Comparison of 4% Albumin and Ringer's Acetate on Hemodynamics in On-pump Cardiac Surgery: An Exploratory Analysis of a Randomized Clinical Trial.

OBJECTIVES: Compare hemodynamics between 4% albumin and Ringer's acetate. DESIGN: Exploratory analysis of the double-blind randomized ALBumin In Cardiac Surgery trial. SETTING: Single-center study in Helsinki University Hospital. PARTICIPANTS: We included 1,386 on-pump cardiac surgical patients. INTERVENTION: We used 4% albumin or Ringer's acetate administration for cardiopulmonary bypass priming, volume replacement intraoperatively and 24 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Hypotension (time-weighted average mean arterial pressure of <65 mmHg) and hyperlactatemia (time-weighted average blood lactate of >2 mmol/L) incidences were compared between trial groups in the operating room (OR), and early (0-6 hours) and late (6-24 hours) postoperatively. Associations of hypotension and hyperlactatemia with the ALBumin In Cardiac Surgery primary outcome (≥1 major adverse event [MAE]) were studied. In these time intervals, hypotension occurred in 118, 48, and 17 patients, and hyperlactatemia in 313, 131, and 83 patients. Hypotension and hyperlactatemia associated with MAE occurrence. Hypotension did not differ between the groups (albumin vs Ringer's: OR, 8.8% vs 8.5%; early postoperatively, 2.7% vs 4.2%; late postoperatively, 1.2% vs 1.3%; all p > 0.05). In the albumin group, hyperlactatemia was less frequent late postoperatively (2.9% vs 9.1%; p < 0.001), but not earlier (OR, 22.4% vs 23.6%; early postoperatively, 7.9% vs 11.0%; both p > 0.025 after Bonferroni-Holm correction). CONCLUSIONS: In on-pump cardiac surgery, hypotension and hyperlactatemia are associated with the occurrence of ≥1 MAE. Compared with Ringer's acetate, albumin did not decrease hypotension and decreased hyperlactatemia only late postoperatively. Albumin's modest hemodynamic effect is concordant with the finding of no difference in MAEs between albumin and Ringer's acetate in the ALBumin In Cardiac Surgery trial.

Time Patterns in Internal Human Exposure Data to Bisphenols, Phthalates, DINCH, Organophosphate Flame Retardants, Cadmium and Polyaromatic Hydrocarbons in Europe.

Human biomonitoring (HBM) data in Europe are often fragmented and collected in different EU countries and sampling periods. Exposure levels for children and adult women in Europe were evaluated over time. For the period 2000-2010, literature and aggregated data were collected in a harmonized way across studies. Between 2011-2012, biobanked samples from the DEMOCOPHES project were used. For 2014-2021, HBM data were generated within the HBM4EU Aligned Studies. Time patterns on internal exposure were evaluated visually and statistically using the 50th and 90th percentiles (P50/P90) for phthalates/DINCH and organophosphorus flame retardants (OPFRs) in children (5-12 years), and cadmium, bisphenols and polycyclic aromatic hydrocarbons (PAHs) in women (24-52 years). Restricted phthalate metabolites show decreasing patterns for children. Phthalate substitute, DINCH, shows a non-significant increasing pattern. For OPFRs, no trends were statistically significant. For women, BPA shows a clear decreasing pattern, while substitutes BPF and BPS show an increasing pattern coinciding with the BPA restrictions introduced. No clear patterns are observed for PAHs or cadmium. Although the causal relations were not studied as such, exposure levels to chemicals restricted at EU level visually decreased, while the levels for some of their substitutes increased. The results support policy efficacy monitoring and the policy-supportive role played by HBM.

Cardiovascular Mortality in 10 Cohorts of Middle-Aged Men Followed-Up 60 Years until Extinction: The Seven Countries Study.

OBJECTIVES: To investigate mortalities from three major groups of cardiovascular diseases (CVDs) in a pooled cohort and followed up until extinction. MATERIALS AND METHODS: Ten cohorts of men (N = 9063) initially aged 40-59, in six countries, were examined and followed-up for 60 years. The major CVD groups were coronary heart disease (CHD), cerebrovascular diseases (STROKE) and other heart diseases of uncertain etiology (HDUE). RESULTS: Death rates from CHD were higher in countries with high serum cholesterol levels (USA, Finland and The Netherlands) and lower in countries with low cholesterol levels (Italy, Greece and Japan), but the opposite was observed for STROKE and HDUE, which became the most common CVD mortalities in all countries during the last 20 years of follow-up. Systolic blood pressure and smoking habits were, at an individual level, the common risk factors for the three groups of CVD conditions, while serum cholesterol level was the most common risk factor only for CHD. Overall, death rates for the pooled CVDs were 18% higher in North American and Northern European countries, while CHD rates were 57% higher in the same countries. CONCLUSIONS: Differences in lifelong CVD mortalities across different countries were smaller than expected due to the different rates of the three groups of CVD, and the indirect determinant of this seemed to be baseline serum cholesterol levels.

Recommendations on TNFα inhibitor biosimilar use in clinical practice: a comparison of European gastroenterology IBD guidance.

BACKGROUND: Professional associations publish guidance advising gastroenterologists on prescribing biosimilars; however, guidelines differ between countries and change over time. This study aimed to map the presence and content of guidance from European gastroenterology associations on TNFα inhibitor biosimilar use and its development over time. RESEARCH DESIGN AND METHODS: Guidelines on biosimilar prescribing from national gastroenterology associations in the European Economic Area (EEA) partnered with the European Crohn's and Colitis Organization (ECCO) were collected. Treatment guidelines and biosimilar position papers from 2010 to 2022 were included. Data were extracted using a template. RESULTS: 26 of 30 EEA countries have an ECCO-partnered gastroenterology association, of which 14 (53.8%) had national guidelines addressing biosimilars, four (15.4%) followed ECCO's position, and three (11.6%) had treatment guidelines without mentioning biosimilars. From five countries (19.2%) no guidelines were retrieved. Among 18 countries with guidance, 14 (77.8%) associations endorsed initiating biological treatment with biosimilars, and 13 (72.2%) endorsed transitioning from originator to biosimilar. Nine associations published multiple guidelines over time addressing biosimilars; overall, their positions became more encouraging. CONCLUSIONS: The majority of gastroenterology associations endorsed biosimilar use. The lack of (up-to-date) guidelines for some associations indicates an area of improvement to support biosimilar use in clinical practice.

Development of non-communicable disease risk factors in Finland: projections up to 2040.

BACKGROUND: Non-communicable diseases are a major cause of mortality and morbidity worldwide. They share the same behavioural risk factors (smoking, sedentary behaviour, alcohol consumption and an unhealthy diet), all of which are modifiable risk factors, and biological consequences (hypertension, elevated total cholesterol, obesity and diabetes). METHODS: Using data from a series of cross-sectional health examination surveys conducted among the adult population in Finland from 1997 to 2017, a projection of risk factor development (smoking, leisure time sedentary behaviour, hypertension, elevated total cholesterol, overweight and obesity, and diabetes) up to the year 2040 was made. The projections were estimated using a multiple imputation method. RESULTS: Smoking prevalence is estimated to continue to decline up to 2040, similar to hypertension and elevated total cholesterol. By contrast, obesity and diabetes will develop unfavourably, with an increase in prevalence. The increase in obesity is mainly due to polarisation - that is, normal-weight people remain of a normal weight, but overweight people tend to gain more weight and become obese. The observed and estimated changes for leisure time sedentary lifestyle were not statistically significant. CONCLUSIONS: Projections of risk factors for non-communicable diseases are needed to guide public health policies and programmes, decision-making and the allocation of health care resources for prevention and care. In Finland, favourable developments have been seen in many of the risk factors, but obesity and diabetes show unfavourable development. There is a need to continue regular, systematic monitoring of the development of risk factors through health examination surveys and to set national goals and programmes to tackle the existing problems.

Projections for obesity, smoking and hypertension based on multiple imputation.

AIMS: Information on the future development of prevalences of risk factors and health indicators is needed to prepare for the forthcoming burden of disease in the population and to allocate resources properly for prevention. We aim to present how multiple imputation can be used flexibly to project future prevalences. METHODS: The proposed approach uses data on repeated cross-sectional surveys from different years. We create future samples with age and sex distributions corresponding to the official national population forecasts. Then, the risk factors are simulated using multiple imputation by chained equations. Finally, the imputations are pooled to obtain the prevalences of interest. Covariates, such as sociodemographic variables as well as their possible interactions and non-linear terms, can be included in the modelling. The future development of these covariates is also projected simultaneously. We apply the procedure to data from five Finnish health examination surveys conducted between 1997 and 2017, and project the prevalences of obesity, smoking and hypertension to 2020 and 2025. RESULTS: The prevalence of obesity is projected to increase to 24% for both men and women in 2025. The prevalences of hypertension and smoking are expected to continue decreasing, and the differences between men and women are projected to remain so that men will have higher prevalences. CONCLUSIONS: Simulation of future observations by multiple imputation can be used as a flexible yet relatively easy-to-use projection method.

Cardiovascular mortality in Northern and Southern European cohorts of the Seven Countries Study at 60-year follow-up.

OBJECTIVES: The aim of this study was to describe and interpret differences in major cardiovascular disease (CVD) mortality during 60 years between Northern European and Southern European cohorts of the Seven Countries Study of Cardiovascular Diseases. MATERIAL AND METHODS: Northern Europe included two cohorts from Finland and one from the Netherlands, and Southern Europe included two cohorts from Italy and two from Greece, for a total of 2360 and 2792 CVD-free men, respectively, at entry examination. Coronary heart disease (CHD), STROKE and other Heart Diseases of Uncertain Etiology (HDUE) deaths were the outcomes and Cox models were solved separately based on 12 risk factors. RESULTS: In 60 years, overall death rates were 99.8% in both Northern and Southern Europe and the pooled CVD rates were 46.9% (significantly higher) and 42.2%, respectively: CHD mortality was higher in Northern Europe, whereas STROKE and HDUE mortality were higher in Southern Europe. Significant Cox coefficients for both areas (but not significantly different between areas) were age, smoking habits, SBP and serum cholesterol for CHD, and only age and SBP did so for STROKE and HDUE. Age at death was lower for CHD, intermediate for STROKE and higher for HDUE in both areas. CONCLUSION: The advantage for Southern Europe was small in terms of overall CVD death rates, but definitely larger in terms of expectancy of life due to the differences in age at death in the three types of CVD mortality. Mean entry levels of serum cholesterol, 50 mg/dl higher in Northern Europe than in Southern Europe are a major culprit of these outcomes.

Exposure to heavy metals and red blood cell parameters in children: A systematic review of observational studies.

Background: Mechanistic studies show that heavy metals interfere with the hematopoietic system by inhibiting key enzymes, which could lead to anemia. However, the link between children's exposure and red blood cell (RBC) parameters has been inconsistent. We aimed to summarize evidence on human studies exploring the association between exposure to lead, mercury, cadmium, arsenic, and chromium VI and RBC parameters in children. Methods: Following the PRISMA guidelines, we searched PubMed, Scopus, and Web of Science databases for studies published between January 2010 and April 2022. Eligible papers included human observational studies that directly assessed exposure (internal dose) to the heavy metals under study and RBC parameters in participants aged ≤ 18 years. We excluded studies using hospital-based samples. Study quality was assessed using the National Institutes of Health's Quality Assessment Tools for Cohort and Cross-Sectional Studies. We synthesized the evidence using vote counting based on the direction of the relationship. Results: Out of 6,652 retrieved papers, we included a total of 38 (33 assessing lead, four mercury, two cadmium, and two arsenic; chromium VI was not assessed in any included paper). More than half of the studies were conducted in Asia. We found evidence of a positive relationship between lead concentration and hemoglobin (proportion of studies reporting negative relationships = 0.750; 95% Confidence Interval (CI) 0.583, 0.874) and mean corpuscular hemoglobin (0.875; 95% CI 0.546, 0.986), and a positive relationship with red cell distribution width (0.000; 95%CI 0.000, 0.379). When considering only good-quality studies (24% of the Pb studies), only the relationship with hemoglobin levels remained (0.875; 95% CI: 0.546, 0.986). Conclusion: We found evidence of a negative relationship between lead concentration and hemoglobin and mean corpuscular hemoglobin and of a positive relationship with red cell distribution width in children. We also identified a need to conduct more studies in European countries. Future studies should use standardized practices and make efforts to increase study quality, namely by conducting comprehensive longitudinal studies. Our findings support the need to take further actions to limit heavy metal exposure during childhood.

High R wave as a risk factor for cardivoascular and all-cause mortality. A 45-year follow-up of 13 cohorts of the Seven Countries Study.

OBJECTIVES: To study the role of high R waves predicting cardiovascular (CVD) and all-cause mortality in a male middle-aged population followed-up 45 years. MATERIAL AND METHODS: A total of 7985 CVD-free men aged 40-59 years were enrolled in 13 cohorts in seven countries (USA, Finland, the Netherlands, Italy, Serbia, Greece, Japan) and high R waves were classified by Minnesota Code 3.1 (as a dichotomous variable) from baseline resting otherwise normal ECG at entry examination together with other personal characteristics. Cox models were solved to detect the possible predictive role of high R waves for CVD and all-cause mortality. RESULTS: In Cox models high R waves were predictive of 45-year major CVD deaths with a hazard ratio of 1.17 (95% confidence intervals of 1.03-1.33) after adjustment for 6 major CVD risk factors (age, systolic blood pressure, serum cholesterol, cigarette smoking, physical activity and body mass index). The predictive role of high R wave was less evident for 45-year all-cause mortality and after adjustment for the 6 covariates the HR of high R wave lost its significance. A multiple logistic model indicated that body mass index, serum cholesterol, systolic blood pressure and mainly vigorous physical activity were directly related to high R wave prevalence while heart rate, subscapular skinfold, laterality index and shoulder pelvis shape did so in an inverse way. CONCLUSION: High R waves seem associated with an excess CVD mortality in a 45-year follow-up of middle-aged men, while their role is diluted when the end-point is all-cause mortality.

Environmental Substances Associated with Chronic Obstructive Pulmonary Disease-A Scoping Review.

Chronic obstructive pulmonary disease (COPD) is a slowly developing non-communicable disease (NCD), causing non-reversible obstruction and leading to marked morbidity and mortality. Besides traditional risk factors such as smoking, some environmental substances can augment the risk of COPD. The European Human Biomonitoring Initiative (HBM4EU) is a program evaluating citizens' exposure to various environmental substances and their possible health impacts. Within the HBM4EU, eighteen priority substances or substance groups were chosen. In this scoping review, seven of these substances or substance groups are reported to have an association or a possible association with COPD. Main exposure routes, vulnerable and high-exposure risk groups, and matrices where these substances are measured are described. Pesticides in general and especially organophosphate and carbamate insecticides, and some herbicides, lead (Pb), and polycyclic aromatic hydrocarbons (PAHs) showed an association, and cadmium (Cd), chromium (Cr and CrVI), arsenic (As), and diisocyanates, a possible association with COPD and/or decreased lung function. Due to long latency in COPD's disease process, the role of chemical exposure as a risk factor for COPD is probably underestimated. More research is needed to support evidence-based conclusions. Generally, chemical exposure is a growing issue of concern, and prompt action is needed to safeguard public health.

Chronic bronchitis in the 50-year follow-up of the European cohorts of the Seven Countries Study: prevalence, mortality and association with cardiovascular diseases.

OBJECTIVES: To study prevalence of chronic bronchitis (CB) in residential populations and its relationship with mortality in a 50-year follow-up. MATERIAL AND METHODS: In the late 1950's-early 1960's, 7047 men aged 40-59 years were enrolled in 10 European cohorts of the Seven Countries Study (in Finland, the Netherlands, Italy, Serbia and Greece). After baseline examination, follow-up for mortality was extended during 50 years (45 year in the Serbian cohorts). Prevalence of CB, and 50-year mortality from CB and other major causes of death were used as end-points to identify their determinants using multivariate models. RESULTS: Prevalence of CB was directly associated with smoking habits and inversely associated with high socio-economic status (SES), forced expiratory volume in ¾ sec (FEV) and the ratio FEV/vital capacity (VC). Fifty-year mortality from CB was directly predicted by CB prevalence (from a minimum hazard ratio [HR] 2.35, 95% confidence limits [CI] 1.70-3.24, to a maximum HR 3.01, CI 2.18-5.20, depending on diagnostic criteria and different models) and age, and inversely by high SES, FEV and FEV/VC. The same applied in models predicting mortality from coronary heart disease (HR for prevalent CB: 1.53, CI 1.24-1.88), major cardiovascular diseases (HR 1.43, CI 1.23-1.67) and all-cause mortality (HR 1.48, CI 1.34-1.64) all adjusted for age, high SES, smoking habits and FEV. CONCLUSIONS: CB is strongly associated with major cardiovascular disease and all-cause mortality while FEV and FEV/VC seem to carry at least partly an independent role from CB in predicting long-term mortality.

Scoping Review-The Association between Asthma and Environmental Chemicals.

Asthma is one of the most common chronic diseases worldwide affecting all age groups from children to the elderly. In addition to other factors such as smoking, air pollution and atopy, some environmental chemicals are shown or suspected to increase the risk of asthma, exacerbate asthma symptoms and cause other respiratory symptoms. In this scoping review, we report environmental chemicals, prioritized for investigation in the European Human Biomonitoring Initiative (HBM4EU), which are associated or possibly associated with asthma. The substance groups considered to cause asthma through specific sensitization include: diisocyanates, hexavalent chromium Cr(VI) and possibly p-phenylenediamine (p-PDA). In epidemiological studies, polyaromatic hydrocarbons (PAHs) and organophosphate insecticides are associated with asthma, and phthalates, per- and polyfluoroalkyl substances (PFASs), pyrethroid insecticides, mercury, cadmium, arsenic and lead are only potentially associated with asthma. As a conclusion, exposure to PAHs and some pesticides are associated with increased risk of asthma. Diisocyanates and Cr(VI) cause asthma with specific sensitization. For many environmental chemicals, current studies have provided contradicting results in relation to increased risk of asthma. Therefore, more research about exposure to environmental chemicals and risk of asthma is needed.

Energy-adjusted Dietary Inflammatory Index scores predict long-term cardiovascular disease mortality and other causes of death in an ecological analysis of the Seven Countries Study.

Using data from the Seven Countries Study of Cardiovascular Diseases, the first study to conduct international comparisons of men in different European, USA, and Japanese cohorts, we examined the effect of diet-associated inflammation on prediction of coronary heart disease-, other major cardiovascular disease- and all-cause mortality after 50-years of follow-up. The energy-adjusted Dietary Inflammatory Index was used to quantify the effect of diet on systemic inflammation. Positive linear correlations were observed between the cohort-average energy-adjusted Dietary Inflammatory Index score and both overall death rates (R = 0.61, p = 0.0114) and major cardiovascular disease mortality rates (R = 0.51, p = 0.0337) but not cancer. Correlations for all-cause mortality were higher when the Belgrade outlier cohort was omitted (R = 0.72, p = 0.0024) or when analyses were adjusted for socioeconomic status (R = 0.67, p = 0.0065). There was also a significant reverse correlation between energy-adjusted Dietary Inflammatory Index score and age at death (R = -0.50 to -0.68, p = 0.0480 to 0.0012). Adjusting for systolic blood pressure, cholesterol, and smoking habits did not modify these correlations that were still significant. With control for these covariates a significant correlation emerged for coronary heart disease. Results obtained using a 25-year follow-up to allow unprojected data from all cohorts were similar. Results from this long-term follow-up study are consistent with a recommendation to increase consuming an anti-inflammatory diet characterized by high concentrations of fruits and vegetables and low consumption of simple carbohydrates and fats.

Age at death in elderly cohorts of four European countries of the Seven Countries Study: the role of comorbidities.

PURPOSE: To study age at death (AD) in elderly men as a function of risk factors and morbid conditions in a 25-year follow-up. MATERIALS AND METHODS: Men enrolled in the Seven Countries Study belonging to 8 cohorts in 4 European countries (Finland, The Netherlands, Italy and Serbia) were examined between 1984 and 1989 (aged 65-84 years) with measurement of some cardiovascular risk factors and recording of a few major morbid conditions. AD was measured after 25-year follow-up and used in multiple linear regression (MLR) models as dependent variable; while, risk factors and morbid conditions had the role of independent variables. RESULTS: Out of 2457 men, 2290 died during 25-year follow-up. Overall mean AD was of 82.0 years and slightly different across cohorts, the lowest being recorded in Finland. Age at entry examination and HDL cholesterol were directly associated with AD; while, blood pressure, heart rate, smoking habits and morbid conditions (major cardiovascular diseases, either independently or combined together with diabetes, chronic bronchitis, cancer and silent ECG abnormalities) were inversely related to AD. Body mass index had a parabolic relation with AD with longer survival for levels around 24 units; while, total serum cholesterol was not related to AD. However, only three independent variables were statistically significant when tested in each individual country (age, heart rate and stroke). In a MLR model, where a comorbidity score was entered as independent variable (everything else being equal), the presence of 1 morbid condition was associated with a reduced AD by 1.87 years that increased up to 6.39 years when 4 morbid conditions were present. CONCLUSION: AD seems a valuable indicator of all-cause mortality when the study population has reached or approached the extinction.

Inequalities by education and marital status in the co-occurrence of cardiovascular risk factors in Finland persisted between 1997-2017.

Understanding on sociodemographic variation of the co-occurrence of cardiovascular disease risk factors is crucial for planning future prevention strategies. We aimed at examining (1) the co-occurrence of smoking, obesity, hypertension and elevated serum cholesterol by education and marital status, and (2) its trends in different sociodemographic groups in Finland. We used data from cross-sectional health examination surveys among the general population (25-64 years): for 1997-2012 the National FINRISK Study and for 2017 the FinHealth 2017 Survey (n = 25036). A risk factor accumulation score with categories (1) zero, (2) one, (3) two, and (4) three or four elevated risk factors was the outcome in multinomial logistic regression. The risk factor score was more favourable among women, among high education groups, and slightly among participants living with a spouse. Among men, the lowest risk factor score class became more prevalent especially in the intermediate education group, which approached the highest education group over time. Our results indicate an overall transition towards a more favourable risk factor distribution. However, risk factor accumulation among the least educated remained emphasizing the need to develop and implement more targeted prevention interventions and public health policies to decrease the risk factor burden particularly in this group.

Coronary heart disease mortality trends during 50 years as explained by risk factor changes: The European cohorts of the Seven Countries Study.

OBJECTIVES: The purpose of this study was to relate risk factor changes during decades with 50-year coronary heart disease mortality in European cohorts of middle-aged men of the Seven Countries Study. MATERIAL AND METHODS: In the 1950s-early 1960s, nine cohorts of 6518 men aged 40-59 years were examined in five European countries. Smoking habits, systolic blood pressure and serum cholesterol were measured at entry and five times during the next 35 years and a comprehensive Risk Factor Change Score was created. Coronary heart disease mortality data was collected during a 50-year follow-up, modelled by the Weibull distribution, whose shape (Weibull shape) was related to the Risk Factor Change Score by linear regression. RESULTS: The Risk Factor Change Score showed slight declines in the Finnish and Dutch cohorts, moderate or large increases in the other cohorts. These effects were related to a decrease of smoking habits in all cohorts, an increase of blood pressure in all cohorts except East Finland, a decrease of serum cholesterol in Finland and the Netherlands, whereas serum cholesterol increases were slight in Italy and large in Serbia and Greece. Weibull distribution shape for coronary heart disease mortality showed slight deceleration in one Finnish and the Dutch cohorts, large acceleration in the Serbian and Greek cohorts. The correlation coefficient of the Risk Factor Change Score versus Weibull shape for the nine cohorts was 0.78 (R2 = 0.60; p = 0.0132). CONCLUSIONS: Spontaneous long-term changes of major coronary risk factor levels were associated with changes in the same direction of coronary heart disease mortality risk modelled by the Weibull distribution, expressing a kind of 'natural experiment' with an outcome that matches those of controlled preventive trials.

Protocol of a research project 'Projections of the burden of disease and disability in Finland - health policy prospects' using cross-sectional health surveys and register-based follow-up.

INTRODUCTION: With the rapid ageing of the population in Europe, reliable estimates of the future development of the disease and disability burden as well as healthy life years in the older sections of the population are crucial. Meanwhile, the future prospects of the health and functional ability of the working-aged population are critical. The aims of the Projections of the burden of disease and disability in Finland - health policy prospects research project are to provide information about the long-term consequences of health-related behaviours of the population and to project the potential improvement of the burden of disease and disability based on realistic scenarios about the development of risk behaviours in the total population and its subgroups. METHODS AND ANALYSIS: The analyses will be based on data from representative cross-sectional and longitudinal health examination surveys (HESs) conducted between 1972 to 2017 in Finland, and register data from several national administrative registers. Included HESs (FINRISK Surveys from 1972 to 2012, Mini-Finland Survey from 1978 to 1980, the Health 2000/2011 Surveys and the FinHealth 2017 Study) provide abundant information about biological and behavioural risk factors and the health and morbidity of the population. The modifiable risk factors used as predictors include hypertension, hyperlipidaemia, obesity, diabetes, physical inactivity, smoking, alcohol use and unfavourable diet. The main outcomes are ischaemic heart disease, cerebrovascular diseases, lung cancer, chronic obstructive pulmonary disease, Alzheimer's disease and diabetes. Within the project, novel projection techniques of data-driven Bayesian hierarchical models to provide robust and comparable estimates will be developed. ETHICS AND DISSEMINATION: The prevailing legislation and regulations have been followed for all surveys. Surveys since 1997 have been approved by the respective Ethics Committees covering the scope of this project. A written informed consent was obtained from participants since 1997. The outputs of the project will include 8 to 10 scientific papers in peer-reviewed journals.

Age at death of major cardiovascular diseases in 13 cohorts. The seven countries study of cardiovascular diseases 45-year follow-up.

OBJECTIVES: To explore age at death (AD) for major cardiovascular diseases (CVD) and their risk factors in originally middle-aged men followed nearly to extinction in the Seven Countries Study. MATERIALS AND METHODS: Thirteen cohorts of men aged 40-59 years (N = 10,628) in seven countries (USA, Finland, the Netherlands, Italy, Serbia, Greece, Japan) were enrolled in late 1950s and early 1960s and were followed 45 years for mortality. AD was computed for coronary heart disease (CHD), stroke (STR), heart disease of uncertain aetiology (HDUE) and for all-causes. AD was compared across CHD-HDUE-STR. Cox models were computed for each end-point using baseline age, cigarettes smoking, systolic blood pressure and serum cholesterol. RESULTS: After 45 years 92.9% of men had died. The most common CVD death was CHD in most cohorts except some Mediterranean and Japanese cohorts where STR or HDUE were most prevalent. In 13 cohorts mean AD was 74.5, 73.5, 75.7 and 79.1 years, respectively, for all-cause, CHD, STR and HDUE mortality (all possible differences were significant). The difference, across cohorts, between the highest and the lowest mean AD was 12.9, 9.0 and 4.7 years for CHD, HDUE and STR mortality, respectively. Risk factors explored were significant predictors of all three CVD end-points, except serum cholesterol, specific to CHD mortality. CONCLUSIONS: AD is a useful indicator of previous health and aging populations. STR and HDUE are diseases appearing later in life, thus being associated with a higher AD compared with CHD mortality.

The strength of the multivariable associations of major risk factors predicting coronary heart disease mortality is homogeneous across different areas of the Seven Countries Study during 50-year follow-up.

OBJECTIVES: To compare the magnitude of multivariable coefficients and hazard ratios of four cardiovascular risk factors across five worldwide regions of the Seven Countries Study in predicting 50-year coronary deaths. MATERIAL AND METHODS: A total of 13 cohorts of middle-aged men at entry (40-59 years old) were enrolled in the mid-1900s from five relatively homogeneous groups of cohorts (areas): USA, Finland and Zutphen - the Netherlands, Italy and Greece, Serbia, Japan for a total of 10,368 middle-aged men. The major risk factors measured at baseline were age, number of cigarettes smoked, systolic blood pressure and serum cholesterol. Cox proportional hazards models were solved for 50-year (45 years for Serbia) deaths from coronary heart disease (CHD), and the multivariable coefficients were compared for heterogeneity. RESULTS: The highest levels of risk factors and CHD death rates were found in Finland and Zutphen - the Netherlands and the lowest in Japan. All four risk factors were predictive for long-term CHD mortality in all regions, except serum cholesterol in Japan where the mean levels and CHD events were lowest. Tests of heterogeneity of coefficients for single risk factors in predicting CHD mortality were non-significant across the five areas. The same analyses for the first 25 years of follow-up produced similar findings. CONCLUSIONS: The strength of the multivariable associations of four major traditional CHD risk factors with long-term CHD mortality appears to be relatively homogeneous across areas, pending needed further evidence.

Adjusting for selective non-participation with re-contact data in the FINRISK 2012 survey.

AIMS: A common objective of epidemiological surveys is to provide population-level estimates of health indicators. Survey results tend to be biased under selective non-participation. One approach to bias reduction is to collect information about non-participants by contacting them again and asking them to fill in a questionnaire. This information is called re-contact data, and it allows to adjust the estimates for non-participation. METHODS: We analyse data from the FINRISK 2012 survey, where re-contact data were collected. We assume that the respondents of the re-contact survey are similar to the remaining non-participants with respect to the health given their available background information. Validity of this assumption is evaluated based on the hospitalisation data obtained through record linkage of survey data to the administrative registers. Using this assumption and multiple imputation, we estimate the prevalences of daily smoking and heavy alcohol consumption and compare them to estimates obtained with a commonly used assumption that the participants represent the entire target group. RESULTS: When adjusting for non-participation using re-contact data, higher prevalence estimates were observed compared to prevalence estimates based on participants only. Among men, the smoking prevalence estimate was 28.5% (23.2% for participants) and heavy alcohol consumption prevalence was 9.4% (6.8% for participants). Among women, smoking prevalence was 19% (16.5% for participants) and heavy alcohol consumption was 4.8% (3% for participants). CONCLUSIONS: The utilisation of re-contact data is a useful method to adjust for non-participation bias on population estimates in epidemiological surveys.