Motivational interviewing improves exclusive breastfeeding in an Australian randomised controlled trial.

AIM: To increase maintenance of breastfeeding through improved primary care support. METHOD: A cluster randomised controlled trial recruited 15 rural family doctor's offices and 330 women who were currently breastfeeding took part. Eight practices formed the intervention group (154 women) and seven formed the control group (176 women). The practice nurses who provided the intervention used a specially designed motivational flowchart to speak to the mothers when they brought their child for immunisation at 2, 4 and 6 months. The nurses also attended preparatory workshops on breastfeeding management, counselling skills, motivational interviewing and reflective practice and were given resources and support. Breastfeeding rates were measured at 4 and 6 months. RESULTS: Randomisation equally distributed all measured variables except prenatal intentions to rejoin employment within 12 months (70% intervention, 56% control, p < 0.05). After adjustment, the 4-month figures showed significantly higher rates of exclusive breastfeeding (OR 1.88; 95%CI 1.01-3.50; p = 0.047) and full breastfeeding (water/juice allowed) (OR 1.95; 95%CI 1.03-3.69; p = 0.04) in the intervention group. There were no differences at 6 months. CONCLUSION: A motivational interviewing intervention by primary care health professionals who have undertaken a replicable training programme is feasible and effective in increasing exclusive breastfeeding and full/predominant breastfeeding at 4 months.

Components of primary care interventions to treat childhood overweight and obesity: a systematic review of effect.

The primary care setting presents an opportunity for intervention of overweight and obese children but is in need of a feasible model-of-care with demonstrated effectiveness. The aims were to (i) identify controlled interventions that treated childhood overweight or obesity in either a primary care setting or with the involvement of a primary healthcare professional and (ii) examine components of those interventions associated with effective outcomes in order to inform future intervention trials in primary care settings. Major health and medicine databases were searched: MEDLINE, CINAHL, EMBASE, Cochrane Reviews, CENTRAL, DARE, PsychINFO and ERIC. Articles were excluded if they described primary prevention interventions, involved surgical or pharmacological treatment, were published before 1990 or not published in English. Twenty-two papers describing 17 studies were included. Twelve studies reported at least one significant intervention effect. Comparison of these 12 interventions provides evidence for: training for health professionals before intervention delivery; behaviour change options (including healthy diet, activity and sedentary behaviour); effecting behaviour change via a combination of counselling, education, written resources, support and motivation; and tailoring intensity according to whether behavioural, anthropometric or metabolic changes are the priority. These components are practicable to future intervention studies in primary care.

The Severe Heart Failure Questionnaire: Italian translation and linguistic validation.

INTRODUCTION: The quality of life (QoL) is an important outcome indicator for heart failure management. As the use of a validate questionnaire in a different cultural context can affect data interpretation our main objective is the Italian translation and linguistic validation of the Severe Heart Failure Questionnaire (SHF) and its comparison with the MLHF (Minnesota Living with Heart Failure) Questionnaire. METHODS: The SHF and "The Minnesota Living with Heart Failure Questionnaire" were translated. A consensus involving parallel back-translations was established among a group of cardiologists, psychologists and biostatisticians. SHF and MLHF were both administrated to a sample of 50 patients. RESULTS: The patients' median age was 63 years. Ace inhibitors therapy was administered in 88% of cases and betablockers in 56% of cases. Finally the Italian version of SHF correlates well with MLHF for all domains, except life satisfaction SHF domain. DISCUSSION: The Italian version of the SHF correlates well with MLHF for almost all domains and it represents a valid alternative for quality of life assessment in heart failure patients.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases.

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Overweight and hypertension: longitudinal study in school-aged children.

AIM: A continuous increase in overweight has been documented in the paediatric population. The increase occurred in many developed and also developing countries. In the United States prevalence of overweight is 21.5% among African-Americans, 21.8% among Hispanics, and 12.3% among non-Hispanic whites; in Europe, from 10% to 20% in Northern Europe and 20% to as high as 36% in parts of Southern Italy (International Obesity Task Force data). The association between overweight and hypertension in children has been reported. This longitudinal study assessed the prevalence of hypertension and the relationships between gender, overweight, and blood pressure. METHODS: School-based screening was performed in 1.563 children (3-16 years). Age, gender, height, weight and blood pressure were registered every year for 3 subsequent years, in the period 1997-2000. Body mass index (BMI, kg/m2) was calculated and overweight was defined as centile corresponding to BMI = or >25 at 18 years. Blood pressure > 95th centile defined hypertension. RESULTS: The prevalence of elevated blood pressure at first, second and third screenings was 35.1%, 33.8% and 23.9% in males, and 41%, 40.2% and 31.2% in females. The relative risk was significant for overweight subjects. CONCLUSIONS: These results confirm an increasing epidemic of cardiovascular risk in children, as evidenced by an increase in the prevalence of overweight and hypertension. This increase in association with other cardiovascular risk factors that include dyslipidemia, insulin resistance, glucose intolerance, type II diabetes mellitus, suggest the necessity of accurate prevention strategies.

Ipratropium bromide versus long-acting beta-2 agonists for stable chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a condition associated with high morbidity, mortality and cost to the community. Patients often report symptomatic improvement with long acting beta-2 agonists (LABAs) and anticholinergic bronchodilator medications, both of which are recommended in COPD guidelines. These medications have different mechanisms of action and therefore theoretically could have an additive effect when combined. As these medications are prescribed in COPD as long term therapy, it is important to assemble reliable evidence on their relative and additive effects. OBJECTIVES: To compare the relative efficacy and safety of regular long term use (at least four weeks) of ipratropium bromide and LABA in patients with stable COPD. Comparisons were made between single agents and in combination versus LABAs alone. SEARCH STRATEGY: We searched the Cochrane Airways Group Specialised Register of Trials (August 2005) and reference lists of articles. We also contacted drug companies for relevant trial data. SELECTION CRITERIA: All randomised controlled trials comparing treatment for at least four weeks with an anticholinergic agent (ipratropium bromide) alone or in combination with LABA versus LABA alone, delivered via metered dose inhaler or nebuliser, in non-asthmatic adult subjects with stable COPD. DATA COLLECTION AND ANALYSIS: Three review authors independently performed data extraction and study quality assessment. We contacted study authors and pharmaceutical companies for missing data. MAIN RESULTS: Seven studies met the inclusion criteria of the review (2652 participants). Monotherapy comparison (six studies): There was a significantly greater change in favour of salmeterol in morning PEF and FEV1. There were no significant differences in quality of life, exacerbations, or symptoms. Formoterol appeared to confer some benefits over ipratropium treatment in terms of morning peak flow. Combination comparison (three studies): There was a significant improvement in post-bronchodilator lung function, supplemental short-acting beta-agonist use and HRQL in favour of combination therapy compared with salmeterol alone. AUTHORS' CONCLUSIONS: The available data from the trials suggest that there is little difference between regular long term use of IpB alone and salmeterol if the aim is to improve COPD symptoms and exercise tolerance. However, salmeterol was more effective in improving lung function variables. In terms of post-bronchodilator lung function, combination therapy conferred modest benefits and a significant improvement in HRQL, and reduced supplemental short-acting beta-agonist requirement, although this effect was not consistent. Additional studies are needed to assess the relative effects of combining therapies, using validated subjective measurements, and should consider concordance and the convenience of people having to use different inhaler devices.

General practice vs surgical-based follow-up for patients with colon cancer: randomised controlled trial.

This trial examined the optimal setting for follow-up of patients after treatment for colon cancer by either general practitioners or surgeons. In all, 203 consenting patients who had undergone potentially curative treatment for colon cancer were randomised to follow-up by general practitioners or surgeons. Follow-up guidance recommended three monthly clinical review and annual faecal occult blood tests (FOBT) and were identical in both study arms. Primary outcome measures (measured at baseline, 12 and 24 months were (1) quality of life, SF-12; physical and mental component scores, (2) anxiety and depression: Hospital Anxiety and Depression Scale and (3) patient satisfaction: Patient Visit-Specific Questionnaire. Secondary outcomes (at 24 months) were: investigations, number and timing of recurrences and deaths. In all, 170 patients were available for follow-up at 12 months and 157 at 24 months. At 12 and 24 months there were no differences in scores for quality of life (physical component score, P=0.88 at 12 months; P=0.28 at 24 months: mental component score, P=0.51, P=0.47; adjusted), anxiety (P=0.72; P=0.11) depression (P=0.28; P=0.80) or patient satisfaction (P=0.06, 24 months). General practitioners ordered more FOBTs than surgeons (rate ratio 2.4, 95% CI 1.4-4.4), whereas more colonoscopies (rate ratio 0.7, 95% CI 0.5-1.0), and ultrasounds (rate ratio 0.5, 95% CI 0.3-1.0) were undertaken in the surgeon-led group. Results suggest similar recurrence, time to detection and death rates in each group. Colon cancer patients with follow-up led by surgeons or general practitioners experience similar outcomes, although patterns of investigation vary.

Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a condition associated with high morbidity, mortality and cost to the community. Patients often report symptomatic improvement with short-acting beta-2 agonists (SABA) and anticholinergic bronchodilator medications, and both are recommended in COPD guidelines. These medications have different mechanisms of action and therefore could have an additive effect when combined. OBJECTIVES: To compare the relative efficacy and safety of regular long term use (at least four weeks) of ipratropium bromide and short- acting beta-2 agonist therapy in patients with stable COPD. SEARCH STRATEGY: The Cochrane Airways Group Specialised Register of Trials was searched. Bibliographies were checked to identify relevant cross-references. Drug companies were contacted for relevant trial data. The searches are current to August 2005. SELECTION CRITERIA: All randomised controlled trials comparing at least 4 weeks of treatment with an anticholinergic agent (ipratropium bromide) alone or in combination with a beta-2 agonist (short acting) versus the beta-2 agonist alone, delivered via metered dose inhaler or nebuliser, in non-asthmatic adult subjects with stable COPD. DATA COLLECTION AND ANALYSIS: Data extraction and study quality assessment was performed independently by three reviewers. Authors of studies and relevant manufacturers were contacted if data were missing. MAIN RESULTS: Eleven studies (3912 participants) met the inclusion criteria of the review. Small benefits of ipratropium over a short-acting beta-2 agonist were demonstrated on lung function outcomes. There were small benefits in favour of ipratropium on quality of life (HRQL), as well as a reduction in the requirement for oral steroids. Combination therapy with ipratropium plus a short-acting beta-2 agonist conferred benefits over a short-acting beta-2 agonist alone in terms of post-bronchodilator lung function. There was no significant benefit of combination therapy in subjective improvements in HRQL, but again there was a reduction in the requirement for oral steroids. AUTHORS' CONCLUSIONS: The available data from the trials included in this review suggest that the advantage of regular long term use of ipratropium alone or in combination with a short-acting beta-2 agonist or over a beta-2 agonist alone are small, if the aim is to improve lung function, symptoms and exercise tolerance. Until further data are available, the strategy of providing a short-acting beta-2 agonist on a PRN basis, and then either continuing with the short-acting beta-2 agonist regularly or conducting an "n of 1" trial of regular beta-2 agonist or regular anticholinergic to determine the treatment that gives the best relief of symptoms (and continuing with it), would seem cost effective. This strategy does need formal evaluation. Patient preference is also important, as is the relative importance of avoiding the use of systemic corticosteroids.

Osteoporosis screening in people with airways disease.

We tested associations between risk factors and bone mineral density in airways disease subjects, and developed a clinical screening tool to identify people who could benefit from bone mineral density testing. Subjects were recruited through hospital outpatients and pharmacies (Newcastle, n = 172). With survey refinement, we then tested a revised tool in a second sample (Adelaide, n = 317). Study factors included oral/inhaled corticosteroid use, asthma severity, respiratory admissions, physical activity, percent predicted forced expiratory volume in one second (FEV1), body mass index, and smoking history. Outcomes were bone mineral density of lumbar vertebra (L2-4) and total (or neck of) femur. Analysis was logistic regression with generation of a simple screening algorithm based upon coefficients. Scoring algorithm risk factors for T-score of < - 2.0: age > or = 68 = 10 points, bone mineral density < 20 = 25, weight < 60 kg = 20, 60-69 kg = 10, > or = 80 cigarette pack years = 15, low-level leisure activity = 5, area under receiver operator curve 0.83. For a cut-off score of 10, sensitivity was 91.2%, specificity 53.9%, positive and negative predictive values 52.3 and 91.7%, and 67.2% were correctly classified. In conclusions, our model has acceptable sensitivity, although limited specificity. Use of this tool may reduce unnecessary referrals for bone mineral density measurement.

Caspase-3 and -8 activation and cytokine removal with a novel cellulose triacetate super-permeable membrane in an in vitro sepsis model.

Pro-apoptotic molecules are generated during sepsis which may be responsible for alteration of organ function in sepsis. Removal of systemic apoptotic activity may affect recovery from sepsis. Current high flux membranes might not be sufficiently permeable to eliminate pro-apoptotic factors. We evaluated the elimination of pro-apoptotic factors induced by LPS in human whole blood by a super-permeable cellulose triacetate membrane (SUREFLUX FH 150, Nipro, Osaka, Japan) in comparison to a standard high flux cellulose triacetate membrane (UT 700, Nipro, Osaka, Japan) and a polyethersulfone plasmafilter (Bellco, Mirandola Italy) in an in vitro blood circulation. We spiked human whole blood with lipopolysaccharide from Escherichia coli (Serotype 026-86, 10 mg/ml), incubated it for 3 hours to allow cytokine generation and recirculated it at 300 ml/min for 3 hours. The UF line was first returned to the blood module at 10 min. After this, the UF was drained from 10 to 60 min at a rate of 1000 ml/h. Zero balance was obtained by re-infusion of bicarbonate buffered hemofiltration fluid. Apoptosis was assessed on U937 monocytes (incubated with plasma or ultrafiltrate) by fluorescence microscopy dyes (Hoechst 33342, propidium iodide) and annexin V flow cytometry. Caspase-3 and Caspase-8 activity was assessed on the recirculated blood monocytes by spectrophotometric methods. IL-2, IL-10 and TNFalpha were determined by commercially available ELISAs. Sieving coefficients and clearances were determined for the different cytokines. Caspase-3 and Caspase-8 were activated by LPS and remained either stable or increased during in vitro circulation. Apoptosis activity of U937 cells, when incubated with the ultrafiltrate, increased in parallel with arterial plasma values (for Uf: UT700 = 23.1%; Sureflux FH150 = 42.5%). However, by 60 min the apoptotic activity recorded with the ultrafiltrate was reduced to the levels of arterial plasma (for Uf: UT700 = 19.8%; Sureflux FH150 = 11.2%). Sieving coefficients in the super-permeable membrane were significantly higher for all measured cytokines in comparison to the standard high flux membrane (e.g. TNFalpha 0.72 vs 0.03 p < 0.001) and close to the values observed for the plasmafiltration membrane. Nevertheless protein losses measured by albumin leakage were much lower with the Sureflux filter in comparison to the plasmafilter. In conclusion, pro-apoptotic factors can be eliminated by dialytic membranes with the removal rate maximized by using super high flux dialysers which may represent a compromise between hemofiltration and plasmafiltration membranes.

Cost comparison of at-home treatment of deep venous thrombosis with low molecular weight heparin to inpatient treatment with unfractionated heparin.

AIMS: Low molecular weight heparins (LMWH) permit safe and effective treatment of uncomplicated deep venous thrombosis (DVT) at home. The aim of this study was to evaluate the cost minimization, cost shifting and patient satisfaction associated with at-home DVT treatment using the LMWH enoxaparin, compared to standard inpatient care in an Australian health-care setting. METHODS: Subjects presenting with a principal diagnosis of uncomplicated DVT to the Emergency Department at The Queen Elizabeth Hospital, Adelaide, were recruited over 1997-1999. Costs to the hospital, to Federal funding (Medicare) and to patients were tracked prospectively, and satisfaction was also measured. Subjects were matched to historical controls (1994-1997) for age, gender and level of comorbidity (same or lower) by two medical officers who were blinded to costs. Control costs were obtained using the clinical costing system Trendstar, and adjusted for consumer price index. RESULTS: Twenty-eight subjects participated in the at-home programme. Of these, 26 were discharged without any inpatient admission (including one who agreed to self-injection) and two were admitted briefly. Audit demonstrated that only 29% of eligible subjects were managed at home. Mean (SEM) total treatment cost was $756 (76) per patient for at-home, and $2,208 (146) for controls. Minimal cost shifts to patients and to Medicare occurred, and satisfaction was high. CONCLUSIONS: At-home treatment of uncomplicated DVT using enoxaparin in an Australian metropolitan setting provides effective cost minimization, with little cost-shifting. Our cost minimisation estimates are conservative as most at-home subjects received enoxaparin twice daily (now used once per day) and controls had at least as high comorbidity. However, uptake of the at-home programme was limited.

Randomised trials within the general practice evaluation program. Why so few?

BACKGROUND: The General Practice Evaluation Program (GPEP) provided competitive funding for general practice research from 1990-1999. METHODS: Projects funded by GPEP between November 1990 and December 1999 were audited to determine the extent of randomised trials and other interventional studies. RESULTS: Thirty-three (13%) of the 248 projects were interventional studies; of these 21 (8% of all projects) were randomised trials. CONCLUSIONS: While GPEP has made a significant contribution toward Australian general practice research, few randomised trials and other interventional studies have been funded. Reasons include the specific evaluative focus and restrictions on project duration and funding. Randomised trials should be supported within future general practice research funding.

Incidence and prevalence of ischemic heart disease in Italy: estimates from the MIAMOD method.

BACKGROUND: When considering large areas, population-based data on coronary events are generally lacking, and such is the case for the national level. While mortality data are currently and exhaustively collected, data regarding the incidence and prevalence are often available only for subgroups of the population. METHODS: The incidence and prevalence of coronary events were estimated using a mathematical method on the basis of official mortality and population data from national statistics and survival data on coronary events from the Area Friuli of the MONICA Project, and forecasted for northern, central and southern Italy. RESULTS: The incidence is described from 1970 to 1994 and projected to the year 2004; prevalence is reported at the years 1990 and 2000. The coronary event incidence has been decreasing since 1977 among men and since 1974, 4 years before the observed mortality decline, among women. The prevalence has continued to increase as a result of three main factors: increasing survival, population aging, and incidence trend. CONCLUSIONS: Incidence and prevalence data distributed for northern, central and southern Italy are essential to plan and implement major projects aimed at improving medical care services and to evaluate the impact of public health interventions and of spontaneously changing habits among the population.

[Socioeconomic aspects and cardiovascular risk factors: experience at the Cardiovascular Epidemiologic Observatory]. / Aspetti socio-economici e fattori di rischio cardiovascolare: i'esperienza dell'Osservatorio Epidemiologico Cardiovascolare.

BACKGROUND: Cardiovascular diseases are more frequent among the poorer social classes of the population. Studies including social and economic factors offer useful information when planning the strategy required in primary prevention. The aim of this investigation was to evaluate the association between socio-economic levels and cardiovascular risk factors in 3198 women and 3218 men aged 35-74 years enrolled for a cross sectional study within the Cardiovascular Epidemiologic Observatory, carried out in 1998 to evaluate the distribution of risk factors and the prevalence of cardiovascular risk conditions. METHODS: The level of education was used to determine the socio-economic status; the distribution of the risk factors and the prevalence of risk conditions were analyzed for the different levels of education. Models of logistic regression were used to evaluate the relation between the socio-economic status and obesity, cigarette smoking, hypertension, and hypercholesterolemia. RESULTS: A higher level of education is significantly protective against both obesity and cigarette smoking. With regard to obesity among males compared to those with a university degree the odds ratio increased to 1.6 for those with an upper secondary education diploma (95% confidence interval--CI 1.09-2.51) and to 3.5 for those without any qualification (95% CI 1.97-6.21). Among women the odds ratio increased to 3.2 (95% CI 1.81-5.81) and to 4.8 (95% CI 2.55-8.98) for the same levels of education. With regard to smoking among males compared to those with a university degree the odds ratio increased to 1.4 for those holding an upper secondary education diploma (95% CI 1.07-1.94) and to 2.3 for those without any qualification (95% CI 1.40-3.68). For men living in central or southern Italy, the odds ratio for cigarette smoking increased to 1.3 (95% CI 1.06-1.57) and to 1.5 (95% CI 1.24-1.82) and the odds ratio for hypercholesterolemia decreased to 0.8 (95% CI 0.62-0.95) and to 0.7 (95% CI 0.58-0.89); with regard to women, living in the same geographic areas the odds ratio for obesity increased to 1.3 (95% CI 1.03-1.65) and to 2.3 (95% CI 1.81-2.83). CONCLUSIONS: In primary prevention it is important to focus the attention on obesity and on smoking habits among the poorer social classes.

Surveillance of ischaemic heart disease: results from the Italian MONICA populations.

BACKGROUND: The major objectives are to report on coronary event mortality, incidence and attack rates and changes over time observed in the Italian MONICA populations and to assess if trends are consistent when different disease definitions are considered. An analysis of diagnostic agreement between clinical and MONICA categories is presented in the context of developing a model for estimating disease incidence in a population, based on currently available data. METHODS: Data were provided by the three Italian MONICA (MONItoring trends and determinants of CArdiovascular diseases) registers. The areas of Brianza and Friuli, both located in northern Italy, completed the 10-year period of registration. Data from the MONICA Latina area, located close to Rome, were limited to the first 3 years of registration. These data are used for assessing geographical differences in rates in the mid- 1980s and estimating the diagnostic agreement between International Classification of Diseases (ICD) codes and MONICA categories. Two diagnostic aggregates have been used: the standard MONICA diagnostic definition for myocardial infarction (MI), which includes non-fatal definite myocardial infarction and fatal coronary events, and the coronary event definition which includes, in addition, non-fatal possible myocardial infarctions. RESULTS: From the mid-1980s to the mid-1990s, a considerable reduction in all-cause, cardiovascular and coronary mortality rates occurred in the monitored populations. Data from the MONICA registers confirm the accuracy of official reports of death rates and changes in Italy. Comparisons of time differences in attack and incidence rates of myocardial infarction and all coronary events indicate that the impact of the more severe manifestations of coronary heart diseases (fatal coronary event and acute MI) reduced during the period of observation, but when less severe events (minor myocardial infarction and angina pectoris) are considered, the overall impact of the disease on the population remained stable. CONCLUSION: Epidemiological surveillance of coronary syndromes is relevant over this time period of impressive changes in prevention and treatment. Continuing restrictions in available resources necessitate the development of simplified registration systems.

Estimating population-based incidence and prevalence of major coronary events.

BACKGROUND: Population-based data on coronary events are generally lacking for large areas, such as at the nation-wide level. While mortality data are currently and exhaustively collected in all developed countries and in a few developing countries, incidence and prevalence are often available only for certain subgroups of the population under study. METHODS: We propose to estimate population-based incidence and prevalence of coronary events through a mathematical method using mortality and survival data as input, and to forecast coronary event occurrence using an age, period and cohort approach. The method reconstructs incidence and prevalence of major coronary events in Italy from 1970 to 1997 and projects trends up to the year 2007 using survival data on coronary events from the Area Friuli-MONICA (MONItoring of CArdiovascular diseases) register. RESULTS: Major coronary event incidence has been decreasing since 1977 for men and since 1974, for women. Conversely, major coronary event prevalence increased up to the end of the 1980s for men and up to the early 1980s for women, and it has been declining thereafter. Major coronary event prevalence results from three main effects: increasing survival, population ageing, and incidence trend. CONCLUSIONS: Availability of national population data, collection of population-based survival data from the MONICA registers and appropriate statistical and mathematical methods help to estimate and project incidence and prevalence trends for major coronary events. This information is essential to plan and implement actions aimed at improving medical care services, and to evaluate the impact of public health interventions as well as spontaneously changing habits. Incidence, prevalence, mortality, projections, ischaemic heart disease, coronary events