Asthma severity and impact on perinatal outcomes: an updated systematic review and meta-analysis.

BACKGROUND: Large-scale studies exploring the associations of asthma severity, exacerbations and medication use with adverse perinatal outcomes have been published in recent years. OBJECTIVES: To update evidence on the associations of asthma severity, exacerbations and medication use with the adverse perinatal outcomes of preterm delivery (PD), low birthweight (LBW) and small-for-gestational-age (SGA). SEARCH STRATEGY: PubMed, Embase, Wanfang, and China National Knowledge Infrastructure (CNKI) from inception to 1 January 2021. SELECTION CRITERIA: Cohort studies comparing the likelihood of adverse perinatal outcomes in groups of asthmatic women stratified by asthma severity, asthma exacerbations or medication use, or comparing the likelihood of adverse perinatal outcomes between non-asthmatic women and asthmatics of various levels of severity and exacerbation. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed risk of bias. Random-effects models were used to meta-analyse the results. MAIN RESULTS: Twenty studies met the inclusion criteria. The odds of delivering SGA babies increased with maternal asthma severity. Pregnant women with an asthma exacerbation had higher odds of delivering LBW babies and SGA babies, compared with pregnant women with asthma but without an exacerbation (pooled adjusted odds ratio [OR] 1.15, 95% CI 1.02-1.29 for LBW; number of studies with adjusted OR 3; I2 = 0%) (pooled adjusted OR 1.13, 95% CI 1.04-1.23 for SGA; number of studies with adjusted OR 4; I2 = 0%) and compared to pregnant women without asthma. Oral corticosteroids use during pregnancy was associated with increased odds of LBW, but not PD. CONCLUSIONS: The available data suggest that maternal asthma severity and exacerbations are associated with increased odds of LBW and SGA babies. TWEETABLE ABSTRACT: A systematic review and meta-analysis found that maternal asthma severity and exacerbations are associated with increased odds of delivering low birthweight and small-for-gestational-age babies.

Age at menarche and risk of vasomotor menopausal symptoms: a pooled analysis of six studies.

OBJECTIVE: To examine the association between age at menarche and risk of vasomotor menopausal symptoms (VMS) and whether midlife body mass index (BMI) modified the association. DESIGN: A pooled analysis of six cohort studies. SETTING: The International collaboration on the Life course Approach to reproductive health and Chronic disease Events (InterLACE). POPULATION: 18 555 women from the UK, USA and Australia. METHODS: VMS frequency data (never, rarely, sometimes and often) were harmonised from two studies (n = 13 602); severity data (never, mild, moderate and severe) from the other four studies (n = 4953). Multinominal logistic regression models were used to estimate relative risk ratios (RRRs) and 95% CIs adjusted for confounders and incorporated study as random effects. MAIN OUTCOME MEASURES: Hot flushes and night sweats. RESULTS: Frequency data showed that early menarche ≤11 years was associated with an increased risk of 'often' hot flushes (RRR 1.48, 95% CI 1.24-1.76) and night sweats (RRR 1.59, 95% CI 1.49-1.70) compared with menarche at ≥14 years. Severity data showed similar results, but appeared less conclusive, with RRRs of 1.16 (95% CI 0.94-1.42) and 1.27 (95% CI 1.01-1.58) for 'severe' hot flushes and night sweats, respectively. BMI significantly modified the association as the risk associated with early menarche and 'often' VMS was stronger among women who were overweight or obese than those of normal weight, while this gradient across BMI categories was not as strong with the risk of 'severe' VMS. CONCLUSIONS: Early age at menarche is a risk factor for VMS, particularly for frequent VMS, but midlife BMI may play an important role in modifying this risk. TWEETABLE ABSTRACT: Overweight and obesity exacerbate the risk of vasomotor symptoms associated with early menarche.

Protective effect of hormone therapy among women with hysterectomy/oophorectomy.

Study question: Does exposure to menopausal hormone therapy (MHT) in mid-aged women alter their risk of cardiovascular disease (CVD) mortality and all-cause mortality? Summary answer: MHT soon after menopause is unlikely to increase the risk of CVD mortality or all-cause mortality and may have a protective effect for women with hysterectomy/oophorectomy. What is known already: The balance of benefits and risks of MHT are currently unclear and may differ according to when treatment starts and whether women have an intact uterus. Study design size, duration: A total of 13 715 participants from the mid-aged population-based cohort (born 1946-1951) of the Australian Longitudinal Study on Women's Health (ALSWH) were followed from 1998 to 2013. Participants/materials setting methods: The measures included cardiovascular and all-cause mortality, exposure to MHT and menopausal status (based on 3-yearly self-reports). Electronic prescriptions data on MHT were also available from mid-2002 onwards. At each follow-up survey wave, participants were classified as: an existing user of MHT, an initiator of MHT or a non-initiator of MHT. Main results and the role of chance: After adjusting for confounding variables, existing users of MHT had a reduced risk (hazard ratio 0.63; 95% CI, 0.43-0.92) of CVD mortality compared with non-initiators. Insufficient evidence of an association was identified for initiators of MHT (0.66; 0.35-1.24). For all-cause mortality, risks were reduced for both initiators (0.69; 0.55-0.87) and existing users (0.80; 0.70-0.91). In a subgroup analysis, women with hysterectomy/oophorectomy had lower risks of CVD mortality for both initiators (0.14; 0.02-0.98) and existing users (0.55; 0.34-0.90), but no evidence of an association was found for women whose MHT commenced during or after menopause. Similarly for all-cause mortality, only the women with hysterectomy/oophorectomy had lower risks for both initiators (0.47; 0.31-0.70) and existing users (0.69; 0.58-0.82). Limitations, reasons for caution: Limitations include the observational nature of the study, the small number of deaths, MHT use being self-reported and the classification of menopausal status also being based on self-reported information. Wider implications of the findings: Women considering MHT soon after menopause can be reassured that the treatment is unlikely to increase their risk of CVD mortality or all-cause mortality. Study funding/competing interest(s): The Australian Longitudinal Study on Women's Health is funded by the Australian Department of Health. G.D.M. is funded by the Australian Research Council Future Fellowship. L.C. was funded by a China scholarship council (CSC) graduate scholarship. All authors report no conflict of interest. Trial registration number: N/A.

Young women's psychological distress after a diagnosis of polycystic ovary syndrome or endometriosis.

STUDY QUESTION: Do young women with polycystic ovary syndrome (PCOS) or endometriosis report more psychological distress than their peers without a history of these conditions? SUMMARY ANSWER: Young women (aged 18-23 years) with PCOS or endometriosis had a greater risk of moderate to severe psychological distress than women without a history of these conditions. WHAT IS KNOWN ALREADY: Psychological distress appears common among women with PCOS and endometriosis. However, population-based studies that examine the psychological outcomes for adolescents and young women are generally absent from the literature. STUDY DESIGN, SIZE, DURATION: This is a secondary analysis of data collected from 17 015 young, Australian women participating in a national, longitudinal cohort study. Women were first surveyed in 2012-2013 when they were aged 18-23 years. In 2014, women completed the second survey when they were aged 19-24 years and 11324 (67%) women responded. PARTICIPANTS/MATERIALS, SETTING, METHODS: We analysed data from 11 238 women who participated in both Surveys 1 and 2 and who responded to questions about PCOS and endometriosis. Using logistic regression, we compared the odds of moderate to severe psychological distress at Surveys 1 and 2 for women reporting a recent diagnosis (within the last 12 months) of PCOS or endometriosis and women with a pre-existing diagnosis, with that for women without a history of these conditions. MAIN RESULTS AND THE ROLE OF CHANCE: At Survey 2, around 60% of women reporting a diagnosis of PCOS or endometriosis had moderate to severe levels of psychological distress. Compared to women without a history of these conditions, the odds of moderate to severe psychological distress at Survey 2 were significantly higher for women recently diagnosed with PCOS [Adjusted Odds Ratio (AOR) = 1.62, 95% CI = 1.21-2.18] or endometriosis (AOR= 1.77; 95% CI = 1.20-2.63) and for women with a pre-existing diagnosis of PCOS (AOR = 1.57, 95% CI = 1.30-1.89) or endometriosis (AOR = 1.61; 95% CI = 1.26-2.06). Women recently diagnosed with PCOS or endometriosis also had a greater likelihood of moderate to severe distress in the year prior to their diagnosis. The association between PCOS and psychological distress was attenuated when adjusting for BMI, but hormonal contraceptive use did not attenuate the risk of distress among the women with PCOS or endometriosis. LIMITATIONS, REASONS FOR CAUTION: All data were self-reported and, therefore, the diagnoses of PCOS or endometriosis were not confirmed by a medical practitioner. WIDER IMPLICATIONS OF THE FINDINGS: Health professionals should be aware of the potential psychosocial and healthcare needs among young women with these conditions, particularly women with PCOS who are obese. While hormonal contraceptives may help to regulate the hormonal aspects of these conditions, they do not appear to reduce women's psychological distress. Because psychological distress among the young women in this study remained elevated even after diagnosis, this supports the need for multidisciplinary health care to help women adjust to their diagnosis and treatment regimens and facilitate positive, long-term mental health outcomes. Future research that examines medical and psychosocial sources of distress for young women with PCOS and endometriosis is needed. STUDY FUNDING/COMPETING INTERESTS: I.J.R. was supported by an Australian National Health and Medical Research Council Centre for Research Excellence (grant number: APP1000986). G.D.M. is funded by the Australian Research Council Future Fellowship (FT120100812). The Australian Longitudinal Study on Women's Health is funded by the Australian Government Department of Health. H.T. is supported by an Australian National Health and Medical Research Council Practitioner Fellowship. The authors declare that no competing interests exist. TRIAL REGISTRATION NUMBER: N/A.

Unit cohesion, traumatic exposure and mental health of military personnel.

BACKGROUND: The benefit of military unit cohesion to morale and psychological resilience is well established. But it remains unclear whether unit cohesion modifies the association between deployment-related traumatic exposure and mental health problems. AIMS: To examine the association between unit cohesion, traumatic exposure and poor mental health [symptoms of post-traumatic stress disorder (PTSD), psychological distress and alcohol dependency] and assess whether the relationship between traumatic exposure and poor mental health differs by level of unit cohesion. METHODS: A self-reported cross-sectional survey of Australian military personnel deployed to Iraq or Afghanistan between 2001 and 2009. RESULTS: Among 11411 participants, those with low levels of unit cohesion had higher odds of PTSD symptoms [aOR (95% CI): 2.54 (1.88, 3.42)], very high psychological distress [aOR (95% CI): 4.28 (3.04, 6.02)] and a high level of alcohol problems [aOR (95% CI): 1.71 (1.32, 2.22)] compared with those reporting high unit cohesion on deployment. Higher exposure to traumatic events on deployment was associated with greater risk of PTSD symptoms, very high levels of psychological distress and high levels of alcohol problems in this cohort. However, there was no evidence of a statistically significant interaction between unit cohesion and traumatic exposures in influencing poor mental health. CONCLUSIONS: Our findings suggest that both unit cohesion and traumatic exposure are independently associated with poor mental health. Efforts to improve military unit cohesion may help to improve the mental health resilience of military personnel, regardless of their level of traumatic exposure.

Factors associated with low unit cohesion in Australian Defence Force members who deployed to the Middle East (2001-2009).

INTRODUCTION: Unit cohesion has been shown to bolster the mental health of military personnel; hence, it is important to identify the characteristics that are associated with low unit cohesion, so that interventions to improve unit cohesion can be targeted and implemented. Little is known about the factors associated with low unit cohesion. This research aims to identify demographic, military service and deployment factors associated with low unit cohesion. METHODS: Data from a self-reported cross-sectional study of 11 411 current or ex-serving Australian military personnel deployed to Iraq or Afghanistan between 2001 and 2009 were used. Multivariable logistic regression was used to investigate the research aims. RESULTS: Being female (adjusted OR (aOR) (95% CI) 1.35 (1.21 to 1.51)), non-commissioned officer (aOR (95% CI) 1.50 (1.39 to 1.62)), lower ranked (aOR (95% CI) 1.74 (1.51 to 2.01)) or having left military service (aOR (95% CI) 1.71 (1.46 to 2.02)) was associated with reporting low unit cohesion. Potentially modifiable factors such as performing logistic roles on deployment (aOR (95% CI) 1.13 (1.01 to 1.27)), dissatisfaction with work experience on deployment such as working with colleagues who did not do what was expected of them (aOR (95% CI) 4.09 (3.61 to 4.64)), and major problems at home while deployed (aOR (95% CI) 1.50 (1.38 to 1.63)) were also associated with reporting low unit cohesion. CONCLUSIONS: This is the first study to identify demographic, military service and deployment factors associated with low unit cohesion. The modifiable nature of unit cohesion means that military leaders could use this information to identify subgroups for targeted resilience interventions that may reduce vulnerabilities to mental health problems and improve the job satisfaction, preparedness and deployment experiences of serving members.

Validity of self-reported osteoporosis in mid-age and older women.

UNLABELLED: The validity of self-reported osteoporosis is often questioned, but validation studies are lacking. We validated self-reported prevalence and incidence of osteoporosis against self-reported and administrative data on medications. The concurrent validity was moderate to good for self-reported prevalent osteoporosis, but only poor to moderate for self-reported incident osteoporosis in mid-age and older women, respectively. Construct validity was acceptable for self-reported prevalent but not for incident osteoporosis. INTRODUCTION: The validity of self-reported osteoporosis is often questioned, but validation studies are lacking. The aim was to examine the validity of self-reported prevalence and incidence of osteoporosis against self-reported and administrative data on medications. METHODS: Data were from mid-age (56-61 years in 2007) and older (79-84 years in 2005) participants in the Australian Longitudinal Study on Women's Health. Self-reported diagnosis was compared with medication information from (1) self-report (n(mid) = 10,509 and n(old) = 7,072), and (2) pharmaceutical prescription reimbursement claims (n(mid) = 6,632 and n(old) = 4,668). Concurrent validity of self-report was examined by calculating agreement, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Construct validity was tested by examining associations of self-reported diagnosis with osteoporosis-related characteristics (fracture, weight, bodily pain, back pain, and physical functioning). RESULTS: Agreement, sensitivity and PPV of self-reported prevalent diagnosis were higher when compared with medication claims (mid-age women: kappa = 0.51, 95% confidence interval [CI] = 0.46-0.56; older women: kappa = 0.65, 95% CI = 0.63-0.68) than with self-reported medication (mid-age women: kappa = 0.41, 95% CI = 0.37-0.45; older women: kappa = 0.57, 95% CI = 0.55-0.59). Sensitivity, PPV and agreement were lower for self-reported incident diagnosis (mid-age women: kappa = 0.39, 95% CI = 0.32-0.47; older women: kappa = 0.55, 95% CI = 0.51-0.61). Statistically significant associations between self-reported diagnosis and at least four of five characteristics were found for prevalent diagnosis in both age groups and for incident diagnosis in older women. CONCLUSIONS: The concurrent validity was moderate to good for self-reported prevalent osteoporosis, but only poor to moderate for self-reported incident osteoporosis in mid-age and older women, respectively. Construct validity was acceptable for self-reported prevalent but not for incident osteoporosis.

Vasomotor menopausal symptoms and cardiovascular disease risk in midlife: A longitudinal study.

OBJECTIVE: To ascertain the association between vasomotor menopausal symptoms (VSM), hot flushes and night sweats, and cardiovascular disease, coronary heart disease and cerebrovascular disease. STUDY DESIGN: The study sample comprised 8881 women (aged 45-50 years) with available hospital separation data from the 1946-51 cohort (1996-2016) of the ongoing Australian Longitudinal Study on Women's Health, a national prospective cohort study. MAIN OUTCOME MEASURES: First fatal or non-fatal cardiovascular disease, coronary heart disease, and cerebrovascular disease events were obtained through linkage with hospital admission data, the National Death Index, and Medicare Benefits Schedule. Hot flushes and night sweats were assessed via questionnaires at each main survey. Additionally, we calculated the duration of symptoms based on whether or not women reported vasomotor menopausal symptoms in each survey. RESULTS: There were 925 cardiovascular disease, 484 coronary heart disease and 154 cerebrovascular disease events. There was no consistent evidence of any association with vasomotor menopausal symptoms, hot flushes and night sweats. We did find marginally statistically significant associations between presence of night sweats and cardiovascular disease (Hazard Ratio = 1.18, 95 % Confidence Interval: 1.01-1.38), and between the duration of vasomotor menopausal symptoms [years] and coronary heart disease (Hazard Ratioper year = 1.03, 95 % Confidence Interval: 1.00-1.05). However, given the number of associations tested, these findings could very well have arisen by chance. CONCLUSION: In this large longitudinal study with 20 years of follow-up and clinical outcomes we did not find a convincing association between vasomotor menopausal symptoms, hot flushes, night sweats and cardiovascular disease, coronary heart disease and cerebrovascular disease.

Time-course of PTSD symptoms in the Australian Defence Force: a retrospective cohort study.

AIMS: Understanding the time-course of post-traumatic stress disorder (PTSD), and the underlying events, may help to identify those most at risk, and anticipate the number of individuals likely to be diagnosed after exposure to traumatic events. METHOD: Data from two health surveys were combined to create a cohort of 1119 Australian military personnel who deployed to the Middle East between 2000 and 2009. Changes in PTSD Checklist Civilian Version (PCL-C) scores and the reporting of stressful events between the two self-reported surveys were assessed. Logistic regression was used to examine the association between the number of stressful events reported and PTSD symptoms, and assess whether those who reported new stressful events between the two surveys, were also more likely to report older events. We also assessed, using linear regression, whether higher scores on the Kessler Psychological Distress Scale or the Alcohol Use Disorder Identification Test were associated with subsequent increases in the PCL-C in those who had experienced a stressful event, but who initially had few PTSD symptoms. RESULTS: Overall, the mean PCL-C scores in the two surveys were similar, and 78% of responders stayed in the same PCL-C category. Only a small percentage moved from having few symptoms of PTSD (PCL-C < 30) in Survey 1 to meeting the criteria for PTSD (PCL-C ≥ 50) at Survey 2 (1% of all responders, 16% of those with PCL-C ≥ 50 at Survey 2). Personnel who reported more stressful lifetime events were more likely to score higher on the PCL-C. Only 51% reported the same stressful event on both surveys. People who reported events occurring between the two surveys were more likely to record events from before the first survey which they had not previously mentioned (OR 1.48, 95% CI (1.17, 1.88), p < 0.001), than those who did not. In people who initially had few PTSD symptoms, a higher level of psychological distress, was significantly associated with higher PCL-C scores a few years later. CONCLUSIONS: The reporting of stressful events varied over time indicating that while the impact of some stressors endure, others may increase or decline in importance. When screening for PTSD, it is important to consider both traumatic experiences on deployment and other stressful life events, as well as other mental health problems among military personnel, even if individuals do not exhibit symptoms of PTSD on an initial assessment.

Risk of primary and recurrent acute myocardial infarction from lipoprotein(a) in men and women.

OBJECTIVES: This study sought to examine whether lipoprotein(a) concentrations were risk factors for a first acute and recurrent myocardial infarction. BACKGROUND: There is conflicting evidence concerning the risk of acute myocardial infarction from lipoprotein(a). No studies have examined the risk of recurrent acute myocardial infarction from lipoprotein(a), and few have addressed the risk in women. METHODS: This was a population-based case-control study of 893 men and women 35 to 69 years old participating in the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (MONICA) Project in Newcastle, Australia in 1993 to 1994. Case and control patients were classified into those with and without a previous myocardial infarction, and median lipoprotein(a) concentrations were compared after adjusting for other variables. Quintiles of lipoprotein(a) concentration were also examined. RESULTS: Compared with control subjects without a previous myocardial infarction, median lipoprotein(a) concentrations increased from case patients with a first myocardial infarction (15 mg/liter higher, 95% confidence interval [CI] -36 to 60) to control patients with a previous myocardial infarction (159 mg/ liter higher, 95% CI 40 to 278) and case patients with a previous myocardial infarction (60 mg/liter higher, 95% CI -16 to 136, p < 0.01, test for trend). Women had significantly higher lipoprotein(a) concentrations than men (median 71 mg/liter higher, 95% CI 23 to 118). The highest quintile of lipoprotein(a) (>550 mg/liter) was a significant risk factor for a first acute myocardial infarction (odds ratio [OR] 1.77, 95% CI 1.03 to 3.03); but in those with a previous myocardial infarction, the highest quintile was not associated with recurrent myocardial infarction (OR 0.84, 95% CI 0.30 to 2.37). CONCLUSIONS: High lipoprotein(a) concentrations may be a marker of vascular or tissue injury or may be associated with other genetic or environmental factors that cause acute myocardial infarction. Currently, lipoprotein(a) measurement cannot be recommended for assessment of risk for acute myocardial infarction.

The impact of diabetes on survival among patients with first myocardial infarction.

OBJECTIVE: The purpose of this paper is to estimate the impact of diabetes on survival among patients with first acute myocardial infarction, using data from the World Health Organization (WHO) Monitoring Trends and Determinants of Cardiovascular Disease (MONICA) Project in Newcastle, New South Wales, Australia. RESEARCH DESIGN AND METHODS: The WHO MONICA Project is a community-based surveillance system that monitors coronary heart disease morbidity and mortality. All patients with suspected coronary events were observed for 28 days after the onset of symptoms. RESULTS: Of 5,322 patients with acute myocardial infarction and no previous history of ischemic heart disease (3,643 men and 1,679 women), 333 men (9%) and 224 women (13%) had a history of diabetes. The age-adjusted 28-day case fatality for women with diabetes (25%) was significantly higher than for women without diabetes (16%); relative risk 1.56 (95% CI: 1.19-2.04). The difference for men was also significant (25% with diabetes and 20% without diabetes); relative risk 1.25 (95% CI: 1.02-1.53). Age-specific case fatality increased significantly with age in both men and women without diabetes, but systematic age effects were not so apparent in patients with diabetes. Case fatality significantly decreased over the study period in patients without diabetes, but not among the diabetic patients. CONCLUSIONS: The increased risk of death in the diabetic patients remained after accounting for their poorer risk factor profiles; even if they reached the hospital alive, diabetic patients were also less likely to survive than nondiabetic patients. The relative impact of diabetes on survival is greater in women than in men.

Fruit and vegetable consumption and prevalence and incidence of depressive symptoms in mid-age women: results from the Australian longitudinal study on women's health.

BACKGROUND/OBJECTIVES: There is continued interest in the associations between diet and depression and several studies have focused on individual dietary factors or diet patterns to investigate the relationship. We investigated the association between fruit and vegetables and symptoms of depression in the mid-age cohort of the Australian Longitudinal Study on Women's Health. SUBJECTS/METHODS: A total of 6271 women with a mean age of 55.45 (1.45 s.d.) years were followed up at three surveys over 6 years. A score of ⩾ 10 on the Center for Epidemiological Studies Depression-10 scale indicated depressive symptoms. Fruit and vegetable intake was assessed using short questions. RESULTS: A total of 381 women (6.1%) were depressed at all three surveys over the 6-year survey period. Cross-sectional logistic regression analysis using general estimating equations showed a reduced odds of depressive symptoms (odds ratio (OR) 0.86 (95% confidence interval (CI) 0.79-0.95, P=0.001)) among women who ate ⩾ 2 of fruit/day even after adjustment for several factors including smoking, alcohol, body mass index, physical activity, marital status, education, energy, fish intake and comorbidities. The predictive model also showed a reduced odds of depressive symptoms (OR 0.82 (95% CI 0.70-0.96, P=0.012)) among women who ate ⩾ 2 pieces of fruit/day. There was also an association between vegetable intake and prevalence of depressive symptoms at higher levels of intake. CONCLUSIONS: Increasing fruit consumption may be one important factor for reducing both the prevalence and incidence of depressive symptoms in mid-age women.

Secondary prevention after acute myocardial infarction.

The hypothesis that 6 months after acute myocardial infarction, adoption of secondary prevention activities would be higher, quality of life better, and blood cholesterol lower in patients randomly allocated to a mail-out intervention program than in those receiving usual care was tested. Patients were aged < 70 years, admitted to hospitals in and around Newcastle, Australia with a suspected heart attack and discharged alive from the hospital. Cluster randomization, based on the patient's family practitioner, was used to allocate consenting patients to an intervention or usual care group. A low-cost mail-out program was designed to help patients reduce dietary fat, obtain regular exercise by walking and (for smokers only) to quit smoking. Supplementary telephone contact was also used. In addition, a letter was sent to the family doctor regarding the benefit of aspirin and beta blockers for secondary prevention. Of eligible patients, 71% participated, and 79% of the 213 intervention subjects and 87% of the 237 usual care ones returned a 6-month follow-up questionnaire. Self-reported fat intake was significantly lower, an "emotional" score obtained from a quality-of-life questionnaire was significantly higher in the intervention than in the usual care group, and "physical" and "social" scores for quality of life were slightly higher. Blood cholesterol level and other variables were not different between the groups at 6 months. Simple low-cost programs providing support and advice on lifestyle change may be beneficial, particularly in improving patients' perceived quality of life.

Case fatality after an acute cardiac event: the effect of smoking and alcohol consumption.

The objective of this study was to use a population-based register of acute cardiac events to investigate the association between survival after an acute event and history of smoking and alcohol consumption. The population was all residents of the Lower Hunter Region of Australia aged 25 to 69 years who suffered myocardial infarction or sudden cardiac death between 1986 and 1994. Among 10,170 events, 2504 resulted in death within 28 days. After adjusting for sex, age and medical history, current smokers had a similar risk of dying after an acute cardiac event to never-smokers [odds ratio (OR)=1.10, 95% confidence interval (CI) 0.94-1.29]. People who consumed more than 8 alcoholic drinks per day on more than 2 days per week (OR=1.93, 95% CI 1.39-2.69) and former moderate to heavy drinkers (OR=4.59, 95% CI 3.65-5.76) were more likely to die than people who were nondrinkers. The results of this large community study, suggesting no effect of smoking on case fatality and an increased risk of death after an acute cardiac event for heavy drinkers and former moderate to heavy drinkers, highlight the importance of a population view of case fatality. These results can also shed some light on reasons for the paradoxical results from clinical trials.

A comparison of two quality-of-life questionnaires for cancer clinical trials: the functional living index--cancer (FLIC) and the quality of life questionnaire core module (QLQ-C30).

Choosing a measure instrument for a study raises the question of whether instruments designed for the same purpose produce the same results. We investigated this question for two instruments designed to measure subjective quality of life (QOL) in cancer clinical trials: the Functional Living Index-Cancer (FLIC) and the Quality of Life Questionnaire Core module (QLQ-C30). These were administered concurrently to 98 cancer patients. Four patient groups were defined: (1) well, no chemotherapy (n = 23); (2) adjuvant chemotherapy (n = 24); (3) stable disease, active chemotherapy (n = 24); (4) progressive disease (n = 27). Both instruments have global, role, social, emotional, pain, and nausea scales; QLQ-C30 also assesses physical function, cognitive function, and fatigue, while FLIC assesses hardship. Correlation analysis indicated convergent validity for the global, role, emotional, pain and nausea dimensions, but not the social dimension. Both instruments indicated that groups 1 and 2 had better QOL than group 4 in at least one dimension. However, different dimension-specific results meant that qualitatively different conclusions would have been drawn if either instrument had been used singly: FLIC indicated that group 1 had better role function that group 4 and suffered less hardship and that group 1 suffered less nausea than group 3, while the QLQ-C30 data indicated that group 2 had better physical function than group 4. The only consistent result was for pain: both instruments indicated group 4 had more pain than either groups 1 or 2. Thus the choice of QOL instrument for use in a particular trial will affect both the results and conclusions. It is important, therefore, to consider carefully which instrument is most likely to detect important differences relevant to the patients' lives in that setting.

How soon after quitting smoking does risk of heart attack decline?

A population-based case-control study (involving 1282 cases and 2068 controls) was conducted to examine the risk of myocardial infarction or coronary death after cigarette smokers quit smoking. The odds ratios for current smokers were significantly elevated compared to non-smokers (OR = 2.7 for men and OR = 4.7 for women). For ex-smokers odds ratios declined rapidly after quitting and after about 3 years they were not significantly different from unity. Fibrinogen concentrations measured in the controls only were higher in current smokers and ex-smokers up to 2 years after quitting than in non-smokers and after that time were similar to levels in non-smokers; however, most of the differences among categories of smokers were not statistically significant. These results support the hypothesis that risk of a coronary event in ex-smokers declines rapidly after quitting and within 2-3 years is similar to the risk for non-smokers.

Changing patterns of coronary heart disease in the hunter region of New South Wales, Australia.

A population-based observational study of men and women aged 35-69 years in the Hunter Region of New South Wales, Australia, was conducted to assess the impact of risk-factor modification and increased drug therapy on the trends in major coronary events and case fatality. From 1985 to 1993, there were 3006 coronary deaths and 6450 nonfatal major coronary events. Rates of death and nonfatal myocardial infarction declined, but there was an increase in hospital admissions for prolonged chest pain. Reductions in cigarette smoking, diastolic blood pressure, total cholesterol, and increased use of aspirin can fully explain the 3.3% (95% confidence interval [CI] 2.4, 4.2) average annual reduction in rates of major coronary events for men and the 4.1% (95% CI 2.7, 5.5) reduction for women. In contrast, increased use of aspirin, beta-blockers, fibrinolytic therapy, and angiotensin-converting enzyme inhibitors explain less than half of the 8.9% (95% CI 5.9, 11.8) and 6.9% (95% CI 2.7, 10.9) average annual reduction in case fatality in hospital for men and women, respectively. These trends suggest a decline in severity of coronary heart disease consistent with reductions in risk-factor levels and improved acute medical treatment.

A self-administered quality-of-life questionnaire after acute myocardial infarction.

A slightly modified version of the Quality-of-Life after Myocardial Infarction (QLMI) questionnaire developed by Oldridge and colleagues was applied in a self-administered mode to patients with suspected acute myocardial infarction (AMI) in a randomized controlled trial of secondary prevention. Acceptability of the questionnaire was good, with 93% of responders answering all items. Factor analysis suggested three quality-of-life (QL) dimensions which we called "emotional", "physical" and "social". These differed somewhat from the dimensions proposed by Oldridge and colleagues. However, a sensitivity analysis showed relative invariance of results to weighting schemes. Scores on our three dimensions were responsive to differences between the treatment groups, and demonstrated construct validity based on associations between the measured QL and variables expected to affect QL. We conclude that the QLMI questionnaire has good potential as an instrument for assessing QL in post-AMI patients and that it can be successfully self-administered.

Cigarette smoking and sick leave in an industrial population in Shanghai, China.

A study of cigarette smoking and sick leave was conducted at a large petrochemical complex in Shanghai, China in 1988. Among a random sample of 1856 men the smoking prevalence was 80% with the highest rate (84%) occurring in the age group 25-34 years. Only 53% of smokers and 76% of nonsmokers said they believed smoking was harmful to health and knowledge of which diseases were associated with smoking was poor. Retrospective data were also collected on sick leave in 1986 and 1987. In 1986 13% of men took sick leave and in 1987 12%; the mean duration of sick leave was 3 days per year. In 1986 the odds ratios (OR) for taking sick leave were 2.37 for heavy smokers and 1.45 for light smokers compared to unity for nonsmokers; the corresponding OR for 1987 were 1.70 and 1.28 for heavy and light smokers compared with nonsmokers. Smoking was positively associated with sick leave even after adjustment for age, consumption of alcohol and exposure to chemicals; OR = 1.56 (95% confidence interval (Cl): 1.06-2.31) in 1986 and OR = 1.32 (95% Cl: 0.90-1.95) in 1987. Demonstration of this association even in a young population with low sick leave rates illustrates yet again the adverse effects of smoking on health and the urgent need to reduce the very high prevalence of smoking in China.

Mortality from malignant melanoma in Australia: effects due to country of birth.

Mortality from malignant melanoma is much higher among native born Australians than among people born in other countries. For immigrants death rates increase with period of residence in Australia. Our analysis fails to reveal any increased risk associated with fair skin or Celtic origin. Geographic and socio-economic patterns of mortality from melanoma are similar for Australian-born individuals and those born elsewhere. These mortality difference parallel incidence patterns for the disease. Our findings support the theory that sunlight is a major determinant of melanoma and are compatible with the hypothesis that it is initiated by traumatic sunburn.