The impact of old age on cancer-specific and non-cancer-related survival following elective potentially curative surgery for Dukes A/B colorectal cancer.

Previous studies have suggested that survival following surgery for colorectal cancer is poorer in the elderly. However, the findings were inconsistent and none of the studies adjusted for case mix. The aim of this study was to establish whether there were age-related differences in cancer (colorectal)-specific and non-cancer (colorectal)-related survival in patients undergoing elective potentially curative resection for Dukes stage A/B colorectal cancer. One thousand and forty three patients who underwent elective potentially curative resection for Dukes' A/B colorectal cancer between 1991 and 1994 in 11 hospitals in Scotland were included in the study. Ten year cancer-specific and non-cancer-related survival and the hazard ratios were calculated according to age groups (<64; 65-74/>74 years). On follow-up 273 patients died of their cancer and 328 died of non-cancer-related causes. At 10 years, overall survival was 45%, cancer specific was 70% and non-cancer-related survival was 64%. On multivariate analysis of all factors, age (HR 1.38, 95% CI 1.18-1.62, P<0.001), sex (HR 1.74, 95% CI 1.36-2.23, P<0.001), site (HR 1.42, 95% CI 1.11-1.81, P<0.01) and Dukes' stage (HR 1.71, 1.19-2.47, P<0.01) were independently associated with cancer-specific survival. On multivariate analysis of all factors, age (HR 2.14, 1.84-2.49, P<0.001), sex (HR 1.43, 1.15-1.79, P<0.01) and deprivation (HR 1.30, 1.09-1.55, P<0.01) were independently associated with non-cancer-related survival. The results of this study show that increasing age impacts negatively both on cancer-specific and non-cancer-related survival following elective potentially curative resection for node-negative colorectal cancer. However, the effect of increasing age is greater on the non-cancer-related survival. These results suggest that cancer-specific and non-cancer-related mortality should be considered separately in survival analysis of these cancer patients.

Axillary recurrence in breast cancer.

AIM: To determine whether axillary recurrence reflects inadequate axillary treatment or adverse pathological features. METHODS: The case-records were reviewed of 2122 women aged under 75 years, treated for invasive breast cancer during the time-period 1/1/86-31/12/91 in a geographically defined area. Data were abstracted on operations performed, pathological features, post-operative treatments and details of axillary recurrence. The risk of axillary recurrence was examined by pathological, treatment and patient factors. RESULTS: Axillary recurrence was more than twice as likely after inadequate compared to adequate treatment of the axilla (adequate staging or axillary radiotherapy or clearance). Delayed treatment of the axilla was not as successful as adequate primary treatment: multiple axillary recurrences were twice as common, one third of which were uncontrolled at time of death. Inadequate surgical treatment was associated with increased rates of recurrence despite endocrine therapy, chemotherapy or radiotherapy. Lymphoedema was twice as common if axillary radiotherapy was combined with any axillary surgical procedure. CONCLUSIONS: Axillary recurrence is more common in tumours with adverse pathology but may also result from inadequate axillary treatment. In order to minimise axillary recurrence, optimal treatment of the axilla entails adequate staging (sampling of four or more nodes) and treatment (axillary clearance or radiotherapy and endocrine therapy) in all women.

Empowering primary care to tackle the obesity epidemic: the Counterweight Programme.

OBJECTIVE: To improve the management of obese adults (18-75 y) in primary care. DESIGN: Cohort study. SETTINGS: UK primary care. SUBJECTS: Obese patients (body mass index > or =30 kg/m(2)) or BMI> or =28 kg/m(2) with obesity-related comorbidities in 80 general practices. INTERVENTION: The model consists of four phases: (1) audit and project development, (2) practice training and support, (3) nurse-led patient intervention, and (4) evaluation. The intervention programme used evidence-based pathways, which included strategies to empower clinicians and patients. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation. MAIN OUTCOME MEASURES: Proportion of practices trained and recruiting patients, and weight change at 12 months. RESULTS: By March 2004, 58 of the 62 (93.5%) intervention practices had been trained, 47 (75.8%) practices were active in implementing the model and 1549 patients had been recruited. At 12 months, 33% of patients achieved a clinically meaningful weight loss of 5% or more. A total of 49% of patients were classed as 'completers' in that they attended the requisite number of appointments in 3, 6 and 12 months. 'Completers' achieved more successful weight loss with 40% achieving a weight loss of 5% or more at 12 months. CONCLUSION: The Counterweight programme provides a promising model to improve the management of obesity in primary care.

Childhood IQ and all-cause mortality before and after age 65: prospective observational study linking the Scottish Mental Survey 1932 and the Midspan studies.

OBJECTIVES: The objective was to investigate how childhood IQ related to all-cause mortality before and after age 65. DESIGN: The Midspan prospective cohort studies, followed-up for mortality for 25 years, were linked to individuals' childhood IQ from the Scottish Mental Survey 1932. METHODS: The Midspan studies collected data on risk factors for cardiorespiratory disease from a questionnaire and at a screening examination, and were conducted on adults in Scotland in the 1970s. An age 11 IQ from the Scottish Mental Survey 1932, a cognitive ability test conducted on 1921-born children attending schools in Scotland, was found for 938 Midspan participants. The relationship between childhood IQ and mortality risk, adjusting for adulthood socio-economic confounders, was analysed. The effect of adjustment for childhood IQ on the relationship between established risk factors (blood pressure, smoking, height and respiratory function) and mortality was also investigated. RESULTS: For deaths occurring up to age 65, there was a 36% increased risk per standard deviation decrease (15 points) in childhood IQ which was reduced to 29% after adjusting for social class and deprivation category. There was no statistically significant relationship between childhood IQ and deaths occurring after the age of 65. Adjustment for childhood IQ attenuated the risk factor-mortality relationship in deaths occurring up to age 65, but had no effect in deaths occurring after age 65. CONCLUSIONS: Childhood IQ was significantly related to deaths occurring up to age 65, but not to deaths occurring after age 65.

Are two really better than one? Empirical examination of repeat blood pressure measurements and stroke risk in the Renfrew/Paisley and collaborative studies.

BACKGROUND AND PURPOSE: Blood pressure measured on 2 occasions in 2 large prospective cohort studies in Scotland was related to stroke, defined as stroke mortality or hospital admission for stroke. The purpose was to investigate whether 2 blood pressure readings gave a more accurate estimate of stroke risk over a long follow-up period than 1 reading. METHODS: In the 1970s, the Renfrew/Paisley general population study investigated 3060 men and 3502 women and the Collaborative study investigated 2683 employed men on 2 occasions. The mean years between screening were 4 and 5, respectively. Blood pressure measured on the 2 occasions was related to stroke risk in 17-year and 21-year follow-up periods after the second screening, respectively. RESULTS: For both systolic and diastolic blood pressure, the mean of the measures on the 2 occasions, the maximum of the 2 measures and the measure corrected for regression dilution was more strongly related to stroke over the follow-up periods than either single measure. CONCLUSIONS: Two blood pressure measurements seem better than 1 for indicating stroke risk. Underestimation using single measures will lead to both misclassification of the risk of disease for individuals and also the population-attributable risk of disease associated with elevated blood pressure.

Influence of socioeconomic circumstances in early and later life on stroke risk among men in a Scottish cohort study.

BACKGROUND AND PURPOSE: The purpose of the study was to investigate stroke risk by socioeconomic measures. METHODS: The analysis was based on a large cohort study of 5765 working men, from 27 workplaces in Scotland, who were screened between 1970 and 1973. Stroke was defined as having a hospital admission with a main diagnosis of stroke or dying of stroke in the 25-year follow-up period. RESULTS: There were 416 men who had a stroke. Men with manual occupations when screened, on first entering the workforce, men with manual occupations, and men whose fathers had manual occupations had significantly higher rates of stroke than men in the nonmanual categories. Men who left full-time education at age 16 years or under also had significantly higher rates of stroke. Men living in more deprived areas had higher rates of stroke, but the rates were not statistically significant. The most marked difference was in relation to father's social class, and although adjusting for risk factors for stroke attenuated the relative rates, men whose fathers were in manual social classes had higher relative rates of stroke than men whose fathers were in nonmanual classes (adjusted relative rate for father's social class III manual was 1.37 [95% CI 1.03 to 1.81] and for father's social class IV or V was 1.46 [1.09 to 1.96]). Men who were upwardly mobile (father's social class manual, own social class nonmanual) had a rate of stroke similar to that of stable manual men. CONCLUSIONS: Poorer socioeconomic circumstance was associated with greater stroke risk, with adverse early-life circumstances of particular importance.

Cancer risk of hypertensive patients taking calcium antagonists.

OBJECTIVE: To measure rates of incident and fatal cancer in hypertensive patients taking calcium antagonists and to compare these with rates in three control groups. DESIGN: A retrospective analysis of cancer in patients of the Glasgow Blood Pressure Clinic prescribed either a calcium antagonist or other antihypertensive drugs (non-calcium antagonist group). Record linkage of the clinic with the West of Scotland Cancer Registry and with the Registrar General, Scotland provided information on incidence of cancer and on deaths and their causes. PATIENTS: 2297 patients were prescribed calcium antagonist and 2910 were prescribed antihypertensive drugs other than calcium antagonist. MAIN OUTCOME MEASURES: Relative risk of cancer, the ratio of observed to expected cancers in the calcium antagonist group, was estimated using expected values based on three control groups; namely the non-calcium antagonist group, a middle-aged population of Renfrew and Paisley and the West of Scotland population. RESULTS: There were 134 incident cancers in the calcium antagonist group, representing relative risks of 1.02 [95% confidence interval (CI) 0.82-1.271 compared with the non-calcium antagonist group, 1.01 (95% CI 0.84-1.18) compared with Renfrew-Paisley controls and 1.02 (95% CI 0.85-1.19) compared with West of Scotland controls. Findings for cancer mortality were similarly negative. Risks were no higher for older patients. CONCLUSIONS: Our study lends no support to the suggestion that calcium antagonists cause cancer.

Are women more sensitive to smoking than men? Findings from the Renfrew and Paisley study.

BACKGROUND: Prescott et al. found that the relative risks associated with smoking for respiratory and vascular deaths were higher for women who inhale than for inhaling men, and found no gender differences in relative risks of smoking-related cancers. The purpose of the present study was to assess whether these findings are reproducible, using data from the Renfrew and Paisley study. METHODS: Age-standardized mortality rate differences and age-adjusted mortality rate ratios (using Cox's proportional hazard model) were calculated for male and female smokers by amount smoked compared with never smokers. These analyses were repeated after excluding non-inhalers. RESULTS: The all-cause mortality rate ratio was higher for men than for women in all categories of amount smoked, although this difference was only statistically significant in the light smokers (1.83 [95% CI : 1.61-2.07] for men and 1.41 [95% CI : 1.28-1.56] for women, P = 0.001). The cause-specific mortality rate ratios tended to be higher for men than for women, and this difference was most substantial for neoplasms (2.57 [95% CI : 2.01-3.29] for male light smokers and 1.35 [95% CI : 1.14-1.61] for female light smokers, P < 0.001) and, in particular, for lung cancer (11.10 [95% CI : 5.89-20.92] for male light smokers and 4.73 [95% CI : 2.99-7.50] for female light smokers, P = 0.03). Furthermore, looking at the rate differences the effects of smoking were uniformly greater in men than in women. These results were virtually unchanged after excluding non-inhalers. CONCLUSION: We found similar results to Prescott et al. when all smokers were considered, but could not reproduce their findings when non-inhalers were excluded. Given the fact that we showed greater rate differences in men than in women, we think that it is too early to conclude that women may be more sensitive than men to some of the deleterious effects of smoking.

Breathlessness, chronic bronchitis and reduced pulmonary function as predictors of cardiovascular disease mortality among men in England, Scotland and the United States.

Relationships between cardiovascular disease (CVD) mortality and breathlessness, a definition of chronic bronchitis, and pulmonary function are investigated among men in two employed populations (17,717 London civil servants and 4904 Scottish workers) and in two communities (844 men in Tecumseh, Michigan and 6859 men in Renfrew and Paisley Burghs, Scotland). Men are aged 40-64 years at entry in all studies except Renfrew-Paisley, where they are aged 45-64 years. Length of follow-up ranges from 6 to 16 years. Age and smoking habits were controlled for in all analyses. Chronic phlegm production is not significantly associated with CVD mortality, and 'chronic bronchitis' is significantly associated with mortality only in the employed populations. Low FEV1 is significantly associated with CVD mortality only in the Whitehall study; however, the rate ratios are above one in all studies. Breathlessness is significantly associated with CVD mortality in all studies. These associations between CVD mortality and 'chronic bronchitis', low FEV1, and breathlessness persist after also controlling for employment grade, systolic blood pressure, antihypertensive medication, ECG changes, plasma cholesterol level, body mass index and diabetes. Only the associations between breathlessness and mortality persist after further controlling for low FEV1 and myocardial ischaemia. The rate ratios between breathlessness and mortality are about two for all studies. It is concluded that in these populations, breathlessness is an independent and major predictor of CVD mortality.

Social class differences in lung cancer mortality: risk factor explanations using two Scottish cohort studies.

BACKGROUND: The study investigated differences in lung cancer mortality risk between social classes. METHODS: Twenty years of mortality follow-up were analysed in 7052 men and 8354 women from the Renfrew/Paisley general population study and 4021 working men from the Collaborative study. RESULTS: More manual than non-manual men and women smoked, reported morning phlegm, had worse lung function and lived in more deprived areas. Lung cancer mortality rates were higher in manual than non-manual men and women. Significantly higher lung cancer mortality risks were seen for manual compared to non-manual workers when adjusting for age only and adjustment for smoking reduced these risks to 1.41 (95% CI : 1.12-1.77) for men in the Renfrew/Paisley study, 1.28 (95% CI : 0.94-1.75) for women in the Renfrew/Paisley study and 1.43 (95% CI : 1.02-2.01) for men in the Collaborative study. Adjustment for lung function, phlegm and deprivation category attenuated the risks which were of borderline significance for men in the Renfrew/Paisley study and non significant for women in the Renfrew/Paisley study and men in the Collaborative study. Adding extra socioeconomic variables, available in the Collaborative study only, reduced the difference between the manual and non-manual social classes completely. CONCLUSIONS: There is a difference in lung cancer risk between social classes, in addition to the effect of smoking. This can be explained by poor lung health, deprivation and poor socioeconomic conditions throughout life. As well as anti-smoking measures, reducing socioeconomic inequalities and targeting individuals with poor lung function for help with smoking cessation could help reduce future lung cancer incidence and mortality.

More 'malignant' than cancer? Five-year survival following a first admission for heart failure.

BACKGROUND: The prognostic impact of heart failure relative to that of 'high-profile' disease states such as cancer, within the whole population, is unknown. METHODS: All patients with a first admission to any Scottish hospital in 1991 for heart failure, myocardial infarction or the four most common types of cancer specific to men and women were identified. Five-year survival rates and associated loss of expected life-years were then compared. RESULTS: In 1991, 16224 men had an initial hospitalisation for heart failure (n=3241), myocardial infarction (n=6932) or cancer of the lung, large bowel, prostate or bladder (n=6051). Similarly, 14842 women were admitted for heart failure (n=3606), myocardial infarction (n=4916), or cancer of the breast, lung, large bowel or ovary (n=6320). With the exception of lung cancer, heart failure was associated with the poorest 5-year survival rate (approximately 25% for both sexes). On an adjusted basis, heart failure was associated with worse long-term survival than bowel cancer in men (adjusted odds ratio, 0.89; 95% CI, 0.82-0.97; P<0.01) and breast cancer in women (odds ratio, 0.59; 95% CI, 0.55-0.64; P<0.001). The overall population rate of expected life-years lost due to heart failure in men was 6.7 years/1000 and for women 5.1 years/1000. CONCLUSION: With the notable exception of lung cancer, heart failure is as 'malignant' as many common types of cancer and is associated with a comparable number of expected life-years lost.

Bacteriuria in patients undergoing prostatectomy.

A review of the literature revealed that the reported incidence of bacteriuria arising before and after prostatectomy varied considerably, that there had been little investigation of the organisms isolated, and that the value of chemoprophylaxis at the time of prostatectomy was unproven. Using standard criteria and technical procedures, 248 patients undergoing prostatectomy were studied over a two-and-a-half-year period. Preoperative bacteriuria occurred in 28% of patients. The incidence was significantly increased in patients catheterised before operation (44%) compared with those who had not been catheterised (18%). The incidence of bacteriuria was directly related to the duration of catheter drainage. Postoperatively, 40% of patients with sterile urine at the time of prostatectomy developed bacteriuria. There was an increased prevalence of Enterococcus and coagulase-negative Staphylococcus isolates from postprostatectomy bacteriuria compared with preprostatectomy bacteriuria. Based on this information, suggestions can be made regarding the choice of a suitable chemoprophylactic agent and the optimum timing and duration of its administration.

Morphological characteristics and distribution patterns of epithelial cells in the cytological diagnosis of gastric cancer.

The morphological features of epithelial cells in gastric biopsy touch smears from 296 cases (248 benign, 48 malignant) were retrospectively reviewed. By subjective criteria no single purely morphological characteristic could be identified that was consistently capable of separating benign from malignant specimens. The value of cell distribution patterns in diagnosis was therefore objectively analysed in the 231 adequate specimens (190 benign, 41 malignant). A score of over 20% for single epithelial cells was found to have a sensitivity of 95.1% and specificity of 99.5% in the diagnosis of carcinoma. Quantitative analysis of cell distribution pattern is a simple test, which does not require special equipment, yet can be helpful in the interpretation of gastric cytology.

Problems in the interpretation of small area analysis of epidemiological data: the case of cancer incidence in the West of Scotland.

STUDY OBJECTIVE: The aim was to examine the extent to which random variation alone will produce differences in observed incidence rates between small areas which will affect measures of spatial clustering and estimates of relative risk. DESIGN: This was a study of changes in the pattern of spatial concentration of cancer incidence over a five year time period. A comparison was made of observed incidence rates for 34 tumour sites with randomly generated values and, where possible, with expected values derived from known relative risks. SETTING: Twenty six local government districts in the West of Scotland. MAIN RESULTS: A statistically significant relationship was observed between sample size and the stability of a summary measure of spatial concentration. Almost all observed highest:mean rate ratios were within the 95% confidence interval of the simulated distribution of these values. In three cases examined, both observed and simulated highest:lowest rate ratios were larger than those expected on the basis of known exposures to risk. CONCLUSIONS: In the absence of a prior hypothesis, small area analysis of epidemiological data for periods of less than 10 years will almost always give misleading results for all but the most common diseases.

Cigarette smoking and male lung cancer in an area of very high incidence. I. Report of a case-control study in the West of Scotland.

Altogether 656 male lung cancer cases and 1312 age and sex matched controls were interviewed between 1976 and 1981 in a case-control study of cigarette smoking habits and lung cancer in Glasgow and the West of Scotland, an area with the highest recorded incidence in the world. The relative risk of lung cancer increased significantly for smokers whose consumption was below 20 cigarettes per day but did not rise significantly in those who smoked more than 20 cigarettes per day. Other smoking characteristics such as inhalation and tar yields of brands smoked did not explain this finding. Additionally, the relative risks observed at all levels of cigarette consumption were low in comparison with those in the published literature. By constructing an index of cigarette exposure which included the tar yields of brands smoked, an assessment of the risk of lung cancer in relation to tar exposure independent of amount smoked was derived. Only in smokers of less than 15 cigarettes per day was there a statistically significant reduction in risk of lung cancer associated with lower levels of tar yield.

Cigarette smoking and male lung cancer in an area of very high incidence. II. Report of a general population cohort study in the West of Scotland.

A general population cohort of 7055 men aged 45-64 and resident in Renfrew and Paisley, two urban burghs in the West of Scotland, has been followed for 10 1/2 years. Analysis of the cigarette smoking and lung cancer (incidence and mortality) relation has been undertaken in order to establish whether unusual results found in a case-control study of cigarette smoking and lung cancer in the adjacent city of Glasgow could be confirmed. Lung cancer incidence and mortality rates increased markedly for exposure categories up to an average consumption of 15-24 cigarettes per day. Above this level the rates increased only marginally. Expressing these rates relative to that estimated for the never-smoked group and comparing them with the relative risks estimated in the case-control study revealed a similarity in terms of both the shape and the level of the dose-response relation. Comparison of the lung cancer rates found in this cohort with those observed in other cohort studies in the literature (UK doctors, US Veterans, and American Cancer Society volunteers) suggested that the West of Scotland rates were substantially higher at all levels of cigarette exposure.

The relation between questions indicating transient ischaemic attack and stroke in 20 years of follow up in men and women in the Renfrew/Paisley Study.

STUDY OBJECTIVE: Transient ischaemic attack (TIA) is often a precursor to stroke, so identification of people experiencing TIA could assist in stroke prevention by indicating those at high risk of stroke who would benefit most from intervention for other stroke risk factors. The objective of this study was to investigate whether answers to a simple questionnaire for TIA could predict the occurrence of stroke in the following 20 years. DESIGN: Prospective cohort study, conducted between 1972 and 1976, with 20 years of follow up. SETTING: Renfrew and Paisley, Scotland. PARTICIPANTS: 7052 men and 8354 women aged 45-64 years at the time of screening completed a questionnaire and attended a physical examination. The questionnaire asked participants if they had ever, without warning, suddenly lost the power of an arm, suddenly lost the power of a leg, suddenly been unable to speak properly or suddenly lost consciousness. These four questions were taken as indicators of TIA and were related to subsequent stroke mortality or hospital admission. MAIN RESULTS: For women, each question was significantly related to stroke risk, whereas for men only the question on loss of power of arm was significantly related to stroke risk. Men and women answering two or more questions positively had double the relative rate of stroke compared with men and women answering none of the questions positively, even after adjusting for other risk factors for stroke. CONCLUSIONS: A simple questionnaire for TIA could help predict stroke over 20 years of follow up. Targeting men and women who report TIA with early treatment could help to prevent strokes from occurring.

Prognostic factors in women with breast cancer: distribution by socioeconomic status and effect on differences in survival.

STUDY OBJECTIVE: To quantify and investigate differences in survival from breast cancer between women resident in affluent and deprived areas and define the contribution of underlying factors to this variation. DESIGN: Analysis of two datasets relating to breast cancer patients in Scotland: (1) population-based cancer registry data; (2) a subset of cancer registration records supplemented by abstraction of prognostic variables (stage, node status, tumour size, oestrogen receptor (ER) status, type of surgery, use of radiotherapy and use of adjuvant systemic therapy) from medical records. SETTING: Scotland. PATIENTS: (1) Cancer registration data on 21,751 women aged under 85 years diagnosed with primary breast cancer between 1978 and 1987; (2) national clinical audit data on 2035 women aged under 85 years diagnosed with primary breast cancer during 1987 for whom adequate medical records were available. MAIN RESULTS: Survival differences of 10% between affluent and deprived women were observed in both datasets, across all age groups. In the audit dataset, the distribution of ER status varied by deprivation group (65% ER positive in affluent group v 48% ER positive in deprived group; under 65 age group). Women aged under 65 with non-metastatic disease were more likely to have breast conservation than a mastectomy if they were affluent (45%) than deprived (32%); the affluent were more likely to receive endocrine therapy (65%) than the deprived (50%). However, these factors accounted for about 20% of the observed difference in survival between women resident in affluent and deprived areas. CONCLUSIONS: Deprived women with breast cancer have poorer outcomes than affluent women. This can only partly be explained by deprived women having more ER negative tumours than affluent women. Further research is required to identify other reasons for poorer outcomes in deprived women, with a view to reducing these survival differences.

Increased mortality from breast cancer and inadequate axillary treatment.

BACKGROUND: The assessment of axillary nodal status remains divisive: inaccurate staging may result in untreated axillary disease, and appropriate adjuvant therapy not being delivered. The impact of inadequate axillary treatment on survival remains controversial. We analyse the impact of failure to adequately assess the axillary nodal status on survival. METHODS: All women with confirmed breast cancer in a 15-year period were identified, and the original pathology reports examined, and details of radiotherapy obtained. The survival of women by axillary sample size was compared to a reference group of women and corrected for nodal status, tumour size, age, deprivation category and speciality of treating surgeon. FINDINGS: Sampling less than four nodes is associated with a significantly increased risk of death. This cannot be due to understaging the extent of axillary disease nor is fully explainable by differential prescription of adjuvant therapies. We conclude that the survival of the women studied may have been adversely effected by inadequate axillary treatment.

Childhood IQ and cardiovascular disease in adulthood: prospective observational study linking the Scottish Mental Survey 1932 and the Midspan studies.

This study investigated the influence of childhood IQ on the relationships between risk factors and cardiovascular disease (CVD), coronary heart disease (CHD) and stroke in adulthood. Participants were from the Midspan prospective cohort studies which were conducted on adults in Scotland in the 1970s. Data on risk factors were collected from a questionnaire and at a screening examination, and participants were followed up for 25 years for hospital admissions and mortality. 938 Midspan participants were successfully matched with their age 11 IQ from the Scottish Mental Survey 1932, in which 1921-born children attending schools in Scotland took a cognitive ability test. Childhood IQ was negatively correlated with diastolic and systolic blood pressure, and positively correlated with height and respiratory function in adulthood. For each of CVD, CHD and stroke, defined as either a hospital admission or death, there was an increased relative rate per standard deviation decrease (15 points) in childhood IQ of 1.11 (95% confidence interval 1.01-1.23), 1.16 (1.03-1.32) and 1.10 (0.88-1.36), respectively. With events divided into those first occurring before and those first occurring after the age of 65, the relationships between childhood IQ and CVD, CHD and stroke were only seen before age 65 and not after age 65. Blood pressure, height, respiratory function and smoking were associated with CVD events. Relationships were stronger in the early compared to the later period for smoking and FEV1, and stronger in the later compared to the earlier period for blood pressure. Adjustment for childhood IQ had small attenuating effects on the risk factor-CVD relationship before age 65 and no effects after age 65. Adjustment for risk factors attenuated the childhood IQ-CVD relationship by a small amount before age 65. Childhood IQ was associated with CVD risk factors and events and can be considered an important new risk factor.