levels 1–2) and severe (levels 3–5) dementia syndromes among participants exposed to ETS was calculated in multivariate adjusted regression models. Results 626 participants (10.6%) had severe dementia syndromes and 869 (14.7%) moderate syndromes. Participants exposed to ETS had a significantly increased risk of severe syndromes (adjusted RR 1.29, 95% CI 1.05 to 1.59). This was dose-dependently related to exposure level and duration. The cumulative exposure dose data showed an adjusted RR of 0.99 (95% CI 0.76 to 1.28) for >0–24 level years of exposure, 1.15 (95% CI 0.93 to 1.42) for 25–49 level years, 1.18 (95% CI 0.87 to 1.59) for 59–74 level years, 1.39 (95% CI 1.03 to 1.84) for 75–99 level years and 1.95 (95% CI 1.34 to 2.83) for ≥100 level years. Significant associations with severe syndromes were found in never smokers and in former/current smokers. There were no positive associations between ETS and moderate dementia syndromes. Conclusions ETS should be considered an important risk factor for severe dementia syndromes. Avoidance of ETS may reduce the rates of severe dementia syndromes worldwide.

Atrial fibrillation is a major risk factor for first and recurrent ischaemic stroke, and anticoagulation, mainly by use of coumarin medications, is an effective strategy for reducing ischaemic stroke occurrence in these patients. However, the coumarin medications have disadvantages. Over the past decade, important strides have been made towards developing improved anticoagulant medications. This review discusses these new developments and what they mean for the future of primary and secondary ischaemic stroke prevention in patients with atrial fibrillation. Relevant papers were identified with electronic searches of the Medline and EMBASE databases. Ongoing trials were checked using the Trials Results Centre website. The direct thrombin inhibitors, and the factor Xa inhibitors are the two major new anticoagulant drug classes under development at present. In phase III trials, dabigatran and rivaroxaban demonstrated at least as good performance as warfarin at reducing the rate of ischaemic stroke, systemic embolus, and haemorrhagic ischaemic stroke, whilst maintaining a comparable or lower rate of major bleeding events. Drug level monitoring was not required due to stable pharmacodynamics. AZD0837, apixaban, YM-150, edoxaban and betrixaban all showed promising results in phase II trials, as did S35972 in animal, in vitro and ex vivo models. The future of these new anticoagulants looks encouraging, although there are still some significant challenges to overcome. We need to consider the accumulation of long-term safety and efficacy data, and the development of effective means of reversal of anticoagulation for the direct thrombin inhibitors and factor Xa inhibitors.

Background National Health Service (NHS) mental health workforce configuration is at the heart of successful delivery, and providers are advised to produce professional development strategies. Recent policy changes in England have sharpened the focus on competency based role development. We determined levels of intervention activities, engagement and competence and their influencing factors in a community-setting mental health workforce. Methods Using a modified questionnaire based on the Yorkshire Care Pathways Model we investigated 153 mental health staff working in Coventry and Warwickshire NHS Trust. A median score of competence was computed across 10 cluster activities. Low engagement and competence levels were examined in a logistic regression model. Results In 220 activities, Monitoring risk was the highest rate of engagement (97.6%) and Group psychological therapy/Art/Drama therapy was the lowest engagement (3.6%). The median competence level based on all activities was 3.95 (proficient). There were significant differences in the competence level among professional groups; non-qualified support group (3.00 for competent), Counsellor/Psychologist/Therapist (3.38), Occupational therapists (3.76), Nurses (4.01), Medical staff (4.05), Social workers (4.25) and Psychologists (4.62 for proficient/expert). These levels varied with activity clusters; the lowest level was for Counsellor/Psychologist/Therapist in the accommodation activity (1.44 novice/advance beginner) and the highest for Occupational therapists in personal activity (4.94 expert). In a multivariate analysis, low competence was significantly related to non-qualified community support professions, late time of obtaining first qualification, more frequencies of clinical training, and training of cognitive behavioural therapy. The associations were similar in the analysis for 10 activity clusters respectively. Conclusions There was a reasonable competence level in the community-setting mental health workforce, but competence varied with professional groups and cluster activities. New staff and other non-qualified support professions need to receive efficient training, and the training content is more important than frequency to increase level of competence.

Background Current knowledge about incident dementia is mainly derived from studies undertaken in the West, showing that dementia is related to older age, low socio-economic status, lack of social network, depression and cardiovascular disease risk factors. We know little about incidence and predictors of dementia in China, where the prevalence is increasing and the patterns of risk factors are different. Methods Using a standard interview method, we examined 1526 non-demented people aged ≥65 years who had at least minimal educational level in China in a 7.5-year follow up. Incident dementia was diagnosed by GMS-AGECAT algorithms and psychiatrists. Results Age-standardised incidence of dementia was 14.7 per 1000 person-years (95%CI 11.3–18.2 per 1000 person-years). The increased risk was significantly associated with age, female gender (adjusted odds ratio 2.48, 95%CI 1.20–5.13), low educational levels, smoking, angina (2.58, 1.01–6.59) and living with fewer family members. Among participants with low educational level, the increased risk was associated with higher income, and with the highest and lowest occupational classes; adjusted odds ratio 2.74 (95%CI 1.12–6.70) for officers/teachers, 3.11 (1.61–6.01) for manual labourers/peasants. Conclusions Our findings of high incidence of dementia and increased risk among people having low education levels but high income suggest a more potential epidemic and burden of dementia populations in China. Maintaining social network and activities and reducing cardiovascular factors in late life could be integrated into current multi-faceted preventive strategies for curbing the epidemic of dementia.

Anoop Shah and colleagues performed a retrospective cohort study and a systematic review, and show evidence that in people with stable coronary disease there were threshold hemoglobin values below which mortality increased in a graded, continuous fashion., Background Low haemoglobin concentration has been associated with adverse prognosis in patients with angina and myocardial infarction (MI), but the strength and shape of the association and the presence of any threshold has not been precisely evaluated. Methods and findings A retrospective cohort study was carried out using the UK General Practice Research Database. 20,131 people with a new diagnosis of stable angina and no previous acute coronary syndrome, and 14,171 people with first MI who survived for at least 7 days were followed up for a mean of 3.2 years. Using semi-parametric Cox regression and multiple adjustment, there was evidence of threshold haemoglobin values below which mortality increased in a graded continuous fashion. For men with MI, the threshold value was 13.5 g/dl (95% confidence interval [CI] 13.2–13.9); the 29.5% of patients with haemoglobin below this threshold had an associated hazard ratio for mortality of 2.00 (95% CI 1.76–2.29) compared to those with haemoglobin values in the lowest risk range. Women tended to have lower threshold haemoglobin values (e.g, for MI 12.8 g/dl; 95% CI 12.1–13.5) but the shape and strength of association did not differ between the genders, nor between patients with angina and MI. We did a systematic review and meta-analysis that identified ten previously published studies, reporting a total of only 1,127 endpoints, but none evaluated thresholds of risk. Conclusions There is an association between low haemoglobin concentration and increased mortality. A large proportion of patients with coronary disease have haemoglobin concentrations below the thresholds of risk defined here. Intervention trials would clarify whether increasing the haemoglobin concentration reduces mortality. Please see later in the article for the Editors' Summary, Editors' Summary Background Coronary artery disease is the main cause of death in high-income countries and the second most common cause of death in middle- and low-income countries, accounting for 16.3%, 13.9%, and 9.4% of all deaths, respectively, in 2004. Many risks factors, such as high blood pressure and high blood cholesterol level, are known to be associated with coronary artery disease, and prevention and treatment of such factors remains one of the key strategies in the management of coronary artery disease. Recent studies have suggested that low hemoglobin may be associated with mortality in patients with coronary artery disease. Therefore, using blood hemoglobin level as a prognostic biomarker for patients with stable coronary artery disease may be of potential benefit especially as measurement of hemoglobin is almost universal in such patients and there are available interventions that effectively increase hemoglobin concentration. Why was This Study Done? Much more needs to be understood about the relationship between low hemoglobin and coronary artery disease before hemoglobin levels can potentially be used as a clinical prognostic biomarker. Previous studies have been limited in their ability to describe the shape of this relationship—which means that it is uncertain whether there is a “best” hemoglobin threshold or a continuous graded relationship from “good” to “bad”—to assess gender differences, and to compare patients with angina or who have experienced previous myocardial infarction. In order to inform these knowledge gaps, the researchers conducted a retrospective analysis of patients from a prospective observational cohort as well as a systematic review and meta-analysis (statistical analysis) of previous studies. What Did the Researchers Do and Find? The researchers conducted a systematic review and meta-analysis of previous studies and found ten relevant studies, but none evaluated thresholds of risk, only linear relationships. The researchers carried out a new study using the UK's General Practice Research Database—a national research tool that uses anonymized electronic clinical records of a representative sample of the UK population, with details of consultations, diagnoses, referrals, prescriptions, and test results—as the basis for their analysis. They identified and collected information from two cohorts of patients: those with new onset stable angina and no previous acute coronary syndrome; and those with a first myocardial infarction (heart attack). For these patients, the researchers also looked at all values of routinely recorded blood parameters (including hemoglobin) and information on established cardiovascular risk factors, such as smoking. The researchers followed up patients using death of any cause as a primary endpoint and put this data into a statistical model to identify upper and lower thresholds of an optimal hemoglobin range beyond which mortality risk increased. The researchers found that there was a threshold hemoglobin value below which mortality continuously increased in a graded manner. For men with myocardial infarction, the threshold value was 13.5 g/dl: 29.5% of patients had hemoglobin below this threshold and had a hazard ratio for mortality of 2.00 compared to those with hemoglobin values in the lowest risk range. Women had a lower threshold hemoglobin value than men: 12.8 g/dl for women with myocardial infarction, but the shape and strength of association did not differ between the genders, or between patients with angina and myocardial infarction. What Do These Findings Mean? These findings suggest that there are thresholds of hemoglobin that are associated with increased risk of mortality in patients with angina or myocardial infarction. A substantial proportion of patients (15%–30%) have a hemoglobin level that places them at markedly higher risk of death compared to patients with lowest risk hemoglobin levels and importantly, these thresholds are higher than clinicians might anticipate—and are remarkably similar to World Health Organization anemia thresholds of 12 g/dl for women and 13 g/dl for men. Despite the limitations of these observational findings, this study supports the rationale for conducting future randomized controlled trials to assess whether hemoglobin levels are causal and whether clinicians should intervene to increase hemoglobin levels, for example by oral iron supplementation. Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000439. Wikipedia provides information about hemoglobin (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages) The World Health Organization provides an overview of the global prevalence of coronary artery disease, a factsheet on the top ten causes of death, as well as information on anemia

To determine the effectiveness and cost-effectiveness of a range of strategies based on conventional clinical information and novel circulating biomarkers for prioritising patients with stable angina awaiting coronary artery bypass grafting (CABG).MEDLINE and EMBASE were searched from 1966 until 30 November 2008.We carried out systematic reviews and meta-analyses of literature-based estimates of the prognostic effects of circulating biomarkers in stable coronary disease. We assessed five routinely measured biomarkers and the eight emerging (i.e. not currently routinely measured) biomarkers recommended by the European Society of Cardiology Angina guidelines. The cost-effectiveness of prioritising patients on the waiting list for CABG using circulating biomarkers was compared against a range of alternative formal approaches to prioritisation as well as no formal prioritisation. A decision-analytic model was developed to synthesise data on a range of effectiveness, resource use and value parameters necessary to determine cost-effectiveness. A total of seven strategies was evaluated in the final model.We included 390 reports of biomarker effects in our review. The quality of individual study reports was variable, with evidence of small study (publication) bias and incomplete adjustment for simple clinical information such as age, sex, smoking, diabetes and obesity. The risk of cardiovascular events while on the waiting list for CABG was 3 per 10,000 patients per day within the first 90 days (184 events in 9935 patients with a mean of 59 days at risk). Risk factors associated with an increased risk, and included in the basic risk equation, were age, diabetes, heart failure, previous myocardial infarction and involvement of the left main coronary artery or three-vessel disease. The optimal strategy in terms of cost-effectiveness considerations was a prioritisation strategy employing biomarker information. Evaluating shorter maximum waiting times did not alter the conclusion that a prioritisation strategy with a risk score using estimated glomerular filtration rate (eGFR) was cost-effective. These results were robust to most alternative scenarios investigating other sources of uncertainty. However, the cost-effectiveness of the strategy using a risk score with both eGFR and C-reactive protein (CRP) was potentially sensitive to the cost of the CRP test itself (assumed to be 6 pounds in the base-case scenario).Formally employing more information in the prioritisation of patients awaiting CABG appears to be a cost-effective approach and may result in improved health outcomes. The most robust results relate to a strategy employing a risk score using conventional clinical information together with a single biomarker (eGFR). The additional prognostic information conferred by collecting the more costly novel circulating biomarker CRP, singly or in combination with other biomarkers, in terms of waiting list prioritisation is unlikely to be cost-effective.

\ud Objective To determine the effectiveness and cost effectiveness of using information from circulating biomarkers to inform the prioritisation process of patients with stable angina awaiting coronary artery bypass graft surgery.\ud \ud Design: Decision analytical model comparing four prioritisation strategies without biomarkers (no formal prioritisation, two urgency scores, and a risk score) and three strategies based on a risk score using biomarkers: a routinely assessed biomarker (estimated glomerular filtration rate), a novel biomarker (C reactive protein), or both. The order in which to perform coronary artery bypass grafting in a cohort of patients was determined by each prioritisation strategy, and mean lifetime costs and quality adjusted life years (QALYs) were compared.\ud \ud Data sources: Swedish Coronary Angiography and Angioplasty Registry (9935 patients with stable angina awaiting coronary artery bypass grafting and then followed up for cardiovascular events after the procedure for 3.8 years), and meta-analyses of prognostic effects (relative risks) of biomarkers.\ud \ud Results: The observed risk of cardiovascular events while on the waiting list for coronary artery bypass grafting was 3 per 10 000 patients per day within the first 90 days (184 events in 9935 patients). Using a cost effectiveness threshold of £20 000-£30 000 (€22 000-€33 000; $32 000-$48 000) per additional QALY, a prioritisation strategy using a risk score with estimated glomerular filtration rate was the most cost effective strategy (cost per additional QALY was

To investigate determinants of, and outcomes from, coronary angiography and intervention in patients with non-ST-segment elevation myocardial infarction (NSTEMI).Observational study.44 British hospitals with interventional facilities.13,489 admissions with NSTEMI; July 2005 to December 2006.Rate of angiography during index admission; death and readmission to hospital within 180 days.Significantly lower rates of angiography were seen for women, the elderly, the most deprived and those having cardiac, and most non-cardiac, comorbidities. Performance of angiography, compared with no angiography, was not associated with lower rate of readmission (multiple adjusted hazard ratio (HR) = 0.96, 95% CI 0.74 to 1.24) unless accompanied by coronary intervention (HR = 0.73, 95% CI 0.56 to 0.95). Angiography was associated with reduction in 180-day mortality for survivors of hospitalisation (HR = 0.59, 95% CI 0.49 to 0.72); with greater reduction when followed by an intervention (HR = 0.34, 95% CI 0.28 to 0.42). This mortality benefit after intervention was seen both in women (HR = 0.42, 95% CI 0.29 to 0.60) and men (HR = 0.31, 95% CI 0.24 to 0.41), and across age groups:65 years (HR = 0.25, 95% CI 0.14 to 0.44), 65-79 years (HR = 0.29, 95% CI 0.22 to 0.39) andor =80 years (HR = 0.52, 95% CI 0.37 to 0.74). Mortality benefit was not significantly attenuated by the presence of comorbidities.Performance of angiography and coronary intervention after NSTEMI was associated with mortality benefit that persisted in the presence of both cardiac and non-cardiac comorbidities. Mortality benefit was seen across age groups and was similar for both sexes.

BackgroundDepression and dementia often exist concurrently. The associations of depressive syndromes and severity of depression with incident dementia have been little studied.AimsTo determine the effects of depressive syndromes and cases of depression on the risk of incident dementia.MethodParticipants in China and the UK aged ⩾565 years without dementia were interviewed using the Geriatric Mental State interview and re-interviewed 1 year later in 1254 Chinese, and 2 and 4 years later in 3341 and 2157 British participants respectively (Ageing in Liverpool Project Health Aspects: part of the Medical Research Council – Cognitive Function and Ageing study).ResultsIncident dementia was associated with only the most severe depressive syndromes in both Chinese and British participants. The risk of dementia increased, not in the less severe cases of depression but in the most severe cases. The multiple adjusted hazard ratio (HR)=5.44 (95% CI 1.67–17.8) for Chinese participants at 1-year follow-up, and HR=2.47 (95% CI 1.25–4.89) and HR=2.62 (95% CI 1.18–5.80) for British participants at 2- and 4-year follow-up respectively. The effect was greater in younger participants.ConclusionsOnly the most severe syndromes and cases of depression are a risk factor for dementia.

There is speculation that women and South Asian people are more likely than men and white people to report atypical angina and that they are less likely to undergo invasive management of angina. We sought to determine whether atypical symptoms of angina pectoris in women and South Asians impacted clinically important outcomes and clinical management.We prospectively identified 2189 South Asian people and 5605 white people with recent-onset chest pain at 6 chest-pain clinics in the United Kingdom. We documented hospital admissions for acute coronary syndromes, coronary deaths as well as coronary angiography and revascularization procedures.Atypical chest pain was reported by more women than men (56.5% vs 54.5%, p0.054) and by more South Asian patients than white patients (59.9% vs 52.5%, p0.001). Typical symptoms were associated with coronary death or acute coronary syndromes among women (hazard ratio [HR] 2.30, 95% CI 1.70-3.11, p0.001) but not among men (HR 1.23, 95% CI 0.96-1.57, p = 0.10). Typical symptoms were associated with coronary outcomes in both South Asian and white patients. Among those with typical symptoms, women (HR 0.76, 95% CI 0.63-0.92, p = 0.004) and South Asian patients (HR 0.52, 95% CI 0.41-0.67, p0.001) were less likely than men and white patients to receive angiography.Compared to those with atypical chest pain, women and South Asian patients with typical pain had worse clinical outcomes. However, sex and ethnic background did not explain differences in the use of invasive procedures.

BackgroundRecent studies have shown a temporal association between depressive symptoms and cognitive decline. However, the relationship between syndromes of depression and dementia is unknown.MethodA total of 1736 people aged ⩾65 years in China and 5222 older people in the UK were interviewed using the Geriatric Mental State Examination (GMS) and reinterviewed at follow-up. Five levels of syndromes of depression and dementia were diagnosed using the Automated Geriatric Examination for Computer Assisted Taxonomy (AGECAT).ResultsAlthough there were fewer depressive syndromes in Chinese than British participants, both populations showed a similarly high level of syndromes of dementia (organic disorder) (20% for women, 14% for men). There was a significant cross-sectional correlation between syndrome levels of depression and dementia (correlation coefficients: 0.141–0.248 for Chinese, 0.168–0.248 for British). This was maintained for different age, gender and people with and without cardiovascular disease (CVD). The relationship between syndromes of baseline depression and follow-up dementia was less substantial: the correlation coefficient was 0.075 [95% confidence interval (CI) 0.021–0.128] for the Chinese sample at the 1-year follow-up, and 0.093 (95% CI 0.061–0.125) for the British at the 2-year follow-up and 0.093 (95% CI 0.049–0.130) at the 4-year follow-up. This relationship disappeared in participants without baseline organic syndromes. In a multiple adjusted logistic regression analysis, an increased risk of organic syndromes seemed to be associated with baseline, mainly in the highest level of, depressive syndromes.ConclusionsThe relationship between syndromes of depression and dementia might be temporal. The lack of an obvious dose–response relationship between baseline depressive syndromes and follow-up dementia syndromes suggests that the causal relationship between depression and dementia needs further investigation.

To examine the frequency and determinants of re-infarction after thrombolytic treatment of ST-elevation myocardial infarction (STEMI).Observational study of national registry.Emergency ambulance services and admitting hospitals in England and Wales.35 356 patients with STEMI given thrombolytic treatment in 2005-6.Re-infarction during hospital admission.For 22 391 patients (63.3%) the presence or absence of re-infarction was recorded, and 1460 (6.5%) had re-infarction. Re-infarction rates with in-hospital treatment were similar for reteplase (6.5%) and tenecteplase (6.4%). When the interval from pre-hospital treatment to hospital arrival was greater than 30 minutes re-infarction rates were 12.5% for reteplase, and 11.4% for tenecteplase. Overall, re-infarction rates were higher after pre-hospital treatment with tenecteplase than reteplase (9.6% vs 6.6%, p = 0.005). After multivariate analysis independent predictors of re-infarction for tenecteplase were pre-hospital treatment, OR 1.44 (95% CI 1.21 to 1.71, p0.001) and weight in the highest quartile compared to the lowest, OR 1.66 (95% CI 1.19 to 2.31, p = 0.003). For reteplase neither factor predicted re-infarction. Bleeding was less common with pre-hospital treatment-overall 1.8% against 3.1%; intracerebral bleeding 0.4% against 0.7%.Pre-hospital treatment with tenecteplase was associated with higher re-infarction rates. Longer intervals from pre-hospital treatment to arrival in hospital were associated with high re-infarction rates for both tenecteplase and reteplase. Differences in the use of adjunctive anti-thrombotic therapy in the two treatment environments may underlie the differences in re-infarction rates and bleeding complications observed between pre-hospital and in-hospital thrombolytic treatment.

Mild to moderate renal impairment (MMRI) is associated with an excess cardiovascular mortality but the reason for this is unclear. Increased left ventricular mass (LVM) is associated with severe renal dysfunction and a higher cardiovascular mortality. However, whether increased LVM also occurs in patients with milder renal dysfunction is unknown.336 consecutive patients under investigation for chest pain who underwent concurrent coronary angiography, serum creatinine (Cr) and LVM assessment, were recruited from a university hospital in Shanghai, China. The main outcome measures were: LVM normalised for body surface area (NLVM), renal function determined by Cr, creatinine clearance (CrCl) (Cockroft-Gault equation) and glomerular filtration rate (GFR) (Modification of Diet in Renal Disease equation).Mean+/-SD age was 56.8+/-9.5 years, 282 (84%) were male, mean NLVM 107.1+/-36.8 g/m(2), Cr 0.94+/-0.22 mg/dL, CrCl 82.7+/-21.7 mL/min/1.73 m(2) and GFR 89.4+/-24.6 mL/min/1.73 m(2). NLVM was related to Cr (r=-0.30), CrCl (r=0.19) and GFR (r=0.24) (all p0.001). A multiple logistic regression model using quartile analysis of renal function showed that those patients with a Cr 1.06-2.00 mg/dL, CrCl 34.8-67.5 mL/min/1.73 m(2) and a GFR 36.2-73.4 mL/min/1.73 m(2) were significantly associated with increased NLVM, independent of other variables. Using definitions derived from the National Kidney Foundation Guidelines multiple regression analysis showed MMRI to be independently associated with increased NLVM: Cr 1.2-1.9 mg/dL, odds ratio (OR) 2.77 (CI 1.04-7.40) (p=0.04); CrCl 30-89.9 mL/min/1.73 m(2), OR 1.63 (CI 0.91-2.93) (p=0.11); GFR 30-89.9 mL/min/1.73 m(2), OR 1.76 (CI 1.07-2.90) (p=0.03).In patients being investigated for chest pain, MMRI is significantly and independently associated with increased LVM.

Background With the gradual aging of the population, geriatric depression has become a major public health issue in China owing to its overall upward trend and associated negative socio-economic impact. Dearth of information regarding the burden and correlates of geriatric depression among Uyghur minority population in Xinjiang Autonomous Region, called for a comprehensive survey involving representative sample for designing efficient targeted intervention to control this disabling disease. Methods A cross-sectional study was conducted among 1329 consenting Uyghur elderly in 2011 in six randomly selected communities/villages in Xinjiang. Information about socio-demographics, behavior, negative life-events, satisfaction regarding income/quality of life and other chronic diseases were collected while assessment of geriatric depression was done using Geriatric Mental State Schedule (GMS). Results Among these participants, majority were currently married, had attended elementary school or less, had an average annual family income of less than 3000 Yuan/person, had strong religious beliefs while 10.61% (2.77% in urban and 23.60% in rural area) had geriatric depression (5.91% among male and 14.58% among females). 61.83% were suffering from other chronic diseases, 96.16% could take care of themselves and 39.28% had experienced negative events during last two years. Religious belief (AOR = 3.92, 95% CI 1.18–13.03), satisfaction regarding quality of life (AOR = 0.53, 95% CI 0.37–0.84) and income (AOR = 0.75, 95% CI 0.35–1.60), suffering from more chronic diseases (AOR = 1.70, 95% CI 1.42–2.04), experiencing three or more negative events (AOR = 1.72, 95% CI 0.92–3.22) and lack of ability to take self-care (AOR = 2.20, 95% CI 1.09–4.48) were all associated with having geriatric depression with or without adjustment for gender, education and occupation. Conclusion High prevalence of geriatric depression among Uyghur elderly in Xinjiang seemed to call for urgent interventions, specifically targeting rural residents, who experienced more negative life-events, were suffering from chronic diseases and were dissatisfied with their income and quality of life.