Is the effect of low birth weight on cardiovascular mortality mediated through high blood pressure?

OBJECTIVE: To explore whether the inverse association between birth weight and mortality from circulatory diseases is mediated through blood pressure in men aged 50-75 years. DESIGN: Cohort study with retrospectively collected data on size at birth. SUBJECTS AND SETTING: The study included 1334 men born during 1920-1924, living in Uppsala, Sweden, who were examined at the ages of 50 and 60 years, and followed-up to the end of 1995. MAIN OUTCOME MEASURES: Mortality from circulatory diseases based on routine death registration. RESULTS: Birth weight showed a specific, inverse association with mortality from circulatory diseases: the rate ratio was 0.67 (95% confidence interval 0.50 to 0.89) per 1000 g increase in birth weight. This association was not appreciably affected by adjustment for sociodemographic characteristics or smoking, but was strengthened slightly by adjustment for body mass index at the ages of 50 and 60 years. Adjustment for systolic blood pressure at the age of 50 years only slightly reduced the strength of the inverse association between birth weight and mortality from ischaemic heart disease, and did not affect the inverse association between birth weight and mortality from stroke. Adjustments for systolic and diastolic blood pressure and hypertension treatment at the ages of 50 and 60 years did not reduce the strength of the association between birth weight and mortality from circulatory diseases at the age of 60-75 years. CONCLUSIONS: The inverse association between birth weight and mortality from circulatory diseases in men aged 50-75 years is independent of adult sociodemographic characteristics, smoking and adult obesity and does not seem to be mediated through an increased blood pressure in those with low birth weight.

Social determinants of birthweight and length of gestation in Estonia during the transition to democracy.

BACKGROUND: To investigate social variation in birthweight and length of gestation in Estonia in the period of transition to a democracy and market economy. METHODS: All live births resulting from singleton pregnancies reported to the Estonian Medical Birth Registry in 1992-1997 (n = 84, 629) were studied with respect to social variation in birthweight and preterm delivery (<37 weeks gestation). The results were adjusted for maternal age, parity, education, nationality, marital status, smoking in pregnancy, sex of the infant (and gestational age). RESULTS: Between 1992 and 1997, mean birthweight increased from 3,465g to 3,497g (P < 0.001) and the preterm rate fell from 5.8% to 5.1% (P = 0.001). Maternal education, marital status and nationality were all independently related to the mean birthweight and the risk of preterm birth. The mean difference in birthweight between children of mothers with basic and university education was 87 g (95% CI : 74-100). Children born to mothers of non-Estonian compared to Estonian nationality were on average 77 g lighter (95% CI: 70-84). While the effect of nationality and marital status on birthweight was relatively stable during the study period, differences in birth outcome by maternal education became stronger. CONCLUSIONS: The mean birthweight increased and the preterm rate decreased in Estonia as a whole during the transition. However, the improvements were not shared equally by all social groups. An increase in variation in birthweight by maternal education was particularly notable.

Can confounding by sociodemographic and behavioural factors explain the association between size at birth and blood pressure at age 50 in Sweden?

STUDY OBJECTIVE: To evaluate whether socioeconomic confounding explains the relationship between size at birth and blood pressure at age 50. DESIGN: Cross sectional study with retrospectively collected data on size at birth. SETTING: Uppsala, Sweden. PARTICIPANTS: 1333 men born in 1920-24, and a subset of 615 men for analyses including early social circumstances. MAIN OUTCOME MEASURES: Blood pressure measured after 10 minutes rest in supine position. Crude and adjusted effect measures were compared. MAIN RESULTS: Controlling for sociodemographic characteristics at age 50, such as socioeconomic position, highest education achieved and marital status did not reduce the strength of the association between birth weight and systolic blood pressure at 50 years. In the total population, the slope of the body mass index adjusted relationship changed from -3.4 mmHg/kg to -3.5 mmHg/kg on additional adjustment for sociodemographic characteristics at age 50 (both p values < 0.01). Controlling for behavioural characteristics at age 50, such as smoking and recent alcohol drinking, did not affect the relationship between birth weight and blood pressure at 50. In the 615 men for whom information on sociodemographic circumstances in early life was available, adjustment for factors such as social class of the family, mother's marital status or area of residence, led to a slight reduction of the effect of birth weight on systolic blood pressure at age 50. The slope of the body mass index adjusted relationship changed from -2.8 mmHg/kg to -2.6 mmHg/kg after additional adjustment for early life circumstances in the sample as a whole (p values 0.09 and 0.12). Simultaneous adjustment for sociodemographic characteristics at birth together with sociodemographic and behavioural characteristics at age 50 led to only a slight reduction of the effect of birth weight on systolic blood pressure at 50 years. CONCLUSION: The strong inverse associations between birth weight and blood pressure among 50 year old Swedish men are highly unlikely to be explained by confounding with socioeconomic circumstances at birth or in adult life.

Neonatal and postneonatal mortality in Germany since unification.

BACKGROUND: After unification, the gap in infant mortality rates between the two parts of Germany widened until 1996 before converging. The reasons for these changes have not, so far, been apparent. OBJECTIVES: To investigate trends in neonatal and postneonatal mortality in the eastern (the new Länder) and western (the old Länder) part of Germany after unification in 1990 and to identify the scope for further improvement. DESIGN: Examination of trends in birth weights, birth weight specific neonatal mortality and cause specific postneonatal mortality in the two parts of Germany from 1990 to 1996 and 1997 by analysing routinely available vital statistics data. RESULTS: In both parts of Germany, neonatal mortality fell considerably, by 33 per cent in the east and 17 per cent in the west, from 4.5 and 3.5 per thousand live births in 1990 to 3.0 and 2.9 in 1997, respectively. This was attributable to an improvement in survival of infants at all birth weights but especially among those with very low birth weights, accounting for an estimated 83 to 85 per cent of the overall improvement. The birth weight distribution showed a slight worsening in the new and the old Länder with an increase in the proportion of those under 1500 g and, in the east, a 24 per cent increase in the proportion of high birth-weight infants of 4000 and more grams. Trends in postneonatal mortality revealed a worsening of about 32 per cent in the east from 1990 to 1991 followed by a decline of over 50 per cent up to 1997, leading to comparable mortality rates of 1.8 per thousand live births in the east and 2.0 in the west. While both parts experienced a decrease of 40 to 48 per cent in deaths from all diseases, the decline in deaths because of accidents and injuries was markedly higher in the new Länder although they are still exceeding the western rate by 3.7 per 100,000 live births in 1997. CONCLUSIONS: Since unification, the two parts of Germany underwent a complex process that has led finally to convergence of parameters of infant health that are most likely to have been because of improvements in the quality of perinatal care. To improve infant mortality in Germany, policy measures should focus on preventive rather than curative measures as the proportion of very low birthweight babies is increasing in both parts of Germany.

Health needs of the Roma population in the Czech and Slovak Republics.

In the growing literature on the human rights of Roma people in Central Europe, their relatively poor health status is often mentioned. However, little concrete information exists about the contemporary health status of the Roma in this region. We sought information on the health of the Roma in two of countries with significant Roma minorities, the Czech and Slovak Republics, by means of systematic searches for literature on the health of Roma people published in Czech or Slovak or by authors from the two countries. Published research on health of the Roma population is sparse. The topics that have received attention suggest a focus on concepts of contagion or social Darwinism, indicating a greater concern with the health needs of the majority populations with which they live. What limited evidence exists indicates that the health needs of the Roma population are considerable. With very few exceptions, the health status of Roma is worse than that of non-Roma population in both countries. The burden of communicable disease among Roma is high and diseases associated with poor hygiene seem to be particularly important. Evidence on health care suggests poor communication between Roma and health workers and low uptake of preventative care. The health needs of Roma lack visibility, not only because of the absence of research but also the absence of advocacy on their behalf. Since 1989, Czech and Slovak researchers have largely turned away from health research on particular ethnic groups. This probably reflects a growing sensitivity about stigmatising Roma, but it also makes it difficult to know how their circumstances might be improved. There is a need for further research into the health of Roma people with particular emphasis on non-communicable disease and for interventions that would improve their health.

Neonatal mortality in the Czech Republic during the transition.

OBJECTIVES: To identify factors underlying the reduction in neonatal mortality in the Czech Republic during the 1990s and to identify scope for further improvements. DESIGN: Examination of trends in birth weight and birth weight specific neonatal mortality in the Czech Republic and comparison with figures from Sweden, which has one of the lowest neonatal mortality rates in Europe. SETTING: The Czech Republic. SUBJECTS: All singleton births occurring in the Czech Republic in 1989-1991 and 1994-1995, with a comparison group of all singleton births in Sweden in 1989-1991. MAIN OUTCOME MEASURES: Neonatal mortality rate. RESULTS: Despite a slight worsening in the birth weight distribution, the neonatal mortality rate in the Czech Republic fell from 5.6 to 3.8 per thousand live births. This was due to an improvement in the survival of infants at all birth weights but especially amongst the lightest. Eighty percent of the overall improvement was due to greater survival among those under 2500 g. Comparison with Swedish birth weight specific rates indicates that, for the country as a whole, only small additional gains are likely as a result of improved survival at a given birth weight but, instead, a reduction in the proportion of low birth weight babies would have a much greater effect. Regional analysis indicates that the improvements have been much greater in Prague than in the rest of the country. CONCLUSIONS: An effective strategy to reduce neonatal mortality in the Czech Republic should have two elements. The first is to address the socio-economic determinants of low birth weight. The second is to reduce regional inequalities in the quality of neonatal care. This should, however, be supplemented by more detailed investigation to identify specific amenable factors.

Epidemiology of childhood burns at the Burn Centre in Brno, Czech Republic.

Three hundred and ninety-four children were admitted to the burn centre in Brno over a 3-year period. The overall incidence was 31 children per 100,000 children aged 0-14 years. The majority of patients were aged 1-3 years and almost 80 per cent of them were scalded. Proportionally more boys than girls were injured, in most cases at home in the presence of one or both parents. The highest risk time for injuries was between 16.00 and 18.00 h. Seasonal variations had no significant influence on the increased number of admissions to the burn centre. Sixty-six per cent of the children had minor burns. Four children died of the consequences of burns during the period studied. Social and economic factors had a significant influence on the incidence of childhood burns.

Temporal and spatial pattern of infant mortality in Germany after unification.

OBJECTIVES: After unification in 1990 the two parts of Germany underwent a complex process that has led to convergence of infant mortality. The pattern of change did, however, differ in east and west. This study investigates whether these differences conceal a complex pattern of heterogeneity at the regional level. METHODS: Examination of routine data on infant, neonatal and postneonatal mortality. Time trends in the 16 federal states of Germany (Länder) from 1991 to 1997 were studied using a log-linear model. RESULTS: In 1991, infant mortality was higher in almost all eastern Länder than in the west. By 1997, this east-west gap had disappeared. Over this period, infant mortality fell in all Länder but one. The decline was steepest in the east, ranging from 31% to 52%. Improvements were largely due to steep declines in both neonatal and postneonatal mortality. CONCLUSIONS: This study shows that, at the time of unification, there was an almost complete demarcation between east and west, a pattern that disappeared by 1997. There is, however, still a substantial regional variation in infant mortality that is largely determined by postneonatal mortality.

Reduced fetal growth rate and increased risk of death from ischaemic heart disease: cohort study of 15 000 Swedish men and women born 1915-29.

OBJECTIVE: To establish whether fetal growth rate (as distinct from size at birth) is associated with mortality from ischaemic heart disease. DESIGN: Cohort study based on uniquely detailed obstetric records with 97% follow up over the entire life course and linkage to census data in adult life. SUBJECTS: All 14 611 babies delivered at the Uppsala Academic Hospital, Sweden, during 1915-29 followed up to end of 1995. MAIN OUTCOME MEASURES: Mortality from ischaemic heart disease and other causes. RESULTS: Cardiovascular disease showed an inverse association with birth weight for both men and women, although this was significant only for men. In men a 1000 g increase in birth weight was associated with a proportional reduction in the rate of ischaemic heart disease of 0.77 (95% confidence interval 0.67 to 0.90). Adjustment for socioeconomic circumstances at birth and in adult life led to slight attenuation of this effect. Relative to the lowest fourth of birth weight for gestational age, mortality from ischaemic heart disease in men in the second, third, and fourth fourths was 0.81 (0.66 to 0.98), 0.63 (0.50 to 0.78), and 0.67 (0.54 to 0.82), respectively. The inclusion of birth weight per se and birth weight for gestational age in the same model strengthened the association with birth weight for gestational age but removed the association with birth weight. CONCLUSION: This study provides by far the most persuasive evidence of a real association between size at birth and mortality from ischaemic heart disease in men, which cannot be explained by methodological artefact or socioeconomic confounding. It strongly suggests that it is variation in fetal growth rate rather than size at birth that is aetiologically important.

Failure to realise growth potential in utero and adult obesity in relation to blood pressure in 50 year old Swedish men.

OBJECTIVES: To clarify the type of fetal growth impairment associated with increased blood pressure in adult life, and to establish whether this association is influenced by obesity and is mediated through impairment of insulin action. DESIGN: Cross sectional survey with retrospective ascertainment of size at birth from obstetric archives. SUBJECTS: 1333 men resident in Uppsala, Sweden, who took part in a 1970 study of coronary risk factors at age 50 and for whom birth weight was traced. MAIN OUTCOME MEASURES: Systolic and diastolic blood pressure at age 50. RESULTS: In the full study population for a 1000g increase in birth weight there was a small change in systolic blood pressure of -2.2mmHg (95% confidence interval -4.2 to - 0.3mmHg) and in diastolic blood pressure of -1.0mmHg (-2.2 to 0.1mmHg). Much stronger effects were observed among men who were born at term and were in the top third of body mass index at age 50, for whom a 1000g increase in birth weight was associated with a change of -9.1mmHg (-16.4 to-1.9mmHg) systolic and -4.2mmHg (-8.3 to -0.1mmHg) diastolic blood pressure. Men who were light at birth (<3250g) but were above median adult height had particularly high blood pressure. Adjustment for insulin concentrations reduced the associations of birth weight with systolic and diastolic blood pressure. CONCLUSIONS: A failure to realise growth potential in utero (as indicated by being light at birth but tall as an adult) is associated with raised adult blood pressure. Impaired fetal growth may lead to substantial increases in adult blood pressure among only those who become obese. Metabolic disturbances, possibly related to insulin resistance, may provide a pathway through which fetal growth affects blood pressure.

Defining and assessing health-related quality of life.

In recent years, there has been an increasing interest in quality of life assessment in clinical research and practice, as well as in public health and policy analysis. Indicators of health-related quality of life are important not only for health professionals and their patients, but also for health administrators and health economists in health care planning and policy making. Most studies on the outcome of treatments and interventions now include some kind of a quality of life measure. This usually takes a form of an assessment of symptoms and physical functioning, measurement of psychological well-being, life satisfaction, or coping and adjustment. Numerous scales of psychological health, physical health status and physical functioning have been developed for use in the assessment of health outcomes and a wide range of instruments for measurement of health-related quality of life is available. These fall into two broad categories of generic and disease-specific instruments. The selection of an instrument depends upon its measurement properties but also upon the specific context in which the instrument is going to be used. Adequate attention needs to be paid to the translation and validation of instruments for use across countries and cultural contexts.

Time trends in incidence of hypertrophic scarring in children treated for burns.

Control of burn-scar hypertrophy remains a priority program in the care of burned children. We analysed data from 779 clinical notes of children aged from 0 to 15 years who were hospitalised at the Burn Centre in Brno between 1991 and 1996. The occurrence of hypertrophic scarring in burn-injured children was studied by monitoring two periods separately, the first period from 1991 to 1993 and the second period with better clinical advantages from 1994 to 1996 using outpatients' records. The incidence of scar hypertrophy was at least 32% in both periods. However, the occurrence of hypertrophic scarring in these two periods did not appear to have been influenced by changes in clinical practice.

[Health care needs and their assessment. Part 1. The role of health needs in the development, regulation and evaluation of the health care system]. / Zdravotní potreby a jejich hodnocení. Cást 1. Význam zdravotní potreby pro tvorbu, regulaci a hodnocení zdravotnického systému.

The authors draw attention to the fact that higher spending on health care will not necessarily translate into better health. They advocate the importance of theoretical conceptual work and research in the field of health care and health services management. The needs-based approach is recommended as an alternative to the current models based on patient-physician interactions. The relationships between health needs, demands and health services provided should be further explored and their potential role as a basis for health policy in the Czech Republic should be addressed.

[A deadly pandemic is still spreading. The harmful effects of smoking are a serious warning for all]. / Smrtící pandemie se stále sírí. Nicivé dusledky kourení jsou vázným varováním pro vsechny.

The author draw attention to the serious character of the pandemic caused by smoking which on a worldwide scale is responsible for the premature death of 4.2 million people every year. In the Czech Republic every year 22,000 people die from the sequelae of smoking. The authors refer to work which contributed to the evidence of the harmful impact of smoking on health. The World Health Organization contributes markedly to efforts to control smoking. The authors present brief information on the conference in Warsaw held in February 2002, they mention briefly data on smoking in Europe and the Czech Republic. They draw attention to the new strategy of the tobacco industry and appeal for joint and coordinated activities the objective of which would be to prevent health problems caused by smoking.

[Social determinants of health. Basic facts and recommendations for practice within the context of the Health City Program]. / Sociální determinanty zdraví. Základní fakta a doporucení pro praxi v kontextu programu Zdravá mesta.

Paper provides some basic information on selected social determinants of health that had been summarised in the process of creating, detailing, implementing and evaluating the European health policy led by WHO. The social areas discussed are: social gradient, stress, early life experiences, social exclusion, job control at work, unemployment, social support, addiction, food, and transport. We also present a brief summary of policy recommendations related to social determinants of health. This information is relevant both for the development of the health services system and the system of health care and policy in a broader sense.

[Health care needs and their assessment. Part 2. The need for health and health care]. / Zdravotní potreby a jejich hodnocení. Cást 2. Potreba zdraví a potreba zdravotní péce.

Health needs assessment is primarily concerned with the benefits that can be expected from the provision of different kinds of health services. These are closely related to the levels of health risks and illness in the population and the expected effectiveness of the service in reducing health risks and the consequences of illness as indicated by results of evaluative research or by clinical consensus. Levels of disease and health risks in a population are commonly referred to as needs for health, and the levels of expected benefit are referred to as the needs for services or care.

[Assessment of health needs, their geographic distribution and association of health care indicators in Districts within the Czech Republic]. / Odhad zdravotních potreb, jejich územní rozlození a návaznost na vybrané ukazatele poskytování zdravotnických sluzeb v okresech Ceské republiky.

BACKGROUND: The objective of the present study was to use available data provided by the programme Health Services Indicators (HSI) for partial analyses focused on the estimated health services needs in different districts of the Czech Republic (CR) and on evaluation of some intentions of the health policy. METHODS AND RESULTS: After evaluation of the standardized and gross mortality rates in different districts of the CR the authors evaluated relationships of selected indicators recorded in 1995. The correlation of the gross mortality as an orientational estimate of health services needs in different districts of the CR and expenditures of health insurance companies for health care per one insured subject was low and was not statistically significant (r = -0.062). A close correlation with expenditure of health insurance companies was found with the number of doctors (r = 0.894), the number of nurses (r = 0.842) and the number of hospital beds (r = 0.679). The number of population per general practitioner correlated only weakly with the expenditure of health insurance companies (r = 0.012). A marked correlation (r = -0.676) was found between the percentage of general practitioners from the total number of doctors in the district and expenditures of the health insurance companies. CONCLUSIONS: The authors recommend that the role of general practitioners in the system of health care should be appreciated and that primary care should be conceived as the basis of effective, economical and high standard health care. It is desirable that HSI data should become the baseline of systematic operational research into health services.

[Relation between socioeconomic factors and mortality in districts in the Czech Republic 1989-1993]. / Vztah mezi socioekonomickými faktory a úmrtností v okresech Ceské republiky v období 1989-1993.

BACKGROUND: Socioeconomic factors have been identified as important determinants of morbidity and mortality in many populations but only few studies examined their importance in the Czech population. The objective of this study was to analyse the relationship between socioeconomic characteristics and mortality in districts of the Czech Republic in 1989-1993. METHODS AND RESULTS: The association between age-standardised mortality (for men and women separately) from all causes, all cancers, lung cancer, cardiovascular and ischaemic heart disease in the age group 35-64 and socioeconomic characteristics of districts reported from the 1991 Census was studied in multiple linear regression. In principle, associations between socioeconomic factors and mortality were similar for all causes of death. Mortality was inversely related to percentage of population with secondary and university education and to proportion of population with any religious denomination. After controlling for other factors, correlation coefficients (r) between all cause mortality and proportion of population with primary education were 0.69 in men and 0.64 in women; for the proportion of population with any religious denomination the r were -0.42 and -0.72, respectively. Relation of mortality to mean of persons per room was stronger in women (r = 0.29) than in men (r = 0.10). Population density was most closely correlated with ischemic heart disease (r = 0.41) in men and 0.43 in women). Available socioeconomic factors explained over 60% of geographical variation in mortality from all causes, more than 50% of variation in cancers and about 40% of variation in ischaemic heart disease. CONCLUSIONS: Although ecological studies do not allow firm identification of causal factors, our results agree well with other studies, and confirm the important effect of socioeconomic factors on health in the Czech population.

Primary health care in the Czech Republic: brief history and current issues.

The objective of this paper is to describe the recent history, current situation and perspectives for further development of the integrated system of primary care in the Czech Republic. The role of primary care in the whole health care system is discussed and new initiatives aimed at strengthening and integrating primary care are outlined. Changes brought about by the recent reform processes are generally seen as favourable, however, a lack of integration of health services under the current system is causing various kinds of problems. A new strategy for development of primary care in the Czech Republic encourages integration of care and defines primary care as co-ordinated and complex care provided at the level of the first contact of an individual with the health care system.