The contribution of lifestyle and work factors to social inequalities in self-rated health among the employed population in Switzerland.

We sought to examine the joint and independent contributions of working conditions and health-related behaviours in explaining social gradients in self-rated health (SRH). Nationally representative cross-sectional data from the Swiss Health Survey of 2007 were used for this study. Bi- and multivariate statistical analyses were carried out on a sample of 6950 adult employees of working age. We examined a comprehensive set of five health behaviours and lifestyle factors as well as twelve physical and psychosocial work factors as potential mediators of the relationship between social status and SRH. Analyses were stratified by sex and performed using two measures of social status, educational level and occupational position. Strong social gradients were found for SRH, but mainly in men whereas in women the associations were either not linear (educational level) or not statistically significant (occupational position). Social gradients were also found for most lifestyle and all physical and psychosocial work factors studied. These three groups of factors equally contributed to and largely accounted for the social gradients in SRH although not all of the individual factors turned out to be independent and significant risk factors for poor SRH. Such risk factors included physical inactivity and obesity, poor posture and no or low social support at work (both sexes), heavy smoking (men) and underweight, overweight, uniform arm or hand movements at work, monotonous work and job insecurity (women). In conclusion, social inequalities (or more precisely educational and occupational status differences) in SRH were more pronounced in men and can be attributed for the most part to a sedentary lifestyle and to a physically demanding and socially unsupportive and insecure work environment. Apart from this main finding and overall pattern, sex-specific risk profiles were observed with regard to SRH and need to be taken into consideration.

Cancer comortality patterns in schizophrenia and psychotic disorders: a new methodological approach for unique databases.

The aim of this study was to determine the pattern of cancer comortality in deaths registered with schizophrenia and psychotic disorders. It focused on the question of whether the proportions of different types of cancer diverge when they are co-registered with schizophrenia/psychotic disorders or with other causes of death in mortality statistics. We developed an analysis approach applicable to common mortality statistics data when no linkage with morbidity databases or other registers is possible. The analysis covered Swiss mortality data from a 39-year period (1969 - 2007) and was confined to the most frequent cancers. We applied a two-step case-control analysis with bootstrapping (1000 repetitions). The cases were defined by the cancer-schizophrenia registrations for each specific cancer, whereas the controls were matched from the remaining cases (matching criteria: sex, age, region, subperiod). Cancers with deviant standardized mortality ratios (SMRs) included stomach cancer (1.6; 2.2 after reweighting), lung cancer (0.8; 0.5 after reweighting) and breast cancer (1.6; 1.5 after reweighting). The comortality pattern of cancers in schizophrenia and psychotic disorders diverges from the pattern found in other co-registered causes of death. The relatively low frequency of lung cancers is particularly paradoxical in view of the smoking habits of schizophrenia patients.

Religion and suicide in patients with mental illness or cancer.

In Switzerland, the highest rates of suicide are observed in persons without religious affiliation and the lowest in Catholics, with Protestants in an intermediate position. We examined whether this association was modified by concomitant psychiatric diagnoses or malignancies, based on 6,909 suicides (ICD-10 codes X60-X84) recorded in 3.69 million adult residents 2001-2008. Suicides were related to mental illness or cancer if codes F or C, respectively, were mentioned on the death certificate. The protective effect of religion was substantially stronger if a diagnosis of cancer was mentioned on the death certificate and weaker if a mental illness was mentioned.

Death has a preference for birthdays-an analysis of death time series.

PURPOSE: To examine the relation between the day of death and the day of birth. To determine whether the "death postponement" hypothesis or the "anniversary reaction" hypothesis is more appropriate. METHODS: We analyzed data from the Swiss mortality statistics 1969-2008. Deaths below the age of 1 were excluded from the analysis. Time series of frequencies of deaths were based on differences between the day of death and the day of birth. We applied autoregressive integrated moving average modeling with intervention effects both in straight and reverse time series. RESULTS: The overall death excess on the day of birth was 13.8%, mainly because of cardiovascular and cerebrovascular diseases (more in women than in men) as well as suicides and accidents (in particular, falls in men). Unexpectedly, we also found an excess of deaths in cancers. An (negative) aftereffect was found in cancers, and (positive) anticipatory effects were found in falls in men. CONCLUSIONS: In general, birthdays do not evoke a postponement mechanism but appear to end up in a lethal way more frequently than expected ("anniversary reaction").

Characteristics and Outcome in Acute Coronary Syndrome Patients with and without Established Modifiable Cardiovascular Risk Factors: Insights from the Nationwide AMIS Plus Registry 1997-2010.

OBJECTIVES: Little is known about patients without known modifiable risk factors presenting initially with acute coronary syndrome (ACS). This study assessed baseline characteristics and outcomes of ACS patients with and without the known modifiable risk factors arterial hypertension, dyslipidemia, obesity, smoking or diabetes. METHODS: All ACS patients enrolled in the AMIS Plus Registry between 1997 and 2010 were analyzed until hospital discharge; a subgroup was re-assessed at the 1-year follow-up. Outcome measures were in-hospital mortality and major adverse cardiac or cerebrovascular events (MACCE) defined as a composite outcome of mortality, re-infarction and cerebrovascular events. RESULTS: Of 33,306 patients, 2,125 (6.4%) had none of these modifiable risk factors. They were older (males), had less moderate or severe comorbidities and were more frequently in Killip class I on admission. Treatment of ACS patients with or without modifiable risk factors was similar with regard to interventional therapies and use of antiplatelet agents. In-hospital mortality was lower in patients without modifiable risk factors but in-hospital MACCE and 1-year survival was similar. CONCLUSION: Lack of modifiable risk factors was an independent predictor of lower in-hospital mortality but not of MACCE in patients who presented with ACS.

Health risk or resource? Gradual and independent association between self-rated health and mortality persists over 30 years.

BACKGROUND: Poor self-rated health (SRH) is associated with increased mortality. However, most studies only adjust for few health risk factors and/or do not analyse whether this association is consistent also for intermediate categories of SRH and for follow-up periods exceeding 5-10 years. This study examined whether the SRH-mortality association remained significant 30 years after assessment when adjusting for a wide range of known clinical, behavioural and socio-demographic risk factors. METHODS: We followed-up 8,251 men and women aged ≥ 16 years who participated 1977-79 in a community based health study and were anonymously linked with the Swiss National Cohort (SNC) until the end of 2008. Covariates were measured at baseline and included education, marital status, smoking, medical history, medication, blood glucose and pressure. RESULTS: 92.8% of the original study participants could be linked to a census, mortality or emigration record of the SNC. Loss to follow-up 1980-2000 was 5.8%. Even after 30 years of follow-up and after adjustment for all covariates, the association between SRH and all-cause mortality remained strong and estimates almost linearly increased from "excellent" (reference: hazard ratio, HR 1) to "good" (men: HR 1.07 95% confidence interval 0.92-1.24, women: 1.22, 1.01-1.46) to "fair" (1.41, 1.18-1.68; 1.39, 1.14-1.70) to "poor"(1.61, 1.15-2.25; 1.49, 1.07-2.06) to "very poor" (2.85, 1.25-6.51; 1.30, 0.18-9.35). Persons answering the SRH question with "don't know" (1.87, 1.21-2.88; 1.26, 0.87-1.83) had also an increased mortality risk; this was pronounced in men and in the first years of follow-up. CONCLUSIONS: SRH is a strong and "dose-dependent" predictor of mortality. The association was largely independent from covariates and remained significant after decades. This suggests that SRH provides relevant and sustained health information beyond classical risk factors or medical history and reflects salutogenetic rather than pathogenetic pathways.

Birth cohort effects in neurological diseases: amyotrophic lateral sclerosis, Parkinson's disease and multiple sclerosis.

BACKGROUND: Generational differences in disease rates are the main subject of age-period-cohort (APC) analysis, which is mostly applied in cancer and suicide research. This study applied APC analysis to selected neurological diseases: amyotrophic lateral sclerosis (ALS), Parkinson's disease (PD) and multiple sclerosis (MS). METHODS: The analyses were based on Swiss mortality data. Age-stratified data has been available for MS, PD and ALS since 1901, 1921, and 1942, respectively. APC analysis was performed within the framework of logit models. Main effect models were extended by implementing nested effects, i.e. age effects nested in subperiods, in order to account for the fact that age profiles may change for reasons other than generational influences. RESULTS: In preliminary analyses, APC analysis yielded noteworthy birth cohort effects in all three diseases. After implementing nested effects, the birth cohort effects disappeared in ALS, and smoothed out in PD, where they were greater for the generations born before the 1920s. In MS, the birth cohort effects remained stable, and exhibited a peak in cohorts born in the 1910s and 1920s. CONCLUSIONS: APC analysis yielded some evidence for birth cohort effects, i.e. predisposing risk factors that may change in historical terms, in MS and PD, but probably not in ALS.

Lower age at first myocardial infarction in female compared to male smokers.

BACKGROUND: Smoking is one of the most important risk factors for myocardial infarction. Smokers usually suffer their first myocardial infarction earlier in life compared to non-smokers. This age difference seems to be greater in women than in men. The aim of this study was to examine the age and sex differences in terms of smoking in patients with first myocardial infarction who were enrolled in the Swiss National Registry of myocardial infarction, AMIS Plus. METHODS: Data of 15,711 patients admitted to an AMIS Plus hospital between 1999 and 2008 with a first myocardial infarction were analysed. Several multivariate regression, interaction and sensitivity analyses were conducted. RESULTS: The mean age at first myocardial infarction was 68.5 ± 12.2 years for non-smokers and 56.6 ± 11.7 years for smokers (P < 0.001). After stratification by sex the difference between non-smokers and smokers was 10.2 years in men and 13.1 years in women. Even after adjustment for risk factors (overweight, hypertension, dyslipidaemia, diabetes), comorbidities (peripheral vascular disease, cerebrovascular disease, chronic lung disease), regular cardiovascular medication intake before admission, Killip classification and ECG on admission, male smokers were 8.7 years younger than male non-smokers at first myocardial infarction. In women, the age difference between smokers and non-smokers was 10.8 years, giving a sex-specific difference of 2.1 years (P < 0.001). CONCLUSIONS: In the AMIS Plus cohort, smoking was associated with younger age at first myocardial infarction and this was much more pronounced in women. Public health campaigns should take into account the impact of smoking on premature first myocardial infarction, especially in women.

Acute coronary syndromes in young patients: presentation, treatment and outcome.

BACKGROUND: Acute coronary syndromes (ACS) in very young patients have been poorly described. We therefore evaluate ACS in patients aged 35 years and younger. METHODS: In this prospective cohort study, 76 hospitals treating ACS in Switzerland enrolled 28,778 patients with ACS between January 1, 1997, and October 1, 2008. ACS definition included ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). RESULTS: 195 patients (0.7%) were 35 years old or younger. Compared to patients>35 years, these patients were more likely to present with chest pain (91.6% vs. 83.7%; P=0.003) and less likely to have heart failure (Killip class II to IV in 5.2% vs. 23.0%; P<0.001). STEMI was more prevalent in younger than in older patients (73.1% vs. 58.3%; P<0.001). Smoking, family history of CAD, and/or dyslipidemia were important cardiovascular risk factors in young patients (prevalence 77.2%, 55.0%, and 44.0%). The prevalence of overweight among young patients with ACS was high (57.8%). Cocaine abuse was associated with ACS in some young patients. Compared to older patients, young patients were more likely to receive early percutaneous coronary interventions and had better outcome with fewer major adverse cardiac events. CONCLUSIONS: Young patients with ACS differed from older patients in that the younger often presented with STEMI, received early aggressive treatment, and had favourable outcomes. Primary prevention of smoking, dyslipidemia and overweight should be more aggressively promoted in adolescence.

Impact of a normal or non-specific admission ECG on the treatment and early outcome of patients with myocardial infarction in Swiss hospitals between 2003 and 2008.

BACKGROUND: Diagnosis of acute myocardial infarction (AMI) rests upon clinical, electrocardiographic and biochemical parameters. Previous studies reported AMI patients who present with non-specific ECGs. OBJECTIVES: To examine clinical or demographic features of AMI patients presenting with or without ECG changes and assess the impact of these ECGs on treatment and outcome. METHODS: Using the AMIS Plus data, patients admitted between 2003 and 2008 with a definite diagnosis of AMI (clinical symptoms, elevated troponin levels) were stratified according to the admission ECG into group 1 with normal/non-specific ECGs and group 2 with ECG changes. RESULTS: Of 14 957 patients, 1085 (7.3%) belonged to group 1 and 13 872 (92.7%) to group 2. There were no differences between the two groups in age (65.9 yr vs. 65.4 yr), gender (28% female), diabetes (19% vs. 18%), hypertension (61% vs. 59%), family history (35% vs. 33%) or smoking (37% vs. 38%). Dyslipidaemia (62% vs. 56%; p <0.001), history of CAD (39% vs. 35%; p = 0.023) and obesity (BMI >30 kg/m2 [23% vs. 19%; p = 0.003]) were more frequent in group 1 who were admitted longer after symptom onset (280 min vs. 230 min). Patients in group 1 were exposed to less intensive pharmacological and interventional treatments (aspirin [93.6% vs. 95.3%; p = 0.012], clopidogrel [70% vs. 73%; p = 0.046], unfractionated heparin [59% vs. 65%; p <0.001], ACE inhibitors or angiotensin II antagonists [46% vs. 53%; p <0.001]). However, therapy with beta-blockers (72% vs. 70%), statins (75% vs. 76%) and nitrates (59% vs. 57%) did not differ between groups. Patients in group 1 underwent PCI significantly less frequently (69% vs. 77%) with a longer hospital delay (589 min vs. 96 min). No differences were found for reinfarction (both 1.4%) and a cerebrovascular event (0.4% vs. 0.8%). Cardiogenic shock (5% vs. 2%; p <0.001) and mortality during hospitalisation were higher in group 2 (6% vs. 3%; p <0.001). A normal/non-specific ECG on admission was not an independent predictor of in-hospital mortality (OR 0.61; 95% CI 0.34-1.11; p = 0.104). CONCLUSIONS: Despite less intensive treatment, AMI patients who presented with a normal/non-specific ECG developed cardiogenic shock less frequently during their hospitalisation and had a lower crude mortality rate compared to those with ECG changes on admission. Nevertheless, reinfarctions and cerebrovascular events occurred evenly in all AMI patients, regardless of their admission ECG.

Smoking and psychiatric disorders: have subthreshold disorders been overlooked?

INTRODUCTION: The association between smoking and mental disorders has been confirmed by several studies using cross-sectional and retrospective designs. The present study illustrates the need for differentiating subthreshold psychiatric disorders in the analysis. METHODS: The analysis is based on cumulative ("lifetime") prevalences of mental disorders and smoking in the Zurich study. This is a longitudinal community study with a stratified sample of 591 participants and six interviews from 1979 to 1999. RESULTS: The percentage of lifetime smokers in the Zurich study was higher both in persons with a lifetime psychiatric diagnosis (72%) and in persons with subthreshold disorders (60%) than in those without any diagnosis (40%). DISCUSSION: The association between smoking and mental disorders turned out to be clearly stronger if subthreshold mental disorders were appropriately considered in the analyses. Constructing appropriate reference groups is as crucial for the analysis of mental disorders and their outcomes as constructing adequate diagnostic groups.

Adult versus adolescent onset of smoking: how are mood disorders and other risk factors involved?

AIMS: To examine the strength of association between smoking and mood disorders and the association between smoking and its traditional risk factors, comparing those who started smoking in adolescence with those who started smoking in early adulthood. DESIGN AND PARTICIPANTS: The analyses relied on prospective data from the Zurich Study. This longitudinal community study started in 1979 with a stratified sample of 591 participants aged 20/21 years, weighted towards those with mental disorders. Follow-up interviews were conducted at ages 23, 28, 30, 35 and 41. MEASUREMENTS: In this analysis the adult versus adolescent onset of smoking was regressed on the cumulative prevalence of mood disorders, personality characteristics measured by the Freiburg Personality Inventory, common risk factors such as parental smoking, conduct and school problems, troubles with the family and basic socio-demographic variables (sex, education). FINDINGS: In the Zurich Study cohort we found that 61.6% were former or current smokers, of whom 87% started smoking before the age of 20 and 13% after the age of 20. Adolescent onset of smoking was associated strongly with later major depression, dysthymia or bipolar disorders and, furthermore, with parental smoking, extroverted personality and discipline problems and rebelliousness in youth. However, only depression and dysthymia were associated with adult onset smoking and other risk factors associated with smoking were not so associated in this group. CONCLUSIONS: Correlates of smoking onset in adolescence are mainly not applicable to the onset of smoking in young adulthood. Smoking onset beyond adolescence is an open research issue.

Epidemiology and pathophysiology of obesity as cause of cancer.

According to World Health Organisation estimates 1.1 billion people were overweight or obese worldwide in the year 2000 with the prevalence rapidly increasing. Compelling evidence suggests that excess body weight is a risk factor for several cancer types including cancer of the colon, breast, endometrium, kidney, oesophagus, as well as possibly additional sites. According to previous meta-analyses and systematic literature reviews, an important proportion of cancer has been estimated to be attributable to excess body weight. The extrapolation of a European meta-analysis [1] to the Swiss situation broadly estimates that around 700 cancers could be prevented in the absence of overweight and obesity in this country. The data presented highlights the public health relevance of preventing excess body weight. Several interacting metabolic and hormonal pathways seem to underlie the association between being overweight and cancer with insulin-resistance playing a central role. Since evidence is mounting that excess body weight can also adversely affect cancer prognosis, obesity is a primary target for cancer control programs.

Swiss doctors' attitudes towards end-of-life decisions and their determinants: a comparison of three language regions.

OBJECTIVES: To investigate attitudes to end-of-life decisions, and the influence of cultural factors and of doctors' personal characteristics on these attitudes. METHOD: As part of a European research project (EURELD), a study on attitudes towards medical end-of-life decisions was conducted among doctors in the German-, French- and Italian-speaking areas of Switzerland. A written questionnaire was sent to a random sample of nine different types of specialist; it presented 14 statements on end-of-life decisions and doctors were asked whether they agreed or disagreed with them. RESULTS: The response rate was 64%. 1360 questionnaires were studied. The results show general agreement with statements on the alleviation of pain and other symptoms with possible life-shortening effect, as well as on non-treatment decisions. The language region was a strong determinant of agreement on some attitudes towards end-of-life decisions. Agreement on the use of lethal drugs and alleviation of pain and other symptoms with possible life-shortening effect was higher among French-speaking than among German- and Italian-speaking doctors. For nontreatment decisions, agreement was higher in the German-speaking region than in the French- and Italian-speaking regions of the country. Italian-speaking doctors were strongly opposed to any kind of end-of-life decision. Religious believers and those who attended a larger number of terminal patients tended to disagree more often with end-of-life decisions than the other doctors. CONCLUSIONS: In end-of-life decision-making, Switzerland represents "Europe in miniature". The impact on end-of-life decisions of cultural factors and the number of terminal patients attended needs further consideration.

Mortality in heroin-assisted treatment in Switzerland 1994-2000.

BACKGROUND: A major goal of heroin-assisted treatment in Switzerland has been to reduce the drug-related mortality of heroin users. Therefore, a continuous monitoring of deaths under treatment is essential. AIMS: To assess mortality of participants in heroin-assisted treatment in Switzerland over a 7-year period from 1994 to 2000, and to compare this mortality to the general population and to other populations of opioid users, as reported in the literature. METHOD: Estimation of person years under heroin-assisted treatment from the complete case registry of heroin-assisted treatment in Switzerland. Estimation of standardized mortality ratios comparing the population in treatment to the Swiss population (standardized to the year 2000). RESULTS: Over the 7-year period, the crude death rate of patients in heroin-assisted treatment, and including one month after discharge from treatment, was 1% per year. The standardized mortality ratio for the entire observation period was 9.7 (95% C.I. 7.3-12.8), with females having higher standardized mortality ratios (SMR 17.2) than males (SMR 8.4). There was no clear time trend. CONCLUSION: Mortality in heroin-assisted treatment was low compared to the mortality rate of Swiss opioid users 1990s (estimated to be between 2.5 and 3%). It was also low compared to mortality rates of opioid users in other maintenance treatments in other countries as reported in the literature. The SMR was also lower than that reported in the only meta-analysis in the literature: 13.2 (95% C.I. 12.3-14.1). The low mortality rate is all the more noteworthy as heroin-assisted treatment in Switzerland included only refractory opioid addicts with existing severe somatic and/or mental problems. DECLARATION OF INTEREST: No conflicts of interest declared.

The Check Bus Project and its effectiveness on health promotion at work.

Employees of two large companies in Switzerland took part in a nationwide health information and promotion campaign at work, which included various physical examinations. A total of 5,849 consecutive participants were sent a questionnaire to determine whether changes had been made in their lifestyles and if they had benefited from participation; 2,361 (40.4%) responded. The campaign was rated highly at 8.3 on a scale from 1 to 10. Respondents reported benefiting most from the personal examination results, in particular the measurement of bone density, examination of the carotid arteries and discussions with the staff. Of the respondents, 921 stated they changed their lifestyle in the area of physical activity (64.4%) and nutrition (63.6%). Multiple logistic regression analysis showed the variables predictive of responding were age, hierarchy, diet and smoking. Health promotion at work and the choice of offered examinations may influence the effects of health care promotion at the workplace and the readiness of participants to improve their attitudes to health. Health promotion at work is highly regarded by employees who pay more attention to diet, smoke less and in particular those over 50 yr of age. High-tech equipment in a mobile unit may attract employers and employees may profit most from the individual examination results; 39% of the respondents stated they changed their lifestyle as a consequence of the Check Bus campaign.

Dosage regimes in the prescription of heroin and other narcotics to chronic opioid addicts in Switzerland--Swiss national cohort study.

AIMS: Within the guidelines of the research programme on medical prescription of narcotics for opioid addicts (PROVE), heroin, morphine, and methadone were prescribed to heavily opioid addicted individuals in Switzerland since 1994. This contribution analyses the course of dose levels during the treatment period. DESIGN: Naturalistic description of consumed dosages per day and month. SETTING AND PARTICIPANTS: The study describes the dosages prescribed to all individuals who began outpatient treatment in the PROVE programme in Switzerland between 1994 and 1996. MEASUREMENTS: Consumed amount of narcotics per day and the course of dosage of injectable heroin in different treatment regimes. FINDINGS: Heroin was the most frequently prescribed narcotic. Of all consumption days, heroin had been applied in 77% as injection and in 9% in a smokeable form. The mean daily dosage was 474 mg for intravenous application and 993 mg for the smokeable form. Second most frequent was the prescription of oral methadone, in most cases in combination with heroin. The mean amount of daily consumption of oral methadone was 53 mg. There were dosage differences between treatment regimes. During the course of treatment the mean dosage for injectable heroin per day decreased significantly and, depending on the treatment regime, almost linearly. CONCLUSIONS: The significance of heroin dosages in heroin-assisted therapy for treatment outcome should be further explored, especially in the light of the markedly higher dosages in Switzerland compared to the UK. During the treatment period, dosages did not increase but generally decreased, indicating no further increase in tolerance.

Development of a monitoring system for heroin-assisted substitution treatment in Switzerland.

OBJECTIVES: Switzerland introduced heroin-assisted treatment as a routine treatment for drug addicts. As a result the evaluation instruments were changed from a detailed scientific project to a routine monitoring system. The process for developing this monitoring system is described. METHODS: The questionnaires and assessment instruments were restyled with staff of the treatment agencies. Indicators measuring quality of treatment and measures from the future national statistic on the addiction support system were integrated into admission, course and discharge questionnaires. Currently a system for feedback to treatment agencies is being developed. RESULTS: All 21 treatment agencies are participating in the monitoring. Assessment quality is high. CONCLUSIONS: The described monitoring should provide continuous delivery of basic relevant data on patients.