Time trends in cardiovascular and all-cause mortality in the 'old' and 'new' European Union countries.

AIMS: There are large differences in all-cause and cardiovascular disease (CVD) mortality between eastern and western countries in Europe. We reviewed the development of these mortality trends in countries of the European Union (EU) over the past 40 years and evaluated available data regarding possible determinants of these differences. METHODS AND RESULTS: We summarized all-cause mortality and specific cardiovascular mortality for two country groups - 10 countries that joined the European Union (EU) after 2004 (East), and 15 countries that joined before 2004 (West). Standardized mortality rates were retrieved from the World Health Organization "European Health for All" database for each country between 1970 and 2007. Currently (in the 2000s), mortality due to circulatory system disease, ischemic heart disease (IHD), cerebrovascular disease (CBVD), and all-causes in the 'new' EU countries (East) is approximately twice that in the 'old' EU countries (West). These differences were much smaller in the 1970s. The increasing gap in mortality between West and East is primarily the result of a continuous and rapid improvement in the West. CONCLUSION: Differences in lifestyle (i.e. diet, alcohol consumption, physical activity, and smoking) provide insufficient explanation for the observed mortality gap in these two groups of EU countries. Higher expenditures on health, better access to invasive and acute cardiac care, and better pharmacological control of hypertension and hypercholesterolemia in the West are well documented. Socioeconomic and psychosocial factors may also contribute to the changes in mortality trends.

One size fits all: or horses for courses? Recovery-based care in specialist mental health services.

INTRODUCTION: The 'recovery approach' to the management of severe mental health problems has become a guiding vision of service provision amongst many practitioners, researchers, and policy makers as well as service users. METHOD: This qualitative pilot study explored the meaning of 'recovery' with users of three specialist mental health services (eating disorders, dual diagnosis, and forensic) in 18 semi-structured interviews. RESULTS: The relevance of themes identified in mainstream recovery literature was confirmed; however, the interpretation and relative weight of these themes appeared to be affected by factors that were specific to the diagnosis and treatment context. 'Clinical' recovery themes were also seen as important, as were aspects of care that reflect core human values, such as kindness.

Psychological vulnerability in children next-born after stillbirth: a case-control follow-up study.

BACKGROUND: Case studies and anecdotal accounts suggest that perinatal loss may impact upon other children in the family, including those born subsequent to loss. However, there is a dearth of systematically collected quantitative data on this potentially vulnerable group. METHODS: Case-controlled follow-up of 52 mothers with history of stillbirth with their next-born children aged 6-8 years, and 51 control mother-child dyads. Previously reported baseline data included maternal antenatal and postnatal psychological assessment, and infant security of attachment at 12 months. Follow-up assessments included maternal psychiatric and socio-demographic data, mother and teacher-rated scales of the child's strengths and difficulties, child IQ, observer-rated mother-child interaction and maternal reports of child health. RESULTS: There were no significant between-group differences in child cognitive or health assessments, or in teacher-rated child difficulties. However, mothers with history of stillbirth (the index group) reported increased child difficulties, in particular peer problems, and more adverse interaction was observed in respect of higher levels of maternal criticism of the child's actions, more overall controlling behaviour by the mother, a less harmonious emotional atmosphere and a lower level of maternal engagement with the child. Some of these effects appeared to be mediated by maternal perinatal psychological symptoms and family breakdown. CONCLUSIONS: This study provides no evidence to suggest that siblings born after stillbirth are clinically at risk but does lend empirical support to clinical reports that such children are seen by their mothers as having problems and that they are exposed to less optimal interaction with their mothers. Possible interpretations of these findings are discussed in the context of theoretical accounts of 'replacement child' and 'vulnerable child' syndromes.

Long-term psychosocial sequelae of stillbirth: phase II of a nested case-control cohort study.

Stillbirth is associated with increased psychological morbidity in the subsequent pregnancy and puerperium. This study aimed to assess longer-term psychological and social outcomes of stillbirth and to identify factors associated with adverse outcome. We conducted seven-year follow-up of a cohort of women who were initially assessed during and after a pregnancy subsequent to stillbirth, together with pair-matched controls. All women were living with a partner at baseline and none had live children. Measured outcomes at follow-up included depression, posttraumatic stress disorder (PTSD) and partnership breakdown. Comparison variables included social and psychological factors and, for the stillbirth group, factors relating to the lost pregnancy. There were no differences between groups in case level psychological morbidity, but significantly higher levels of PTSD symptoms persisted in stillbirth group mothers who had case level PTSD 7 years earlier. Stillbirth group mothers were more likely to have experienced subsequent partnership breakdown. In the stillbirth group such breakdown was associated with having held the stillborn infant and having had case-level PTSD. Interpretations and clinical implications of these findings are discussed.

Lifestyle changes and blood pressure control: a community-based cross-sectional survey (2006 Ontario Survey on the Prevalence and Control of Hypertension).

To evaluate lifestyle changes and their impact on hypertension control in a sample of hypertensive respondents in Ontario, Canada, diet, physical activity, and other nonpharmacologic measures were recorded using a structured questionnaire during the 2006 Ontario Survey on the Prevalence and Control of Hypertension. Responses were weighted to the total adult population of 7,996,653 in Ontario. The prevalence of hypertension was 21%; 42% of hypertensive persons received therapy with antihypertensive drugs and lifestyle changes, and 41% received therapy with drugs only. Blood pressure was controlled in 85% of respondents who used only drugs and in 78% of those who stated that they received therapy with combined drug treatment and lifestyle changes. Fewer than half of hypertensive respondents practiced lifestyle changes (in combination with drug treatment) for blood pressure control. Lifestyle measures in addition to medication use did not result in better control of hypertension compared to only medication use.

Results of the Ontario survey on the prevalence and control of hypertension.

BACKGROUND: Available information on the prevalence and management of hypertension in the Canadian population dates back to 1986-1992 and probably does not reflect the current status of this major risk factor for cardiovascular disease. We sought to evaluate the current prevalence and management of hypertension among adults in the province of Ontario. METHODS: Potential respondents from randomly selected dwellings within target neighbourhoods in 16 municipalities were contacted at their homes to request participation in the study. For potential respondents who agreed to participate, blood pressure was measured with an automated device. Estimation weights were used to obtain representative estimates of population parameters. Responses were weighted to the total adult population in Ontario of 7,996,653. RESULTS: From 6436 eligible dwellings, contact was made with 4559 potential participants, of whom 2992 agreed to participate. Blood pressure measurements were obtained for 2551 of these respondents (age 20-79 years). Hypertension, defined as systolic blood pressure of 140 mm Hg or more, diastolic blood pressure of 90 mm Hg or more, or treatment with an antihypertensive medication, was identified in 21.3% of the population overall (23.8% of men and 19.0% of women). Prevalence increased with age, from 3.4% among participants 20-39 years of age to 51.6% among those 60-79 years of age. Hypertension was more common among black people and people of South Asian background than among white people; hypertension was also associated with higher body mass index. Among participants with hypertension, 65.7% were undergoing treatment with control of hypertension, 14.7% were undergoing treatment but the hypertension was not controlled, and 19.5% were not receiving any treatment (including 13.7% who were unaware of their hypertension). The extent of control of hypertension did not differ significantly by age, sex, ethnic background or comorbidities. INTERPRETATION: In Ontario, the overall prevalence of hypertension is high in the older population but appears not to have increased in recent decades. Hypertension management has improved markedly among all age groups and for both sexes.

The psychological effects of stillbirth and neonatal death on fathers: systematic review.

OBJECTIVE: To review the available evidence on the psychological effects of perinatal death on fathers. METHOD: Electronic search of CINAHL, MEDLINE and PsycINFO databases from 1966-2005. INCLUSION CRITERIA: papers describing at least one psychological outcome for fathers who had experienced stillbirth or neonatal death. EXCLUSION CRITERIA: papers not in English, dissertations, reviews, books without original data, intervention studies, studies of parents without separate results for fathers, studies where perinatal loss was not distinguished from other losses, first person accounts of a single experience, studies reporting on fewer than five fathers. Seventy-seven potential papers were obtained and screened by two authors. Seventeen studies were included. Study quality was rated using a checklist and main findings were summarized. RESULTS: Quality of methodology varied. Qualitative studies described classical grief responses, but less guilt than mothers. Fathers described experiences related to their social role and potential conflict between grieving couples. Quantitative research reported symptoms of anxiety and depression, but at a lower level than mothers. Fathers may develop post-traumatic stress disorder following stillbirth. DISCUSSION: Case prevalence of psychological disorders is unknown. More good quality research is needed. The social role of fathers as carers for their partners needs recognition when planning care for bereaved families.

ADHD and infant disorganized attachment: a prospective study of children next-born after stillbirth.

OBJECTIVE: To examine whether infant disorganized attachment predicts ADHD at school age. METHOD: A cohort of 53 children who had been identified as having significant levels of disorganized attachment in infancy is compared to a control group. Symptoms and signs of ADHD at age 7 are evaluated together with a range of relevant maternal variables. RESULTS: An association is found between infant disorganized attachment scores and teacher-rated symptoms of ADHD (but not ADHD caseness). Probable ADHD caseness in the child is associated with self-rated retrospective ADHD scores in mothers. Possible ADHD caseness is associated with a measure of unresolved mourning in mothers. Mother-rated ADHD in the child was associated with low overall maternal psychosocial functioning. CONCLUSION: The finding of a link between scores for disorganized attachment at 1 year and later teacher-rated symptoms of ADHD suggests the need for further studies.

Is interview a reliable method to verify the compliance with antihypertensive therapy? An international central-European study.

BACKGROUND: Non-compliance with prescribed antihypertensive medication is an important contributor to the failure of antihypertensive therapy. OBJECTIVE: To assess the validity of a short questionnaire in the identification of non-compliant patients. METHODS: In three central-European countries, work-site screening for hypertension was conducted. Blood pressure was measured using an automatic electronic blood pressure measuring device (BpTRU). Respondents were interviewed by trained personnel and a short questionnaire focused on blood pressure awareness and treatment compliance was completed. RESULTS: A total of 2812 persons were screened: 841(29.9%) respondents were hypertensive, and out of these the total number of treated hypertensive subjects was 359 (42.6%). Mean systolic blood pressure and diastolic blood pressure were significantly lower in the compliant group than the non-compliant group (systolic blood pressure, 139.4 and 146.2 mmHg, respectively, P = 0.002; and diastolic blood pressure, 89.2 and 92.3 mmHg, respectively, P < 0.01). The non-compliant group was younger than the compliant group (mean age, 46.7 versus 48.9 years, respectively, P = 0.01). Females, patients on combined therapy and non-smokers were more compliant than males, those on mono-therapy and smokers (P = 0.01, P = 0.004 and P = 0.005, respectively). CONCLUSION: Patients reporting strict compliance with prescribed drug therapy have significantly lower systolic blood pressure and diastolic blood pressure than those who admit even an occasional lapse in taking medication. A properly formulated questionnaire can identify non-compliant patients.

High prevalence of prehypertension and hypertension in a working population in Hungary.

BACKGROUND: Hungary has one of the highest mortality rates due to strokes among the European Union countries. As elevated blood pressure (BP) is the principal risk factor for strokes, we assessed BP levels, as well as awareness and treatment status of hypertension and prehypertension in a working population sample in Hungary. METHODS: Worksite employees in Budapest and Szeged were screened for their BP using an automated BP measuring instrument (BpTRU). BpTRU readings of heart rate (HR) were also recorded. Respondents were classified as normotensives (NT), prehypertensives (PHTN) and hypertensives (HTN) according to their BP levels, as defined by the JNC 7 guidelines. Body height and body weight were measured and body mass index (BMI) was calculated. Self-reported information regarding smoking was collected. RESULTS: In total, 2,012 respondents were recruited (1,000 white collar; 1,012 blue-collar workers), with a mean (±s.d.) age of 34.8 (±9.9) years. Of all respondents, 22.6% were identified as HTN and 39.8% as PHTN. Among HTN, 40% were unaware of their condition and only 18.5% were adequately treated. PHTN were similar in age as NT, but showed significantly higher HR. CONCLUSIONS: A high proportion of relatively young and apparently healthy Hungarian employees were diagnosed with prehypertension and hypertension. Only a small proportion of HTN had their BP controlled. BMI and HR were significantly higher among individuals with prehypertension compared to NT. Whether the high rates of hypertension, prehypertension, and low levels of control explain the high stroke mortality and unfavorable cardiovascular disease (CVD) profile of Hungary needs further study.

A cross-national comparative study of blood pressure levels and hypertension prevalence in Canada and Hungary.

PURPOSE: Hungary has one of the highest cardiovascular (CV) mortality and stroke rates compared to other countries in Europe and North America. Data from two recent blood pressure (BP) screening projects in Hungary and Canada provided us with the opportunity to compare potential differences in the prevalence of hypertension between these countries. METHODS: From the Ontario Blood Pressure Survey, 880 white Canadians between 20 and 62 years old with white-collar occupation were selected and compared with a total of 1000 Hungarian bank employees in the same age range. Identical methods were employed for CV risk factor screening and BP measurements using the BpTRU instrument. Hypertension was defined by elevated BP measurement (SBP ≥140  mmHg and/or DBP ≥90  mmHg) or current intake of antihypertensive medication. RESULTS: Canadian participants were on average 10 years older with a higher rate of obesity, diabetes and high cholesterol. Smoking was more prevalent among Hungarians (29.4 vs. 22.5%, P  <  0.001). Despite being younger, Hungarians exhibited significantly higher SBP (121.3  ±  4.3 vs. 111.6  ±â€Š 14.1, P  <  0.001) and DBP (78.5  ±â€Š 10.5 vs. 70.8  ±â€Š 9.5, P  <  0.001), which remained significant after adjustment for age and use of antihypertensive medication as well as sex and CV risk factors. Age-adjusted prevalence of hypertension was significantly higher and poorly controlled among Hungarians (P  <  0.001). CONCLUSION: The increased prevalence of hypertension among young and middle-aged Hungarians compared with Canadians could represent an essential contributor to the high CV mortality and stroke rates in Hungary. BP awareness, treatment and control require improved medical attention and should be addressed early among young Hungarians.

Promoting recovery in long-term institutional mental health care: an international Delphi study.

OBJECTIVE: Service provision in psychiatric and social care is increasingly guided by recovery principles. However, little is known about the degree of consensus among stakeholders in diverse contexts on the components of care that most promote recovery. This study aimed to identify specific items of care that key stakeholders regard as most important in promoting recovery for people with longer-term mental health problems in institutional care, to measure consensus between and across stakeholder groups and countries, and to develop a conceptual framework of the most important domains of care. METHODS: Ten European countries in various stages of deinstitutionalization participated in a series of conventional three-round iterative Delphi exercises. In each country individuals in four separate expert groups (service users, mental health professionals, caregivers, and advocates) identified components of care that they considered important to recovery and then rated their group's suggestions in terms of importance. Median and consensus ratings were measured. High-ranking items were grouped into domains. RESULTS: A total of 4,098 separate items of care were proposed by the 40 participating groups. Eleven broad domains of care important for recovery were identified: social policy and human rights, social inclusion, self-management and autonomy, therapeutic interventions, governance, staffing, staff attitudes, institutional environment, postdischarge care, caregivers, and physical health care. Consensus between groups and countries was generally high, but some modest differences in priorities were noted. CONCLUSIONS: The most consistently highly rated consensus domain was therapeutic interventions. Domains and components of care related to recovery principles were also viewed as important across stakeholder groups.

2006 Ontario Survey on the Prevalence and Control of Hypertension (ON-BP): rationale and design of a community-based cross-sectional survey.

BACKGROUND: The presently available Canadian data, based on direct measurements of blood pressure (BP) from the Canadian Heart Health Surveys, are more than 15 years old. In view of major changes in the demographics and health status of the Ontario population, there is an urgent need to update this information. On the initiative of the Heart and Stroke Foundation of Ontario, the University of Ottawa Heart Institute, jointly with Statistics Canada, designed and implemented a population-based cross-sectional survey of hypertension in the Province of Ontario: the 2006 Ontario Survey on the Prevalence and Control of Hypertension (ON-BP). OBJECTIVES: To establish the prevalence of hypertension in the Ontario adult population between the ages of 20 and 79 years; to assess the awareness, current status and management of hypertension; and to gather respondent information about sex, age, physical measurements, personal health practices, socioeconomic measures, ethnicity and comorbidities. METHODS: The present paper describes the background history and the successive steps undertaken during the implementation of this project. CONCLUSIONS: The authors' experiences from the ON-BP indicate that close co-operation between research scientists, statisticians, governmental and nongovernmental organizations -- in the present case, the Heart and Stroke Foundation of Ontario -- is essential to conduct a successful, large-scale survey of BP distribution.

Psychological impact of stillbirth on fathers in the subsequent pregnancy and puerperium.

BACKGROUND: Approximately 1 in 200 UK pregnancies ends in stillbirth. Although serious psychological effects of stillbirth on mothers are well established, much less is known about the impact of such loss on fathers. AIMS: To assess the psychological morbidity of fathers in the pregnancy and post-partum year subsequent to a stillbirth, to test within-couple effects and to identify risk factors. METHOD: This was a community-based cohort study of 38 pregnant couples whose previous pregnancy had ended in stillbirth, and 38 pair-matched controls. Psychological assessments took place antenatally and at 6 weeks, 6 months and 1 year postnatally. RESULTS: Fathers in the index group experienced significant levels of anxiety and post-traumatic stress disorder antenatally, but all of their symptoms remitted postnatally (after the birth of a live baby). Fathers' symptom levels were lower than those of mothers at all time points. In contrast to mothers, fathers experienced greater anxiety when a subsequent pregnancy (following stillbirth) was delayed. CONCLUSIONS: The vulnerability of fathers to psychological distress during the pregnancy after a stillbirth needs to be recognised.

An investigation into the possible overlap between PTSD and unresolved responses following stillbirth: an absence of linkage with only unresolved status predicting infant disorganization.

It has been suggested that the characteristic lapses in thinking and reasoning of the unresolved/disorganized (U) state of mind following traumatic loss involve psychological mechanisms similar to those found in PTSD and that a fuller understanding of these mechanisms may help explain the disruptions in parental caretaking behaviour that lead to disorganized infant attachment. This paper investigates whether PTSD, assessed in 60 mothers in the pregnancy after stillbirth, predicts infant disorganized (D) attachment in next-born children, and whether there was any association between U and PTSD. We report that in this population there was no significant correspondence between U and PTSD scores or caseness and no association between maternal PTSD and infant D. We discuss possible interpretations of these findings.