Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies

BACKGROUND

Low-risk limits recommended for alcohol consumption vary substantially across different national guidelines. To define thresholds associated with lowest risk for all-cause mortality and cardiovascular disease, we studied individual-participant data from 599 912 current drinkers without previous cardiovascular disease.

METHODS

We did a combined analysis of individual-participant data from three large-scale data sources in 19 high-income countries (the Emerging Risk Factors Collaboration, EPIC-CVD, and the UK Biobank). We characterised dose-response associations and calculated hazard ratios (HRs) per 100 g per week of alcohol (12·5 units per week) across 83 prospective studies, adjusting at least for study or centre, age, sex, smoking, and diabetes. To be eligible for the analysis, participants had to have information recorded about their alcohol consumption amount and status (ie, non-drinker vs current drinker), plus age, sex, history of diabetes and smoking status, at least 1 year of follow-up after baseline, and no baseline history of cardiovascular disease. The main analyses focused on current drinkers, whose baseline alcohol consumption was categorised into eight predefined groups according to the amount in grams consumed per week. We assessed alcohol consumption in relation to all-cause mortality, total cardiovascular disease, and several cardiovascular disease subtypes. We corrected HRs for estimated long-term variability in alcohol consumption using 152 640 serial alcohol assessments obtained some years apart (median interval 5·6 years [5th-95th percentile 1·04-13·5]) from 71 011 participants from 37 studies.

FINDINGS

In the 599 912 current drinkers included in the analysis, we recorded 40 310 deaths and 39 018 incident cardiovascular disease events during 5·4 million person-years of follow-up. For all-cause mortality, we recorded a positive and curvilinear association with the level of alcohol consumption, with the minimum mortality risk around or below 100 g per week. Alcohol consumption was roughly linearly associated with a higher risk of stroke (HR per 100 g per week higher consumption 1·14, 95% CI, 1·10-1·17), coronary disease excluding myocardial infarction (1·06, 1·00-1·11), heart failure (1·09, 1·03-1·15), fatal hypertensive disease (1·24, 1·15-1·33); and fatal aortic aneurysm (1·15, 1·03-1·28). By contrast, increased alcohol consumption was log-linearly associated with a lower risk of myocardial infarction (HR 0·94, 0·91-0·97). In comparison to those who reported drinking >0-≤100 g per week, those who reported drinking >100-≤200 g per week, >200-≤350 g per week, or >350 g per week had lower life expectancy at age 40 years of approximately 6 months, 1-2 years, or 4-5 years, respectively.

INTERPRETATION

In current drinkers of alcohol in high-income countries, the threshold for lowest risk of all-cause mortality was about 100 g/week. For cardiovascular disease subtypes other than myocardial infarction, there were no clear risk thresholds below which lower alcohol consumption stopped being associated with lower disease risk. These data support limits for alcohol consumption that are lower than those recommended in most current guidelines.

FUNDING

UK Medical Research Council, British Heart Foundation, National Institute for Health Research, European Union Framework 7, and European Research Council.

The rising prevalence of diabetes and impaired glucose tolerance: the Australian Diabetes, Obesity and Lifestyle Study

OBJECTIVE

To determine the population-based prevalence of diabetes and other categories of glucose intolerance (impaired glucose tolerance [IGT] and impaired fasting glucose [IFG]) in Australia and to compare the prevalence with previous Australian data.

RESEARCH DESIGN AND METHODS

A national sample involving 11,247 participants aged > or =25 years living in 42 randomly selected areas from the six states and the Northern Territory were examined in a cross-sectional survey using the 75-g oral glucose tolerance test to assess fasting and 2-h plasma glucose concentrations. The World Health Organization diagnostic criteria were used to determine the prevalence of abnormal glucose tolerance.

RESULTS

The prevalence of diabetes in Australia was 8.0% in men and 6.8% in women, and an additional 17.4% of men and 15.4% of women had IGT or IFG. Even in the youngest age group (25-34 years), 5.7% of subjects had abnormal glucose tolerance. The overall diabetes prevalence in Australia was 7.4%, and an additional 16.4% had IGT or IFG. Diabetes prevalence has more than doubled since 1981, and this is only partially explained by changes in age profile and obesity.

CONCLUSIONS

Australia has a rapidly rising prevalence of diabetes and other categories of abnormal glucose tolerance. The prevalence of abnormal glucose tolerance in Australia is one of the highest yet reported from a developed nation with a predominantly Europid background.

Increasing walking: how important is distance to, attractiveness, and size of public open space?

BACKGROUND

Well-designed public open space (POS) that encourages physical activity is a community asset that could potentially contribute to the health of local residents.

METHODS

In 1995-1996, two studies were conducted-an environmental audit of POS over 2 acres (n =516) within a 408-km2 area of metropolitan Perth, Western Australia; and personal interviews with 1803 adults (aged 18 to 59 years) (52.9% response rate). The association between access to POS and physical activity was examined using three accessibility models that progressively adjusted for distance to POS, and its attractiveness and size. In 2002, an observational study examined the influence of attractiveness on the use of POS by observing users of three pairs of high- and low-quality (based on attractiveness) POS matched for size and location.

RESULTS

Overall, 28.8% of respondents reported using POS for physical activity. The likelihood of using POS increased with increasing levels of access, but the effect was greater in the model that adjusted for distance, attractiveness, and size. After adjustment, those with very good access to large, attractive POS were 50% more likely to achieve high levels of walking (odds ratio, 1.50; 95% confidence level, 1.06-2.13). The observational study showed that after matching POS for size and location, 70% of POS users observed visited attractive POS.

CONCLUSIONS

Access to attractive, large POS is associated with higher levels of walking. To increase walking, thoughtful design (and redesign) of POS is required that creates large, attractive POS with facilities that encourage active use by multiple users (e.g., walkers, sports participants, picnickers).

Developing a reliable audit instrument to measure the physical environment for physical activity

BACKGROUND

The physical environment plays an important role in influencing participation in physical activity, although which factors of the physical environment have the greatest effect on patterns of activity remain to be determined. We describe the development of a comprehensive instrument to measure the physical environmental factors that may influence walking and cycling in local neighborhoods and report on its reliability.

METHODS

Following consultation with experts from a variety of fields and a literature search, we developed a Systematic Pedestrian and Cycling Environmental Scan (SPACES) instrument and used it to collect data over a total of 1987 kilometers of roads in metropolitan Perth, Western Australia. The audit instrument is available from the first author on request. Additional environmental information was collected using desktop methods and geographic information systems (GIS) technology. We assessed inter- and intra-rater reliability of the instrument among the 16 observers who collected the data.

RESULTS

The observers reported that the audit instrument was easy to use. Both inter- and intra-rater reliability of the environmental scan instrument were generally high.

CONCLUSIONS

Our instrument provides a reliable, practical, and easy-to-use method for collecting detailed "street-level" data on physical environmental factors that are potential influences on walking in local neighborhoods.

Cardiovascular Risk Factors Associated With Venous Thromboembolism

Importance

It is uncertain to what extent established cardiovascular risk factors are associated with venous thromboembolism (VTE).

Objective

To estimate the associations of major cardiovascular risk factors with VTE, ie, deep vein thrombosis and pulmonary embolism.

Design, Setting, and Participants

This study included individual participant data mostly from essentially population-based cohort studies from the Emerging Risk Factors Collaboration (ERFC; 731 728 participants; 75 cohorts; years of baseline surveys, February 1960 to June 2008; latest date of follow-up, December 2015) and the UK Biobank (421 537 participants; years of baseline surveys, March 2006 to September 2010; latest date of follow-up, February 2016). Participants without cardiovascular disease at baseline were included. Data were analyzed from June 2017 to September 2018.

Exposures

A panel of several established cardiovascular risk factors.

Main Outcomes and Measures

Hazard ratios (HRs) per 1-SD higher usual risk factor levels (or presence/absence). Incident fatal outcomes in ERFC (VTE, 1041; coronary heart disease [CHD], 25 131) and incident fatal/nonfatal outcomes in UK Biobank (VTE, 2321; CHD, 3385). Hazard ratios were adjusted for age, sex, smoking status, diabetes, and body mass index (BMI).

Results

Of the 731 728 participants from the ERFC, 403 396 (55.1%) were female, and the mean (SD) age at the time of the survey was 51.9 (9.0) years; of the 421 537 participants from the UK Biobank, 233 699 (55.4%) were female, and the mean (SD) age at the time of the survey was 56.4 (8.1) years. Risk factors for VTE included older age (ERFC: HR per decade, 2.67; 95% CI, 2.45-2.91; UK Biobank: HR, 1.81; 95% CI, 1.71-1.92), current smoking (ERFC: HR, 1.38; 95% CI, 1.20-1.58; UK Biobank: HR, 1.23; 95% CI, 1.08-1.40), and BMI (ERFC: HR per 1-SD higher BMI, 1.43; 95% CI, 1.35-1.50; UK Biobank: HR, 1.37; 95% CI, 1.32-1.41). For these factors, there were similar HRs for pulmonary embolism and deep vein thrombosis in UK Biobank (except adiposity was more strongly associated with pulmonary embolism) and similar HRs for unprovoked vs provoked VTE. Apart from adiposity, these risk factors were less strongly associated with VTE than CHD. There were inconsistent associations of VTEs with diabetes and blood pressure across ERFC and UK Biobank, and there was limited ability to study lipid and inflammation markers.

Conclusions and Relevance

Older age, smoking, and adiposity were consistently associated with higher VTE risk.

Glycemic exposure is associated with reduced pulmonary function in type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE

To examine prospectively the relationship between diabetes, glycemic control, and spirometric measures.

RESEARCH DESIGN AND METHODS

From a community-based cohort, 495 Europid (i.e., of European descent) patients with type 2 diabetes who had no history of pulmonary disease underwent baseline spirometry between 1993 and 1994. A subset of 125 patients was restudied a mean of 7.0 years later. The main outcome measures included forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), vital capacity (VC), and peak expiratory flow (PEF) corrected for body temperature, air pressure, and water saturation and were expressed either in absolute terms or as percentage-predicted value for age, sex, and height.

RESULTS

Mean percentage-predicted values of each spirometric measure were decreased >10% in the whole cohort at baseline and absolute measures continued to decline at an annual rate of 68, 71, and 84 ml/year and 17 l/min for FVC, FEV1, VC, and PEF, respectively, in the 125 prospectively studied patients. Declining lung function measures were consistently predicted by poor glycemic control in the form of a higher updated mean HbA1c, follow-up HbA1c, or follow-up fasting plasma glucose. In a Cox proportional hazards model, decreased FEV1 percentage-predicted value was an independent predictor of all-cause mortality.

CONCLUSIONS

Reduced lung volumes and airflow limitation are likely to be chronic complications of type 2 diabetes, the severity of which relates to glycemic exposure. Airflow limitation is a predictor of death in type 2 diabetes after adjusting for other recognized risk factors.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

Neighbourhood design and fear of crime: a social-ecological examination of the correlates of residents' fear in new suburban housing developments

This study explored the relationship between neighbourhood design and residents' fear of crime in new suburban housing developments. Self-report and objective data were collected as part of the RESIDential Environments (RESIDE) Project. A neighbourhood form index based on the planning and land-use characteristics that draw people into public space, facilitate pedestrian movement and ensure the presence of 'territorial guardians' was developed for each participant (n=1059) from objective environmental data. With each additional index attribute, the odds of being fearful reduced (trend test p value=0.001), and this persisted even after progressive adjustment for demographics, victimisation, collective efficacy and perceived problems. The findings support the notion that a more walkable neighbourhood is also a place, where residents feel safer, and provides further evidence endorsing a shift away from low density, curvilinear suburban developments towards more walkable communities with access to shops, parks and transit.

Dog ownership, health and physical activity: a critical review of the literature

This review examines the association between dog ownership and adult physical activity levels. While there is evidence to suggest that dog ownership produces considerable health benefit and provides an important form of social support that encourages dog owners to walk, there is limited evidence on the physical environmental and policy-related factors that affect dog owners walking with their dog. With the high level of dog ownership in many industrialized countries, further exploration of the relationship between dog ownership and physical activity levels may be important for preventing declining levels of physical activity and the associated detrimental health effects.

Quality or quantity? Exploring the relationship between Public Open Space attributes and mental health in Perth, Western Australia

Mental health is a public health priority globally. Public Open Space (POS) may enhance mental health by facilitating contact with nature and the development of supportive relationships. Despite growing interest in the influence of the built environment on mental health, associations between POS attributes and mental health remain relatively unexplored. In particular, few studies have examined the relative effects of the quantity and quality of POS within a neighbourhood on mental health. Guided by a social-ecological framework, this study investigated the relationship between POS attributes (i.e., quantity and quality) and better mental health (i.e., low risk of psychological distress) in residents of new housing developments in the Perth metropolitan area, Western Australia. The extent to which relationships between POS attributes and mental health were confounded by psychosocial factors (e.g., social support, sense of community) and frequent use of POS was also explored. Data were obtained from a cross-sectional survey (n = 911), a POS audit, and Geographical Information Systems, and was analysed using logistic regression. Approximately 80% of survey participants were at low risk of psychological distress. Residents of neighbourhoods with high quality POS had higher odds of low psychosocial distress than residents of neighbourhoods with low quality POS. This appeared to be irrespective of whether or not they used POS. However, the quantity of neighbourhood POS was not associated with low psychological distress. From a mental health perspective, POS quality within a neighbourhood appears to be more important than POS quantity. This finding has policy implications and warrants further investigation.

Development of a reliable measure of walking within and outside the local neighborhood: RESIDE's Neighborhood Physical Activity Questionnaire

BACKGROUND

The RESIDential Environment project (RESIDE) is a longitudinal study evaluating the impact of a new residential design code on walking.

OBJECTIVE

To develop a reliable measure of walking--undertaken within and outside the neighborhood--and overall physical activity.

METHODS

A test-retest reliability study was undertaken (n = 82, mean age 39 years). The instrument was based on the International Physical Activity Questionnaire (IPAQ-short version) and Active Australia Survey. It measured usual frequency and duration of (1) recreational- and transport-related walking within and outside the neighborhood and (2) other vigorous and moderate physical activities.

RESULTS

Reliability of recall of whether participants had walked within (k = 0.84) and outside (0.73) the neighborhood was acceptable. Similarly, recall of frequency and duration of transport and recreational-related walking within the neighborhood was excellent (ICC > or = 0.82), as was recall of transport-related walking trips outside the neighborhood (ICC > or = 0.84). Reliability for duration of recreational walking outside the neighborhood was fair to good (ICC = 0.55). The reliability of indices of total physical activity based on MET min/week (ICC = 0.82) and MET min/week dichotomized to 'sufficient' physical activity for health (kappa = 0.67) were both acceptable.

CONCLUSIONS

The Neighborhood Physical Activity Questionnaire (NPAQ) is sufficiently reliable for studies examining environmental correlates of walking within the neighborhood.

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.

The association between neighborhood greenness and cardiovascular disease: an observational study

Background

Previous studies have demonstrated links between cardiovascular disease and physical inactivity and poor air quality, which are both associated with neighborhood greenness. However, no studies have directly investigated neighborhood greenness in relation to coronary heart disease risk. We investigated the effect of neighborhood greenness on both self-reported and hospital admissions of coronary heart disease or stroke, accounting for ambient air quality, socio-demographic, behavioral and biological factors.

Method

Cross-sectional study of 11,404 adults obtained from a population representative sample for the period 2003–2009 in Perth, Western Australia. Neighborhood greenness was ascertained for a 1600 m service area surrounding the residential address using the mean and standard deviation of the Normalized Difference Vegetation Index (NDVI) obtained from remote sensing. Logistic regression was used to assess associations with medically diagnosed and hospitalization for coronary heart disease or stroke.

Results

The odds of hospitalization for heart disease or stroke was 37% (95% CI: 8%, 57%) lower among adults in neighborhoods with highly variable greenness (highest tertile) compared to those in predominantly green, or predominantly non-green neighborhoods (lowest tertile). This effect was independent of the absolute levels of neighborhood greenness. There was weaker evidence for associations with the mean level of neighborhood greenness.

Conclusion

Variability in neighborhood greenness is a single metric that encapsulates two potential promoters of physical activity - an aesthetically pleasing natural environment and access to urban destinations. Variability in greenness within a neighborhood was negatively associated with coronary heart disease and stroke.

The influence of the neighborhood physical environment on early child health and development: A review and call for research

This review examines evidence of the association between the neighborhood built environment, green spaces and outdoor home area, and early (0-7 years) child health and development. There was evidence that the presence of child relevant neighborhood destinations and services were positively associated with early child development domains of physical health and wellbeing and social competence. Parents׳ perceptions of neighborhood safety were positively associated with children׳s social-emotional development and general health. Population representative studies using objective measures of the built environment and valid measures of early child development are warranted to understand the impact of the built environment on early child health and development.

Investigations of thyroid hormones and antibodies based on a community health survey: the Busselton thyroid study

OBJECTIVE

Overt or subclinical thyroid dysfunction is common within the community, yet the significance of subtle anomalies in thyroid function tests remains contentious. The aims of this study were to: (a) establish reference intervals for serum-free thyroxine (FT4), thyroid-stimulating hormone (TSH) and thyroid antibodies (antithyroperoxidase, TPOAb and antithyroglobulin, TgAb) in the Busselton community of south-western Western Australia; and (b) determine the prevalence of thyroid hormone anomalies in this community.

SUBJECTS AND DESIGN

In 1981, 2115 adults residing in Busselton participated in a cross-sectional health survey that involved blood collection and a questionnaire on lifestyle and general health history.

MEASUREMENTS

Serum samples were analysed for FT4, TSH, TPOAb and TgAb by immunochemiluminescent assays.

RESULTS

Based on standard statistical approaches and using guidelines recommended by the National Academy of Clinical Biochemistry (NACB), reference intervals were derived for each analyte: 9-23 pmol/l for FT4, 0.4-4.0 mIU/l (TSH), < 35 KIU/l (TPOAb) and < 55 KIU/l (TgAb). The prevalence of elevated thyroid antibodies was 12.4% among subjects without a history of thyroid disease and is more common in women than in men. Elevated thyroid antibody levels were observed at both extremes of TSH abnormality, but were more commonly increased when TSH levels were above 4.0 mIU/l (63% subjects) than for those with TSH levels 0.4-4.0 mIU/l (7.8% subjects).

CONCLUSIONS

This study establishes the prevalence of antibodies to thyroperoxidase and thyroglobulin in a community-based sample and reference intervals for free T4 and TSH. When the NACB decision limits are applied to older men or women, there is a markedly increased number with 'elevated' autoantibody levels compared to sex- and age-specific reference intervals.

The impact of neighborhood walkability on walking: does it differ across adult life stage and does neighborhood buffer size matter?

We explored the impact of neighborhood walkability on young adults, early-middle adults, middle-aged adults, and older adults' walking across different neighborhood buffers. Participants completed the Western Australian Health and Wellbeing Surveillance System Survey (2003-2009) and were allocated a neighborhood walkability score at 200m, 400m, 800m, and 1600m around their home. We found little difference in strength of associations across neighborhood size buffers for all life stages. We conclude that neighborhood walkability supports more walking regardless of adult life stage and is relevant for small (e.g., 200m) and larger (e.g., 1600m) neighborhood buffers.

Understanding dog owners' increased levels of physical activity: results from RESIDE

We examined the influence of dog ownership on physical activity, independent of demographic, intrapersonal, and perceived environmental factors, in a cross-sectional survey of 1813 adults. Although only 23% of the dog owners walked their dogs 5 or more times per week, the adjusted odds of achieving sufficient physical activity and walking were 57% to 77% higher among dog owners compared with those not owning dogs (P< .05). Dog ownership was independently associated with physical activity and walking. Actively encouraging more dog walking may increase community physical activity levels.

Reduced pulmonary function and its associations in type 2 diabetes: the Fremantle Diabetes Study

To determine whether diabetes is associated with reduced lung function, we studied 421 Anglo-Celt/European subjects, representing 20.5% of all patients with type 2 diabetes identified in an urban Australian catchment area of 120097 people. In addition to collection of detailed demographic and diabetes-specific data, spirometry was performed and forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), vital capacity (VC) and peak expiratory flow (PEF) measured. When expressed as a percentage of those predicted (%pred) for age, sex and height, the means of all spirometric measures were reduced by > or =9.5%. After controlling for smoking, age and gender in a linear regression model, HbA(1c) was not associated with any measure of lung function (P>0.13) but diabetes duration was significantly associated with FEV1(%pred) and PEF(%pred) (P< or =0.04) and had borderline associations with FVC(%pred) and VC(%pred) (P< or =0.064). In separate analyses controlling for smoking alone, age, body mass index (BMI), coronary heart disease (CHD) and retinopathy were independently and inversely associated with FVC(%pred), FEV1(%pred) and VC(%pred) (P<0.05). In sub-group analyses, these three spirometric measures were associated with BMI, CHD and diabetes duration in males, and age and BMI in females. Pulmonary function is reduced in type 2 diabetes. Diabetes duration seems a more important influence than glycaemic control, but obesity and vascular disease may also contribute.

Effect of length of stay in intensive care unit on hospital and long-term mortality of critically ill adult patients

BACKGROUND

Critical illness leading to prolonged length of stay (LOS) in an intensive care unit (ICU) is associated with significant mortality and resource utilization. This study assessed the independent effect of ICU LOS on in-hospital and long-term mortality after hospital discharge.

METHODS

Clinical and mortality data of 22 298 patients, aged 16 yr and older, admitted to ICU between 1987 and 2002 were included in this linked-data cohort study. Cox's regression with restricted cubic spline function was used to model the effect of LOS on in-hospital and long-term mortality after adjusting for age, gender, acute physiology score (APS), maximum number of organ failures, era of admission, elective admission, Charlson's co-morbidity index, and diagnosis. The variability each predictor explained was calculated by the percentage of the chi(2) statistic contribution to the total chi(2) statistic.

RESULTS

Most hospital deaths occurred within the first few days of ICU admission. Increasing LOS in ICU was not associated with an increased risk of in-hospital mortality after adjusting for other covariates, but was associated with an increased risk of long-term mortality after hospital discharge. The variability on the long-term mortality effect associated with ICU LOS (2.3%) appeared to reach a plateau after the first 10 days in ICU and was not as important as age (35.8%), co-morbidities (18.6%), diagnosis (10.9%), and APS (3.6%).

CONCLUSIONS

LOS in ICU was not an independent risk factor for in-hospital mortality, but it had a small effect on long-term mortality after hospital discharge after adjustment for other risk factors.

Long term survival after evidence based treatment of acute myocardial infarction and revascularisation: follow-up of population based Perth MONICA cohort, 1984-2005

OBJECTIVE

To examine trends in long term survival in patients alive 28 days after myocardial infarction and the impact of evidence based medical treatments and coronary revascularisation during or near the event.

DESIGN

Population based cohort with 12 year follow-up.

SETTING

Perth, Australia.

PARTICIPANTS

4451 consecutive patients with a definite acute myocardial infarction according to the World Health Organization MONICA (monitoring trends and determinants in cardiovascular disease) criteria admitted to hospital during 1984-7, 1988-90, and 1991-3.

MAIN OUTCOME MEASURES

All cause mortality identified from official mortality records and the hospital morbidity data, with death from cardiovascular disease as a secondary end point.

RESULTS

In the 1991-3 cohort, 28 day survivors of acute myocardial infarction had a 7.6% absolute event reduction (95% confidence interval 4% to 11%) or a 28% lower relative risk reduction (16% to 38%), unadjusted for risk of death, over 12 years after the incident admission compared with the 1984-7 cohort, similar to the survival of the 1988-90 cohort. The improved survival for the 1991-3 cohort persisted after adjustment for demographic factors, coronary risk factors, severity of disease, and event complications with an adjusted relative risk reduction of 26% (14% to 37%), but this was not apparent after further adjustment for medical treatments in hospital and coronary revascularisation procedures within 12 months of the incident myocardial infarction.

CONCLUSION

The improving trends in 12 year survival after a definite acute myocardial infarction are associated with progressive use of evidence based treatments during the initial admission to hospital and in the 12 months after the event. These changes in the management of acute myocardial infarction are probably contributing to the continuing decline in mortality from coronary heart disease in Australia.

Trends from 1996 to 2007 in incidence and mortality outcomes of heart failure after acute myocardial infarction: a population-based study of 20,812 patients with first acute myocardial infarction in Western Australia

Background

Advances in treatment for acute myocardial infarction (AMI) are likely to have had a beneficial impact on the incidence of and deaths attributable to heart failure (HF) complicating AMI, although limited data are available to support this contention.

Methods and Results

Western Australian linked administrative health data were used to identify 20 812 consecutive patients, aged 40 to 84 years, without prior HF hospitalized with an index (first) AMI between 1996 and 2007. We assessed the temporal incidence of and adjusted odds ratio/hazard ratio for death associated with HF concurrent with AMI admission and within 1 year after discharge. Concurrent HF comprised 75% of incident HF cases. Between the periods 1996–1998 and 2005–2007, the prevalence of HF after AMI declined from 28.1% to 16.5%, with an adjusted odds ratio of 0.50 (95% CI, 0.44 to 0.55). The crude 28‐day case‐fatality rate for patients with concurrent HF declined marginally from 20.5% to 15.9% (P<0.05) compared with those without concurrent HF, in whom the case‐fatality rate declined from 11.0% to 4.8% (P<0.001). Concurrent HF was associated with a multivariate‐adjusted odds ratio of 2.2 for 28‐day mortality and a hazard ratio of 2.2 for 1‐year mortality in 28‐day survivors. Occurrence of HF within 90 days of the index AMI was associated with an adjusted hazard ratio of 2.7 for 1‐year mortality in 90‐day survivors.

Conclusions

Despite encouraging declines in the incidence of HF complicating AMI, it remains a common problem with high mortality. Increased attention to these high‐risk patients is needed given the lack of improvement in their long‐term prognosis.

Evaluation of the implementation of a state government community design policy aimed at increasing local walking: design issues and baseline results from RESIDE, Perth Western Australia

OBJECTIVES

To describe the design and baseline results of an evaluation of the Western Australian government's pedestrian-friendly subdivision design code (Liveable Neighborhood (LN) Guidelines).

METHODS

Baseline results (2003-2005) from a longitudinal study of people (n=1813) moving into new housing developments: 18 Liveable, 11 Hybrid and 45 Conventional (i.e., LDs, HDs and CDs respectively) are presented including usual recreational and transport-related walking undertaken within and outside the neighborhood, and 7-day pedometer steps.

RESULTS

At baseline, more participants walked for recreation and transport within the neighborhood (52.6%; 36.1% respectively), than outside the neighborhood (17.7%; 13.2% respectively). Notably, only 20% of average total duration of walking (128.4 min/week (SD159.8)) was transport related and within the neighborhood. There were few differences between the groups' demographic, psychosocial and perceived neighborhood environmental characteristics, pedometer steps, or the type, amount and location of self-reported walking (p>0.05). However, asked what factors influenced their choice of housing development, more participants moving into LDs reported aspects of their new neighborhood's walkability as important (p<0.05).

CONCLUSIONS

The baseline results underscore the desirability of incorporating behavior and context-specific measures and value of longitudinal designs to enable changes in behavior, attitudes, and urban form to be monitored, while adjusting for baseline residential location preferences.