Cognitive functions explain discrete parameters of normal walking and dual-task walking, but not postural sway in quiet stance among physically active older people.

BACKGROUND: Postural control is dependent on the central nervous system's accurate interpretation of sensory information to formulate and execute adequate motor actions. Research has shown that cognitive functions are associated with both postural control and fall risk, but specific associations are not established. The aim of this study was to explore how specific components of everyday postural control tasks are associated with both general and specific cognitive functions. METHODS: Forty-six community-dwelling older adults reported their age, sex, physical activity level, falls and fall-related concerns. The following cognitive aspects were assessed: global cognition, executive functions, processing speed and intraindividual variability. Postural control was quantified by measuring postural sway in quiet stance, walking at a self-selected pace, and walking while performing a concurrent arithmetical task. Separate orthogonal projections of latent structures models were generated for each postural control outcome using descriptive and cognitive variables as explanatory variables. RESULTS: Longer step length and faster gait speed were related to faster processing speed and less intraindividual variability in the choice reaction test. Moreover, longer step length was also related to less fall-related concerns and less severe fall-related injuries, while faster gait speed was also related to female sex and poorer global cognition. Lower dual-task cost for gait speed was explained by the executive function inhibition and faster processing speed. Postural sway in quiet stance was not explained by cognitive functions. CONCLUSIONS: Cognitive functions explained gait speed and step length during normal walking, as well as the decrease of gait speed while performing a concurrent cognitive task. The results suggest that different cognitive processes are important for different postural control aspects. Postural sway in quiet stance, step time and gait variability seem to depend more on physical and automatic processes rather than higher cognitive functions among physically active older people. The relationships between cognitive functions and postural control likely vary depending on the specific tasks and the characteristics of different populations.

Increased co-contraction reaction during a surface perturbation is associated with unsuccessful postural control among older adults.

BACKGROUND: As a strategy to maintain postural control, the stiffening strategy (agonist-antagonist co-contractions) is often considered dysfunctional and associated with poor physical capacity. The aim was to investigate whether increased stiffening is associated with unsuccessful postural control during an unpredictable surface perturbation, and which sensory and motor variables that explain postural stiffening. METHODS: A sample of 34 older adults, 75.8 ± 3.8 years, was subjected to an unpredicted surface perturbation with the postural task to keep a feet-in-place strategy. The participants also completed a thorough sensory- and motor test protocol. During the surface perturbation, electromyography was measured from tibialis anterior and gastrocnemius to further calculate a co-contraction index during the feed-forward and feedback period. A binary logistic regression was done with the nominal variable, if the participant succeeded in the postural task or not, set as dependent variable and the co-contraction indexes set as independent variables. Further, the variables from the sensory and motor testing were set as independent variables in two separate Orthogonal Projections of Latent Structures (OPLS)-models, one with the feed-forward- and the other with the feedback co-contraction index as dependent variable. RESULTS: Higher levels of ankle joint stiffening during the feedback, but not the feed-forward period was associated with postural task failure. Feedback stiffening was explained by having slow non-postural reaction times, poor leg muscle strength and being female whereas feed-forward stiffening was not explained by sensory and motor variables. CONCLUSIONS: When subjected to an unpredicted surface perturbation, individuals with higher feedback stiffening had poorer postural control outcome, which was explained by poorer physical capacity. The level of feed-forward stiffening prior the perturbation was not associated with postural control outcome nor the investigated sensory and motor variables. The intricate causal relationships between physical capacity, stiffening and postural task success remains subject for future research.

Both psychological factors and physical performance are associated with fall-related concerns.

BACKGROUND: Fall-related concern strongly correlates to activity avoidance in older people. In this complex phenomenon, different terminology and instruments are often used interchangeably. Three main concepts make up fall-related concerns: fear of falling, consequence concern, and falls self-efficacy. It is suggested that fall-related concerns are mediated by psychological and physical factors. AIMS: Our aims were to describe the prevalence of fall-related concerns and find explanatory factors for its most studied concept-falls self-efficacy-in an older population. METHODS: We executed a cross-sectional study on a random sample of 153 community-dwelling older people (70 years or older). We used validated and reliable instruments as well as structured interviews to gather data on the three concepts of fall-related concerns and possible mediating factors. We then calculated descriptive statistics on prevalence and regression models for the total group, and men and women, separately. RESULTS: 70% of the total sample (80% of women and 53% of men) reported at least one of the three concepts of fall-related concern. For the total sample, fear of falling, morale, and physical performance were associated factors with falls self-efficacy. For women, the number of prescription medications was added. For men, physical performance and concerns for injury were associated. CONCLUSION: Fall-related concern is prevalent in large proportions with higher prevalence for women than for men. Important factors are fear of falling, morale, and physical performance. Gender differences in the emergence and variance of fall-related concern and the relation between physical performance and fall-related concern should be targeted in future research endeavors.

Effects of deep cervical flexor training on impaired physiological functions associated with chronic neck pain: a systematic review.

BACKGROUND: Neck pain is a major health issue with high rates of recurrence. It presents with a variety of altered sensorimotor functions. Exercise is a cornerstone of rehabilitation and many training methods are used. Exercise is evaluated in most randomized controlled trials on its pain relieving effects. No review has assessed the effect of exercise on the altered physiological functions or determined if there are differential effects of particular training methods. This review investigated the effects of deep cervical flexor (DCF) training, a training method commonly used for patients with neck pain, and compared it to other training methods or no training on outcomes of cervical neuromuscular function, muscle size, kinematics and kinetics. METHODS: Web of Science, Scopus, CINAHL, PubMed were searched from inception until January 2018. Twelve randomized controlled trials were included that compared DCF training as sole intervention to other training or no interventions in persons with neck pain. The Cochrane Risk of Bias tool was used to assess the method quality. All outcome measures were analysed descriptively and meta-analyses were performed for measures evaluated in three or more studies. RESULTS: DCF training was compared to cervical endurance, strength, proprioception and mobility training, muscle stretching, and no intervention control groups. Physiological outcome measures included neuromuscular co-ordination (craniocervical flexion test), functional tasks, muscle fatigability, muscle size, kinematics (joint position sense, posture and range of motion) and kinetics (strength, endurance and contraction accuracy). Strong evidence was found for effectiveness of DCF training on neuromuscular coordination, but it had no or small effects on strength and endurance at higher loads. DCF training improved head and cervical posture, while evidence was limited or contradictory for other measures. CONCLUSIONS: DCF training can successfully address impaired neuromuscular coordination, but not cervical flexor strength and endurance at higher contraction intensities. A multimodal training regime is proposed when the aim is to specifically address various impaired physiological functions associated with neck pain.

Patients' Perceptions of Perioperative Quality of Care in Relation to Self-rated Health.

PURPOSE: To explore (1) associations between patient and perioperative factors and dimensions of quality of care and (2) perioperative patients' self-rated physical health in relation to information, encouragement, and participation. DESIGN: A nonexperimental descriptive exploratory design (n = 170 participants). METHODS: Analyses were performed using quantitative techniques; collected data were quantitative in nature. Multiple logistic regression and Mann-Whitney U tests were used to analyze the data. FINDINGS: The factor associated with patients' satisfaction within the dimension of "identity-oriented approach of the caregivers," including the quality of information, encouragement, and participation, was self-estimated physical health. Those who estimated their physical health as being good were generally more satisfied. Patients who rated their physical health as being less than good were significantly less satisfied with the information provided before surgery about their stay in the postanesthesia care unit (PACU). CONCLUSIONS: Nurses should chart patients' estimations of their physical health initially in care to provide reinforced support for patients who estimate their physical health is less than good. Before surgery, patients who have estimated their physical health as being less than good should be given realistic information about their stay in the PACU-that they will be in a PACU after surgery, what that stay means, and why it is necessary.

Patterns of Changes in Patients' Postoperative Recovery From a Short-Term Perspective.

PURPOSE: To explore patterns of changes in patients' postoperative recovery over 1 month within different surgery groups. DESIGN: A quantitative longitudinal survey design was used. METHODS: A standardized questionnaire was used (N = 167 patients); the postoperative recovery profile for self-assessment of recovery. The postoperative recovery profile developed for hospitalized patients contains 17 items distributed over five dimensions: physical symptoms, physical function, psychological function, social function, and activity. FINDINGS: Overall, orthopaedic patients perceived a lower recovery than general surgery patients. All major surgery groups and subgroups except for joint replacement patients indicated significant systematic changes toward lower levels of problems. The orthopaedic patients assessed their psychological functioning as impaired, and the gastric bypass group was the most recovered. CONCLUSIONS: The patients' expectations should be charted initially, and patients should be given realistic information to achieve a realistic hope for a good life in the future. A patient's recovery trajectory may not start after the surgery is completed. Rather, it has already commenced before surgery.

Influence of self-care advice on patient satisfaction and healthcare utilization.

AIM: The aim of this study is to explore the influence of nurse-led self-care advice on healthcare utilization and patients' satisfaction with telephone nursing. BACKGROUND: Many consultations in high-cost settings are for conditions that are manageable through self-care and callers with greater satisfaction with the nurse interaction are nearly four times more likely to engage in self-care. DESIGN: Cross-sectional study. METHODS: Questionnaires were sent out to 500 randomly selected callers to the Swedish Healthcare Direct in Northern Sweden during March 2014. Callers were asked about their satisfaction with the consultation, their intended actions prior to consultation, the recommendation given by the nurse and the action undertaken after the call. RESULTS: Young callers and persons recommended watchful waiting or recurrence if no improvements were significantly less satisfied with their care. When calling on their own behalf, both men and women rated the severity of their symptoms equally and were advised to self-care to the same extent. Self-care advice had a constricting influence on self-reported healthcare utilization, with 66·1% of cases resulting in a lower level of care than first intended. Feeling reassured after the call was the aspect of nursing care that influenced satisfaction the most. CONCLUSION: Receiving self-care advice rather than referral to a general practitioner influences patient satisfaction negatively. Feeling reassured after consultation is strongly related to satisfaction, which in turn has been found to increase the likelihood of engaging in self-care behaviour.

Sensitivity and false alarm rate of a fall sensor in long-term fall detection in the elderly.

BACKGROUND: About a third of home-dwelling older people fall each year, and institutionalized older people even report a two- or threefold higher rate for falling. Automatic fall detection systems have been developed to support the independent and secure living of the elderly. Even though good fall detection sensitivity and specificity in laboratory settings have been reported, knowledge about the sensitivity and specificity of these systems in real-life conditions is still lacking. OBJECTIVE: The aim of this study was to evaluate the long-term fall detection sensitivity and false alarm rate of a fall detection prototype in real-life use. METHODS: A total of 15,500 h of real-life data from 16 older people, including both fallers and nonfallers, were monitored using an accelerometry-based sensor system with an implemented fall detection algorithm. RESULTS: The fall detection system detected 12 out of 15 real-life falls, having a sensitivity of 80.0%, with a false alarm rate of 0.049 alarms per usage hour with the implemented real-time system. With minor modification of data analysis the false alarm rate was reduced to 0.025 false alarms per hour, equating to 1 false fall alarm per 40 usage hours. CONCLUSION: These data suggest that automatic accelerometric fall detection systems might offer a tool for improving safety among older people.

Perceptions of needs related to the practice of self-care for minor illness.

AIMS AND OBJECTIVES: The aim of this study was to describe people's perceptions of needs to feel confident in self-care for minor illnesses as well as their perceptions about supporting and obstructing factors in the practice of self-care. BACKGROUND: Minor illness constitutes a large part of primary care, and patients' attendance to doctors' appointments for minor illness has been seen to increase future attendance for the same condition. Almost half of the consultations with telenurses result in the provision of self-care advice. DESIGN: A cross-sectional survey. METHOD: Primary data were collected using a questionnaire, and the study participants (n = 315) were randomly selected from the national Swedish address register. RESULTS: Having knowledge and receiving health care advice and reliable information were perceived to be needs in order for participants to feel confident in self-care. Having family or friends to consult with was perceived to be a positive factor influencing confidence in self-care, especially for persons under the age of 35. Health care services were perceived to support self-care practice by offering easy access to care, giving information about self-care, and offering increased follow-up after consultations. Lack of knowledge, along with difficulties being away from work, were obstructing factors in the practice of self-care. CONCLUSIONS: Young age was the factor influencing people's perceptions of needs and supporting factors the most. Young age and low knowledge scores about minor illnesses were the two factors that had the most influence on perceived obstructing factors. RELEVANCE TO CLINICAL PRACTICE: Nurses play a major role in the promotion of self-care and in the dissemination of self-care advice. If health care services fail to meet the needs of care-seekers with minor illnesses, patients might turn to out-of-hours clinics and emergency departments for help.

Patients' perceptions of their postoperative recovery for one month.

AIMS AND OBJECTIVES: To explore orthopaedic and general surgery patients' perceptions of their postoperative recovery for one month. BACKGROUND: In general, nursing research in the postoperative context has been directed towards a single symptom or area, which is valuable. However, there is a lack of studies of orthopaedic and general surgery patients' perceptions of postoperative recovery from a short-term perspective. DESIGN: A quantitative approach with a longitudinal design was used. METHODS: A total of 180 patients participated in the study. Data were collected using a standardised questionnaire, the Postoperative Recovery Profile, for self-assessment of recovery. Descriptive statistics reported as proportions were used for the categorical variables. Analytic statistics were used to identify statistically significant differences. Mean values and t-tests were used for quantity variables, and Mann-Whitney U-tests and Chi-squared tests were used for nonparametric variables. RESULTS: Overall, the orthopaedic patients were substantially less recovered than the general surgery patients. Two-thirds of the orthopaedic patients and half of the general surgery patients perceived severe or moderate pain in the acute recovery phase. Within the general surgery group, there were significant differences in the recovery between the Gastric Bypass patients and colon/ileum surgery patients. The gastric bypass patients were overall more recovered than the other groups of patients. The Gastric Bypass patients reported that they had improved after one month compared to their own status prior to surgery. CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE: Nursing support for orthopaedic patients must be improved, especially after they are discharged from the hospital. To structure and monitor individual recovery, a top-five priority profile of the most important problems should be used during follow-up calls after the patient is discharged from the hospital. Postoperative pain continues to represent a clinical problem that requires attention. Heterogeneity in the perceptions of recovery within the general surgery group was indicated, which may depend on the surgical procedure as well as the patients' expectations and comparisons with their lives before surgery. Rather than return to their preoperative levels, certain patients tend to continue towards a new or different life postoperatively.

Patients' Perceptions of Quality of Care During the Perioperative Procedure.

PURPOSE: To describe patients' perceptions of quality of care during the perioperative period and to identify areas for quality improvement. DESIGN: A cross-sectional descriptive survey design was used. METHODS: The data were collected (N = 170) using a questionnaire for perioperative care. The methods were descriptive statistics, reported as percentages, and a manifest content analysis of the free text. FINDING: The areas identified for improvement were information and participation. The participants lacked knowledge, preferred to hand over decision making to the hospital staff, and indicated that having personalized information about the surgery and perioperative period was important. However, too detailed information before surgery could cause increased anxiety. CONCLUSIONS: This study indicates that participation and information needs in perioperative settings seem to be situation specific. In addition, these needs seem to be personal and surgery specific. Further studies are required to clarify the differences in the satisfaction and quality of care between groups of patients in the perioperative context.

Psychometric evaluation of a Swedish Self-Efficacy scale and Recovery Locus of Control scale in the context of minor illness.

Reliable and valid instruments are essential when examining the role of self-efficacy and locus of control in the self-care context. The aim of this study was to test the validity and reliability of the Self-Efficacy Scale in Self-Care (SESSC) and the Swedish version of the Recovery Locus of Control scale (RLoC) in the context of minor illness. A descriptive correlational design was used to assess the psychometric characteristics of the scales. The study population was 317 randomly selected Swedish inhabitants aged 18-80. The results from this study showed that the RLoC has limitations in reliability and validity and should not be applied in the context of self-care of minor illness. The SESSC proved to be a reliable and valid instrument in assessing self-efficacy in self-care for minor illness.

What Explains Successful or Unsuccessful Postural Adaptations to Repeated Surface Perturbations among Older Adults?

As we age there are natural physiological deteriorations that decrease the accuracy and flexibility of the postural control system, which increases the risk of falling. Studies have found that there are individual differences in the ability to learn to manage repeated postural threats. The aim of this study was to investigate which factors explain why some individuals are less proficient at adapting to recurrent postural perturbations. Thirty-five community dwelling older adults performed substantial sensory and motor testing and answered surveys regarding fall-related concerns and cognitive function. They were also subjected to three identical surface perturbations where both kinematics and electromyography was captured. Those that were able to adapt to the third perturbation were assigned to the group "Non-fallers" whereas those that fell during all perturbations were assigned to the group "Fallers". The group designation dichotomized the sample in a hierarchical orthogonal projection of latent structures- the discriminant analysis model. We found that those who fell were older, had poorer physical performance, poorer strength and longer reaction times. The Fallers' postural control strategies were more reliant on the stiffening strategy along with a more extended posture and they were less skillful at making appropriate feedforward adaptations prior to the third perturbation.

Positive Self-Perceptions of Aging Play a Significant Role in Predicting Physical Performance among Community-Dwelling Older Adults.

Self-perceptions of aging (SPA) is associated with various health-related outcomes, including physical performance. No previous study has investigated the potential predictive influence of SPA on physical performance among Swedish community-dwelling older adults. This was a cross-sectional study using a random sample of 153 Swedish community-dwelling individuals aged 70 and older. Multiple logistic regression analysis was performed, using the subscale "Attitude Towards Own Aging" of the Philadelphia Geriatric Center Morale Scale, as a measure of SPA. The Short Physical Performance Battery (SPPB) was dichotomized and used as the outcome variable. SPA was a significant predictor (OR = 1.546, CI = 1.066-2.243) of physical performance, adjusted for age, cognitive function, and life-space mobility. Further analyses revealed significant sex differences, with SPA not being included in the model for the men whilst it was still a significant predictor (OR = 1.689, CI = 1.031-2.765) of physical performance in the group of women. SPA plays a significant role in predicting physical performance among Swedish community-dwelling older adults. To further clarify this relationship and its consequences, future longitudinal research should focus on the relationship between SPA, physical performance, and fall risk.

Hand grip strength is strongly associated with lower limb strength but only weakly with postural control in community-dwelling older adults.

BACKGROUND: Hand grip strength is frequently used as a measurement of muscle strength, especially among older adults. Muscle strength is only one of the many components in postural control and it is currently unclear to what extent hand grip strength is associated with postural control. The aim was to analyze the association between hand grip strength and lower limb muscle strength, and postural control among older adults. METHODS: Forty-five community-dwelling individuals over 70 years of age provided isometric hand grip strength and lower limb strength (including hip extension and abduction, knee flexion and extension, and ankle dorsiflexion and plantarflexion), as well as postural control measurements. In the latter, center of pressure excursions were recorded for quiet stance and limits of stability tests on a force plate. Orthogonal projection of latent structures regression models were used to analyze associations between hand grip strength and lower limb strength as well as postural control, respectively. RESULTS: Lower limb strength explained 74.4% of the variance in hand grip strength. All lower limb muscle groups were significantly associated with hand grip strength. In a corresponding model, postural control measured with center of pressure excursions explained 20.7% of the variance in a statistically significant, albeit weak, model. CONCLUSIONS: These results support that hand grip strength is a valid method to estimate lower limb strength among older adults on a group level. However, strength measurements seem insufficient as a substitute for measuring postural control, and therefore specific balance tests are necessary.

Frequency domain shows: Fall-related concerns and sensorimotor decline explain inability to adjust postural control strategy in older adults.

Human postural control is a complex system and changes as we age. Frequency based analyses have been argued to be useful to identify altered postural control strategies in balance tasks. The aim of this study was to explore the frequency domain of the quiet stance centre of pressure of older adults with various degrees of fall-related concerns and sensorimotor functioning. We included 45 community dwelling older adults and used a force plate to register 30 seconds of quiet stance with eyes open and closed respectively. We also measured sensory and motor functions, as well as fall-related concerns and morale. We analysed the centre of pressure power spectrum density and extracted the frequency of 4 of its features for each participant. Orthogonal projection of latent structures-discriminant analysis revealed two groups for each quiet stance trial. Group 1 of each trial showed less sensory and motor decline, low/no fall-related concerns and higher frequencies. Group 2 showed more decline, higher fall-related concerns and lower frequencies. During the closed eyes trial, group 1 and group 2 shifted their features to higher frequencies, but only group 1 did so in any significant way. Higher fall-related concerns, sensory and motor decline, and explorative balancing strategies are highly correlated. The control system of individuals experiencing this seems to be highly dependent on vision. Higher fall-related concerns, and sensory and motor decline are also correlated with the inability to adjust to faster, more reactive balancing strategies, when vision is not available.

To be seen as a unique person after suffering a second myocardial infarction: Expressed needs of patients and descriptions of personnel.

OBJECTIVES: The aim of this study was to describe patients' expressed needs during cardiac rehabilitation after suffering a second myocardial infarction in comparison to personnel's descriptions of how they work with these patients. RESEARCH METHODOLOGY: A descriptive qualitative design. Interviews were conducted with patients affected by two myocardial infarctions and registered nurses, physiotherapists and cardiologists working with cardiac rehabilitation. Data were analysed with qualitative content analysis. FINDINGS: An interpretation of the underlying meaning in the categories was formulated into one theme: 'To be seen as a unique person'. Patients expressed a need for individualised care; they wanted the cardiac rehabilitation to be customised to their condition and prognosis; however, they did not perceive their care was individualised. Personnel described the importance of the care being individualised, although they had guidelines to follow. It was crucial for them to see the individual and discover what was important for each patient. CONCLUSIONS: There was a shared opinion from patients and personnel that individual care is essential. Using the concept and working in accordance with person-centred care could meet the patients' need for individualised care.

Decline in sensorimotor systems explains reduced falls self-efficacy.

Physical performance including balance tasks is one of the main factors explaining the variance in falls self-efficacy in older adults. Balance performance is often measured by use of gross assessment scales, which assess the result of integration of all systems involved in postural control. We aimed to investigate which measurements of postural control correlate to falls self-efficacy scores as measured by the FES-I instrument, and which sensory and motor systems best explain them. A cross sectional study was designed, in which 45 older adults performed quiet stance and limits of stability trials during which their center of pressure (CoP) excursion was recorded. Falls self-efficacy was measured using the Falls Efficacy Scale - International. Eyesight, vestibular function, proprioception, reaction time and strength were also measured. Hierarchical orthogonal projection of latent structures was used to model FES-I with the CoP trials and then with the sensory and muscle function data. Fes-I could be explained to 39%, with the eyes open trials and the limits of stability trials loading the heaviest. The base model could be explained to 40% using the sensory and muscle function data, with lower limb strength, leg proprioception, neck proprioception, reaction time and eyesight loading the heaviest.

The second myocardial infarction: Is there any difference in symptoms and prehospital delay compared to the first myocardial infarction?

BACKGROUND: Knowledge is limited concerning the type of symptoms and the time from onset of symptoms to first medical contact at first and second myocardial infarction in the same patient. AIM: This study aimed to describe the type of symptoms and the time from onset of symptoms to first medical contact in first and second myocardial infarctions in men and women affected by two myocardial infarctions. Furthermore, the aim was to identify factors associated with prehospital delays ≥2 h at second myocardial infarction. METHODS: A retrospective cohort study with 820 patients aged 31-74 years with a first and a second myocardial infarction from 1986 through 2009 registered in the Northern Sweden MONICA registry. RESULTS: The most common symptoms reported among patients affected by two myocardial infarctions are typical symptoms at both myocardial infarction events. Significantly more women reported atypical symptoms at the second myocardial infarction compared to the first. Ten per cent of the men did not report the same type of symptoms at the first and second myocardial infarctions; the corresponding figure for women was 16.2%. The time from onset of symptoms to first medical contact was shorter at the second myocardial infarction compared to the first myocardial infarction. Patients with prehospital delay ≥2 h at the first myocardial infarction were more likely to have a prehospital delay ≥2 h at the second myocardial infarction. CONCLUSIONS: Symptoms of second myocardial infarctions are not necessarily the same as those of first myocardial infarctions. A patient's behaviour at the first myocardial infarction could predict how he or she would behave at a second myocardial infarction.

The second myocardial infarction: Higher risk factor burden and earlier second myocardial infarction in women compared with men. The Northern Sweden MONICA study.

BACKGROUND: Several studies have examined various parameters and experiences when patients suffer their first myocardial infarction (MI), but knowledge about when they suffer their second MI is limited. AIM: To compare risk factors for MI, that is, diabetes, hypertension and smoking, for the first and second MI events in men and women affected by two MIs and to analyse the time intervals between the first and second MIs. METHODS: A retrospective cohort study of 1017 patients aged 25-74 years with first and second MIs from 1990 through 2009 registered in the Northern Sweden MONICA registry. RESULTS: More women than men have diabetes and hypertension and are smokers at the first MI. Similar differences between the genders remain at the time of the second MI for diabetes and hypertension, although both risk factors have increased. Smoking decreased at the second MI without any remaining difference between genders. Women suffer their second MI within a shorter time interval than men do. Within 16 months of their first MI, 50% of women had a second MI. The corresponding time interval for men was 33 months. CONCLUSION: Patients affected by an MI should be made aware of their risk of recurrent MI and that the risk of recurrence is highest during the first few years after an MI. In patients affected by two MIs, women have a higher risk factor burden and suffer their second MI earlier than men do and thus may need more aggressive and more prompt secondary prevention.