Warfarin intake in relation to diagnosis reduces mortality in patients with colorectal cancer - a register-based study.

BACKGROUND: Several studies have analyzed the effect of anticoagulants on cancer survival, with varying results. This study aimed to assess the effect of warfarin on survival in patients with colorectal cancer (CRC) in relation to timing of warfarin initiation. METHODS: Data on 10,051 individuals aged ≥45 years in the Västra Götaland Region of Sweden, and diagnosed with CRC between 2000 and 2009, were obtained from the Swedish National Cancer Register. Those who received warfarin treatment (n= 1,216) during the study period were labeled cases and those who did not (n= 8,873) were labeled controls. For statistical analysis, National Cancer Register data were merged with mortality data from the Swedish National Cause of Death register and data from the regional warfarin treatment register. RESULTS: Hazard rates for CRC-specific mortality were lower in cases than in controls. When warfarin was used for any reason at any time, cases had a significantly lower CRC-specific mortality than controls among both women (hazard ratio [HR] 0.71; 95 % confidence interval [CI] 0.59-0.85; p= 0.0002) and men (HR 0.61; 95 % CI 0.52-0.72; p < 0001). Warfarin treatment after CRC diagnosis reduced CRC-specific mortality by 80 %; however, when warfarin was given before or ≥5 years after diagnosis, CRC-specific mortality did not significantly decrease. The number needed to treat to avoid one death was four. CONCLUSION: Use of warfarin early after diagnosis in patients with CRC was associated with improved survival.

Cumulative incidence and risk factors of myocardial infarction during 20 years of follow-up: comparing two cohorts of middle-aged men born 30 years apart.

OBJECTIVE: To study cumulative incidence and predictors of myocardial infarction (MI) in two random general population samples consisting of middle-aged Swedish men born 30 years apart. METHOD: Results from the "Study of Men Born In 1913" and the "Study of Men Born In 1943", two longitudinal cohort studies performed in the same geographic area and using the same methodology were compared. Both cohorts were followed prospectively from 50 to 70 years of age. MI was defined as first myocardial infarction, fatal or non-fatal. RESULTS: Men born in 1943 had a 34% lower cumulative risk of first MI [HR 0.66 (0.50-0.88), p = 0.0051] during follow-up as compared to men born in 1913. Interaction analysis showed that hypertension had a significantly higher impact on risk of MI in cohort 1943 than in cohort 1913 [HR 2.33 (95% CI 1.41-3.83)] and [HR 1.10 (0.74-1.62)], p = 0.0009 respectively. The population attributable risk for hypertension was 2.5-fold higher in the cohort of men born in 1943 as compared to men born in 1913, and diabetes mellitus and sedentary lifestyle attributed more to MI risk in cohort 1943 than in cohort 1913. On the contrary, smoking and total cholesterol have less attributable risk to MI in cohort 1943 than in cohort 1913. CONCLUSION: Despite declining incident MI and improved cardiovascular prevention in general, hypertension remains an increasingly important attributable risk factor to MI together with diabetes mellitus and sedentary lifestyle over time.

Neuropeptide Y and measures of stress in a longitudinal study of women with the fibromyalgia syndrome.

OBJECTIVES: Neuropeptide Y is associated with stress in animal and human laboratory studies. However, data from clinical studies are scarce and no clinical longitudinal studies have been published. The aim of this clinical study was to assess the possible association between changes in the levels of pain, depression, and stress measures, on the one hand, and plasma neuropeptide Y levels, on the other. METHODS: Forty-four women with the fibromyalgia syndrome were exposed to a Cognitive Behavioral Therapy intervention. Levels of the plasma neuropeptide Y as well as pain, depression, and stress measures were obtained at the start and at the end of the intervention, and after a further six month follow-up. Based on these data, a before-and-after analysis was performed. RESULTS: Almost all measures of pain, depression, and stress improved during the study; specifically, variables measuring life control (coping), depression, and stress-related time urgency improved significantly. Moreover, during the same time period, the mean plasma neuropeptide Y level was reduced from 93.2 ± 38.8 fmol/mL before the Cognitive Behavioral Therapy to 75.6 ± 42.9 fmol/mL (p<0.001) at the end of the study. CONCLUSIONS: After exposure to a Cognitive Behavioral Therapy intervention, levels of most of the pain, depression, and stress measures improved, half of them significantly, as did the levels of neuropeptide Y. This circumstance indicates a possible functional relationship between pain-depression-stress and neuropeptide Y.

Prediction of COPD by the single-breath nitrogen test and various respiratory symptoms.

Early identification of subjects running an increased risk of contracting COPD enables focus on individual preventive measures. The slope of the alveolar plateau of the single-breath nitrogen washout test (N2-slope) is a sensitive measure of small-airway dysfunction. However, its role remains unexplored in predicting hospital admission or death related to COPD, i.e. incident COPD events, in relation to the presence of various respiratory symptoms. A random population sample of 625 men, aged 50 (n=218) or 60 years (n=407), was followed for 38 years for incident COPD events. At baseline, a questionnaire on respiratory symptoms and smoking habits was collected, spirometry and the single-breath nitrogen test were performed, and the N2-slope was determined. Proportional hazard regression (Cox regression) analysis was used for the prediction model. The N2-slope improved the prediction of COPD events significantly beyond that of respiratory symptoms weighted all together and other covariates (hazard ratio 1.63, 95% CI 1.20-2.22; p<0.005), a prediction applicable to subjects without (p=0.001) and with (p<0.05) airway obstruction. Dyspnoea and wheezing were the most predictive symptoms. The combination of the N2-slope and number of respiratory symptoms notably resulted in an effective prediction of incident COPD events even in nonobstructive subjects, as evidenced by a predicted incidence of ∼70% and ∼90% for a very steep N2-slope combined with many respiratory symptoms in subject without and with airway obstruction, respectively. The alveolar N2-slope should be considered in the critical need for further research on early diagnosis of COPD.

Long-term risk of stroke and myocardial infarction in middle-aged men with a hypertensive response to exercise: a 44-year follow-up study.

INTRODUCTION: Data on the prognostic value of hypertensive response to exercise in cardiovascular disease are limited. The aim was to determine whether SBP reactions during exercise have any prognostic value in relation to the long-term risk of stroke and myocardial infarction (MI). PATIENTS AND METHODS: A representative cohort of men from Gothenburg, Sweden, born in 1913, who performed a maximum exercise test at age 54 years, (n = 604), was followed-up for a maximum of 44 years with regard to stroke and MI. RESULTS: Among the 604 men, the mean resting and maximum SBP was 141.5 (SD 18.8) and 212.1 (SD 24.6) mmHg, respectively. For maximum SBP, the risk of stroke increased by 34% (hazard ratio 1.34, 95% confidence interval 1.11-1.61) per 1-SD increase, while no risk increase was observed for MI. The highest risk of stroke among blood pressure groups was observed among men with a resting SBP of at least 140 mmHg and a maximum SBP of at least 210 mmHg with an hazard ratio of 2.09 (95% confidence interval 1.29-3.40), compared with men with a resting SBP of less than 140 mmHg and a maximum SBP of less than 210 mmHg, independent of smoking, blood glucose, cholesterol and BMI. CONCLUSION: Among middle-aged men with high resting and maximum blood pressure during maximum exercise workload, an increased risk of stroke was observed but not for MI. Further studies with larger sample sizes are needed to investigate the underlying mechanisms of the increased risk of stroke among individuals with hypertensive response to exercise.

Comparison of incidence rates and risk factors of heart failure between two male cohorts born 30 years apart.

OBJECTIVE: To compare two cohorts of middle-aged men from the general population born 30 years apart for incidence and predictors of heart failure (HF). METHODS: Two population samples of men, born in 1913 (n=855) and in 1943 (n=797), were examined at 50 years of age and followed up for 21 years (1963-1994 and 1993-2014). Cox regression analysis was used to examine the impact of different factors on the risk of developing HF. RESULTS: Eighty men born in 1913 (9.4%) and 42 men born in 1943 (5.3%) developed HF during follow-up; adjusted HRs comparing the two cohorts (born 1943 vs 1913) were: 0.46 (95% CI 0.28 to 0.74, p=0.002). In both cohorts, higher body mass index, higher diastolic blood pressure, treatment for hypertension, onset of either atrial fibrillation (AF), ischaemic heart disease and diabetes mellitus were associated with higher risk of HF. Higher heart rate was associated with an increased risk only in men born in 1913, whereas higher systolic blood pressure (SBP), smoking, higher glucose, higher cholesterol and physical inactivity were associated with an increased risk in men born in 1943. AF contributed higher risk of incident HF, whereas SBP and physical inactivity contributed lower risk in men born in 1943 compared with men born in 1913. CONCLUSIONS: Men born in 1943 had half the risk of HF after their 50s than those born 30 years earlier. AF, obesity, ischaemic heart disease, diabetes and hypertension remain important precursors of HF.

Decline of substance P levels after stress management with cognitive behaviour therapy in women with the fibromyalgia syndrome.

Background and aims Substance P (CSF-SP) is known to be elevated in females with fibromyalgia syndrome (FMS). The aims of this study were to evaluate the effect of cognitive behaviour therapy (CBT) on plasma SP levels in women with FMS and to find possible clinical behavioural correlates to plasma SP level changes. Methods Forty-eight women with FMS were randomly allocated into two groups. Group 1 received the CBT treatment intervention over the course of 6 months while group 2 was waitlisted. CBT was given with a protocol developed to diminish stress and pain. After 6 months, group 2 was given the same CBT treatment as well. All were followed up 1 year after the start of CBT treatment. This approach allowed for two analytical designs - a randomised controlled trial (RCT) (n=24 vs. n=24) and a before-and-after treatment design (n=48). All women were repeatedly evaluated by the West Haven-Yale Multidimensional Pain Inventory (MPI) and three other psychometric questionnaires and plasma SP was analysed. Results In the RCT design, the plasma SP level was 8.79 fmol/mL in both groups at the start of the trial, after adjustment for initial differences. At the end of the RCT, the plasma SP level was 5.25 fmol/mL in the CBT intervention group compared to 8.39 fmol/mL in the control group (p=0.02). In the before-and-after design, the plasma SP was reduced by 33% (p<0.01) after CBT, but returned to the pre-treatment level at follow-up 1 year after the start of CBT treatment. Plasma SP was associated with the MPI dimensions experienced "support from spouses or significant others" and "life control". Conclusions Plasma SP might be a marker of the effect of CBT in FMS associated with better coping strategies and reduced stress rather than a biochemical marker of pain.

Determinants of Stroke in a General Male Population.

Background and Purpose- To further improve preventive strategies against stroke, there is a need for epidemiological long-term studies. The study aimed at a prospective investigation of stroke determinants in the general male population. Methods- During a period of 48 years, from 50 to 98 years of age, a population-based sample of 854 men was followed using repeated medical examinations, lifestyle questionnaires, data from hospital records and the National Cause of Death Register. Results- Determinants of ischemic stroke were atrial fibrillation (hazard ratio [HR], 6.61; 95% CI, 4.47-9.77); mother dead from cardiovascular disease (HR, 1.53; 1.09-2.17); high education (HR, 0.81; 0.69-0.96); and high physical activity level during leisure time (HR, 0.68; 0.50-0.93). For hemorrhagic stroke heart rate (HR, 1.04; 1.01-1.06) and mother dead from stroke (HR, 3.56; 1.43-8.87) constituted an increased risk. Statistically significant determinants for all stroke were atrial fibrillation (HR, 5.34; 3.68-7.75); high diastolic blood pressure (HR, 1.02; 1.01-1.03); high body weight (HR, 0.96; 0.94-0.99); high educational level (HR, 0.79; 0.68-0.92); wide waist circumference (HR, 1.04; 1.01-1.07); smoking (HR, 1.25; 1.06-1.48); mother dead from cerebrovascular disease (HR, 1.43; 1.05-1.94); and diabetes mellitus (HR, 1.65; 1.02-2.68). Of all men diagnosed with atrial fibrillation, 88% had a stroke during follow-up. Conclusions- Atrial fibrillation was by far the strongest determinant of stroke during 48 years of follow-up in a male population sample followed until the age of 98 years. The results warrant improved prophylaxis through intense treatment of modifiable determinants.

The effect of group-based cognitive behavioral therapy on inflammatory biomarkers in patients with coronary heart disease-results from the SUPRIM-trial.

BACKGROUND: The Secondary Prevention in Uppsala Primary Healthcare Project (SUPRIM) is a prospective randomized controlled trial of a group-based cognitive behavioral therapy (CBT) stress management program for coronary heart disease (CHD) patients. The intervention reduced the risk of fatal or non-fatal first recurrent cardiovascular (CV) events. The aim of the present study was to analyze if the positive effects of the CBT program on clinical outcomes could have been mediated by changes in biomarkers for inflammation. METHODS: Altogether 362 patients with CHD were randomly assigned to intervention or usual care. The inflammatory biomarkers (VCAM-1, TNF-R1, TNF-R2, PTX3, and hs-CRP) were serially assessed at five time points every six months from study start until 24 months later, and analyzed with linear mixed models. RESULTS: Baseline levels of the inflammatory markers were near normal, indicating a stable phase. The group-based CBT stress management program did not significantly affect the levels of inflammatory biomarkers in patients with CHD. Three out of five (VCAM-1, TNF-R2, and PTX3) inflammatory biomarkers showed a slight increase over time in both study groups, and all were positively associated with age. CONCLUSION: Group-based CBT stress management did not affect biomarkers for inflammation in patients with CHD. It is therefore unlikely that inflammatory processes including these biomarkers were mediating the effect the CBT program had on the reduction in CV events. The close to normal baseline levels of the biomarkers and the lack of elevated psychological distress symptoms indicate a possible floor effect which may have influenced the results.

Although Coronary Mortality Has Decreased, Rates of Cardiovascular Disease Remain High: 21 Years of Follow-Up Comparing Cohorts of Men Born in 1913 With Men Born in 1943.

BACKGROUND: Despite a decline in mortality rates from cardiovascular disease (CVD) in the past few decades, the burden of CVD in a contemporary population remains inadequately addressed. Therefore, this study was aimed to investigate secular trends in mortality from coronary artery disease and all-cause mortality over 2 decades, by comparing 2 cohorts of men born 30 years apart and evaluate the prediction of the risk of CVD and all-cause death in a contemporary random sample of Swedish men. METHODS AND RESULTS: Two cohorts of randomly selected men born in 1913 (855 men) and 1943 (798 men) were first examined at age 50 in 1963 and 1993, respectively, and followed longitudinally over 21 years. All-cause mortality and coronary artery disease death were lower in 50- to 71-year-old men born in 1943 compared with those born in 1913, with unadjusted hazard ratios of 0.57 (0.45-0.71) and 0.34 (0.22-0.53), respectively. After adjustment for risk factors (smoking, serum cholesterol, hypertension, systolic blood pressure, diabetes mellitus, body mass index, and physical activity), the differences between the cohorts remained significant for coronary artery disease, hazard ratios 0.57 (0.34-0.94), P=0.029, but not for all-cause mortality hazard ratios 0.82 (0.62-1.07), P=0.14. However, the rate of CVD events during follow-up was still high (30.7%) for the men born in 1943. No statistically significant interaction by birth cohort in contribution of risk factors to death was found between 2 cohorts except physical inactivity. CONCLUSIONS: Despite a marked reduction in the rate of coronary artery disease death over the past 30 years, the burden of CVD events and all-cause mortality remains high. Therefore, intensified efforts to modify contributing risk factors are still required.

Prediction of COPD and Related Events Improves by Combining Spirometry and the Single Breath Nitrogen Test.

Chronic obstructive pulmonary disease (COPD) develops in small airways. Severity of small airway pathology relates to progression and mortality. The present study evaluated the prediction of COPD of a validated test for small airway disease, i.e. a slope of the alveolar plateau of the single breath nitrogen test (N2-slope). The N2-slope, spirometry, age, smoking habits, and anthropometric variables at baseline were obtained in a population-based sample (n = 592). The cohort was followed for first COPD events (first hospital admission of COPD or related conditions or death from COPD) during 38 years. During follow-up, 52 subjects (8.8%) had a first COPD event, of which 18 (3.0%) died with a first COPD diagnosis. In the proportional hazard regression analysis adjusted for age and smoking habits, the cumulative COPD event incidence increased from 5% among those with high forced expired volume in one second (FEV1) to 25% among those with low FEV1, while increasing from 4% among those with the lowest N2-slope to 26% among those with the highest. However, combining the N2-slope and FEV1 resulted in considerable synergy in the prediction of first COPD event and even more so when taking account of smoking habits. The cumulative COPD event incidence rate was 75% among heavy smokers with the highest N2-slope and lowest FEV1, and less than 1% among never smokers with the lowest N2-slope and highest FEV1. Thus, combining the results of the single breath N2-slope and FEV1 considerably improved the prediction of COPD events as compared to either test alone.

Secular changes in cardiovascular risk factors in Swedish 50-year-old men over a 50-year period: The study of men born in 1913, 1923, 1933, 1943, 1953 and 1963.

Background During the past decades, declining trends in mean cholesterol levels and smoking have been observed in Western Europe, whereas obesity and a sedentary lifestyle have increased. Simultaneously, there has been a marked decrease in mortality from cardiovascular (CV) diseases. Methods The aim of the study was to determine whether these trends in CV risk factors continued over a period of 50 years. Six systematic or random population samples of 50-year-old men ( n = 3563) living in Gothenburg, Sweden, were investigated between 1963 and 2013. Results During the 50 years, mean body mass index (BMI) at 50 years of age increased by 2 kg/m2, from 24.8 kg/m2 in 1963 to 26.8 kg/m2 in 2013 ( p < 0.001). A decrease in systolic blood pressure of nearly 10 mmHg was observed from 1963 to 1993, but was not sustained through the past two decades. Mean serum cholesterol fell from 6.42 (SD 1.12) mmol/L to 5.34 (SD 0.97) mmol/L. The prevalence of smoking at 50 years of age decreased markedly from 56.1% in 1963 to 11.9% in 2013. The number of participants with a sedentary lifestyle during leisure time decreased until 1993, but has remained unchanged since. In 2013, 50-year-old men had a 6.9-times higher likelihood of lacking CV risk factors than 50-year-old men in 1963 (95% confidence interval (CI): 3.5-13.3, p < 0.001). The odds ratio for having four or more risk factors was only 0.13 (95% CI: 0.062-0.29, p < 0.001). Conclusion Despite increasing body weight, the total CV risk factor burden has decreased in 50-year-old men over the past 50 years.

Low aerobic capacity in middle-aged men associated with increased mortality rates during 45 years of follow-up.

BACKGROUND: Low aerobic capacity has been associated with increased mortality in short-term studies. The aim of this study was to evaluate the predictive power of aerobic capacity for mortality in middle-aged men during 45-years of follow-up. DESIGN: The study design was a population-based prospective cohort study. METHODS: A representative sample from Gothenburg of men born in 1913 was followed from 50-99 years of age, with periodic medical examinations and data from the National Hospital Discharge and Cause of Death registers. At 54 years of age, 792 men performed an ergometer exercise test, with 656 (83%) performing the maximum exercise test. RESULTS: In Cox regression analysis, low predicted peak oxygen uptake ([Formula: see text]), smoking, high serum cholesterol and high mean arterial blood pressure at rest were significantly associated with mortality. In multivariable analysis, an association was found between predicted [Formula: see text] tertiles and mortality, independent of established risk factors. Hazard ratios were 0.79 (95% confidence interval (CI) 0.71-0.89; p < 0.0001) for predicted [Formula: see text], 1.01 (1.002-1.02; p < 0.01) for mean arterial blood pressure, 1.13 (1.04-1.22; p < 0.005) for cholesterol, and 1.58 (1.34-1.85; p < 0.0001) for smoking. The variable impact (Wald's χ(2)) of predicted [Formula: see text] tertiles (15.3) on mortality was secondary only to smoking (31.4). The risk associated with low predicted [Formula: see text] was evident throughout four decades of follow-up. CONCLUSION: In this representative population sample of middle-aged men, low aerobic capacity was associated with increased mortality rates, independent of traditional risk factors, including smoking, blood pressure and serum cholesterol, during more than 40 years of follow-up.

Early detection of type 2 diabetes mellitus and screening for retinopathy are associated with reduced prevalence and severity of retinopathy.

PURPOSE: To explore whether the prevalence and severity of retinopathy differ in diabetes cohorts diagnosed through screening as compared with conventional health care. METHODS: A total of 257 diabetes patients, 151 detected through screening and 106 through conventional clinical care, were included. Retinopathy was evaluated by fundus photography. The modified Airlie House adaptation of the Early Treatment Retinopathy Study protocol was used to grade the photographs. Averages of clinically collected fasting blood glucose (FBG), blood pressure and body mass index values were compiled from diabetes diagnosis until the eye examination. Blood chemistry, smoking habits and peripheral neuropathy were assessed at the time of the eye examination. RESULTS: Among the screening-detected patients, 22% had retinopathy as compared to 51% among those clinically detected (p < 0.0001). In a multivariate analysis, patients with retinopathy were more likely to have increased average FBG (OR 1.42, 95% CI 1.19-1.70 per mmol/l) and peripheral neuropathy (OR 2.75, 95% CI 1.40-5.43), but less likely to have screening-detected diabetes (OR 0.31, 95% CI 0.17-0.57). Similar results were found using increasing severity grade of retinopathy as outcome. The cumulative retinopathy prevalence for the screening-detected diabetes cohort as compared with the clinically diagnosed cohort was significantly lower from 10 years' follow-up and onwards (p = 0.0002). CONCLUSIONS: Among patients with screening-detected diabetes, the prevalence of retinopathy and increasing severity of retinopathy were significantly lower than among those who had their diabetes diagnosed through conventional care, even when other risk factors for retinopathy such as duration, hyperglycaemia and blood pressure were considered. Early detection of diabetes reduces prediagnostic time spent with hyperglycaemia. In combination with early and regular screening for retinopathy, more effective prevention against retinopathy can be provided.

The single breath nitrogen test and mortality--A 38 years follow up.

BACKGROUND: Spirometry data predict mortality, but are less sensitive to detect dysfunction in small airways as compared to the slope of phase III (the N2 slope) of the single breath nitrogen test. The association between the N2 slope and mortality has been studied with conflicting results. In the present study the prognostic importance of the N2 slope was tested taking spirometry variables into account. METHODS: A systematic general population sample of 595 middle-aged men had a baseline investigation with lung function tests including spirometry and the N2 slope. Age, smoking, and anthropometry variables were registered. The cohort was followed up regarding survival for 38 years. RESULTS: The sample was subdivided by tertiles of the N2 slope. A proportional hazards regression analysis was performed for each group of covariates: anthropometric, smoking variables, and spirometry variables, after accounting for age. Covariates with significant impact on mortality and the highest chi-square levels were smoking habit score and forced expired volume in 1 s corrected for height. These variables, in addition to age and the N2 tertiles were entered into a final proportional hazards regression analysis. In this multivariate model, mortality was significantly related to age (p < .0001), smoking habit score (p < .0001) and the N2 tertiles (p = .0004), but not to FEV1 when N2 slope was allowed for in the model. CONCLUSIONS: Dysfunction in small airways as measured by the N2 slope is significantly associated with overall mortality in middle-aged men, and outrivals spirometry as a predictor in multivariate analysis.

Association of Cardiometabolic Multimorbidity With Mortality.

IMPORTANCE: The prevalence of cardiometabolic multimorbidity is increasing. OBJECTIVE: To estimate reductions in life expectancy associated with cardiometabolic multimorbidity. DESIGN, SETTING, AND PARTICIPANTS: Age- and sex-adjusted mortality rates and hazard ratios (HRs) were calculated using individual participant data from the Emerging Risk Factors Collaboration (689,300 participants; 91 cohorts; years of baseline surveys: 1960-2007; latest mortality follow-up: April 2013; 128,843 deaths). The HRs from the Emerging Risk Factors Collaboration were compared with those from the UK Biobank (499,808 participants; years of baseline surveys: 2006-2010; latest mortality follow-up: November 2013; 7995 deaths). Cumulative survival was estimated by applying calculated age-specific HRs for mortality to contemporary US age-specific death rates. EXPOSURES: A history of 2 or more of the following: diabetes mellitus, stroke, myocardial infarction (MI). MAIN OUTCOMES AND MEASURES: All-cause mortality and estimated reductions in life expectancy. RESULTS: In participants in the Emerging Risk Factors Collaboration without a history of diabetes, stroke, or MI at baseline (reference group), the all-cause mortality rate adjusted to the age of 60 years was 6.8 per 1000 person-years. Mortality rates per 1000 person-years were 15.6 in participants with a history of diabetes, 16.1 in those with stroke, 16.8 in those with MI, 32.0 in those with both diabetes and MI, 32.5 in those with both diabetes and stroke, 32.8 in those with both stroke and MI, and 59.5 in those with diabetes, stroke, and MI. Compared with the reference group, the HRs for all-cause mortality were 1.9 (95% CI, 1.8-2.0) in participants with a history of diabetes, 2.1 (95% CI, 2.0-2.2) in those with stroke, 2.0 (95% CI, 1.9-2.2) in those with MI, 3.7 (95% CI, 3.3-4.1) in those with both diabetes and MI, 3.8 (95% CI, 3.5-4.2) in those with both diabetes and stroke, 3.5 (95% CI, 3.1-4.0) in those with both stroke and MI, and 6.9 (95% CI, 5.7-8.3) in those with diabetes, stroke, and MI. The HRs from the Emerging Risk Factors Collaboration were similar to those from the more recently recruited UK Biobank. The HRs were little changed after further adjustment for markers of established intermediate pathways (eg, levels of lipids and blood pressure) and lifestyle factors (eg, smoking, diet). At the age of 60 years, a history of any 2 of these conditions was associated with 12 years of reduced life expectancy and a history of all 3 of these conditions was associated with 15 years of reduced life expectancy. CONCLUSIONS AND RELEVANCE: Mortality associated with a history of diabetes, stroke, or MI was similar for each condition. Because any combination of these conditions was associated with multiplicative mortality risk, life expectancy was substantially lower in people with multimorbidity.

Men born in 1913 followed to age 100 years.

OBJECTIVES: To examine causes of death for men above 80 years of age, and health status in centenarians in a cohort of men followed from age 50 years. Factors of importance for survival were studied. DESIGN: A representative sample of men born in 1913 was first examined in 1963 and re-examined at ages 54, 60, 67, 75, 80 and 100 years. RESULTS: Of 973 selected men, 855 (88%) were examined at age 50, and 10 were alive at age 100.Twenty-seven percent lived until 80 years. Cardiovascular disease was the most common cause of death after this age. Dementia was recorded in two of ten men at age 100. Long survival was related to the mothers' high age at death, to non-smoking, high social class at age 50 and high maximum working capacity at age 54 years. At age 100, the seven examined men had low/normal blood pressure. Serum values of troponin T, N-terminal pro-brain natriuretic peptides and C-reactive protein were elevated, but echocardiographic findings were normal. CONCLUSIONS: Ten men experienced their 100th birthday. Survival was related to non-smoking, mothers' high age at death, high social class and previous high physical working capacity. Age-adjusted reference levels for laboratory tests are needed for centenarians.

Cognitive behaviour therapy in women with fibromyalgia: A randomized clinical trial.

Background and aims Stress has been pointed out as an important influential factor in the development and maintaining of the fibromyalgia syndrome (FMS) . Since stress may worsen the pain experience, the development of individual strategies for coping with stress is essential to reduce the impact of FMS on daily life. The aim of the study was to investigate whether a group based stress management cognitive behaviour therapy (CBT) programme could influence self-reported stress, wellbeing and life control, as well as self-reported pain behaviour in female FMS patients. Methods 48 female FMS patient were randomized into a cognitive behaviour therapy treatment group (n = 24) and a waitlist control group (n = 24) . When the 6 months waitlist period was over the control group received the same CBT programme. This allowed two analytical approaches, one based on the randomized controlled trial design and one based on a before-and-after design to improve the statistical power of the study. Four psychometric instruments were used: The West Haven-Yale Multidimensional Pain Inventory (three parts, MPI-1 to MPI-3), the Maastricht Questionnaire, the Everyday Life Stress, and the Montgomery-Åsberg Depression rating scale - self-reported. Primary outcome was the MPI-1 dimension 'life control', secondary outcomes were the MPI-1 dimensions 'interference', 'affective distress' and 'support from spouses or significant others', the various MPI-2 dimensions, the 'general activity level' in the MPI-3 dimension, and 'vital exhaustion', 'stress behaviour', and 'depression'. The only tertiary outcome was the MPI-1 dimension 'pain severity'. Results In the RCT design the West Haven-Yale Multidimensional Pain Inventory dimensions 'life control', 'interference from pain', 'affective distress', 'support from spouses or significant others', and 'distracting responses' and ratings for depression improved in the treatment group as compared with the control group. In the before-and after design these improvements were maintained and enhanced during 1-year follow-up, and so was the 'vital exhaustion' and 'stress behaviour'. 'Pain severity' was rated higher after the intervention. Conclusions Cognitive behaviour therapy improved the life control in a female population with FMS. Coping behaviour in response to chronic pain was improved at the same time and in spite of higher subjective ratings of pain. Positive effects were seen on depression, vital exhaustion and stress behaviour. The effects of therapy were maintained and enhanced during the follow up period. It appears that women with FMS after the CBT treatment, according to this protocol obtained tools leading to better acceptance of their disorder. Implications FMS is a disorder with great therapeutic challenges. Total abolishment of pain symptoms is extremely difficult or impossible to achieve. Thus, the development of individual strategies for coping with pain is essential to reduce its impact on daily life. Since stress may worsen the pain experience, coping with stress might be a promising route to accomplishing that goal. In evaluations of interventions for pain it is important to monitor the effect on behaviour responses to pain and not only ratings of pain itself.

Can costs of screening for hypertension and diabetes in dental care and follow-up in primary health care be predicted?

AIM: The purpose was to assess the direct costs of screening for high blood pressure and blood glucose in dental care and of follow-up in primary health care and, based on these data, arrive at a prediction function. Study population. All subjects coming for routine check-ups at three dental health clinics were invited to have blood pressure or blood glucose measurements; 1,623 agreed to participate. Subjects screening positive were referred to their primary health care centres for follow-up. METHODS: Information on individual screening time was registered during the screening process, and information on accountable time, costs for the screening staff, overhead costs, and analysis costs for the screening was obtained from the participating dental clinics. The corresponding items in primary care, i.e. consultation time, number of follow-up appointments, accountable time, costs for the follow-up staff, overhead costs, and analysis costs during follow-up were obtained from the primary health care centres. RESULTS: The total screening costs per screened subject ranged from €7.4 to €9.2 depending on subgroups, corresponding to 16.7-42.7 staff minutes. The corresponding follow-up costs were €57-€91. The total resource used for screening and follow-up per diagnosis was 563-3,137 staff minutes. There was a strong relationship between resource use and numbers needed to screen (NNS) to find one diagnosis (P < 0.0001, degree of explanation 99%). CONCLUSIONS: Screening and follow-up costs were moderate and appear to be lower for combined screening of blood pressure and blood glucose than for separate screening. There was a strong relationship between resource use and NNS.