Organisational downsizing and musculoskeletal problems in employees: a prospective study

OBJECTIVES

To study the association between organisational downsizing and subsequent musculoskeletal problems in employees and to determine the association with changes in psychosocial and behavioural risk factors.

METHODS

Participants were 764 municipal employees working in Raisio, Finland before and after an organisational downsizing carried out between 1991 and 1993. The outcome measures were self reports of severity and sites of musculoskeletal pain at the end of 1993 and medically certified musculoskeletal sickness absence for 1993-5. The contribution of changes in psychosocial work characteristics and health related behaviour between the 1990 and 1993 surveys was assessed by adjustment.

RESULTS

After adjustment for age, sex, and income, the odds ratio (OR) for severe musculoskeletal pain between major and minor downsizing and the corresponding rate ratios for musculoskeletal sickness absence were 2.59 (95% confidence interval (95% CI) 1.5 to 4.5) and 5.50 (3.6 to 7.6), respectively. Differences between the mean number of sites of pain after major and minor downsizing was 0.99 (0.4 to 1.6). The largest contribution from changes in work characteristics and health related behaviour to the association between downsizing and musculoskeletal problems was from increases in physical demands, particularly in women and low income employees. Additional contributory factors were reduction of skill discretion (relative to musculoskeletal pain) and job insecurity. The results were little different when analyses were confined to initially healthy participants.

CONCLUSIONS

Downsizing is a risk factor for musculoskeletal problems among those who remain in employment. Much of this risk is attributable to increased physical demands, but adverse changes in other psychosocial factors may also play a part.

Seasonal variation in cause-specific mortality: are there high-risk groups? 25-year follow-up of civil servants from the first Whitehall study

OBJECTIVES

To determine the seasonal effect on all-cause and cause-specific mortality and to identify high-risk groups.

METHODS

A 25-year follow-up of 19,019 male civil servants aged 40-69 years.

RESULTS

All-cause mortality was seasonal (ratio of highest mortality rate during winter versus lowest rate during summer 1.22, 95% CI : 1.1-1.3), largely due to the seasonal nature of ischaemic heart disease. Participants at high risk based on age, employment grade, blood pressure, cholesterol, forced expiratory volume, smoking and diabetes did not have higher seasonal mortality, although participants with ischaemic heart disease at baseline did have a higher seasonality effect (1.38, 95% CI : 1.2-1.6) than those without (1.18, 95% CI : 1.1-1.3) (P = 0.03).

CONCLUSIONS

Seasonal mortality differences were greater among those with prevalent ischaemic heart disease and at older ages, but were not greater in individuals of lower socioeconomic status or with a high multivariate risk score. Since seasonal differences showed no evidence of declining over time, elucidating their causes and preventive strategies remains a public health challenge.

Hypothetical ratings of coronary angiography appropriateness: are they associated with actual angiographic findings, mortality, and revascularisation rate? The ACRE study

OBJECTIVE

To determine whether ratings of coronary angiography appropriateness derived by an expert panel on hypothetical patients are associated with actual angiographic findings, mortality, and subsequent revascularisation in the ACRE (appropriateness of coronary revascularisation) study.

DESIGN

Population based, prospective study. The ACRE expert panel rated hypothetical clinical indications as inappropriate, uncertain, or appropriate before recruitment of a cohort of real patients.

SETTING

Royal Hospitals Trust, London, UK.

PARTICIPANTS

3631 consecutive patients undergoing coronary angiography (no exclusion criteria).

MAIN OUTCOME MEASURES

Angiographic findings, mortality (n = 226 deaths), and revascularisation (n = 1556 procedures) over 2.5 years of follow up.

RESULTS

The indications for coronary angiography were rated appropriate in 2253 (62%) patients. 166 (5%) coronary angiograms were performed for indications rated inappropriate, largely for asymptomatic or atypical chest pain presentations. The remaining 1212 (33%) angiograms were rated uncertain, of which 47% were in patients with mild angina and no exercise ECG or in patients with unstable angina controlled by inpatient management. Three vessel disease was more likely among appropriate cases and normal coronaries were more likely among inappropriate cases (p < 0.001). Mortality and revascularisation rates were highest among patients with an appropriate indication, intermediate in those with an uncertain indication, and lowest in the inappropriate group (log rank p = 0.018 and p < 0.0001, respectively).

CONCLUSION

The ACRE ratings of appropriateness for angiography predicted angiographic findings, mortality, and revascularisation rates. These findings support the clinical usefulness of expert panel methods in defining criteria for performing coronary angiography.

Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study. Appropriateness of Coronary Revascularisation study

Although the prevalence of angina in women is increasing, women are less likely than men to undergo invasive management of coronary disease. Gender differences in language use may contribute to disparities in management, since the diagnosis of angina relies on a patient's description of their symptoms. This study set out to investigate whether gender differences exist in the language used when describing angina symptoms and perceived health problems at the time of angiography, which might influence the rate of subsequent revascularisation. Content analysis was used to analyse written accounts of 'symptoms and health problems' in 200 (96 female) patients randomly selected within age strata who were undergoing coronary angiography for chronic stable angina in the Appropriateness of Coronary Revascularisation (ACRE) study. Written free text was coded into seven categories: pain location (chest or arm and throat, neck or jaw); pain character; breathlessness; other symptoms; effects on lifestyle; symptom attributions; and patient discourses ('story' or 'factual'). Women described more throat, neck or jaw pain than men among those with low physical functioning ( p=0.06), in the presence of coronary artery disease (p = 0.04) and in those who were not subsequently revascularised (p =0.05). Women also gave more accounts than men of breathlessness and other symptoms, but there was little evidence for gender differences in the use of 'factual' discourses. We conclude that from the time of angiography, gender differences in language use do exist and description of angina pain may influence subsequent revascularisation. Further research is necessary to investigate the nature and consequences of gender differences in language use at this and earlier stages in the referral process.

Relative contribution of early life and adult socioeconomic factors to adult morbidity in the Whitehall II study

STUDY OBJECTIVE

To determine the relative contribution of adult compared with early life socioeconomic status as predictors of morbidity attributable to coronary heart disease (CHD), chronic bronchitis and depression in the Whitehall II study of British civil servants.

DESIGN

Prospective observational study with mean 5.3 years (range 3.7-7.6) follow up.

SETTING

20 civil service departments originally located in London.

PARTICIPANTS

6895 male and 3413 female office-based civil servants aged 35-55 years at baseline.

OUTCOME MEASURES

New cases at follow up of CHD, chronic bronchitis and depression defined using validated questionnaires.

MAIN RESULTS

Employment grade was inversely associated with CHD, chronic bronchitis and depression in men (odds ratio per unit decrease in grade 1.30, 1.44 and 1.20 respectively). Employment grade was strongly related to father's social class. Chronic bronchitis, in women, and depression, in men, were more common among those with fathers of higher social class. When mutual adjustment was made for father's social class, grade at entry to the civil service and current grade, the strongest effects on adult morbidity were found for current grade. Among participants in whom neither parent had died < or =70 years of age the inverse association with adult SES was maintained.

CONCLUSIONS

Adult socioeconomic status was a more important predictor of morbidity attributable to coronary disease, chronic bronchitis and depression than measures of social status earlier in life. In this population, the importance of social circumstances early in life may be in the way they influence employment and social position and thus exposures in adult life.

Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization

BACKGROUND

Ratings by an expert panel of the appropriateness of treatments may offer better guidance for clinical practice than the variable decisions of individual clinicians, yet there have been no prospective studies of clinical outcomes. We compared the clinical outcomes of patients treated medically after angiography with those of patients who underwent revascularization, within groups defined by ratings of the degree of appropriateness of revascularization in varying clinical circumstances.

METHODS

This was a prospective study of consecutive patients undergoing coronary angiography at three London hospitals. Before patients were recruited, a nine-member expert panel rated the appropriateness of percutaneous transluminal coronary angioplasty (PTCA) and coronary-artery bypass grafting (CABG) on a nine-point scale (with 1 denoting highly inappropriate and 9 denoting highly appropriate) for specific clinical indications. These ratings were then applied to a population of patients with coronary artery disease. However, the patients were treated without regard to the ratings. A total of 2552 patients were followed for a median of 30 months after angiography.

RESULTS

Of 908 patients with indications for which PTCA was rated appropriate (score, 7 to 9), 34 percent were treated medically; these patients were more likely to have angina at follow-up than those who underwent PTCA (odds ratio, 1.97; 95 percent confidence interval, 1.29 to 3.00). Of 1353 patients with indications for which CABG was considered appropriate, 26 percent were treated medically; they were more likely than those who underwent CABG to die or have a nonfatal myocardial infarction--the composite primary outcome (hazard ratio, 4.08; 95 percent confidence interval, 2.82 to 5.93)--and to have angina (odds ratio, 3.03; 95 percent confidence interval, 2.08 to 4.42). Furthermore, there was a graded relation between rating and outcome over the entire scale of appropriateness (P for linear trend=0.002).

CONCLUSIONS

On the basis of the ratings of the expert panel, we identified substantial underuse of coronary revascularization among patients who were considered appropriate candidates for these procedures. Underuse was associated with adverse clinical outcomes.

Automatic ectopic beat elimination in short-term heart rate variability measurement

Our studies deal with fully automatic measurement of heart rate variability (HRV) in short term electrocardiograms. Presently, all existing HRV analysis programs require user intervention for ectopic beat identification, especially of supraventricular ectopic beats (SVE). This makes the HRV measurement in large, e.g. epidemiological studies problematic. In this paper, we present a fully automatic algorithm for the discrimination of the ventricular (VE) and SVE ectopic beats from the normal QRS complexes suited for a reliable HRV analysis. The QRS identification is based on the template matching method. The ectopic beats are identified based on several morphological and timing properties of the electrocardiogram (ECG) signal. The method incorporates several approaches and makes HRV analysis of large numbers of electrocardiograms feasible. It uses the template matching for the basic morphology check of the QRS complex and the P-wave, the timing information to avoid unnecessary ectopic beat checks and to adjust thresholds and it also looks for a special QRS morphology, which is common in VEs. We used a testing set of 69 electrocardiograms selected from a large number of recordings. The selected ECGs contained abnormalities including ectopic beats, right branch bundle block, respiratory arrhythmia, blocked atrial extrasystole, high amplitude and wide T-waves. The evaluation of our method showed a specificity of 0.99, supraventricular ectopic beat sensitivity of 0.99 and ventricular ectopic beat sensitivity of 0.98.

Impact of socioeconomic status on coronary mortality in people with symptoms, electrocardiographic abnormalities, both or neither: the original Whitehall study 25 year follow up

OBJECTIVES

To determine the impact of socioeconomic status (SES) on coronary heart disease (CHD) mortality in people with and without prevalent CHD at baseline.

DESIGN

Cohort study with 25 year follow up; prevalent CHD was defined by Q, ST or T wave electrocardiographic (ECG) abnormalities or symptoms (defined by the Rose chest pain questionnaire and self reported doctor diagnosis) or both. SES was defined by four civil service employment grades.

SETTING

London.

PARTICIPANTS

17 907 male civil servants aged 40-69 years.

MAIN OUTCOME MEASURES

CHD mortality (n=2695 deaths).

RESULTS

The lowest versus highest employment grade was associated with increased CHD mortality (age adjusted hazard ratio 1.56 (95% CI 1.2, 2.1)), prevalence of symptoms and, among symptomatic participants only, the prevalence of Q, ST or T abnormalities. Thirty one per cent of CHD deaths occurred in participants with prevalent CHD at baseline. Among participants without Q, ST or T abnormality employment grade was associated with CHD mortality; the hazard ratios (lowest v highest grade) adjusted for age, systolic and diastolic blood pressure were 1.72 (95% CI 1.4, 2.1) for asymptomatic and 1.52 (95% CI 1.1, 2.1) for symptomatic participants; among participants with Q, ST or T abnormality the corresponding hazard ratios were 1.46 (95% CI 0.7, 2.9) and 1.14 (95% CI 0.6, 2.0) respectively.

CONCLUSIONS

SES was inversely associated with CHD mortality in civil servants with and without prevalent CHD at baseline. Further distinguishing the relative contribution of SES to the initiation and progression of CHD requires repeated measures studies of pre-clinical and clinical measures of CHD.

Are there age and sex differences in the investigation and treatment of heart failure? A population-based study

BACKGROUND

Heart failure is a serious, common, and growing problem. Hospital admissions, which account for the bulk of health service costs associated with heart failure, are becoming more frequent.

AIM

To determine whether management of heart failure differs by age and sex.

METHOD

A retrospective case note review of prevalent cases in 16 general practices in West London. Five hundred and eighty-three patients (57% women) with a diagnosis of heart failure were reviewed.

RESULTS

Mean age of patients with heart failure was 78 years (SD = 9.5)--74 years at diagnosis (SD = 10)--and was higher for women than men (76 years versus 71 years, P < 0.001). In 32% of patients there was no record of a chest X-ray, electrocardiogram, or echocardiogram to support diagnosis. Echocardiography, performed in 34% of patients, was less likely in older patients in both sexes (test for trend P = 0.04 in women and 0.02 in men) and, overall, in women (29% compared with 40% of men, P = 0.006). Angiotensin-converting enzyme (ACE) inhibitor treatment, recorded in 54% of patients, decreased with age in both sexes (P < 0.001) and, on unadjusted data, was more likely in men than in women (61% compared with 49%, P = 0.005). On adjustment for age, sex differences in the use of echocardiography and ACE inhibitors were reduced and no longer significant.

CONCLUSIONS

With increasing age, men and women with heart failure were less likely to have undergone echocardiography or to have received an ACE inhibitor. When account was taken of age, there were no statistically significant sex differences in management; however, because of the demographic distribution of heart failure, women are disproportionately affected by age differences in management. Clinical trials, physician practice, and service developments in heart failure have neglected older people. This balance should be redressed.

Waiting for coronary angiography: is there a clinically ordered queue?

Among over 3000 patients undergoing coronary angiography in the absence of a formal queue-management system, we found that a-priori urgency scores were strongly associated with waiting times, prevalence of coronary-artery disease, rate of revascularisation, and mortality. These data challenge the widely held assumption that such waiting lists are not clinically ordered; however, the wide variation in waiting times within urgency categories suggests the need for further improvements in clinical queueing.

Magnitude and consequences of error in coronary angiography interpretation (the ACRE study)

In the routine reporting of coronary angiograms, there are no contemporary estimates of the magnitude and consequences of interobserver variability. We therefore measured the agreement beyond chance between (1) the number of narrowed arteries on an angiographic report extracted from case notes and independent assessments by 2 cardiologists, and (2) actual patient management over an 18-month follow-up period and each cardiologist's hypothetical management proposal based on abstracted clinical details. Two hundred nine angiograms were randomly selected from 4,121 patients in a prospective study (Appropriateness of Coronary Revascularisation [ACRE study]). The number of narrowed arteries was defined using Coronary Artery Surgery Study (CASS) criteria. For the number of narrowed arteries, cardiologists A and B agreed with the angiographic report in 126 patients (60%, weighted kappa = 0.64) and 124 patients (59%, weighted kappa = 0.63), respectively. In a subset of 92 patients (44%) there was unanimous agreement on the number of narrowed arteries (both cardiologists agreed with the angiographic report). Comparing actual management (34 percutaneous transluminal coronary angioplasty and 39 coronary artery bypass grafting procedures on follow-up) with each of the cardiologist's management recommendations showed agreement in 150 patients (72%, kappa = 0.46) and 154 patients (74%, kappa = 0.48) for cardiologists A and B, respectively. These agreements on management improved (p = 0.05) for cardiologist B (but not A) when analysis was confined to the subset of 92 patients, showing agreement in 73 patients (79%, kappa = 0.60). Thus, in routine clinical practice, the agreement beyond chance in interpretation of the number of narrowed arteries was good. Disagreements on subsequent patient management arose as a result of, and independent of, errors in angiographic interpretation.

Rating the appropriateness of coronary angiography, coronary angioplasty and coronary artery bypass grafting: the ACRE study. Appropriateness of Coronary Revascularisation study

BACKGROUND

Previous studies investigating the appropriateness of invasive management of coronary disease had not reported the internal consistency of their ratings and may now be out of date. The aim of this study was to measure the influence of clinical factors on contemporary ratings of the appropriateness of coronary angiography, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) in the Appropriateness of Coronary Revascularisation (ACRE) study.

METHODS

The Delphi-RAND technique was used, in which an expert panel (four cardiologists, three cardiothoracic surgeons, a general physician and a general practitioner), meeting in 1995, rated mutually exclusive indications (n = 2178 for angiography, n = 995 for PTCA and n = 984 for CABG). The main outcome measures were the appropriateness category (inappropriate, uncertain or appropriate) for each of the three procedures and treatment preference.

RESULTS

For revascularization, the strongest determinant of inappropriateness was coronary anatomy. The odds ratio (OR) for inappropriate PTCA was 10.6 (95 per cent confidence interval (CI) 4.8-23.5) for the effect of left main stem or three-vessel disease versus single-vessel disease, and for CABG it was 0.06 (95 per cent CI 0.03-0.15). The number of diseased vessels was strongly related to preference for medical, PTCA or CABG treatment (p for linear trend <0.001). Mild versus severe anginal symptoms were associated with inappropriate angiography (OR 2.0 (95 per cent CI 0.9-9.8), although this effect was stronger when only the cardiologists' ratings were considered (OR 10.1 (95 per cent CI 2.4-42.6)).

CONCLUSION

These are the first UK ratings of appropriateness covering all three procedures. The associations with clinical factors provide evidence of the internal consistency of these ratings. Prospective validation of these ratings against clinical outcomes is under way in the ACRE study.

Human angiotensin I-converting enzyme gene and endurance performance

Human physical performance is strongly influenced by genetic factors. A variation in the structure of the human angiotensin I-converting enzyme (ACE) gene has been reported in which the insertion (I) variant is associated with lower ACE levels than the deletion (D) gene. We have previously reported that the I variant was associated with improved endurance performance in high-altitude mountaineers and British Army recruits. We now examine this genotype distribution in 91 British Olympic-standard runners (79 Caucasians). DNA was extracted from the buccal cells contained in 10 ml of saline mouthwash donated by the subjects, and the I and D variants of the ACE gene were identified by PCR amplification of the polymorphic region. There was an increasing frequency of the I allele with distance run [0.35, 0.53, and 0.62 for </=200 m (n = 20), 400-3,000 m (n = 37), and >/=5,000 m (n = 34), respectively; P = 0.009 for linear trend]. Among 404 Olympic-standard athletes from 19 other mixed sporting disciplines (in which endurance performance was not necessarily a key factor), the I allele did not differ significantly from that found in control subjects: 0.50 vs. 0.49 (P = 0.526). These results support a positive association of the I allele with elite endurance performance.

Determinants of socioeconomic differences in change in physical and mental functioning

Continuous decline in functioning is not an inevitable consequence of ageing, as some individuals maintain high levels of functioning to old age. The origins of functional problems in old age are not only related to current circumstances, but may be traced back to earlier life-experiences. Previous analyses show that change in functioning is related to socioeconomic status, but it is uncertain to what extent these differences can be accounted for by the same health behaviours and material and psychosocial factors that are related to socioeconomic differences in morbidity and mortality. This paper investigates socioeconomic differences in change in mental and physical functioning in a relatively young and healthy population over a three year follow-up period. The data come from the Whitehall II Study of London based civil servants aged 39-63 in 1991-93. We measured functioning with the Short Form 36 (SF-36) General Health Survey and socioeconomic status by civil service employment grade. Among lower employment grade men the odds ratio of being in the quartile of rapid decline in mental and physical functioning was 1.79 and 1.56 respectively. For women the odds ratio for physical functioning was 1.34, but employment grade differences in mental functioning were inconsistent. Among men health behaviours were the most important determinants of employment grade differences in physical functioning change. In addition, material problems and job decision latitude accounted for employment grade differences in physical as well as mental functioning change. However, among women employment grade differences in change in physical functioning can not be accounted for with these risk factors. Analyses of change in determinants may provide further insight into the underlying pathways. Early detection of functional decline and intervention may be a key to better functioning in ageing populations.

Are risk factors for atherothrombotic disease associated with back pain sickness absence? The Whitehall II Study

STUDY OBJECTIVE

To explore the previously stated hypothesis that risk factors for atherothrombotic disease are associated with back pain.

DESIGN

Prospective (mean of four years of follow up) and retrospective analyses using two main outcome measures: (a) short (< or = 7 days) and long (> 7 days) spells of sickness absence because of back pain reported separately in men and women; (b) consistency of effect across the resulting four duration of spell and sex cells.

SETTING

14 civil service departments in London.

PARTICIPANTS

3506 male and 1380 female white office-based civil servants, aged 35-55 years at baseline.

MAIN RESULTS

In age adjusted models, low apo AI was associated with back pain across all four duration-sex cells and smoking was associated across three cells. Six factors were associated with back pain in two cells: low exercise and high BMI, waist-hip ratio, triglycerides, insulin and Lp(a). On full adjustment (for age, BMI, employment grade and back pain at baseline), each of these factors retained a statistically significant effect in at least one duration-sex cell. Triglycerides were associated with short and long spells of sickness absence because of back pain in men in fully adjusted models with rate ratios (95% confidence intervals) of 1.53 (1.1, 2.1) and 1.75 (1.0, 3.2) respectively. There was little or no evidence of association in age adjusted models with: fibrinogen, glucose tolerance, total cholesterol, apoB, hypertension, factor VII, von Willebrand factor, electrocardiographic evidence of coronary heart disease and reported angina.

CONCLUSIONS

In this population of office workers, only modest support was found for an atherothrombotic component to back pain sickness absence. However, the young age of participants at baseline and the lack of distinction between different types of back pain are likely to bias the findings toward null. Further research is required to ascertain whether a population sub-group of atherothrombotic back pain can be identified.

Angiotensin-converting-enzyme gene insertion/deletion polymorphism and response to physical training

BACKGROUND

The function of local renin-angiotensin systems in skeletal muscle and adipose tissue remains largely unknown. A polymorphism of the human angiotensin converting enzyme (ACE) gene has been identified in which the insertion (I) rather than deletion (D) allele is associated with lower ACE activity in body tissues and increased response to some aspects of physical training. We studied the association between the ACE gene insertion or deletion polymorphism and changes in body composition related to an intensive exercise programme, to investigate the metabolic effects of local human renin-angiotensin systems.

METHODS

We used three independent methods (bioimpedance, multiple skinfold-thickness assessment of whole-body composition, magnetic resonance imaging of the mid-thigh) to study changes in body composition in young male army recruits over 10 weeks of intensive physical training.

FINDINGS

Participants with the II genotype had a greater anabolic response than those with one or more D alleles for fat mass (0.55 vs -0.20 kg, p=0.04 by bioimpedance) and non-fat mass (1.31 vs -0.15 kg, p=0.01 by bioimpedance). Changes in body morphology with training measured by the other methods were also dependent on genotype.

INTERPRETATION

II genotype, as a marker of low ACE activity in body tissues, may conserve a positive energy balance during rigorous training, which suggests enhanced metabolic efficiency. This finding may explain some of the survival and functional benefits of therapy with ACE inhibitors.

Differences in biological risk factors for cardiovascular disease between three ethnic groups in the Whitehall II study

This study compares risk factors for cardiovascular disease in civil servants of three ethnic groups screened as part of the Whitehall II cohort study. Previously identified risk factors for cardiovascular disease in 360 Afro-Caribbean and 577 South Asian subjects are compared with the 8973 white Caucasian subjects. Controlling for socio-economic status is more precise than in most previous studies of cardiovascular differences between ethnic groups. After controlling for socio-economic confounding factors, age and sex, South Asian subjects were found to have increased prevalence of hypertension (defined as either having systolic pressure of > 160, diastolic pressure of > 95 or being on antihypertensives) OR 2.3 (95% CI 1.6-3.3), diabetes OR 4.2 (95%, CI 3.0-5.8) and a high risk lipid profile, although total cholesterol was lower than in the white population. Afro-Caribbean subjects had more hypertension OR 4.0 (95% CI 2.8-5.7) and diabetes OR 2.8 (95% CI 1.7-4.6), but this was accompanied by a favourable lipid profile with low cholesterol and high HDL. Afro-Caribbean alcohol and smoking habits were low-risk. Socio-economic status was found to be an important confounding factor for ethnic differences in biochemical risk factors for cardiovascular disease. However, adjusting for socioeconomic class only attenuates observed differences; it does not abolish them.

Cardiothoracic ratio and relative heart volume as predictors of coronary heart disease mortality. The Whitehall study 25 year follow-up

AIM

To examine the association of radiographic measures of heart size with mortality from coronary heart disease.

METHODS AND RESULTS

One thousand, one hundred and ninety-one male civil servants aged 40-69 years were followed-up for mortality over 25 years in relation to cardiothoracic ratio and relative heart volume. A high cardiothoracic ratio and relative heart volume predicted coronary (n = 196 deaths) and all-cause mortality, but not respiratory or malignant mortality. After adjustment for age, systolic and diastolic blood pressure, the highest (> or = 0.47) compared to the lowest quintile of the cardiothoracic ratio (< 0.40) was associated with a rate ratio of 1.84 (95% CI 1.14-2.97) for the effect on coronary heart disease mortality. Further adjustment for heart rate, smoking, cholesterol, angina and ECG ischaemia had little effect, reducing the rate ratio to 1.65 (95% CI 1.01-2.70). Similar rate ratios were observed for relative heart volume.

CONCLUSIONS

Cardiothoracic ratio within the range considered 'normal' in clinical practice predicted coronary heart disease mortality independent of established coronary heart disease risk factors. The relative heart volume, which uses measurements from the lateral as well as the posteroanterior chest X-ray, did not predict coronary heart disease any better than the cardiothoracic ratio. The extent to which left ventricular mass and systolic dysfunction-- pathophysiological correlates of the cardiothoracic ratio and relative heart volume--are independent risk factors for coronary heart disease should be further investigated.

Behavioural and biological correlates of physical functioning in middle aged office workers: the UK whitehall II study

STUDY OBJECTIVES

(1) To identify behavioural and biological correlates of poor physical functioning and (2) to determine whether such associations are independent of disease.

DESIGN

Potential correlates were obtained from questionnaires and screening visits at baseline and five year follow up. Physical functioning was measured at follow up using the 10 item scale from the short-form 36 health survey.

SETTING

London offices at baseline.

PARTICIPANTS

10,308 civil servants (6895 men and 3413 women), with a median age (range) of 49 years (39-63) at follow up.

MAIN RESULTS

Multiple logistic regression showed that cigarette smoking, physical activity, body mass index (BMI), triglycerides, fibrinogen, and insulin were independently associated with poor physical functioning for men. For women, physical activity, eating habits, body mass index, fibrinogen, and insulin were independently associated with poor physical functioning. For example, among men, current smokers who had smoked more than 20 pack years were 1.89 (95% CI 1.35 to 2.67) times as likely to have poor physical functioning as never smokers. Men with BMI of 30 kg/m2 or more were 1.71 (95% CI 1.13 to 2.59) times as likely to have poor physical functioning as those with BMI < 20 kg/m2. The corresponding odds ratio for women was 2.66 (95% CI 1.80 to 3.93). With the exceptions of fibrinogen and insulin, associations remained on exclusion of subjects with physical disease.

CONCLUSIONS

Risk factors established for physical diseases are associated with poor physical functioning in a population of working age. These associations may be independent of current disease.