Participation bias in a population-based echocardiography study

Disparities in esophageal cancer care: a population-based study

BACKGROUND

Vulnerable populations potentially have a worse prognosis for cancer. The present study aimed to identify individual and municipal characteristics of access to health, including education, use of health insurance, gross domestic product per capita (GDPpc), and urban aspects, which could impact the prognosis of patients with esophageal cancer.

METHODS

Data on urban concentration, administrative hierarchy, GDPpc, individual patient characteristics, and access to healthcare were collected from national and state public databases spanning between 2013 and 2022. The study included cities in the state of Sao Paulo, Brazil. Independent variables such as GDPpc, urban concentration, municipal administrative hierarchy, health insurance status, education level, and individual cancer and patient characteristics were evaluated against the outcomes of overall survival (OS), likelihood of undergoing surgical treatment, and time-to-treatment initiation.

RESULTS

A total of 9280 patients with esophageal cancer (85% squamous cell carcinoma and 15% adenocarcinoma) treated in 42 cities were included in the study. In univariate analysis, higher education (hazard ratio [HR] = 0.6; P < .001), female gender (HR = 0.85; P < .001), and having private health insurance (HR = 0.65; P < .001) were identified as protective factors for OS in esophageal cancer. After adjusting for other variables in multivariate analysis, higher education (HR = 0.77; P = .009), female gender (HR = 0.82; P < .001), and private insurance (HR = 0.65; P < .001) remained protective factors. GDPpc was not associated with OS. Urban concentration and hierarchy influenced the likelihood of receiving surgical treatment. Patients from high urban concentrations had shorter time-to-treatment initiation intervals.

CONCLUSION

Populations at risk, particularly those with limited access to education and healthcare, face a worse prognosis for esophageal cancer.

The impact of the institutional abdominoperineal resections volume on short-term outcomes and expenses: a nationwide study

BACKGROUND

The aim of this study was to evaluate the influence of the institutional volume of abdominoperineal resections (APR) on the short-term outcomes and costs in the Brazilian Public Health system.

METHODS

This population-based study evaluated the number of APRs by institutions performed in the Brazilian Public Health system from January/2010 to July/2022. Data were extracted from a public domain from the Brazilian Public Health system.

RESULTS

Four hundred and twelve hospitals performed APRs and were included. Only 23 performed at least 5 APRs per year on average and were considered high-volume institutions. The linear regression model showed that the number of hospital admissions for APRs was negatively associated with in-hospital mortality (Coef. = - 0.001; p = 0.013) and length of stay in the intensive care unit (Coef. = - 0.006; p = 0.01). The number of hospital admissions was not significantly associated with personnel, hospital, and total costs. The in-hospital mortality in high-volume institutions was significantly lower than in low-volume institutions (2.5 vs. 5.9%; p: < 0.001). The mean length of stay in the intensive care unit was shorter in high-volume institutions (1.23 vs. 1.79 days; p = 0.021). In high-volume institutions, the personnel (R$ 952.23 [US$ 186.64] vs. R$ 11,129.04 [US$ 221.29]; p = 0.305), hospital (R$ 4078.39 [US$ 799.36] vs. R$ 4987.39 [US$ 977.53]; p = 0.111), and total costs (R$ 5030.63 [US$ 986.00] vs. R$ 6116.71 [US$ 1198.88]; p = 0.226) were lower.

CONCLUSIONS

Higher institutional APR volume is associated with lower in-hospital mortality and less demand for intensive care. The findings of this nationwide study may affect how Public Health manages APR care.

Experiences and challenges faced by patients with COVID-19 who were hospitalised and participated in a randomised controlled trial: a qualitative study

OBJECTIVES

As part of a randomised controlled trial, this qualitative study aimed to identify experiences and challenges of hospitalised patients with COVID-19 during illness and treatment (objective 1: COVID-19-related perspectives; objective 2: trial participation-related perspectives).

DESIGN

Semistructured interviews following a prespecified interview guide, transcribed verbatim and analysed in accordance with the grounded theory process. Investigator triangulation served to ensure rigour of the analysis.

SETTING

Interviews were embedded in a multicentre, randomised, active-controlled, open-label platform trial testing efficacy and safety of experimental therapeutics for patients with COVID-19 (Austrian Corona Virus Adaptive Clinical Trial).

PARTICIPANTS

20 patients (60±15 years) providing 21 interviews from 8 June 2020 to 25 April 2021.

RESULTS

Qualitative data analysis revealed four central themes with subthemes. Theme 1, 'A Severe Disease', related to objective 1, was characterised by subthemes 'symptom burden', 'unpredictability of the disease course', 'fear of death' and 'long-term aftermaths with lifestyle consequences'. Theme 2, 'Saved and Burdened by Hospitalization', related to objective 1, comprised patients describing their in-hospital experience as 'safe haven' versus 'place of fear', highlighting the influence of 'isolation'. Theme 3, 'Managing One's Own Health', related to objective 1, showed how patients relied on 'self-management' and 'coping' strategies. Theme 4, 'Belief in Medical Research', related to objective 2, captured patients' 'motivation for study participation', many expressing 'information gaps' and 'situational helplessness' in response to study inclusion, while fewer mentioned 'therapy side-effects' and provided 'study reflection'. Investigator triangulation with an expert focus group of three doctors who worked at the study centre confirmed the plausibility of these results.

CONCLUSIONS

Several of the identified themes (2, 3, 4) are modifiable and open for interventions to improve care of patients with COVID-19. Patient-specific communication and information is of utmost importance during clinical trial participation, and was criticised by participants of the present study. Disease self-management should be actively encouraged.

TRIAL REGISTRATION NUMBER

NCT04351724.

Incidence of Preclinical Heart Failure in a Community Population

Background

A high prevalence of preclinical heart failure (HF) (Stages A and B) has previously been shown. The aim of this study was to explore factors associated with the incidence of preclinical HF in a community population.

Methods and Results

Retrospective review of 393 healthy community individuals aged ≥45 years from the Olmsted County Heart Function Study that returned for 2 visits, 4 years apart. At visit 2, individuals that remained normal were compared with those that developed preclinical HF. By the second visit, 191 (49%) developed preclinical HF (12.1 cases per 100 person‐years of follow‐up); 65 (34%) Stage A and 126 (66%) Stage B. Those that developed preclinical HF (n=191) were older (P=0.004), had a higher body mass index (P<0.001), and increased left ventricular mass index (P=0.006). When evaluated separately, increased body mass index was seen with development of Stage A (P<0.001) or Stage B (P=0.009). Echocardiographic markers of diastolic function were statistically different in those that developed Stage A [higher E/e’ (P<0.001), lower e’ (P<0.001)] and Stage B [higher left atrial volume index (P<0.001), higher E/e’ (P<0.001), lower e’ (P<0.001)]. NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) was higher at visit 2 in those that developed Stage A or B (P<0.001 for both). Hypertension (57%), obesity (34%), and hyperlipidemia (25%) were common in the development of Stage A. Of patients who developed Stage B, 71% (n=84) had moderate or severe diastolic dysfunction.

Conclusions

There is a high incidence of preclinical HF in a community population. Development of Stage A was driven by hypertension and obesity, while preclinical diastolic dysfunction was seen commonly in those that developed Stage B.

THE PROGNOSIS OF THE DIFFERENT ESOPHAGEAL NEUROENDOCRINE CARCINOMA SUBTYPES: A POPULATION-BASED STUDY

ABSTRACT Background Neuroendocrine neoplasms are extremely rare and account for 0.4% to 2% of all malignant esophageal neoplasms. The burden of the neuroendocrine histological type on the patients’ prognosis and survival is poorly debated. This study aimed to compare the survival rates of primary neuroendocrine neoplasms compared with adenocarcinoma and squamous cell carcinoma of the esophagus. Methods This is a retrospective cohort from the Surveillance, Epidemiology, and End Results Program database. Overall survival and cancer-specific survival were evaluated with Kaplan-Meier curves and logrank tests. Proportional Cox regression models were used to evaluate variables related to overall survival. Results After eligibility criteria, 66,528 patients were selected. The mean follow-up was 22.6 months (SD 35.6). Adenocarcinoma was predominant (62%), followed by squamous cell carcinoma (36%). Large cell carcinoma, small cell carcinoma, and mixed adenoneuroendocrine carcinoma each account for less than 1% each. On the long-term overall survival analysis, esophageal adenocarcinoma showed a better prognosis than all the other histologic types (P-value for logrank test <0.001). With adenocarcinoma as a reference, HR was 1.32 for large cell carcinoma (95%CI 1.2 to 1.45) and 1.37 for small cell carcinoma (95%CI 1.23 to 1.53). The HR was 1.22 for squamous cell carcinoma (95%CI: 1.2 to 1.24); and 1.3 for adenoneuroendocrine carcinoma (95%CI 1.01 to 1.66). For multivariate Cox regression analysis, besides age and stage, the neuroendocrine subtypes large cell carcinoma and small cell carcinoma were considered independent prognostic variables. Conclusion In the esophagus, large cell carcinoma and small cell carcinoma show poorer long-term survival rates than squamous cell carcinoma and adenocarcinoma.

Artificial Intelligence-Augmented Electrocardiogram Detection of Left Ventricular Systolic Dysfunction in the General Population

OBJECTIVE

To validate an artificial intelligence-augmented electrocardiogram (AI-ECG) algorithm for the detection of preclinical left ventricular systolic dysfunction (LVSD) in a large community-based cohort.

METHODS

We identified a randomly selected community-based cohort of 2041 subjects age 45 years or older in Olmsted County, Minnesota. All participants underwent a study echocardiogram and ECG. We first assessed the performance of the AI-ECG to identify LVSD (ejection fraction ≤40%). After excluding participants with clinical heart failure, we further assessed the AI-ECG to detect preclinical LVSD among all patients (n=1996) and in a high-risk subgroup (n=1348). Next we modelled an imputed screening program for preclinical LVSD detection where a positive AI-ECG triggered an echocardiogram. Finally, we assessed the ability of the AI-ECG to predict future LVSD. Participants were enrolled between January 1, 1997, and September 30, 2000; and LVSD surveillance was performed for 10 years after enrollment.

RESULTS

For detection of LVSD in the total population (prevalence, 2.0%), the area under the receiver operating curve for AI-ECG was 0.97 (sensitivity, 90%; specificity, 92%); in the high-risk subgroup (prevalence 2.7%), the area under the curve was 0.97 (sensitivity, 92%; specificity, 93%). In an imputed screening program, identification of one preclinical LSVD case would require 88.3 AI-ECGs and 8.7 echocardiograms in the total population and 65.7 AI-ECGs and 5.5 echocardiograms in the high-risk subgroup. The unadjusted hazard ratio for a positive AI-ECG for incident LVSD over 10 years was 2.31 (95% CI, 1.32 to 4.05; P=.004).

CONCLUSION

Artificial intelligence-augmented ECG can identify preclinical LVSD in the community and warrants further study as a screening tool for preclinical LVSD.

Sex-specific cut-off values for soluble suppression of tumorigenicity 2 (ST2) biomarker increase its cardiovascular prognostic value in the community

BACKGROUND

Suppression of tumorigenicity 2 (ST2) has important cardiovascular prognostic value in community patients; however, previous analyses have utilized non-sex specific cut-off values. We assessed whether sex-specific ST2 cut-off values would improve the prognostic utility of ST2 in the asymptomatic community.

METHODS

A total of 2042 participants underwent clinical assessment and echocardiographic evaluation. Baseline measurements of high sensitivity troponin, natriuretic peptides and ST2 were obtained in 1681 individuals. ST2, cardiac biomarkers and associated co-morbidities were evaluated by sex-specific ST2 quartile analysis. ST2 concentrations were also analysed as dichotomous variables defined as being above the sex-specific cut-off for each the outcomes of heart failure (HF), major adverse cardiac event (MACE) and mortality.

RESULTS

Median ST2 concentration was 29.4 ng/mL in male subjects and 24.1 ng/mL in female subjects. Higher ST2 concentrations were associated with incident HF (p<0.001; preserved ejection fraction (EF) p<0.001, reduced EF p=0.23), MACE (p=0.003) and mortality (p<0.001) across sex-specific quartiles. Event-based, hazard ratio (HR) analysis revealed sex-specific ST2 cut-offs were significantly more predictive of incident HF, MACE and mortality compared to non-sex-specific analysis even following adjustment for cardiac co-morbidities and traditional biomarkers.

CONCLUSIONS

These data suggest that sex-specific cut-offs, greater than non-sex specific cut-offs, significantly impact the prognostic value of the biomarker ST2 in the asymptomatic community cohort.Clinical SignificanceSuppression of tumorigenicity 2 (ST2) is a biomarker which has known associations with heart failure (HF), major adverse cardiac events (MACEs) and mortality in the general population.Recent data support the concept of sex-specific cut off values and individualized approaches based on sex to predict cardiovascular disease. Given the difference in pathobiology between the sexes, the fact that such approaches improve risk stratification is understandable. Thus, when sex-specific treatments are developed, this may similarly lead to improved outcomes.The use of sex-specific ST2 cut-off values significantly improved the prognostic value in predicting HF, MACE, and mortality in an asymptomatic community. This prognostication was particularly strong for HF with preserved ejection fraction and remained clinically significant following adjustment for cardiac co-morbidities and other traditional cardiac biomarkers (NTproBNP and hscTnI).

Disparities in Students’ Propensity to Consent to Learning Analytics

Use of university students’ educational data for learning analytics has spurred a debate about whether and how to provide students with agency regarding data collection and use. A concern is that students opting out of learning analytics may skew predictive models, in particular if certain student populations disproportionately opt out and biases are unintentionally introduced into predictive models. We investigated university students’ propensity to consent to learning analytics through an email prompt, and collected respondents’ perceived benefits and privacy concerns regarding learning analytics in a subsequent online survey. In particular, we studied whether and why students’ consent propensity differs among student subpopulations bysending our email prompt to a sample of 4,000 students at our institution stratified by ethnicity and gender. 272 students interacted with the email, of which 119 also completed the survey. We identified that institutional trust, concerns with the amount of data collection versus perceived benefits, and comfort with instructors’ data use for learning engagement were key determinants in students’ decision to participate in learning analytics. We find that students identifying ethnically as Black were significantly less likely to respond and self-reported lower levels of institutional trust. Female students reported concerns with data collection but were also more comfortable with use of their data by instructors for learning engagement purposes. Students’ comments corroborate these findings and suggest that agency alone is insufficient; institutional leaders and instructors also play a large role in alleviating the issue of bias.

Progression of Preclinical Heart Failure: A Description of Stage A and B Heart Failure in a Community Population

BACKGROUND

The aims of this study are to evaluate the rate of progression of preclinical (Stage A and B) heart failure, identify associated characteristics, and evaluate long-term outcomes.

METHODS

Retrospective review of the Olmsted County Heart Function Study. Individuals categorized as Stage A or B heart failure at initial visit that returned for a second visit 4 years later were included. Logistic regression analyses evaluated group differences with adjustment for age and sex.

RESULTS

At visit 1, 413 (32%) individuals were classified as Stage A and 413 (32%) as Stage B. By visit 2, 146 (35%) individuals from Stage A progressed with the vast majority (n=142) progressing to Stage B. In comparison, a total of 23 (6%) individuals progressed from Stage B. A greater rate of progression was seen for Stage A compared with Stage B (8.7 per 100 person-years [95% CI, 7.4-10.2] versus 1.4 per 100 person-years [95% CI, 0.9-2.1]; P<0.001). NT-proBNP correlated with progression for Stage B (P=0.01), but not for Stage A (P=0.39). A multivariate model found female sex (odds ratio, 1.65 [95% CI, 1.05-2.58]; P=0.03), increased E/e' (odds ratio, 1.13 [95% CI, 1.02-1.26], P=0.02), and beta blocker use (odds ratio, 2.19 [95% CI, 1.25-3.82], P=0.006) were associated with progression for Stage A. There was a signal that cardiovascular mortality was higher in individuals who progressed, although not statistically significant (P=0.06 for Stage A and P=0.05 for Stage B).

CONCLUSIONS

There is significant progression of preclinical heart failure in a community population, with progression rates higher for Stage A. NT-proBNP correlated with progression for Stage B, but not for Stage A. No statistically significant differences in long-term outcomes were seen. Study results have clinical implications important to help guide future heart failure screening and prevention strategies.

Drug utilization in the Maastricht Study: A comparison with nationwide data

Within the southern region of the Netherlands, the Maastricht Study is an on-going observational prospective population-based cohort study that focuses on the etiology of Type 2 diabetes mellitus (T2DM). Representativeness of the participating population is a crucial but often an unknown factor in population-based cohort studies such as the Maastricht Study. We therefore aimed to assess the representativeness of the study population by comparing drug utilization of the participants of the Maastricht Study with the general population of the Netherlands.Since T2DM patients were oversampled in this study, a sampling method was applied in order to ensure a similar distribution of T2DM over the study population. Drug use in the study population was compared with drug use in the population of the Netherlands, using a Z-test to compare 2 independent proportions.In general, drug use in the study was similar compared with national data. However, in the age group 65 to 74 years total drug use was lower in the study population (833/1000 persons) versus nationwide data (882/1000 persons). The use of pulmonary medications was lower (104/1000 persons vs 141/1000 persons) and the use of hypnotics/anxiolytics was higher (90/1000 persons vs 36/1000 persons) in the Maastricht Study as compared with national data.Drug use in the Maastricht Study population is largely comparable to that in the total Dutch population aged 45 to 74. Therefore, data on drug use by participants in the Maastricht Study can be used to perform studies assessing outcomes associated with drug use.

Cancer survivors who fully participate in the PROFILES registry have better health-related quality of life than those who drop out

Purpose

Attrition and subsequent missing data pose a challenge in longitudinal research in oncology. This study examined factors associated with attrition in the PROFILES registry, and its impact on observed health-related quality of life (HRQOL) estimates.

Methods

Sociodemographic, clinical, and HRQOL data were collected annually from a cohort of 2625 colorectal cancer survivors between 2010 and 2015. Participant characteristics according to time of dropout were compared using analysis of variance and chi-square tests. Predictors of attrition were examined in logistic regression analysis. Multilevel linear mixed models were constructed to investigate associations between attrition and HRQOL over time.

Results

Participants who dropped out were more likely to be female (OR = 1.23, CI = 1.02–1.47), older (OR = 1.20, CI = 1.09–1.33), less educated (OR = 1.64, CI = 1.30–2.11), and to have depressive symptoms (OR = 1.84, CI = 1.39–2.44) than full responders, and less likely to have high socioeconomic status (OR = 0.74, CI = 0.61–0.94). Participants who dropped out earlier reported significantly worse HRQOL, functioning, and psychosocial symptoms, which declined at a steeper rate over time, than full responders.

Conclusions

Cancer survivors’ HRQOL may be overestimated in longitudinal research due to attrition of the most unwell participants.

Implications for Cancer Survivors

Cancer survivors with the poorest health are at risk of dropping out of PROFILES and possibly withdrawing from other activities. Optimizing participation in PROFILES—a potential mechanism for providing information and access to support—is an avenue for keeping this group engaged.

Electronic supplementary material

The online version of this article (10.1007/s11764-019-00793-7) contains supplementary material, which is available to authorized users.

Effect of Diabetes on Life Expectancy in the United States by Race and Ethnicity

We investigated the impact of diabetes on US life expectancy by sex and race/ethnicity using a prospective cohort study design. Cohorts were drawn from 1997-2009 waves of the National Health Interview Survey and linked to death records through December 31, 2011. We combined data on the prevalence of diabetes among decedents with estimates of the hazard ratios of individuals diagnosed with diabetes to calculate population attributable fractions (PAFs) by age, sex, and race/ethnicity at ages 30 and above. These estimates were then applied to deaths in the official US life table for 2010 to estimate effects of diabetes on life expectancy. Diabetes was responsible for a reduction of 0.83 years of life expectancy for men at age 30 and 0.89 years for 30-year-old women. The impact was greatest among Black women at 1.05 years. Estimates based on traditional demographic and actuarial methods using the frequency with which a disease appears as an underlying cause of death on death certificates produced a reduction in life expectancy at age 30 of only 0.33 years. We conclude that diabetes is substantially reducing US longevity and that its effect is seriously underestimated when using data on underlying causes of death.

The interaction of personal, contextual, and study characteristics and their effect on recruitment and participation of pregnant women in research: a qualitative study in Lebanon

Background

Declining participation rates are impeding health research. Little is known about factors influencing the decision to participate in low- and middle-income countries (LMIC). Therefore, this paper reports on the various individual factors and their with contextual factors in influencing participation in research among pregnant women and the recommendations to enhance their recruitment in Lebanon.

Methods

This study used a qualitative research design drawing on focus groups and in-depth interviews. The Theoretical Domain Framework guided data collection and analysis. The three participant groups included: Group 1-Pregnant women (n = 25) attending public pre-natal events and antenatal clinics in Beirut; Group 2-Pregnant women (n = 6) already enrolled in the ongoing Mother and Infant Nutritional Assessment birth cohort study; Group 3-Key informants (n = 13) including health care workers involved in recruiting pregnant women. Conversations were audio recorded, transcribed, translated into English, and thematically analyzed.

Results

Three main factors influencing participation were revealed, with each factor encompassing several sub-themes: (1) personal factors (altruism, self-confidence, personal interest in the topic, previous understanding of the nature and purpose of research, education level, and previous research experience), (2) contextual factors (societal factors, family and friends), and (3) study characteristics (burden of the study, ethical considerations, incentives, and research interpersonal skills and physician endorsement to participate). The results suggested a dynamic interaction among the identified factors, forming two intersecting axes, with a four-quadrant configuration. The y- and x-axes represented personal factors and contextual factors, respectively. Individuals positioned on the lower-left quadrant were the least likely to participate; those on the upper-right quadrant were the most likely to participate; while those on the upper-left and lower-right quadrants were indecisive. Study characteristics seemed to affect the decision of pregnant women to participate situated in any of the four quadrants. Specific recommendations to improve participation were also identified.

Conclusions

Our findings suggested an interaction of personal factors, contextual factors, and study characteristics affecting subjects’ participation. This interaction integrates factors into a novel dynamic framework that could be used in future studies. The recommendations identified may help improve participation of pregnant women in health research hence enhancing the quality and generalizability of research findings in LMIC.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0616-5) contains supplementary material, which is available to authorized users.

Association between Adiposity and disability in the Lc65+ Cohort

OBJECTIVES

To examine the longitudinal association between body mass index (BMI) and waist circumference (WC) with mortality and incident disability in Lc65+ cohort.

DESIGN

Population-based cohort of non-institutionalized adults with up to 8.9 years of follow-up.

SETTING

City of Lausanne, Switzerland.

PARTICIPANTS

1,293 individuals aged 65 to 70 at baseline (58% women).

MEASUREMENTS

BMI, WC and covariates were measured at baseline in 2004-2005. Vital status was obtained up to the 31st December 2013 and difficulty with basic activities of daily living (BADL) was reported in a self-administered questionnaire sent to participants every year. Main outcomes were total mortality and disability, defined as difficulty with BADL for ≥2 years or institutionalization. Cox regression was used with BMI/WC quintiles 2 as the reference.

RESULTS

130 persons died over a median follow-up of 8.47 years (crude mortality rate, men: 16.5/1,000 person-years, women: 9.7/1,000 person-years). In Cox regression adjusted for age, sex, education, financial situation, smoking and involuntary weight loss (IWL) at baseline, mortality was significantly associated with neither BMI nor WC, but there were trends towards non-significant J-curves across both BMI and WC quintiles. Disability (231 cases) tended to increase monotonically across both BMI and WC quintiles and was significantly associated with BMI quintile 5 (HR=2.44, 95% CI [1.65-3.63]), and WC quintiles 4 (HR=1.81 [1.15-2.85]) and 5 (HR=2.58, [1.67-4.00]).

CONCLUSION

Almost half of the study population had a substantially increased HR of disability, as compared to the reference BMI/WC categories. This observation emphasizes the need for life-long strategies aimed at preventing excess weight, muscle loss and functional decline through adequate nutrition and regular physical activity, starting at early age and extending throughout life.

Cancer patients' participation in population-based health surveys: findings from the HUNT studies

Background

The magnitude of participation bias due to non-participation should be considered for cancer patients invited to population-based surveys. We studied participation rates among persons with and without cancer in a large population based study, the Nord-Trøndelag Health Study (HUNT).

Methods

Citizens 20 years or above living in the Nord-Trøndelag County of Norway have been invited three times to comprehensive health surveys. The invitation files with data on sex, invitation date and participation were linked to the Cancer Registry of Norway. In a first step unadjusted crude participation rates (participants/invited persons) were estimated for cancer patients (CaPts) and non-cancer persons (NonCaPers), followed by logistic regression analyses with adjustment for age and sex. To evaluate the “practical” significance of the estimated odds ratios in the cancer diagnosis group, relative risks were also estimated comparing the observed rates to the estimated rates under the counterfactual assumption of no earlier cancer diagnosis among CaPts.

Results

Overall 3 % of the participants in the three HUNT studies were CaPts and 59 % of them had been diagnosed with their first life-time cancer >5 years prior to each survey. In each of the three HUNT surveys crude participation rates were similar for CaPts and NonCaPers. Adjusted for sex and age, CaPts’ likelihood to participate in HUNT1 (1984–86) and HUNT2 (1995–97), but not in HUNT3 (2006–2008), was statistically significantly reduced compared to NonCaPers, equaling a relative risk of 0.98 and 0.96, respectively. The lowest odds ratio emerged for CaPts diagnosed during the last 2 years preceding a HUNT invitation. Only one-third of CaPts participating in a survey also participated in the subsequent survey compared to approximately two-thirds of NonCaPers, and 11 % of CaPts participated in all three HUNT surveys compared to 37 % of NonCaPers.

Conclusion

In the three HUNT surveys no or only minor participation bias exist as to CaPts’ participation rates. In longitudinal studies selection bias as to long-term cancer survivorship should be taken into account, the percentage of repeatedly participating CaPts diminishing more strongly than among NonCaPers.

Impact of general and central adiposity on ventricular-arterial aging in women and men

OBJECTIVES

The aim of this study was to assess the effects of central and general obesity measures on long-term longitudinal changes in ventricular-arterial mechanics.

BACKGROUND

Obesity, female sex, and ventricular-arterial stiffening are associated with the development of heart failure with preserved ejection fraction. Fat distribution and chronic changes in body composition may affect longitudinal changes in LV properties, independent of arterial load.

METHODS

In 1,402 subjects from a randomly selected, community-based population, comprehensive echo-Doppler echocardiography was performed at two examinations separated by 4 years. From this population, 788 subjects had paired data adequate for determining left ventricular end-systolic elastance (Ees), end-diastolic elastance (Eed), and effective arterial elastance (Ea).

RESULTS

Over 4 years, Ea was decreased by 3% in tandem with improved blood pressure control, whereas Ees and Eed were increased by 14% and 8% (all, p < 0.001). Greater weight loss over 4 years was associated with progressively greater decreases in Ea in men and women. After adjustment for Ea change, weight gain was correlated with increases in Eed in both women and men. Central obesity was associated with greater age-related increases in Ees in women but not in men, independent of arterial load, but central obesity did not predict changes in Eed or Ea.

CONCLUSIONS

In these subjects, weight gain was associated with increases in LV diastolic stiffness, even after adjustment for changes in arterial afterload, whereas weight loss was associated with reductions in arterial stiffness. Age-related LV systolic stiffening was increased in women, but not in men, with central obesity. Strategies for promoting weight loss and reducing central adiposity may be effective in preventing heart failure with preserved ejection fraction, particularly in women.

High-sensitivity troponin I and amino-terminal pro--B-type natriuretic peptide predict heart failure and mortality in the general population

INTRODUCTION

High-sensitivity cardiac troponin assays have potent prognostic value in stable cardiovascular disease cohorts. Our objective was to assess the prognostic utility of a novel cardiac troponin I (cTnI) high-sensitivity assay, independently and in combination with amino-terminal pro-B-type natriuretic peptide (NT-proBNP), for the future development of heart failure and mortality in the general community.

METHODS

A well-characterized community-based cohort of 2042 participants underwent clinical assessment and echocardiographic evaluation. Baseline measurements of cTnI with a high-sensitivity assay and NT-proBNP were obtained in 1843 individuals. Participants were followed for new-onset heart failure and mortality with median (25th, 75th percentile) follow-up of 10.7 (7.9, 11.6) and 12.1 (10.4, 13.0) years, respectively.

RESULTS

When measured with a high-sensitivity assay, cTnI greater than the sex-specific 80th percentile was independently predictive of heart failure [hazard ratio 2.56 (95% confidence interval 1.88-3.50), P < 0.001] and mortality [1.91(1.49-2.46), P < 0.001] beyond conventional risk factors in this community-based cohort, with significant increases in the net reclassification improvement for heart failure. The prognostic utility of cTnI measured with a high-sensitivity assay goes beyond NT-proBNP, yet our data suggest that these 2 assays are complementary and most beneficial when evaluated together in identifying at-risk individuals in the community.

CONCLUSIONS

Our findings lay the foundation for prospective studies aimed at identification of individuals at high risk by use of a multimarker approach, followed by aggressive prevention strategies to prevent subsequent heart failure.

Association between alcohol consumption and systolic ventricular function: a population-based study

BACKGROUND

Although moderate alcohol consumption is associated with decreased clinical heart failure, there are no population-based studies evaluating the relationship between alcohol consumption and left ventricular (LV) systolic function. We sought to evaluate the relationship between alcohol consumption and LV systolic function in the community.

METHODS

In a population-based random sample of 2,042 adults, age ≥45 years, we assessed alcohol consumption by a self-administered questionnaire. Responders were categorized by alcohol consumption level: abstainer, former drinker, light drinker (<1 drink a day), moderate drinker (1-2 drinks a day), and heavy drinker (>2 drinks a day). Systolic function was assessed by echocardiography.

RESULTS

We identified 38 cases of systolic dysfunction in 182 abstainers, 309 former drinkers, 1,028 light drinkers, 251 moderate drinkers, and 146 heavy drinkers. A U-shaped relationship was observed between alcohol consumption and moderate systolic dysfunction (LV ejection fraction [LVEF] ≤40%), with the lowest prevalence in light drinkers (0.9%) compared to the highest prevalence in heavy drinkers (5.5%) (odds ratio 0.14, 95% CI 0.04-0.43). This association persisted across different strata of risk factors of systolic dysfunction as well as in multivariate analysis. No significant association between alcohol consumption and systolic function was seen in subjects with LVEF >50% or ≤50%.

CONCLUSIONS

There is a U-shaped relationship between alcohol consumption volume and LVEF, with the lowest risk of moderate LV dysfunction (LVEF ≤40%) observed in light drinkers (<1 drink a day). These findings are parallel to the relationship between alcohol consumption and cardiovascular disease prevalence.

Does attrition during follow-up of a population cohort study inevitably lead to biased estimates of health status?

Attrition is a potential source of bias in cohort studies. Although attrition may be inevitable in cohort studies of older people, there is little empirical evidence as to whether bias due to such attrition is also inevitable. Anonymised primary care data, routinely collected in clinical practice and independent of any cohort research study, represents an ideal unselected comparison dataset with which to compare primary care data from consenting responders to a cohort study. Our objective was to use this method as a novel means to assess if (i) responders at follow-up stages in a cohort study remain representative of responders at baseline and (ii) attrition biases estimates of longitudinal associations. We compared primary care consultation morbidities and prescription prevalences among circa 32,000 patients aged 50+ who contribute to an anonymised general practice database (Consultations in Primary Care Archive (CiPCA)) with those from patients aged 50+ in the North Staffordshire Osteoarthritis Project (NorStOP) cohort, United Kingdom (2002–2008; n = 16,159). 8,197 (51%) persons responded to the NorStOP baseline survey and consented to medical record review. 5,121 and 3,311 responded at 3- and 6-year follow-ups. Differences in consulting prevalence of non-musculoskeletal morbidities between NorStOP responders and CiPCA comparison population did not increase over the two follow-up points except for ischaemic heart disease. Differences observed at baseline for osteoarthritis-related consultations were generally unchanged at the two follow-ups (standardised prevalence ratios for osteoarthritis (1.09–1.13) and joint pain (1.12–1.23)). Age and gender adjusted associations between baseline consultation for chronic morbidity and future new osteoarthritis and related consultations were similar in CiPCA (adjusted Hazard Ratio: 1.40; 95% Confidence Interval: 1.34,1.47) and NorStOP 6-year responders (1.32; 1.15,1.51). There was little evidence that responders at follow-ups represented any further selection bias to that present at baseline. Attrition in cohort studies of older people does not inevitably indicate bias.

Hip fracture prevention with a multifactorial educational program in elderly community-dwelling Finnish women

Guidelines suggest identification of women at fracture risk by bone density measurement and subsequently pharmacotherapy. However, most women who sustain a hip fracture do not have osteoporosis in terms of bone density. The present non-pharmacological intervention among elderly women unselected for osteoporosis reduced hip fracture risk by 55 % providing an alternative approach to fracture prevention.

INTRODUCTION

Hip fractures are expensive for society and cause disability for those who sustain them. We studied whether a multifactorial non-pharmacological prevention program reduces hip fracture risk in elderly women.

METHODS

A controlled trial concerning 60- to 70-year-old community-dwelling Finnish women was undertaken. A random sample was drawn from the Population Information System and assigned into the intervention group (IG) and control group (CG). Of the 2,547 women who were invited to the IG, 1,004 (39 %) and of the 2,120 invited to the CG, 1,174 (55 %) participated. The IG participated in a fracture prevention program for 1 week at a rehabilitation center followed by review days twice. The CG received no intervention. During the 10-year follow-up, both groups participated in survey questionnaire by mail. Outcome of interest was occurrence of hip fractures and changes in bone-health-related lifestyle.

RESULTS

During the follow-up, 12 (1.2 %) women in the IG and 29 (2.5 %) in the CG sustained a hip fracture (P = 0.039). The determinants of hip fractures by stepwise logistic regression were baseline smoking (odds ratio (OR) 4.32 (95 % confidence interval [CI] 2.14-8.71), age OR 1.15/year (95 % CI 1.03-1.28), fall history OR 2.7 (95 % CI 1.24-5.9), stroke history OR 2.99 (95 % CI 1.19-7.54) and participating in this program OR 0.45 (95 % CI 0.22-0.93). Starting vitamin D and calcium supplement use was more common in the IG compared with the CG.

CONCLUSIONS

The results suggest that this non-pharmacological fracture prevention program may reduce the risk of hip fractures in elderly Finnish women.

Longitudinal changes in left ventricular stiffness: a community-based study

BACKGROUND

Cross-sectional studies suggest that left ventricular (LV) and arterial elastance (stiffness) increase with age, but data examining longitudinal changes within human subjects are lacking. In addition, it remains unknown whether age-related LV stiffening is merely a reaction to arterial stiffening or caused by other processes.

METHODS AND RESULTS

Comprehensive echo-Doppler cardiography was performed in 1402 subjects participating in a randomly selected community-based study at 2 examinations separated by 4 years. From this population, 788 subjects had adequate paired data to determine LV end-systolic elastance (Ees), end-diastolic elastance (Eed), and effective arterial elastance. Throughout 4 years, blood pressure, arterial elastance, and LV mass decreased, coupled with significantly greater use of antihypertensive medications. However, despite reductions in arterial load, Ees increased by 14% (2.10±0.67-2.26±0.70 mm Hg/mL; P<0.0001) and Eed increased by 8% (0.13±0.03-0.14±0.04 mm Hg/mL; P<0.0001). Increases in Eed were greater in women than men, whereas Ees changes were similar. Age-related increases in Ees and Eed were correlated with changes in body weight, but were similar in subjects with or without cardiovascular disease. Changes in Ees were correlated with Eed (r=0.5; P<0.0001), but not with other measures of contractility, indicating that the increase in Ees was reflective of passive stiffening rather than enhanced systolic function.

CONCLUSIONS

Despite reductions in arterial load with medical therapy, LV systolic and diastolic stiffness increase over time in humans, particularly in women. In addition to blood pressure control, therapies targeting load-independent ventricular stiffening may be effective to treat and prevent age-associated cardiovascular diseases, such as heart failure.

Human hypertension is characterized by a lack of activation of the antihypertensive cardiac hormones ANP and BNP

OBJECTIVES

This study sought to investigate plasma levels of circulating cardiac natriuretic peptides, atrial natriuretic peptide (ANP) and B-type or brain natriuretic peptide (BNP), in the general community, focusing on their relative differences in worsening human hypertension.

BACKGROUND

Although ANP and BNP are well-characterized regulators of blood pressure in humans, little is known at the population level about their relationship with hypertension. The authors hypothesized that hypertension is associated with a lack of activation of these hormones or their molecular precursors.

METHODS

The study cohort (N = 2,082, age >45 years) was derived from a random sample from Rochester, Minnesota, and each subject had a medical history, clinical examination, and assessment of different plasma forms of ANP and BNP. Patients were stratified by blood pressure. Multivariable linear regression was used to assess differences in natriuretic peptide levels in worsening hypertension.

RESULTS

Compared to normotensive, BNP(1-32) and N-terminal proBNP(1-76) (NT-proBNP(1-76)) were significantly decreased in pre-hypertension (p < 0.05), with BNP(1-32) significantly decreased in stage 1 as well (p < 0.05). Although proBNP(1-108) remained unchanged, the processed form was significantly increased only in stage 2 hypertension (p < 0.05). ANP(1-28) remained unchanged, while NT-ANP(1-98) was reduced in pre-hypertension (p < 0.05).

CONCLUSIONS

The authors demonstrated the existence of an impaired production and/or release of proBNP(1-108) along with a concomitant reduction of BNP(1-32) and NT-proBNP(1-76) in the early stages of hypertension, with a significant elevation only in stage 2 hypertension. Importantly, they simultaneously demonstrated a lack of compensatory ANP elevation in advanced hypertension.

Prefrailty and chronic morbidity in the youngest old: an insight from the Lausanne cohort Lc65+

OBJECTIVES

To estimate the prevalence of prefrailty, frailty, comorbidity, and disability in the youngest old and to identify chronic diseases associated with individual frailty criteria.

DESIGN

Population-based cohort study of noninstitutionalized elderly adults at baseline; cross-sectional analysis.

SETTING

Lausanne, Switzerland.

PARTICIPANTS

One thousand two hundred eighty-three individuals with complete data on frailty, aged 65 to 70 (58.5% women).

MEASUREMENTS

Frailty was assessed according to an adaptation of Fried's criteria (shrinking, weakness, exhaustion, slowness, and low activity, three criteria needed for the diagnosis of frailty, 1 to 2 for prefrailty). Other outcomes were diseases diagnosed by a doctor (≥ 2 chronic diseases: comorbidity) and limitations in activities of daily living (ADLs, basic and instrumental).

RESULTS

At baseline, of 1,283 participants 71.1% were classified as nonfrail, 26.4% as prefrail, and 2.5% as frail. The proportion of women increased across these three groups (56.5%, 62.8%, and 71.9%, respectively; P = .01), as did the proportion of individuals with one or more chronic diseases (68.0%, 82.8%, and 90.6%, respectively; P < .001) and the proportion with basic or instrumental ADL disability (1.6%, 10.3%, and 59.4%, respectively; P < .001). Weakness (low grip strength) was the most frequent criterion (14.3%). Prefrail participants had significantly more comorbidity and ADL disability than nonfrail participants (P < .001). When present in isolation, weakness was associated with two to three times greater prevalence of coronary heart disease, other heart diseases, diabetes mellitus, and arthritis. Similarly, a significant association was identified between exhaustion and depression.

CONCLUSION

Prefrailty is common in the youngest old. The most prevalent frailty criterion is weakness, which is associated with cardiovascular diseases. Longitudinal studies of the evolution of prefrailty should explore the role of potential interactions between individual frailty criteria and specific chronic diseases.

Obstetric trauma, pelvic floor injury and fecal incontinence: a population-based case-control study

OBJECTIVES

Current concepts based on referral center data suggest that pelvic floor injury from obstetric trauma is a major risk factor for fecal incontinence (FI) in women. In contrast, a majority of community women only develop FI decades after vaginal delivery, and obstetric events are not independent risk factors for FI. However, obstetric events are imperfect surrogates for anal and pelvic floor injury, which is often clinically occult. Hence, the objectives of this study were to evaluate the relationship between prior obstetric events, pelvic floor injury, and FI among community women.

METHODS

In this nested case-control study of 68 women with FI (cases; mean age 57 years) and 68 age-matched controls from a population-based cohort in Olmsted County, MN, pelvic floor anatomy and motion during voluntary contraction and defecation were assessed by magnetic resonance imaging. Obstetric events and bowel habits were recorded.

RESULTS

By multivariable analysis, internal sphincter injury (cases-28%, controls-6%; odds ratio (OR): 8.8; 95% confidence interval (CI): 2.3-34) and reduced perineal descent during defecation (cases-2.6 ± 0.2 cm, controls-3.1 ± 0.2 cm; OR: 1.7; 95% CI: 1.2-2.4) increased FI risk, but external sphincter injury (cases-25%, controls-4%; P<0.005) was not independently predictive. Puborectalis injury was associated (P<0.05) with impaired anorectal motion during squeeze, but was not independently associated with FI. Grades 3-4 episiotomy (OR: 3.9; 95% CI: 1.4-11) but not other obstetric events increased the risk for pelvic floor injury. Heavy smoking (≥ 20 pack-years) was associated (P=0.052) with external sphincter atrophy.

CONCLUSIONS

State-of-the-art imaging techniques reveal pelvic floor injury or abnormal anorectal motion in a minority of community women with FI. Internal sphincter injury and reduced perineal descent during defecation are independent risk factors for FI. In addition to grades 3-4 episiotomy, smoking may be a potentially preventable, risk factor for pelvic floor injury.

Predictive utility of atrial, N-terminal pro-atrial, and N-terminal pro-B-type natriuretic peptides for mortality and cardiovascular events in the general community: a 9-year follow-up study

OBJECTIVE

To determine the predictive value of atrial natriuretic peptide (ANP), N-terminal pro-ANP (NT-proANP), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) for mortality and cardiovascular events in the general population in the absence of overt heart failure (HF).

PARTICIPANTS AND METHODS

We identified a community-based cohort of 2042 individuals. Those with stage C or D HF (n=45) and renal insufficiency (n=6) were excluded from the current study. Of the remaining individuals, 1769 (89%) underwent echocardiography and measurement of plasma ANP, NT-proANP, and NT-proBNP. Participants were followed up from January 1, 1997, to May 1, 2009, for mortality, HF, myocardial infarction (MI), and cerebrovascular accident; median follow-up was 9 years.

RESULTS

After adjustment for conventional clinical risk factors, NT-proANP had significant predictive value for mortality but not for HF, MI, or cerebrovascular accident, whereas ANP lacked any predictive value. The predictive value of NT-proANP for mortality was attenuated after adjustment for structural and functional cardiac abnormalities. In contrast, NT-proBNP had predictive value for mortality, HF, and MI after adjustment for conventional risk factors and retained significance for mortality and HF after adjustment for structural and functional cardiac abnormalities.

CONCLUSION

Our results suggest that NT-proBNP is a more robust cardiac biomarker compared with ANP or NT-proANP and is independently predictive of mortality and HF in the general population free of overt HF.

Progression of left ventricular diastolic dysfunction and risk of heart failure

CONTEXT

Heart failure incidence increases with advancing age, and approximately half of patients with heart failure have preserved left ventricular ejection fraction. Although diastolic dysfunction plays a role in heart failure with preserved ejection fraction, little is known about age-dependent longitudinal changes in diastolic function in community populations.

OBJECTIVE

To measure changes in diastolic function over time and to determine the relationship between diastolic dysfunction and the risk of subsequent heart failure.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cohort of participants enrolled in the Olmsted County Heart Function Study. Randomly selected participants 45 years or older (N = 2042) underwent clinical evaluation, medical record abstraction, and echocardiography (examination 1 [1997-2000]). Diastolic left ventricular function was graded as normal, mild, moderate, or severe by validated Doppler techniques. After 4 years, participants were invited to return for examination 2 (2001-2004). The cohort of participants returning for examination 2 (n = 1402 of 1960 surviving [72%]) then underwent follow-up for ascertainment of new-onset heart failure (2004-2010).

MAIN OUTCOME MEASURES

Change in diastolic function grade and incident heart failure.

RESULTS

During the 4 (SD, 0.3) years between examinations 1 and 2, diastolic dysfunction prevalence increased from 23.8% (95% confidence interval [CI], 21.2%-26.4%) to 39.2% (95% CI, 36.3%-42.2%) (P < .001). Diastolic function grade worsened in 23.4% (95% CI, 20.9%-26.0%) of participants, was unchanged in 67.8% (95% CI, 64.8%-70.6%), and improved in 8.8% (95% CI, 7.1%-10.5%). Worsened diastolic dysfunction was associated with age 65 years or older (odds ratio, 2.85 [95% CI, 1.77-4.72]). During 6.3 (SD, 2.3) years of additional follow-up, heart failure occurred in 2.6% (95% CI, 1.4%-3.8%), 7.8% (95% CI, 5.8%-13.0%), and 12.2% (95% CI, 8.5%-18.4%) of persons whose diastolic function normalized or remained normal, remained or progressed to mild dysfunction, or remained or progressed to moderate or severe dysfunction, respectively (P < .001). Diastolic dysfunction was associated with incident heart failure after adjustment for age, hypertension, diabetes, and coronary artery disease (hazard ratio, 1.81 [95% CI, 1.01-3.48]).

CONCLUSIONS

In a population-based cohort undergoing 4 years of follow-up, prevalence of diastolic dysfunction increased. Diastolic dysfunction was associated with development of heart failure during 6 years of subsequent follow-up.

Use of B-type natriuretic peptide as a screening tool for left ventricular diastolic dysfunction in rheumatoid arthritis patients without clinical cardiovascular disease

OBJECTIVE

Patients with rheumatoid arthritis (RA) are at an increased risk for heart failure and left ventricular diastolic dysfunction (LVDD). B-type natriuretic peptide (BNP) may be useful to screen for LVDD in the general population. We compared the effectiveness of BNP as a screening tool for LVDD in RA and non-RA subjects without cardiovascular disease (CVD).

METHODS

Study subjects were recruited from population-based samples with and without RA, excluding subjects with CVD. LVDD was assessed by 2-dimensional and Doppler echocardiography and categorized as none, mild, moderate/severe, or indeterminate. Linear regression and proportional odds models evaluated the association between LVDD and BNP, adjusting for age, sex, and body mass index.

RESULTS

Among 231 RA and 1,730 non-RA subjects without CVD, BNP was significantly higher in subjects with moderate/severe LVDD compared to those with no or mild LVDD (P = 0.02 for RA and P < 0.001 for non-RA subjects). More RA subjects had elevated BNP than non-RA subjects (16% versus 9%; P < 0.001). Positive predictive value (25% in RA and 18% in non-RA subjects) and sensitivity (40% in RA and 26% in non-RA subjects) were similarly low in both cohorts, but specificity was significantly lower in RA than in non-RA subjects (89% versus 94%; P = 0.02).

CONCLUSION

While RA subjects were more likely to have elevated BNP, few RA patients with elevated BNP actually have LVDD. Also, normal BNP levels are less likely to rule out LVDD in RA than in non-RA subjects. Therefore, BNP may be less effective for screening in RA subjects compared to the general population.

Increased prevalence of metabolic syndrome associated with rheumatoid arthritis in patients without clinical cardiovascular disease

OBJECTIVE

to examine whether patients with rheumatoid arthritis (RA) with no overt cardiovascular disease (CVD) have a higher prevalence of metabolic syndrome (MetS) than subjects without RA or CVD. We also examined whether RA disease characteristics are associated with the presence of MetS in RA patients without CVD.

METHODS

subjects from a population-based cohort of patients who fulfilled 1987 American College of Rheumatology criteria for RA between January 1, 1980, and December 31, 2007, were compared to non-RA subjects from the same population. All subjects with any history of CVD were excluded. Waist circumference, body mass index (BMI), and blood pressure were measured during the study visit. Data on CVD, lipids, and glucose measures were ascertained from medical records. MetS was defined using NCEP/ATP III criteria. Differences between the 2 cohorts were examined using logistic regression models adjusted for age and sex.

RESULTS

the study included 232 RA subjects without CVD and 1241 non-RA subjects without CVD. RA patients were significantly more likely to have increased waist circumference and elevated blood pressure than non-RA subjects, even though BMI was similar in both groups. Significantly more RA patients were classified as having MetS. In RA patients, MetS was associated with Health Assessment Questionnaire Disability Index, large-joint swelling, and uric acid levels, but not with C-reactive protein or RA therapies.

CONCLUSION

among subjects with no history of CVD, patients with RA are more likely to have MetS than non-RA subjects. MetS in patients with RA was associated with some measures of disease activity.

Repeated attempts using different strategies are important for timely contact with study participants

OBJECTIVE

To study the effect of different mail- and phone-based strategies, along with patient- and research-related factors, on the time to contact with research participants.

STUDY DESIGN AND SETTING

A prospective evaluation of a 12-week standardized protocol (embedded with two randomized trials of mail- and phone-based strategies) for contacting existing research participants for recruitment into a related study.

RESULTS

Of 146 participants, 87 were eligible for contact via the standardized protocol, and 63 (72%) of these were successfully contacted within 12 weeks after multiple mail- and phone-based efforts. Using Cox proportional hazards regression analysis, the different mail and phone strategies showed no significant difference in the time to contact with participants. Of 34 patient- and research-related factors evaluated, only two were independently associated with time to contact among all 146 participants: (1) participants having their last visit conducted outside of the research clinic because of patient illness/condition had a longer time to contact and (2) those with a self-reported chronic fatigue history had a shorter time to contact.

CONCLUSION

Few patient characteristics and research-related factors accurately predict time to contact. Repeated attempts using different strategies are important for successful and timely contact with study participants.

Comparison of participants and non-participants to the ORISCAV-LUX population-based study on cardiovascular risk factors in Luxembourg

Background

Poor response is a major concern in public health surveys. In a population-based ORISCAV-LUX study carried out in Grand-Duchy of Luxembourg to assess the cardiovascular risk factors, the non-response rate was not negligible. The aims of the present work were: 1) to investigate the representativeness of study sample to the general population, and 2) to compare the known demographic and cardiovascular health-related profiles of participants and non-participants.

Methods

For sample representativeness, the participants were compared to the source population according to stratification criteria (age, sex and district of residence). Based on complementary information from the "medical administrative database", further analysis was carried out to assess whether the health status affected the response rate. Several demographic and morbidity indicators were used in the univariate comparison between participants and non-participants.

Results

Among the 4452 potentially eligible subjects contacted for the study, there were finally 1432 (32.2%) participants. Compared to the source population, no differences were found for gender and district distribution. By contrast, the youngest age group was under-represented while adults and elderly were over-represented in the sample, for both genders. Globally, the investigated clinical profile of the non-participants was similar to that of participants. Hospital admission and cardiovascular health-related medical measures were comparable in both groups even after controlling for age. The participation rate was lower in Portuguese residents as compared to Luxembourgish (OR = 0.58, 95% CI: 0.48-0.69). It was also significantly associated with the professional status (P < 0.0001). Subjects from the working class were less receptive to the study than those from other professional categories.

Conclusion

The 32.2% participation rate obtained in the ORISCAV-LUX survey represents the realistic achievable rate for this type of multiple-stage, nationwide, population-based surveys. It corresponds to the expected rate upon which the sample size was calculated. Given the absence of discriminating health profiles between participants and non-participants, it can be concluded that the response rate does not invalidate the results and allows generalizing the findings for the population.

The prognostic value of N-terminal pro-B-type natriuretic peptide for death and cardiovascular events in healthy normal and stage A/B heart failure subjects

OBJECTIVES

Our objective was to determine the prognostic value of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) for death and cardiovascular events among subjects without risk factors for heart failure (HF), which we term healthy normal.

BACKGROUND

Previous studies report that plasma NT-proBNP has prognostic value for cardiovascular events in the general population even in the absence of HF. It is unclear if NT-proBNP retains predictive value in healthy normal subjects.

METHODS

We identified a community-based cohort of 2,042 subjects in Olmsted County, Minnesota. Subjects with symptomatic (stage C/D) HF were excluded. The remaining 1,991 subjects underwent echocardiography and NT-proBNP measurement. We further defined healthy normal (n = 703) and stage A/B HF (n = 1,288) subgroups. Healthy normal was defined as the absence of traditional clinical cardiovascular risk factors and echocardiographic structural cardiac abnormalities. Subjects were followed for death, HF, cerebrovascular accident, and myocardial infarction with median follow-up of 9.1, 8.7, 8.8, and 8.9 years, respectively.

RESULTS

NT-proBNP was not predictive of death or cardiovascular events in the healthy normal subgroup. Similar to previous reports, in stage A/B HF, plasma NT-proBNP values greater than age-/sex-specific 80th percentiles were associated with increased risk of death, HF, cerebrovascular accident, and myocardial infarction (p < 0.001 for all) even after adjustment for clinical risk factors and structural cardiac abnormalities.

CONCLUSIONS

These findings do not support the use of NT-proBNP as a cardiovascular biomarker in healthy normal subjects and have important implications for NT-proBNP-based strategies for early detection and primary prevention of cardiovascular disease.

Is self-reported "moderate" drinking in the cardiovascular benefit range associated with alcoholic behavior? A population based study

This article aims at identifying a threshold number of drinks per day beyond which there is a high risk of developing alcoholic behavior that would enable physicians to more confidently support the use of alcohol for cardiovascular risk prevention. In a randomly selected, population-based sample of 2,042 adults 45 years or older, we graded alcohol drinking behavior using the Self-Administered Alcoholism Screening Test, quantified alcohol amount by questionnaire, and assessed the prevalence of cardiovascular disease (coronary, peripheral, or cerebrovascular disease) by medical record review. Although optimal alcohol use (< or = 2 drinks/day) was associated with reduced odds of cardiovascular disease, 43% of alcoholics and 82% of problem drinkers reported alcohol use in the optimal range as well. The association of alcohol use in the optimal range with alcohol-related behavioral problems supports the reluctance in physicians from recommending alcohol use for cardiovascular benefit, not withstanding the underreporting of alcohol use by alcoholics.

Age-associated increases in pulmonary artery systolic pressure in the general population

BACKGROUND

In contrast to the wealth of data on isolated systolic hypertension involving the systemic circulation in the elderly, much less is known about age-related change in pulmonary artery systolic pressure (PASP) and its prognostic impact in the general population. We sought to define the relationship between PASP and age, to evaluate which factors influence PASP, and to determine whether PASP is independently predictive of mortality in the community.

METHODS AND RESULTS

A random sample of the Olmsted County, Minn, general population (n=2042) underwent echocardiography and spirometry and was followed up for a median of 9 years. PASP was measured from the tricuspid regurgitation velocity. Left ventricular diastolic pressure was estimated with Doppler echocardiography (E/e' ratio), and arterial stiffening was assessed from the brachial artery pulse pressure. Among 1413 subjects (69%) with measurable PASP (age, 63+/-11 years; 43% male), median PASP was 26 mm Hg (25th to 75th percentile, 24 to 30 mm Hg) and increased with age (r=0.31, P<0.001). Independent predictors of PASP were age, pulse pressure, and mitral E/e' (all P< or =0.003). Increasing PASP was associated with higher mortality (hazard ratio, 2.73 per 10 mm Hg; P<0.001). In subjects without cardiopulmonary disease (any heart failure, coronary artery disease, hypertension, diabetes mellitus, or chronic obstructive lung disease), the age-adjusted hazard ratio was 2.74 per 10 mm Hg (P=0.016).

CONCLUSIONS

We provide the first population-based evidence of age-related increase in pulmonary artery pressure, its association with increasing left heart diastolic pressures and systemic vascular stiffening, and its negative impact on survival. Pulmonary artery pressure may serve as a novel cardiovascular risk factor and potential therapeutic target.

Healthy women's motivators and barriers to participation in a breast cancer cohort study: a qualitative study

PURPOSE

This focus group study describes motivators and barriers to participation in the Mayo Mammography Health Study (MMHS), a large-scale longitudinal study examining the causal association of breast density with breast cancer, involving completion of a survey, providing access to a residual blood sample for genetic analyses, and sharing their results from a screening mammogram. These women would then be followed up long term for breast cancer incidence and mortality.

METHODS

Forty-eight women participated in six focus groups, four with MMHS non-respondents (n = 27), and two with MMHS respondents (n = 21). Major themes were summarized using content analysis. Social cognitive theory (SCT) was used as a framework for interpretation of the findings.

RESULTS

Barriers to participation among MMHS non-respondents were 1) lack of confidence in their ability to fill out the survey accurately (self-efficacy); 2) lack of perceived personal connection to the study or value of participation (expectancies); and 3) fear related to some questions about perceived cancer risk and worry/concern (emotional coping responses). Among MMHS respondents, personal experience with cancer was reported as a primary motivator for participation (expectancies).

CONCLUSIONS

Application of a theoretical model such as social cognitive therapy to the development of a study recruitment plan could be used to improve rates of study participation and provide a reproducible and evaluable strategy.

Abnormal cardiac structure and function in the metabolic syndrome: a population-based study

OBJECTIVE

To measure the association between cardiac structure and function abnormalities and isolated metabolic syndrome (metabolic syndrome excluding established hypertension or diabetes mellitus).

PARTICIPANTS AND METHODS

We collected data prospectively on a population-based random sample of 2042 Olmsted County, Minnesota, residents aged 45 years or older who underwent echocardiography between January 1, 1997, and September 30, 2000. Metabolic syndrome was defined by National Cholesterol Education Program Adult Treatment Panel III criteria.

RESULTS

The prevalence of isolated metabolic syndrome was 21.7% (214/984) in men and 16.7% (177/1058) in women. Left ventricular (LV) mass index was greater (91.7 vs 87.9 g/m2; P=.04) and LV diastolic dysfunction more prevalent (28.2% [50/177] vs 14.9% [81/544]; P<.001) in women with isolated metabolic syndrome than in women without metabolic syndrome; no difference was found in men. When patients with hypertension or diabetes mellitus were included in the cohort, there was a stepwise increase in LV mass index and LV diastolic dysfunction from no metabolic syndrome to isolated metabolic syndrome to metabolic syndrome in women and men.

CONCLUSION

Isolated metabolic syndrome, which is associated with increased LV mass index and LV diastolic dysfunction in women, identifies women with evidence of early ventricular dysfunction.

Abnormal cardiac structure and function in the metabolic syndrome: a population-based study

OBJECTIVE

To measure the association between cardiac structure and function abnormalities and isolated metabolic syndrome (metabolic syndrome excluding established hypertension or diabetes mellitus).

PARTICIPANTS AND METHODS

We collected data prospectively on a population-based random sample of 2042 Olmsted County, Minnesota, residents aged 45 years or older who underwent echocardiography between January 1, 1997, and September 30, 2000. Metabolic syndrome was defined by National Cholesterol Education Program Adult Treatment Panel III criteria.

RESULTS

The prevalence of isolated metabolic syndrome was 21.7% (214/984) in men and 16.7% (177/1058) in women. Left ventricular (LV) mass index was greater (91.7 vs 87.9 g/m2; P=.04) and LV diastolic dysfunction more prevalent (28.2% [50/177] vs 14.9% [81/544]; P<.001) in women with isolated metabolic syndrome than in women without metabolic syndrome; no difference was found in men. When patients with hypertension or diabetes mellitus were included in the cohort, there was a stepwise increase in LV mass index and LV diastolic dysfunction from no metabolic syndrome to isolated metabolic syndrome to metabolic syndrome in women and men.

CONCLUSION

Isolated metabolic syndrome, which is associated with increased LV mass index and LV diastolic dysfunction in women, identifies women with evidence of early ventricular dysfunction.

Central obesity: association with left ventricular dysfunction and mortality in the community

BACKGROUND

We sought to measure the strength of association between 2 indices of obesity, waist-hip ratio (WHR) and body mass index (BMI), with left ventricular (LV) dysfunction and mortality in a community cohort. The distribution of body fat is thought to affect cardiovascular disease risk. The association of BMI (an index of overall obesity) and WHR (an index of central obesity) with LV systolic and diastolic dysfunction in a population-based cohort is unknown.

METHODS

Anthropomorphic measurements and echocardiographic LV function were measured in a cross-sectional population-based sample of 2,042 men and women>45 years old in the Olmsted County Heart Function Study. Five-year prospective mortality was measured.

RESULTS

Increased WHR had a stronger association than BMI with (1) lower LV ejection fraction (r=-0.24, P<.0001 vs r=-0.04, P=.09) and (2) LV diastolic dysfunction (r=0.18, P<.0001 vs r=0.05, P=.02). After adjustment for standard cardiovascular risk factors, WHR continued to be significantly associated with diastolic dysfunction but not with systolic dysfunction. Waist-hip ratio, but not BMI, was strongly predictive of all-cause mortality independent of age and sex (hazard ratio 23.6, CI 4.0-139.8, P=.0005). This relationship was attenuated on adjustment for diastolic dysfunction.

CONCLUSIONS

Waist-hip ratio is a stronger correlate of LV dysfunction and mortality than BMI. These cross-sectional data suggest that the increased risk of mortality from central obesity is mediated at least in part by LV dysfunction, especially diastolic dysfunction.

Effects of baseline comorbidities on cancer screening trial adherence among older African American men

BACKGROUND

The purpose of this study was to examine the effects of baseline comorbidities on screening adherence in a sample of older African American men (ages >or=55 years) enrolled in a case management intervention in a cancer screening trial.

METHODS

Baseline comorbidity data were obtained from 683 African American men who were randomly assigned to a case management intervention group (n = 344) or to a case management control group (n = 339). The effects of comorbidities on the screening adherence rates of each group were then assessed.

RESULTS

No statistically significant interactions were found between each health history characteristic and the intervention. Therefore, analyses were not stratified by intervention status. In general, participants with comorbidities were no less likely to adhere to trial screening than participants without comorbidities. Exceptions were current smokers and participants with chronic bronchitis. Current smokers were less likely than others to adhere to the prostate-specific antigen test (P = 0.02) and the digital rectal examination for prostate cancer screening (P = 0.01), to the chest X-ray for lung cancer screening (P < 0.01), and to the flexible sigmoidoscopy for colorectal cancer screening (P = 0.04). Participants with chronic bronchitis had lower rates of adherence to the chest X-ray (P = 0.06). Having a relative with cancer positively influenced adherence to the digital rectal examination (P = 0.05).

CONCLUSIONS

Overall, older African American men with comorbidities appear to be very good candidates for participation in longitudinal cancer screening trials. However, smoking had a statistically significant and deleterious effect on adherence to all types of screening.

Participation bias and its impact on the assembly of a genetic specimen repository for a myocardial infarction cohort

OBJECTIVE

To assess participation bias in the assembly of a specimen repository for genetic studies and to examine the association of participation with outcome within the Olmsted County myocardial infarction (MI) cohort.

PARTICIPANTS AND METHODS

From January 1, 1979, to May 31, 2006, 3081 persons had MI in Olmsted County, MN. Face-to-face contact was used to recruit patients who were hospitalized for an acute event. Persons who had had an MI before establishment of this repository were contacted by mail. At initial contact, we sought consent to use blood samples for genetic studies. Persons who refused were contacted by mail and were asked to consent to the use of stored tissue samples. For deceased subjects, stored tissue was collected when available.

RESULTS

Of the 3081 persons in the Olmsted County MI cohort, 1994 participated in the study; 1007 (50.5%) blood and 987 (49.5%) tissue specimens were provided. Participants were more likely to be younger men with hypertension, comorbidities, and non-ST-segment elevation MI (all, P<.05). Participants who provided blood specimens were more likely to have non-ST-segment elevation MI and lower Killip class than those who provided tissue. After adjustment for age, sex, hypertension, ST-segment elevation, Killip class, and comorbidities, participation was not associated with outcome. Participants who provided blood specimens were less likely to have heart failure (hazard ratio, 0.49; 95% confidence interval, 0.40-0.59; P<.01) or to die (hazard ratio, 0.16; 95% confidence interval, 0.12-0.21; P<.01) than those who provided tissue.

CONCLUSION

A variety of sources can be used to assemble community specimen repositories. Baseline characteristics differed between participants and nonparticipants and, among participants, by specimen source. Participants who provided blood specimens had better outcomes than those who provided tissue specimens. No survival advantage was observed for participants after combining blood and tissue specimens.

Participation bias assessment in a community-based study of myocardial infarction, 2002-2005

OBJECTIVE

To compare the characteristics and survival of participants and nonparticipants in a community-based study of myocardial infarction (MI).

PARTICIPANTS AND METHODS

Residents of Olmsted County, MN, who presented with elevated cardiac troponin T levels from September 1, 2002, through December 31, 2005, were prospectively enrolled and classified with standardized criteria for MI. With specific Institutional Review Board approval, the medical records of patients with MI who did not provide consent but who had given general research authorization were reviewed, as was done for their consenting peers.

RESULTS

During the study period, 2277 individuals with elevated cardiac troponin T levels were approached, of whom 1863 (82 percent) consented to participate. Among the 414 nonparticipants, 375 (91 percent) had general research authorization. Of the 558 with general research authorization who met the criteria for incident (ie, first-ever) MI, 67 (12 percent) refused to participate. These participants tended to be older (mean plus or minus SD age, 71 plus or minus 14 vs 67 plus or minus 15 years; P equals .04), were more likely to be of races other than white (9 percent vs 2 percent; P equals .01), and had more comorbidities, including peripheral vascular disease (P equals .02), chronic pulmonary disease (P equals .06), heart failure (P equals .07), and impaired creatinine clearance (P equals .02). No significant differences were detected in cardiovascular risk factors or MI characteristics. During a median follow-up of 517 days, nonparticipants experienced increased mortality rates compared with participants (hazard ratio, 1.97; 95 percent confidence interval, 1.21 to 3.20), which was largely attributable to their older age and excess comorbidities (adjusted hazard ratio, 1.43; 95 percent confidence interval, 0.86 to 2.35).

CONCLUSION

In this community-based study of MI, nonparticipants experienced worse survival rates than participants largely because of differences in demographic and clinical characteristics. These differences should be kept in mind when interpreting study results, particularly if participation is low.

Impaired functional status and echocardiographic abnormalities signifying global dysfunction enhance the prognostic significance of previously unrecognized myocardial infarction detected by electrocardiography

BACKGROUND

The relationship between electrocardiographic unrecognized myocardial infarction (UMI), abnormal functional status, echocardiographic abnormalities, and mortality has not been evaluated.

METHODS

A population-based random sample of 2042 Olmsted County residents, age > or = 45 years, was studied by self-administered questionnaire, chart review, ECG and echocardiogram, and 5 year follow-up for all-cause mortality. UMI (n = 81) was diagnosed if ECG-MI criteria were met without previous documented myocardial infarction. Functional Status was assessed by the Goldman Specific Activity Scale.

RESULTS

UMI subjects had an increased prevalence of abnormal functional status compared to no MI controls (22% vs 11%, P < 0.05). This association was independent of sex, obesity, smoking, diabetes, and pulmonary disease. It became insignificant after stratifying for echocardiographic abnormalities. Compared to no MI controls, UMI subjects with impaired functional status had a higher mortality hazard ratio (HR 7.2; P<0.0001) than those without impaired functional status (HR 2.7; P = 0.02). In UMI subjects with impaired functional status and any echocardiographic abnormality signifying global ventricular dysfunction (systolic or diastolic dysfunction, left atrial or left ventricular enlargement), the mortality risk was even higher (HR 9.5; P<0.001) and persisted in multivariate analyses. This increased mortality risk was unaffected by adjustment for regional wall motion abnormalities.

CONCLUSIONS

The assessment of impaired functional status and echocardiographic abnormalities improves the prognostic significance of UMI. Even in the absence of regional wall motion abnormalities, structural abnormalities of global dysfunction may play a role in mediating the increased mortality associated with UMI.

Epidemiology of angina pectoris: role of natural language processing of the medical record

BACKGROUND

The diagnosis of angina is challenging because it relies on symptom descriptions. Natural language processing (NLP) of the electronic medical record (EMR) can provide access to such information contained in free text that may not be fully captured by conventional diagnostic coding.

OBJECTIVE

To test the hypothesis that NLP of the EMR improves angina pectoris ascertainment over diagnostic codes.

METHODS

Billing records of inpatients and outpatients were searched for International Classification of Diseases, Ninth Revision (ICD-9) codes for angina pectoris, chronic ischemic heart disease, and chest pain. EMR clinical reports were searched electronically for 50 specific nonnegated natural language synonyms to these ICD-9 codes. The 2 methods were compared to a standardized assessment of angina by Rose questionnaire for 3 diagnostic levels: unspecified chest pain, exertional chest pain, and Rose angina.

RESULTS

Compared with the Rose questionnaire, the true-positive rate of EMR-NLP for unspecified chest pain was 62% (95% CI 55-67) versus 51% (95% CI 44-58) for diagnostic codes (P < .001). For exertional chest pain, the EMR-NLP true-positive rate was 71% (95% CI 61-80) versus 62% (95% CI 52-73) for diagnostic codes (P = .10). Both approaches had 88% (95% CI 65-100) true-positive rate for Rose angina. The EMR-NLP method consistently identified more patients with exertional chest pain over a 28-month follow-up.

CONCLUSION

EMR-NLP method improves the detection of unspecified and exertional chest pain cases compared to diagnostic codes. These findings have implications for epidemiological and clinical studies of angina pectoris.

Prevalence and prognostic significance of heart failure stages: application of the American College of Cardiology/American Heart Association heart failure staging criteria in the community

BACKGROUND

Heart failure (HF) is a progressive disorder associated with frequent morbidity and mortality. An American Heart Association/American College of Cardiology staging classification of HF has been developed to emphasize early detection and prevention. The prevalence of HF stages and their association with mortality are unknown. We sought to estimate HF stage prevalence in the community and to measure the association of HF stages with mortality.

METHODS AND RESULTS

A population-based, cross-sectional, random sample of 2029 Olmsted County, Minnesota, residents aged > or = 45 years was identified. Participants were classified by medical record review, symptom questionnaire, physical examination, and echocardiogram as follows: stage 0, healthy; stage A, HF risk factors; stage B, asymptomatic cardiac structural or functional abnormalities; stage C, HF symptoms; and stage D, severe HF. In the cohort, 32% were stage 0, 22% stage A, 34% stage B, 12% stage C, and 0.2% stage D. Mean B-type natriuretic peptide concentrations (in pg/mL) increased by stages: stage 0=26, stage A=32, stage B=53, stage C=137, and stage D=353. Survival at 5 years was 99% in stage 0, 97% in stage A, 96% in stage B, 75% in stage C, and 20% in stage D.

CONCLUSIONS

The present study provides prevalence estimates and prognostic validation for HF staging in a community cohort. Of note, 56% of adults > or = 45 years of age were classified as being in stage A (risk factors) or B (asymptomatic ventricular dysfunction). HF staging underscores the magnitude of the population at risk for progression to overt HF.

Prevalence of syncope in a population aged more than 45 years

PURPOSE

Our current understanding of the prevalence of syncope is based on a few small studies of highly selected populations. We sought to estimate the prevalence and recurrence rate of syncope in the general population aged more than 45 years and to analyze their associations with age and sex.

METHODS

We performed a cross-sectional survey of 1925 randomly selected residents of Olmsted County, Minn, 45 years or older, from January 1998 to August 2000.

RESULTS

The median age of the 1925 participants was 62 years, and 905 (47.0%) were male. Overall, 364 subjects reported an episode of syncope in their lifetime, giving an estimated prevalence of 19% (95% confidence interval, 17%-21%). The age-specific prevalence rates were 45 to 54 years (20%), 55 to 64 years (20%), 65 to 74 years (15%), and 75 years or more (21%) (P = .86). Females reported a higher prevalence of syncope (22% vs 15%, P < .001).

CONCLUSIONS

The prevalence of syncope is estimated at 19% in the general population aged more than 45 years. Females have a higher prevalence, and there is no association of syncope prevalence with age.

eHealth recruitment challenges

Little is known about effective eHealth recruitment methods. This paper presents recruitment challenges associated with enrolling African-American girls aged 8-10 years in an eHealth obesity prevention program, their effect on the recruitment plan, and potential implications for eHealth research. Although the initial recruitment strategy was literature-informed, it failed to enroll the desired number of girls within a reasonable time period. Therefore, the recruitment strategy was reformulated to incorporate principles of social marketing and traditional marketing techniques. The resulting plan included both targeted, highly specific strategies (e.g., selected churches), and more broad-based approaches (e.g., media exposure, mass mailings, radio advertisements). The revised plan enabled recruitment goals to be attained. Media appeared to be particularly effective at reaching the intended audience. Future research should identify the most effective recruitment strategies for reaching potential eHealth audiences.

Limitations of estimating glomerular filtration rate from serum creatinine in the general population

OBJECTIVE

To compare estimated glomerular filtration rate (GFR) in the general population on the basis of equations derived from different subsets of the general population.

PARTICIPANTS AND METHODS

Adults (ages _45 years) were randomly selected from 1997 to 2000 from the Olmsted County, Minnesota, population and had their serum creatinine levels measured. The GFR was estimated using previously reported equations derived from a sample of patients with chronic kidney disease (CKD), a sample of healthy persons, and the combined samples. Serum creatinine was measured with the same assay used to derive these equations.

RESULTS

Of 4203 subjects, 2042 (47% participation rate) were enrolled and studied. Serum samples from 1982 subjects were used to measure creatinine levels. The prevalence of a reduced estimated GFR (<60 mL/min per 1.73 m2) was 12% (95% confidence interval [CI], 10%-13%) based on an equation derived with all CKD patients, and this finding was similar to prior reports. However, the prevalence of a reduced estimated GFR was 5.7% (95% CI, 4.8%-6.8%) based on an equation derived with both CKD patients and healthy persons and 0.2% (95% CI, 0.1%-0.5%) based on an equation derived with all healthy persons. Women had a higher risk of reduced estimated GFR according to an equation derived with all CKD patients, but men had a higher risk with an equation derived with both CKD patients and healthy persons.

Risk factors for fecal incontinence: a population-based study in women

BACKGROUND

In women with "idiopathic" fecal incontinence (FI), consensus guidelines recommend anal sphincter imaging and surgical repair, when feasible, of anal sphincter defects believed to cause FI. However, the relative contributions of obstetric trauma and bowel symptoms to FI in the community are unknown.

METHODS

To assess risk factors for FI during the past year, a previously validated questionnaire was mailed to an age-stratified random sample of 5,300 women residing in Olmsted County, Minnesota.

RESULTS

Altogether, 2,800 women (53%) responded. The risk of fecal incontinence increased with age (odds ratio [OR] per decade 1.3, 95% CI 1.2-1.4). The risk of fecal incontinence was higher among women with rectal urgency (OR 8.3, 95% CI 4.8-14.3) whether or not they also had other bowel disturbances (i.e., constipation, diarrhea, or abdominal pain) or had a vaginal delivery with forceps or stitches (OR 9.0, 95% CI 5.6-14.4). Among women with FI, rectal urgency and age were also risk factors for symptom severity. In contrast, obstetric risk factors for anorectal trauma did not increase the risk for FI. The risk for FI was not significantly different among women with cesarean section, vaginal delivery with or without forceps or stitches, or anorectal surgery, compared with nulliparous women without any of these risk factors.

CONCLUSIONS

Rectal urgency rather than obstetric injury is the main risk factor for FI in women. These observations reinforce the importance of behavioral, dietary, and pharmacological measures to ameliorate bowel disturbances before anal imaging in women with "idiopathic" FI.

Amino-terminal pro-B-type natriuretic peptide and B-type natriuretic peptide: biomarkers for mortality in a large community-based cohort free of heart failure

Recent studies report that, in the absence of heart failure and renal failure, plasma B-type natriuretic peptide (BNP) has prognostic value for mortality. We sought to confirm and extend these previous studies to assess BNP, measured by 3 distinct assays, as a biomarker for mortality in a strategy to enhance efforts at primary prevention and to better understand the clinical phenotype of such subjects at risk. We used a community-based cohort of 2042 subjects from Olmsted County, Minn, and individuals with heart or renal failure were excluded. BNP was assessed using 3 assays including Biosite and Shionogi for mature, biologically active BNP and the Roche assay for apparently nonbiologically active amino-terminal pro-BNP (NT-proBNP). Thorough echocardiographic and clinical data were recorded for all of the participants. Median follow-up for mortality was 5.6 years. BNP by all 3 of the assays was predictive of mortality. NT-proBNP and Biosite assays remained significant even after adjustment for traditional clinical risk factors and echocardiographic abnormalities including left ventricular hypertrophy and diastolic dysfunction. Echocardiography documented widespread structural changes in those with increasing BNP levels yet below levels observed in heart failure. We report in a large, well-characterized community-based cohort, free of heart failure, the first study to compare 3 distinct BNP assays as biomarkers for mortality in the same cohort. Our findings confirm the potential use of NT-proBNP and BNP biomarkers for future events and underscore that these peptides may also serve as biomarkers for underlying cardiac remodeling secondary to diverse cardiovascular disease entities.

Unrecognized myocardial infarction: the association with cardiopulmonary symptoms and mortality is mediated via echocardiographic abnormalities of global dysfunction instead of regional dysfunction: the Olmsted County Heart Function Study

BACKGROUND

There are very few data describing the association of electrocardiogram-based unrecognized myocardial infarction (ECG-UMI) with nonanginal cardiopulmonary symptoms, echocardiographic abnormalities, and mortality in the community.

METHODS

We studied 2042 Olmsted County residents, who were randomly selected and aged > or = 45 years, by a survey questionnaire for symptoms, echocardiogram for structural abnormalities, and a 5-year follow-up for all-cause mortality. Unrecognized myocardial infarctions (n = 81) were diagnosed if ECG-based myocardial infarction (MI) criteria were met without the history of a documented recognized MI.

RESULTS

In UMI versus no MI controls, the prevalence (%) of dyspnea on exertion (49 vs 29), orthopnea (6 vs 4), palpitations (20 vs 15), and history of fluid overload (6 vs 1) was significantly higher (P < .05). The associations of exertional dyspnea and history of fluid overload with UMI were independent of age, sex, and pulmonary disease but had a significant reduction in their magnitude after adjusting for global dysfunction (diastolic or systolic dysfunction). All the 4 symptoms were associated with increased risk of mortality (hazard ratios ranging from 2.3 to 9.1, P < .0001), which was meaningfully attenuated by adjusting for ECG-UMI status. Global ventricular dysfunction had a more significant impact on this association than regional ventricular dysfunction (wall motion abnormalities).

CONCLUSIONS

The increased risk of mortality associated with symptoms is at least in part mediated via ECG-UMI. Structural abnormalities of global dysfunction play a greater role in mediating this risk than regional dysfunction, challenging the current clinical practice of calling an ECG-based MI false positive in symptomatic adults in the absence of wall motion abnormalities.