[Hemorrhage of the innominate artery during percutaneous dilatation tracheotomy]. / Blutung des Truncus brachiocephalicus während perkutaner Dilatationstracheotomie.

The report describes the rare case of a periprocedural hemorrhage during percutaneous dilatation tracheotomy. In the final analysis, the innominate artery could be identified as the source of the hemorrhage. Particular attention must be paid to preprocedural evaluation of the puncture site and the procedure following unexpected hemorrhage. Continuation of the percutaneous tracheotomy, with only a clinical suspicion of a vascular injury while the bleeding source remained undetectable, seemed to be the most reasonable option. In this case the potentially life-threatening hemorrhage could be stopped and the elective treatment was completed. Therefore, because palpation of the neck cannot exclude life-threatening vascular aberrations with certainty, a preprocedural ultrasound examination of the anatomical features should be performed before carrying out a dilatation tracheotomy.

The Swedish CArdioPulmonary BioImage Study: objectives and design.

Cardiopulmonary diseases are major causes of death worldwide, but currently recommended strategies for diagnosis and prevention may be outdated because of recent changes in risk factor patterns. The Swedish CArdioPulmonarybioImage Study (SCAPIS) combines the use of new imaging technologies, advances in large-scale 'omics' and epidemiological analyses to extensively characterize a Swedish cohort of 30 000 men and women aged between 50 and 64 years. The information obtained will be used to improve risk prediction of cardiopulmonary diseases and optimize the ability to study disease mechanisms. A comprehensive pilot study in 1111 individuals, which was completed in 2012, demonstrated the feasibility and financial and ethical consequences of SCAPIS. Recruitment to the national, multicentre study has recently started.

The large-scale placebo-controlled beta-blocker studies in systolic heart failure revisited: results from CIBIS-II, COPERNICUS and SENIORS-SHF compared with stratified subsets from MERIT-HF.

AIMS: The four pivotal beta-blocker trials in heart failure (HF) had different inclusion criteria, making comparison difficult without patient stratifying. The aim of this study was to compare, in similar patients, the effects of bisoprolol, metoprolol controlled release/extended release (CR/XL), carvedilol and nebivolol on (i) total mortality, (ii) all-cause mortality or hospitalization due to cardiovascular causes (time to first event), (iii) all-cause mortality or hospitalization because of HF and (iv) tolerability, defined as discontinuation of randomized treatment. METHODS: We compared stratified (s ) subsets in MERIT-HF with patients in CIBIS-II [New York Heart Association (NYHA) class III/IV and ejection fraction (EF) ≤ 35%] and COPERNICUS (NYHA III/IV and EF <25%) and in patients with systolic HF in SENIORS-SHF (age ≥ 70 years and EF ≤ 35%). RESULTS: The annual mortality rates in the placebo and beta-blocker arms were: (i) CIBIS-II (n = 2647), 13.2% vs. 8.8% (relative risk reduction 34%, 95% CI: 19-46, P < 0.0001) and MERIT-HFs (n = 2002), 14.8% vs. 8.6% (relative risk reduction 42%, 95% CI: 24-56, P < 0.0001); (ii) COPERNICUS (n = 2289), 19.7% vs. 12.8% (relative risk reduction 35%, 95% CI: 19-48, P = 0.0014) and MERIT-HFs (n = 795), 19.1% vs. 11.7% (relative risk reduction 39%; 95% CI: 11-58, P = 0.0086); (iii) SENIORS-SHF (n = 1359), 11.3% vs. 9.7% (relative risk reduction 16%, NS) and MERIT-HFs (n = 985), 14.8% vs. 10.1% (relative risk reduction 32%, 95% CI: 2-53, P = 0.038). The effects on the other outcomes assessed were similar. Analyses indicated fewer discontinuations from randomized treatment on beta-blockers compared with placebo in COPERNICUS and the MERIT-HFs subsets. CONCLUSION: The efficacy and tolerability of bisoprolol, carvedilol and metoprolol CR/XL are similar in patients with systolic HF, irrespective of NYHA class or ejection fraction. Nebivolol is less effective and not better tolerated.

ASCORE: an up-to-date cardiovascular risk score for hypertensive patients reflecting contemporary clinical practice developed using the (ASCOT-BPLA) trial data.

A number of risk scores already exist to predict cardiovascular (CV) events. However, scores developed with data collected some time ago might not accurately predict the CV risk of contemporary hypertensive patients that benefit from more modern treatments and management. Using data from the randomised clinical trial Anglo-Scandinavian Cardiac Outcomes Trial-BPLA, with 15 955 hypertensive patients without previous CV disease receiving contemporary preventive CV management, we developed a new risk score predicting the 5-year risk of a first CV event (CV death, myocardial infarction or stroke). Cox proportional hazard models were used to develop a risk equation from baseline predictors. The final risk model (ASCORE) included age, sex, smoking, diabetes, previous blood pressure (BP) treatment, systolic BP, total cholesterol, high-density lipoprotein-cholesterol, fasting glucose and creatinine baseline variables. A simplified model (ASCORE-S) excluding laboratory variables was also derived. Both models showed very good internal validity. User-friendly integer score tables are reported for both models. Applying the latest Framingham risk score to our data significantly overpredicted the observed 5-year risk of the composite CV outcome. We conclude that risk scores derived using older databases (such as Framingham) may overestimate the CV risk of patients receiving current BP treatments; therefore, 'updated' risk scores are needed for current patients.

[Examination of signals for tinnitus sound therapy. Effects of signal dynamics on sound acceptance and tinnitus masking]. / Untersuchungen von Rauschsignalen für die akustische Tinnitustherapie. Auswirkung von Dynamik auf Akzeptanz und Verdeckungswirkung.

BACKGROUND: In terms of sound acceptance and tinnitus-masking efficacy, tinnitus sound therapy appears to be more effective using dynamic natural sounds than static noise signals. The aim of this study was to systematically determine the effects of physical dynamics parameters on tinnitus masking and sound acceptance. MATERIALS AND METHODS: Based on a dynamic model, noise signals with different dynamic properties were synthesized and used to investigate minimal masking levels (MMLs) and spontaneous sound acceptance in six tinnitus patients. RESULTS: High signal dynamics resulted in high MMLs and low sound acceptance. In some instances, low signal dynamics gave rise to slightly lower MMLs than white noise. Despite unfavourable MMLs, natural dynamic sounds were better accepted than synthesized sounds with comparable dynamics. CONCLUSIONS: The higher spontaneous acceptance of natural sounds as compared to white noise appears not to be due solely to physical sound properties, but rather to result primarily from psychological factors. It may be possible to improve sound acceptance in tinnitus sound therapy by using signals with low amounts of dynamics and implementing the use of natural sounds.

Feasibility of the FINDRISC questionnaire to identify individuals with impaired glucose tolerance in Swedish primary care. A cross-sectional population-based study.

AIM: To evaluate the performance of the FINDRISC questionnaire as a tool to recruit individuals with impaired glucose tolerance for lifestyle intervention programmes. METHODS: A cross-sectional population-based study in primary Health Care Centres in a middle-sized Swedish town. All 9734 individuals, aged 35-75 years, living within a defined area, were invited by mail to fill in and return the FINDRISC questionnaire. Participants with a risk score ≥ 15 (n = 525) were invited to perform an oral glucose tolerance test while those with known diabetes were excluded. RESULTS: In total, 5452 questionnaires (58%) were returned and revealed a mean risk-score of 8.5 ± 4.5 (mean ± SD). We found that 525 participants had a risk-score ≥ 15 and 302 (58%) were further examined with an oral glucose tolerance testing (OGTT). Among them we detected 11% with previously undiagnosed Type 2 diabetes, 16% with impaired glucose tolerance and 29% with impaired fasting glucose. A FINDRISC score ≥ 15 was associated with a positive predictive value of 55% for impaired glucose metabolism (impaired fasting glucose + impaired glucose tolerance + Type 2 diabetes) and of 16% for impaired glucose tolerance, respectively. The positive predictive value for impaired glucose tolerance did not increase to more than 17% when choosing the cut-point 17, while there was a significant increase in the positive predictive value for impaired glucose metabolism (70%). CONCLUSIONS: The FINDRISC questionnaire is a useful instrument for identification of individuals with impaired glucose metabolism but seems less effective for detection of individuals with impaired glucose tolerance. Strategies to find individuals with impaired glucose tolerance for implementation of lifestyle changes in primary care should therefore be developed further.

[Examination of speech perception and cognitive functioning in the elderly]. / Untersuchungen zum Sprachverstehen und zu kognitiven Fähigkeiten im Alter.

BACKGROUND: Elderly persons frequently complain about problems with speech understanding especially in complex acoustic situations. Besides hearing impairment the decline of cognitive functions might explain these problems. METHODS: In 12 normal hearing young subjects and 14 elderly listeners with extraordinarily good hearing speech perception was measured in a broad range of different acoustic situations. Cognitive functioning was evaluated with different neuropsychological tests. RESULTS: Despite comparable pure tone thresholds the elderly listeners revealed worse speech discrimination than the young subjects in almost all test situations. Largest differences were found in situations with fluctuating maskers and competing talkers. Most of the speech perception results revealed significant correlations with the outcome from a neuropsychological test addressing declarative verbal memory. CONCLUSIONS: In complex listening situations elderly persons reveal worse speech understanding than younger subjects. Differences in speech perception can partly be attributed to cognitive abilities. In particular, working memory seems to be an important factor.

Prognostic implications of glucose-lowering treatment in patients with acute myocardial infarction and diabetes: experiences from an extended follow-up of the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) 2 Study.

AIMS/HYPOTHESIS: This post hoc analysis from the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) 2 trial reports on extended long-term outcome in relation to glucose-lowering agents in patients with myocardial infarction and type 2 diabetes. METHODS: Patients were randomised as follows: group 1, insulin-based treatment; group 2, insulin during hospitalisation followed by conventional glucose control; and group 3, conventional treatment. Treatment according to the above protocol lasted 2.1 years. Using the total DIGAMI 2 cohort as an epidemiological database, this study presents mortality rates in the randomised groups, and mortality and morbidity rates by glucose-lowering treatment during an extended period of follow-up (median 4.1 and max 8.1 years). RESULTS: Follow-up data were available in 1,145 of the 1,253 patients. The mortality rate was 31% (72% cardiovascular) without significant differences between treatment groups. The total number of fatal malignancies was 37, with a trend towards a higher risk in group 1. The HR for death from malignant disease, compared with group 2, was 1.77 (95% CI 0.87-3.61; p = 0.11) and 3.60 (95% CI 1.24-10.50; p = 0.02) compared with group 3. Insulin treatment was associated with non-fatal cardiovascular events (OR 1.89 95% CI 1.35-2.63; p = 0.0002), but not with mortality (OR 1.30, 95% CI 0.93-1.81; p = 0.13). Metformin was associated with a lower mortality rate (HR 0.65, 95% CI 0.47-0.90; p = 0.01) and a lower risk of death from malignancies (HR 0.25, 95% CI 0.08-0.83; p = 0.02). CONCLUSIONS/INTERPRETATION: Patients with type 2 diabetes and myocardial infarction have a poor prognosis. Glucose-lowering drugs appear to be of prognostic importance. Insulin may be associated with an increased risk of non-fatal cardiac events, while metformin seems to be protective against risk of death.

The economic consequences of non-adherence to lipid-lowering therapy: results from the Anglo-Scandinavian-Cardiac Outcomes Trial.

BACKGROUND: Adherence to lipid-lowering therapy in clinical practice is less than ideal. Analysis of registry data has indicated that this is associated with poor outcomes. The objective of the present analysis was to assess the impact of high adherence to drug (defined as > 80% of days covered), compared with low adherence to drug (< 50% of days covered) in terms of risk of events and long-term economic consequences. DESIGN: Open-label follow up of a randomised placebo-controlled trial in hypertensive patients. METHODS: Cox proportional hazards and Poisson regression models were used to assess the hazard ratio of patients with high adherence compared with low adherence while controlling for cardiovascular risk. A Markov model was used to predict the long-term costs and health outcomes associated with poor adherence during the follow-up period. RESULTS: Both statistical models indicated that high adherence is associated with improved prognosis [Cox model: 0.75; 95% confidence interval (CI): 0.56-0.98, Poisson model hazard ratio: 0.73; 95% CI: 0.58-0.98]. Discounted at 3.5% per year, the Markov model predicts that as a consequence of higher adherence during the follow-up period, costs would be higher (1689 pounds per patient compared with 1323 pounds per patient) because of higher drug costs, but the projected survival and quality-adjusted survival (QALY) would also be longer (10.83 compared with 10.81 life years and 8.13 compared with 8.11 QALYs). CONCLUSION: Given the higher risk of cardiovascular events associated with low adherence shown here, measures to improve adherence are an important part of the prevention of cardiovascular disease.

Effect of gender on prognosis in patients with myocardial infarction and type 2 diabetes.

BACKGROUND: Diabetes is associated with a markedly increased cardiovascular risk, but the role of gender on the combined effects of diabetes and myocardial infarction has been less well explored. METHODS: The Diabetes Mellitus and Insulin Glucose Infusion in Acute Myocardial Infarction 2 (DIGAMI2) trial recruited 837 men and 416 women with type 2 diabetes hospitalized due to myocardial infarction and followed for a median of 2.1 years. The effects of gender on diabetes-specific risk factors and conventional cardiovascular risk predictors of unfavourable outcome were analysed using a Cox proportional hazards model. RESULTS: Women were older, more frequently had hypertension and previous heart failure than men, and were more often treated with diuretics. More men were smokers. Treatment during hospitalization, at discharge and during follow-up, did not differ significantly, apart from the more frequent use of diuretics in women. Total mortality did not differ between genders, but the combined cardiovascular end-point of death, re-infarction or stroke was more common in women (38.9% vs. 32.1%). This difference disappeared after age adjustment. Age and previous heart failure were independent risk predictors in both genders, whereas diabetes complications were an additional risk factor in women only. Blood glucose level at randomization and updated glucose concentration during follow-up were independent predictors of poor outcome in men but not in women. CONCLUSIONS: Age and not gender itself explained the increased cardiovascular event rate seen in women compared with men. A heavier risk factor burden was seen amongst women. Improved risk factor control instituted before the development of a myocardial infarction should be attempted as a possible means of improving the outcome.

Does the estimation of light attenuation in tissue increase the accuracy of reflectance pulse oximetry at low oxygen saturations in vivo?

A new technique was validated in vivo in reflectance pulse oximetry for measuring low oxygen saturations. Two pairs of light emitter/detector diodes allow for estimation of light attenuation (LA) in tissue, which is assumed to be responsible for the inaccuracy of pulse oximetry at less than 70 % arterial oxygen saturation. For validation, 17 newborn piglets were desaturated stepwise from 21 % to 1.25 % inspiratory oxygen concentration during general anesthesia, and arterial oxygen saturation was measured with the reflectance pulse oximeter adjusted for LA in tissue, with a standard transmission pulse oximeter and a hemoximeter. LA in tissue could be quantified and was different between snout and foreleg (probability level (p) < 0.05). At arterial oxygen saturations above 70 %, the bias between the methods was at 0 %-1 % and the variability 4 %-5 %. From 2 % to 100 % arterial oxygen saturation, the reflectance pulse oximeter estimated oxyhemoglobin saturation more accurately than a conventional transmission pulse oximeter (p < 0.05). At low oxygen saturations below 70 %, the bias and variability of the reflectance pulse oximeter calibration were closer to the hemoximeter measurements than the transmission pulse oximeter (p < 0.05). The variability of the reflectance pulse oximeter was slightly lower than the traditional oximeter by taking into account the LA in tissue (9 % versus 11 % -15 %, ns), and thus, the quality of the individual calibration lines improved (correlation coefficient, p < 0.05).

[Development of a German version of the Functioning After Pediatric Cochlear Implantation (FAPCI) questionnaire]. / Entwicklung einer deutschsprachigen Version des Fragebogens Functioning After Pediatric Cochlear Implantation (FAPCI).

BACKGROUND: The Functioning After Pediatric Cochlear Implantation (FAPCI) instrument was recently developed to determine the communicative performance of 2-5-year-old prelingually deafened, cochlear-implanted children. Because of its high reliability and validity, as well as possible additional information compared with existing questionnaires, the 23-item parent-proxy questionnaire was translated from U.S. English to German prior to validation. MATERIAL AND METHODS: Initially, the German inventory was qualitatively developed by experts in audiology and speech pathology in collaboration with a professional American translator. Based on a sample of parents' responses, the outcome was quantitatively validated using psychometric methods (Cronbach's alpha, principal components analysis). Finally, the nomological validity was verified by correlating the overall FAPCI value with an external criterion (i.e., hearing age). RESULTS: For almost all age groups, Cronbach's alpha exceeded the minimum value of the original study (0.86). Principal components analysis revealed a two-factor solution (speech perception/production). The fitting of a nonparametric regression line to the data points showed that the total FAPCI score was positively associated with the time of implant use. CONCLUSION: The results show concordance between the German and the English versions of the FAPCI. The two instruments agree in reliability as well as in validity. The suitability of the German version in the clinical and therapeutic routine needs to be confirmed in further investigations.

[Examining informational masking in cochlear implant users]. / Untersuchungen zum "Informational Masking" bei Kochleaimplantat-Nutzern.

BACKGROUND: Informational masking (IM) refers to the problem of understanding target speech in the simultaneous presence of a masking speech signal. The adverse effects are attributable to the additional information provided by the competing talker. Cochlear implant (CI) recipients are not able to understand speech satisfactorily in situations such as these. The aim of the present study is to examine the extent to which CI recipients are able to use differences between the speakers with respect to level (target-to-masker ratio, TMR) and fundamental frequency (f0) in order to improve speech intelligibility. SUBJECTS AND METHODS: Target (TS) and masker sentences (MS) were selected from the Oldenburg Sentence Test (OlSa) and were modified and superimposed. The TS were explicitly labelled using a keyword. The MS were changed with respect to TMR and f0. The TS intelligibility of different modifications was measured in six post-lingually deafened CI recipients and six normal listeners (NL). RESULTS: The NL revealed speech understanding close to 100% even for small differences in f0 of 40 Hz or level differences of 5 dB. In CI recipients, a significant change in intelligibility could only be demonstrated with increased TMR, but not with differences in f0. CONCLUSIONS: In CI recipients, IM cannot be reduced by means of differences in f0 between the competing talkers, but only by level differences. This might be explained by the restricted spectral resolution and the insufficient transmission of f0 in CIs. Adverse effects in NL can predominantly be attributed to IM, while additional masking effects take place in CI recipients.

Prognostic implications of hypoglycaemic episodes during hospitalisation for myocardial infarction in patients with type 2 diabetes: a report from the DIGAMI 2 trial.

OBJECTIVE: To explore if hypoglycaemic episodes during hospitalisation influence the subsequent prognosis in patients with diabetes and acute myocardial infarction. DESIGN, SETTING AND PATIENTS: Within the framework of the clinical trial DIGAMI 2 hypoglycaemic episodes (blood glucose <3.0 mmol/l with or without symptoms) were recorded in 1253 patients (mean age 68 years; 67% males) with type 2 diabetes and myocardial infarction. The patients were followed during a median of 2.1 years. A total of 947 patients were randomised to an initial insulin infusion while 306 received routinely used glucose lowering therapy. MAIN OUTCOME MEASURES: Unadjusted and adjusted (age, sex, smoking, previous infarction, heart failure, renal function, diabetes duration, coronary interventions, pharmacological treatment and B-glucose at hospital admission) hazard ratios (HR) and 95% confidence intervals (CI) for total mortality and cardiovascular events (death, re-infarction or stroke) were related to hypoglycaemic episodes during the index hospitalisation. RESULTS: During the first 24 hours hypoglycaemic episodes were noted in 111 (12%) insulin-treated (symptomatic 23%) and three (1.0%) routinely treated patients (symptomatic 33%). Symptomatic hypoglycaemia related to mortality (unadjusted HR 1.99; 95% CI 1.20 to 3.29; p = 0.0074) but this difference disappeared following adjustment (HR 1.09; 95% CI 0.64 to 1.87; p = 0.7403). Body weight (OR 0.97; 95% CI 0.95 to 0.98; p<0.0001) and diabetes duration (OR 1.03; 95% CI 1.01 to 1.05; p = 0.0085) were independent predictors of hypoglycaemia CONCLUSIONS: Hypoglycaemia during the initial hospitalisation was not an independent risk factor for future morbidity or mortality in patients with type 2 diabetes and myocardial infarction. Such episodes were, however, more prevalent in patients at high risk for other reasons.

Serum heparan sulfate levels are elevated in endotoxemia.

BACKGROUND: Increased vascular permeability is a characteristic feature of sepsis which, in the past, has been ascribed exclusively to a malfunction of endothelial cells. However, recently it has become evident that the endothelial glycocalyx is of considerable importance concerning various aspects of vascular physiology, e.g. the vascular barrier and inflammation. Heparan sulfate, one of its essential components is characteristically traceable in blood, in case the endothelial glycocalyx is damaged or destroyed. METHODS: In 15 pigs we investigated whether the administration of endotoxin from gram-negative bacteria (Escherichia coli) results in increased serum levels of heparan sulfate, signalizing a shedding of the glycocalyx. In addition, markers of inflammation (white blood cell count, platelet count, tumour necrosis factor-α and interleukin-6) were evaluated over an observation period of 6 hours. RESULTS: Serum heparan sulfate concentrations significantly increased over time in the endotoxin group and were significantly elevated in comparison to the control group 6 hours after administration of endotoxin (p<0.001). In the endotoxin group all markers of inflammation significantly changed during the time course. CONCLUSIONS: The administration of bacterial endotoxin induced a significant rise in degradation products of the endothelial glycocalyx.

Secular changes in cardiovascular risk factors and attack rate of myocardial infarction among men aged 50 in Gothenburg, Sweden. Accurate prediction using risk models.

AIMS: Coronary risk factor changes were related to attack rate of acute myocardial infarction (AMI). METHODS AND RESULTS: Cross-sectional population samples of 50-year-old men were examined every 10th year from 1963 to 2003. Attack rates of AMI were recorded from 1975 to 2004. Prevalence of smoking decreased from 56% in 1963 to 22% in 2003. Leisure time physical activity decreased (n.s.), while psychological stress remained the same. Diabetes prevalence increased from 3.6% to 6.6%. Body mass index (BMI) increased from 24.8 to 26.4 kg m(-2). Blood pressures decreased from 138.2/90.6 to 134.7/84.9 mmHg (P = 0.00001). Serum total cholesterol decreased from 6.42 to 5.50 mmol L(-1) (P = 0.0001), but serum triglycerides increased from 1.26 to 1.71 mmol L(-1) (P = 0.0001). The multivariable risk according to total cholesterol, blood pressure and smoking for AMI decreased from the set value 1.0 in 1963 to 0.418. From 1975-1979 to 2000-2004 attack rates for AMI for the age groups 35-44, 45-54 and 55-64 declined to 45%, 46% and 45%, respectively. The 28-day case fatality declined from 30%, 38% and 46% to 12%, 16% and 20%. CONCLUSION: The more than 50% decline in attack rate of AMI during 30 years was comparable with the decline in risk factors.

Economic evaluation of ASCOT-BPLA: antihypertensive treatment with an amlodipine-based regimen is cost effective compared with an atenolol-based regimen.

OBJECTIVE: To compare the cost effectiveness of an amlodipine-based strategy and an atenolol-based strategy in the treatment of hypertension in the UK and Sweden. DESIGN: A prospective, randomised trial complemented with a Markov model to assess long-term costs and health effects. SETTING: Primary care. PATIENTS: Patients with moderate hypertension and three or more additional risk factors. INTERVENTIONS: Amlodipine 5-10 mg with perindopril 4-8 mg added as needed or atenolol 50-100 mg with bendroflumethiazide 1.25-2.5 mg and potassium added as needed MAIN OUTCOME MEASURES: Cost per cardiovascular event and procedure avoided, and cost per quality-adjusted life-year gained. RESULTS: In the UK, the cost to avoid one cardiovascular event or procedure would be euro18 965, and the cost to gain one quality-adjusted life-year would be euro21 875. The corresponding figures for Sweden were euro13 210 and euro16 856. CONCLUSIONS: Compared with the thresholds applied by NICE and in the Swedish National Board of Health and Welfare's Guidelines for Cardiac Care, an amlodipine-based regimen is cost effective for the treatment of hypertension compared with an atenolol-based regimen in the population studied.

Psychosocial factors and venous thromboembolism: a long-term follow-up study of Swedish men.

BACKGROUND: The link between psychosocial factors and coronary heart disease is well established, but although effects on coagulation and fibrinolysis variables may be implicated, no population-based study has sought to determine whether venous thromboembolism is similarly related to psychosocial factors. OBJECTIVE: To determine whether venous thromboembolism (deep vein thrombosis or pulmonary embolism) is related to psychosocial factors. PATIENTS/METHODS: A stress questionnaire was filled in by 6958 men at baseline from 1970 to 1973, participants in a cardiovascular intervention trial. Their occupation was used to determine socio-economic status. RESULTS: After a maximum follow-up of 28.8 years, 358 cases of deep vein thrombosis and/or pulmonary embolism were identified through the Swedish hospital discharge and cause-specific death registries. In comparison with men who, at baseline, had no or moderate stress, men with persistent stress had increased risk of pulmonary embolism [hazard ratio (HR)=1.80, 95% CI: 1.21-2.67]. After multivariable adjustment, the HR decreased slightly to 1.66 (95% CI: 1.12-2.48). When compared with manual workers, men with white-collar jobs at intermediate or high level and professionals showed an inverse relationship between occupational class and pulmonary embolism (multiple-adjusted HR=0.57, 95% CI: 0.39-0.83). Deep vein thrombosis was not significantly related to either stress or occupational class. CONCLUSION: Both persistent stress and low occupational class were independently related to future pulmonary embolism. The mechanisms are unknown, but effects on coagulation and fibrinolytic factors are likely.