Socioeconomic mobility in adulthood and cardiovascular disease mortality

Clinical, Health-Related Quality of Life, and Gait Differences Among Obesity Classes in Adults With Knee Osteoarthritis

OBJECTIVE

The purpose of this study was to determine whether clinical, health-related quality of life (HRQL), and gait characteristics in adults with knee osteoarthritis (OA) differed by obesity category.

METHODS

This cross-sectional analysis of 823 older adults (mean age 64.6 years, SD 7.8 years) with knee OA and overweight or obesity compared clinical, HRQL, and gait outcomes among obesity classifications (overweight or class I, body mass index [BMI] 27.0-34.9; class II, BMI 35.0-39.9; class III BMI ≥40.0).

RESULTS

Patients with class III obesity had worse Western Ontario McMasters Universities Arthritis Index knee pain (0-20) than the overweight or class I (mean 8.6 vs 7.0; difference 1.5; 95% confidence interval [CI] 1.0-2.1; P < 0.0001) and class II (mean 8.6 vs 7.4; difference 1.1; 95% CI 0.6-1.7; P = 0.0002) obesity groups. The Short Form 36 physical HRQL measure was lower in the class III obesity group compared to the overweight or class I (mean 31.0 vs 37.3; difference -6.2; 95% CI -7.8 to -4.7; P < 0.0001) and class II (mean 31.0 vs 35.0; difference -3.9; 95% CI -5.6 to -2.2; P < 0.0001) obesity groups. The class III obesity group had a base of support (cm) during gait that was wider than that for the overweight or class I (mean 14.0 vs 11.6; difference 3.3; 95% CI 2.6-4.0; P < 0.0001) and class II (mean 14.0 vs 11.6; difference 2.4; 95% CI 1.6-3.2; P < 0.0001) obesity groups.

CONCLUSION

Among adults with knee OA, those with class III obesity had significantly higher pain levels and worse physical HRQL and gait characteristics compared to adults with overweight or class I or class II obesity.

Trajectories of Instrumental and Emotional Social Support and the Associated Risk of Mortality in Bereaved Older Adults in Taiwan

This study identified the trajectories of instrumental and emotional perceived social support (PSS) from 1996 to 2003 and investigated the associated risk of mortality in bereaved older adults in Taiwan. The study analyzed 1,188 bereaved older adults who had experienced loss of a spouse, a child, or both before 1996 from the Taiwan Longitudinal Study on Aging. More favorable trajectories of PSS are associated with lower mortality risk in bereaved older adults. Compared with the spousal or dual bereavement, the parental bereavement benefited more from consistently high instrumental PSS. The present study revealed that consistently high emotional PSS had a stronger protective effect on mortality risk for a widow or widower than did consistently high instrumental support. The findings of this study can serve as an empirical reference to inform social policies and clinical practices for bereaved older adults in culturally similar societies.

Intergenerational Socioeconomic Mobility and Cognitive Impairment Among Chinese Older Adults: Gender Differences

This study examined the impact of intergenerational socioeconomic mobility on the risk of cognitive impairment in a cohort of Chinese older adults aged 60 years and older. Data were derived from the 2014 wave of the Chinese Longitudinal Healthy Longevity Survey. Logistic regression models were performed to assess the impact of three dimensions of socioeconomic mobility (occupational mobility, educational mobility, and residential mobility) on the risk of cognitive impairment. We found that men who were stable with non-professional jobs across generations had a higher risk of cognitive impairment than their counterparts who experienced upward occupational mobility compared to their father. This pattern was not observed in women. There was little evidence that educational mobility or residential mobility affected cognitive impairment in later life. The findings have implications for advancing supportive policies and practices related to maximizing the benefits of education and career advancements for cognition in later life.

Modelling of longitudinal data to predict cardiovascular disease risk: a methodological review

OBJECTIVE

The identification of methodology for modelling cardiovascular disease (CVD) risk using longitudinal data and risk factor trajectories.

METHODS

We screened MEDLINE-Ovid from inception until 3 June 2020. MeSH and text search terms covered three areas: data type, modelling type and disease area including search terms such as "longitudinal", "trajector*" and "cardiovasc*" respectively. Studies were filtered to meet the following inclusion criteria: longitudinal individual patient data in adult patients with ≥3 time-points and a CVD or mortality outcome. Studies were screened and analyzed by one author. Any queries were discussed with the other authors. Comparisons were made between the methods identified looking at assumptions, flexibility and software availability.

RESULTS

From the initial 2601 studies returned by the searches 80 studies were included. Four statistical approaches were identified for modelling the longitudinal data: 3 (4%) studies compared time points with simple statistical tests, 40 (50%) used single-stage approaches, such as including single time points or summary measures in survival models, 29 (36%) used two-stage approaches including an estimated longitudinal parameter in survival models, and 8 (10%) used joint models which modelled the longitudinal and survival data together. The proportion of CVD risk prediction models created using longitudinal data using two-stage and joint models increased over time.

CONCLUSIONS

Single stage models are still heavily utilized by many CVD risk prediction studies for modelling longitudinal data. Future studies should fully utilize available longitudinal data when analyzing CVD risk by employing two-stage and joint approaches which can often better utilize the available data.

Coronary heart disease and stroke mortality trends in Brazil 2000-2018

OBJECTIVE

To analyse the mortality rate trend due to coronary heart disease (CHD) and stroke in the adult population in Brazil.

METHODS

From 2000 to 2018, a time trend study with joinpoint regression was conducted among Brazilian men and women aged 35 years and over. Age-adjusted and age, sex specific CHD and stroke trend rate mortality were measured.

RESULTS

Crude mortality rates from CHD decreased in both sexes and in all age groups, except for males over 85 years old with an increase of 1.78%. The most accentuated declining occurred for age range 35 to 44 years for both men (52.1%) and women (53.2%) due to stroke and in men (33%) due to CHD, and among women (32%) aged 65 to 74 years due to CHD. Age-adjusted mortality rates for CHD and stroke decreased in both sexes, in the period from 2000 to 2018. The average annual rate for CHD went from 97.09 during 2000-2008 to 78.75 during 2016-2018, whereas the highest percentage of change was observed during 2008 to 2013 (APC -2.5%; 95% CI). The average annual rate for stroke decreased from 104.96 to 69.93, between 2000-2008 and 2016-2018, and the highest percentage of change occurred during the periods from 2008 to 2013 and 2016 to 2018 (APC 4.7%; 95% CI).

CONCLUSION

The downward trend CHD and stroke mortality rates is continuing. Policy intervention directed to strengthen care provision and improve population diets and lifestyles might explain the continued progress, but there is no room for complacency.

Life Course Socioeconomic Position, Intergenerational Social Mobility, and Hypertension Incidence in ELSA-Brasil

BACKGROUND

Life course epidemiology is a powerful framework to unravel the role of socioeconomic position (SEP) disparities in hypertension (HTN). This study investigated whether life course SEP is associated with HTN incidence. Specifically, to test whether cumulative low SEP throughout life and unfavorable intergenerational social mobility increased HTN incidence.

METHODS

Longitudinal analysis of 8,754 ELSA-Brasil participants without HTN or cardiovascular in visit 1 (2008-2010). The response variable was the incidence of HTN between visits 1 and 2 (2012-2014). The explanatory variables were childhood, youth, and adulthood SEP, cumulative low SEP, and intergenerational social mobility. Associations were estimated by incidence rate ratios (IRRs) obtained by generalized linear models, with Poisson distribution and logarithmic link function, after adjustment for sociodemographic, behavioral, and health factors.

RESULTS

The incidence of HTN was 43.2/1,000 person-years, being higher in males, elderly (70-74 years), self-declared black, and low SEP individuals. After considering sociodemographic factors, low SEP in childhood, youth, and adulthood remained statistically associated with increased HTN incidence. Individuals in the third (IRR: 1.26; 95% confidence interval (CI): 1.11-1.44) and fourth top quartiles (IRR: 1.29; 95% CI: 1.11-1.49) of cumulative low SEP, vs. first, as well as those with low stable intergenerational trajectory (IRR: 1.29; 95% CI: 1.16-1.43), vs. high stable, also had increased HTN incidence rates.

CONCLUSIONS

Socioeconomic disparities at all phases of the life cycle appear to raise HTN incidence rates, being the individuals with greater accumulation of exposure to low SEP and with more unfavorable intergenerational mobility at greatest risk, even in a short follow-up time.

Socioeconomic Status and Parenting Style From Childhood: Long-Term Effects on Cognitive Function in Middle and Later Adulthood

OBJECTIVES

This study assesses whether childhood socioeconomic status (SES) is related to cognitive function and cognitive change at mid and later life and explores the buffering effects of parenting style and adulthood SES.

METHOD

Data were derived from the 3 waves of the Midlife in the United States (MIDUS) study, a national survey including 7,108 participants aged from 24 to 75 years at baseline. We used multiple regression and multilevel models to investigate the associations between childhood SES, adulthood SES, and cognitive performance and change at midlife and the role of parents' affection and discipline.

RESULTS

Low childhood SES was associated with lower cognitive function and more cognitive decline at mid and later life. Adulthood SES moderated the effect of childhood SES on cognitive function. Interactions showed that paternal discipline was positively related to cognitive function among participants with low childhood SES, and negatively related to cognitive function among participants with high childhood SES. High paternal affection was associated with less cognitive decline at mid and later life.

DISCUSSION

The findings advance the understanding of the long-term consequences of SES and psychosocial factors in early life that can lead to optimal cognitive function in middle and old age.

Socioeconomic status and cardiovascular risk factors in young adults: a cross-sectional analysis of a Brazilian birth cohort

INTRODUCTION

In high-income countries, persons of high socioeconomic status (SES) have a lower cardiovascular risk. However, in middle and low-income countries, the results are controversial.

OBJECTIVE

To evaluate the association between family income and cardiovascular risk factors in young adults.

METHODS

A total of 2,063 individuals of a birth cohort initiated in 1978/79 in the city of Ribeirão Preto, Brazil, were evaluated at age of 23/25 years. Cardiovascular risk factors (hypertension, sedentary lifestyle, smoking, low high-density lipoprotein (HDL)-cholesterol, high low-density lipoprotein (LDL)-cholesterol, high fibrinogen, insulin resistance, diabetes, abdominal and total obesity, and metabolic syndrome) were evaluated according to family income. Income was assessed in multiples of the minimum wage. Simple Poisson regression models were used to estimate the prevalence ratios (PR) with robust estimation of the variance.

RESULTS

High-income women showed lower prevalences of low HDL-cholesterol (PR = 0.47), total obesity (PR = 0.22), abdominal obesity (PR = 0.28), high blood pressure (PR = 0.28), insulin resistance (PR = 0.57), sedentary lifestyle (PR = 0.47), metabolic syndrome (PR = 0.24), and high caloric intake (PR = 0.71) (p < 0.05). High-income men showed lower prevalences of low HDL-cholesterol (PR = 0.73) and sedentarism (PR = 0.81) (p < 0.05). These results may be explained by the fact that high-income women pay more attention to healthy habits and those with the lowest family income are least likely to access health services resources and treatments.

CONCLUSION

Women were in the final phase of the epidemiologic transition, whereas men were in the middle phase.

Invasive Dental Treatment and Risk for a First Myocardial Infarction

Invasive dental treatment is suggested to be associated with an increased risk for the development of cardiovascular events. We tested the hypothesis that the incidence of a first myocardial infarction (MI) within 4 wk after invasive dental treatments is increased. A registry-based case-control study within nationwide health care and population registries in Sweden was performed. The case patients included 51,880 individuals with a first fatal or nonfatal MI between January 2011 and December 2013. For each case, 5 control subjects, free from prior MI and matched for age, sex, and geographic area of residence, were randomly selected from the national population registry through risk set sampling with replacement, resulting in 246,978 control subjects. Information on dental treatments was obtained from the Dental Health Register, and the procedures were categorized into invasive dental treatments or other dental treatments. Conditional logistic regression was used to estimate odds ratios (ORs) for MI with corresponding 95% confidence intervals (CIs). In addition to the matching variables, adjustments were made for the following confounders: diabetes, previous cardiovascular disease (CVD), CVD drug treatment, education, and income. The mean age for case patients and controls subjects was 72.6 ± 13.0 y and 72.3 ± 13.0 y, respectively. Case patients more often had previous CVD (49% vs. 23%; P < 0.001) and diabetes (19% vs. 11%; P < 0.001) and received more treatment with CVD drugs (68% vs. 56%; P < 0.001) than control subjects. There was no association between invasive dental treatments during the 4 wk preceding the MI index date (crude OR = 0.99; 95% CI, 0.92 to 1.06; adjusted for confounders OR = 0.98; 95% CI, 0.91 to 1.06). This study did not support the hypothesis of an increased incidence of MI after recent invasive dental treatment.

The relation between household income and surgical outcome in the Dutch setting of equal access to and provision of healthcare

Background

The impact of socioeconomic disparities on surgical outcome in the absence of healthcare inequality remains unclear. Therefore, we set out to determine the association between socioeconomic status (SES), reflected by household income, and overall survival after surgery in the Dutch setting of equal access and provision of care. Additionally, we aim to assess whether SES is associated with cause-specific survival and major 30-day complications.

Methods

Patients undergoing surgery between March 2005 and December 2006 in a general teaching hospital in the Netherlands were prospectively included. Adjusted logistic and cox regression analyses were used to assess the independent association of SES–quantified by gross household income–with major 30-day complications and long-term postoperative survival.

Results

A total of 3929 patients were included, with a median follow-up of 6.3 years. Low household income was associated with worse survival in continuous analysis (HR: 1.05 per 10.000 euro decrease in income, 95% CI: 1.01–1.10) and in income quartile analysis (HR: 1.58, 95% CI: 1.08–2.31, first [i.e. lowest] quartile relative to the fourth quartile). Similarly, low income patients were at higher risk of cardiovascular death (HR: 1.26 per 10.000 decrease in income, 95% CI: 1.07–1.48, first income quartile: HR: 3.10, 95% CI: 1.04–9.22). Household income was not independently associated with cancer-related mortality and major 30-day complications.

Conclusions

Low SES, quantified by gross household income, is associated with increased overall and cardiovascular mortality risks among surgical patients. Considering the equality of care provided by this study setting, the associated survival hazards can be attributed to patient and provider factors, rather than disparities in healthcare. Increased physician awareness of SES as a risk factor in preoperative decision-making and focus on improving established SES-related risk factors may improve surgical outcome of low SES patients.

Graduating into Lower Risk: Chlamydia and Trichomonas Prevalence among Community College Students and Graduates

BACKGROUND

Community colleges enable youth from economically disadvantaged and minority populations to access college and may enable social mobility including improved health outcomes. However, educational health disparities studies rarely assess the health outcomes for community college graduates.

METHODS

Chlamydia and trichomonas prevalence were assessed with nucleic acid based tests in a nationally representative sample of 6233 high school graduates (ages 18-25) from five educational levels: young adults without post-secondary credentials who were not enrolled in college, community college students, 4-year college students, associate's degree, and bachelor's degree. To reduce confounding between educational attainment and STI status, we used full matching to balance on 22 measures of demographics, socioeconomic status, educational factors, and sexual risk-taking. Estimates of associations between educational attainment and STI status were obtained from multivariate regression in the full (n=6233) and matched (n=1655) samples.

RESULTS

Four-year college students (adjusted incidence rate ratio (IRR) = 0.41, 95% CI [0.27, 0.61], p<0.001), associate's degree holders (IRR = 0.38 [0.15, 0.98], p=0.05), and bachelor's degree holders (IRR = 0.45 [0.23, 0.90], p=0.02) were less than half as likely to test positive for chlamydia than non-college-enrolled high school graduates in multivariate regression. After full matching, associate's degree holders were also less likely to test positive for chlamydia (IRR 0.46 (0.23, 0.85), p=0.03) than community college students. Four-year college students (IRR = 0.52 [0.24, 1.12], p=0.10) and associate's degree holders (IRR = 0.34 [0.12, 0.97], p=0.04) were half as likely to test positive for trichomonas than nonstudents/non-graduates in multivariate regression but did not differ after full matching.

CONCLUSIONS

Community college students come from populations with greater health risks than 4-year college students, but community college graduation may reduce the likelihood of chlamydia infection. STI interventions can meet the needs of young adults who access college through community college by partnering with community college health clinics to encourage continued STI prevention, testing, and treatment after the intervention ends. Public health studies that use inclusive educational attainment measures that incorporate sub-baccalaureate credentials will better capture health disparities.

Associations of social environment, socioeconomic position and social mobility with immune response in young adults: the Jerusalem Perinatal Family Follow-Up Study

OBJECTIVES

Immune response to cytomegalovirus (CMV) impacts adult chronic disease. This study investigates associations of childhood and adulthood social environment, socioeconomic position (SEP) and social mobility with CMV response in young adults.

DESIGN

Historical prospective study design.

SETTING

Subcohort of all 17 003 births to residents of Jerusalem between 1974 and 1976.

PARTICIPANTS

Participants included 1319 young adults born in Jerusalem with extensive archival and follow-up data, including childhood and adulthood SEP-related factors and anti-CMV IgG titre levels and seroprevalence measured at age 32.

MAIN EXPOSURE AND OUTCOME MEASURES

Principal component analysis was used to transform correlated social environment and SEP-related variables at two time points (childhood and adulthood) into two major scores reflecting household (eg, number of siblings/children, religiosity) and socioeconomic (eg, occupation, education) components. Based on these components, social mobility variables were created. Linear and Poisson regression models were used to investigate associations of components and mobility with anti-CMV IgG titre level and seroprevalence, adjusted for confounders.

RESULTS

Lower levels of household and socioeconomic components in either childhood or adulthood were associated with higher anti-CMV IgG titre level and seropositivity at age 32. Compared with individuals with stable favourable components, anti-CMV IgG titre level and risk for seropositivity were higher in stable unfavourable household and socioeconomic components (household: β=3.23, P<0.001; relative risk (RR)=1.21, P<0.001; socioeconomic: β=2.20, P=0.001; RR=1.14, P=0.01), downward household mobility (β=4.32, P<0.001; RR=1.26, P<0.001) and upward socioeconomic mobility (β=1.37, P=0.04; RR=1.19, P<0.001). Among seropositive individuals, associations between household components and mobility with anti-CMV IgG titre level were maintained and associations between socioeconomic components and mobility with anti-CMV IgG titre level were attenuated.

CONCLUSIONS

Our study provides evidence that accumulating low SEP from childhood through adulthood and social mobility may compromise immune response in young adulthood.

Associations of socioeconomic position in childhood and young adulthood with cardiometabolic risk factors: the Jerusalem Perinatal Family Follow-Up Study

BACKGROUND

Several stages in the life course have been identified as important to the development of cardiovascular disease. This study aimed to assess the associations of childhood and adulthood socioeconomic position (SEP) and social mobility with cardiometabolic risk factors (CMRs) later in life.

METHODS

We conducted follow-up examinations of 1132 offspring, aged 32, within a population-based cohort of all births in Jerusalem from 1974 to 1976. SEP was indicated by parents' occupation and education, and adulthood SEP was based on offspring's occupation and education recorded at age 32. Linear regression models were used to investigate the associations of SEP and social mobility with CMRs.

RESULTS

Childhood-occupational SEP was negatively associated with body mass index (BMI; β=-0.29, p=0.031), fat percentage (fat%; β=-0.58, p=0.005), insulin (β=-0.01, p=0.031), triglycerides (β=-0.02, p=0.024) and low-density lipoprotein cholesterol (LDL-C; β=-1.91, p=0.015), independent of adulthood SEP. Adulthood-occupational SEP was negatively associated with waist-to-hip ratio (WHR; β=-0.01, p=0.002), and positively with high-density lipoprotein cholesterol (HDL-C; β=0.87, p=0.030). Results remained similar after adjustment for smoking and inactivity. Childhood-educational SEP was associated with decreased WHR and LDL-C level (p=0.0002), and adulthood-educational SEP was inversely associated with BMI (p=0.001), waist circumference (p=0.008), WHR (p=0.001) and fat% (p=0.0002) and positively associated with HDL-C (p=0.030). Additionally, social mobility (mainly upward) was shown to have adverse cardiometabolic outcomes.

CONCLUSIONS

Both childhood and adulthood SEP contribute independently to CMR. The match-mismatch hypothesis may explain the elevated CMRs among participants experiencing social mobility. Identification of life-course SEP-related aspects that translate into social inequality in cardiovascular risk may facilitate efforts for improving health and for reducing disparities in cardiovascular disease.

The geographic distribution of cardiovascular health in the stroke prevention in healthcare delivery environments (SPHERE) study

BACKGROUND

Community-level factors have been clearly linked to health outcomes, but are challenging to incorporate into medical practice. Increasing use of electronic health records (EHRs) makes patient-level data available for researchers in a systematic and accessible way, but these data remain siloed from community-level data relevant to health.

PURPOSE

This study sought to link community and EHR data from an older female patient cohort participating in an ongoing intervention at the Ohio State University Wexner Medical Center to associate community-level data with patient-level cardiovascular health (CVH) as well as to assess the utility of this EHR integration methodology.

MATERIALS AND METHODS

CVH was characterized among patients using available EHR data collected May through July of 2013. EHR data for 153 patients were linked to United States census-tract level data to explore feasibility and insights gained from combining these disparate data sources. Analyses were conducted in 2014.

RESULTS

Using the linked data, weekly per capita expenditure on fruits and vegetables was found to be significantly associated with CVH at the p<0.05 level and three other community-level attributes (median income, average household size, and unemployment rate) were associated with CVH at the p<0.10 level.

CONCLUSIONS

This work paves the way for future integration of community and EHR-based data into patient care as a novel methodology to gain insight into multi-level factors that affect CVH and other health outcomes. Further, our findings demonstrate the specific architectural and functional challenges associated with integrating decision support technologies and geographic information to support tailored and patient-centered decision making therein.

Does Further Education in Adulthood Improve Physical and Mental Health among Australian Women? A Longitudinal Study

OBJECTIVE

We analyzed whether further education in young adult and mid-life [adult educational mobility] influences physical functioning and depressive symptoms in women.

METHODS

14247 women born 1973-78 (younger cohort) and 13715 women born 1946-51 (mid-aged cohort) from the Australian Longitudinal Study on Women's Health were followed for 14-16 years. Measures were the Short-Form 36 Health Survey physical functioning subscale (SF-36 PF) and Centre for Epidemiologic Studies 10-item Depression Scale (CESD-10). Linear mixed modelling, accounting for time varying covariates, assessed the influence of further education on physical functioning and depressive symptoms over time. Sensitivity analysis to assess the impact of missing data was conducted using multiple imputation.

RESULTS

Compared to younger women with a pre-existing high level of education, women gaining further education (up to age 39 years) from low levels had lower SF-36 PF scores (poorer physical functioning) (fully adjusted beta estimates (95%CIs) -1.52 (-2.59, -0.44)) while those gaining further education from middle to high levels showed equivalent SF-36 PF scores (-0.08 (-0.61, 0.44)). A similar pattern was shown for CESD-10 scores (0.78 (0.29, 1.25); -0.02 (-0.26, 0.21), respectively) where higher scores represented more depressive symptoms. For mid-age women, further education from a middle to high level resulted in equivalent SF-36 PF scores (-0.61 (-1.93,0.71)) but higher CESD-10 scores (0.49 (0.11, 0.86)), compared to highly educated women.

CONCLUSION

Women who delay further education until they are aged between their 40s and 60s can improve or maintain their physical functioning but may have missed the critical time to minimise depressive symptomatology. Public health policy should focus on encouraging women to upgrade their educational qualifications earlier in life in order to potentially offset the negative associations between their initial lower socio-economic position class of origin and their mental health.

Cardiovascular Disease Mortality After Chemotherapy or Surgery for Testicular Nonseminoma: A Population-Based Study

PURPOSE

Increased risks of incident cardiovascular disease (CVD) in patients with testicular cancer (TC) given chemotherapy in European studies were largely restricted to long-term survivors and included patients from the 1960s. Few population-based investigations have quantified CVD mortality during, shortly after, and for two decades after TC diagnosis in the era of cisplatin-based chemotherapy.

PATIENTS AND METHODS

Standardized mortality ratios (SMRs) for CVD and absolute excess risks (AERs; number of excess deaths per 10,000 person-years) were calculated for 15,006 patients with testicular nonseminoma reported to the population-based Surveillance, Epidemiology, and End Results program (1980 to 2010) who initially received chemotherapy (n=6,909) or surgery (n=8,097) without radiotherapy and accrued 60,065 and 81,227 person-years of follow-up, respectively. Multivariable modeling evaluated effects of age, treatment, extent of disease, and other factors on CVD mortality.

RESULTS

Significantly increased CVD mortality occurred after chemotherapy (SMR, 1.36; 95% CI, 1.03 to 1.78; n=54) but not surgery (SMR, 0.81; 95% CI, 0.60 to 1.07; n=50). Significant excess deaths after chemotherapy were restricted to the first year after TC diagnosis (SMR, 5.31; AER, 13.90; n=11) and included cerebrovascular disease (SMR, 21.72; AER, 7.43; n=5) and heart disease (SMR, 3.45; AER, 6.64; n=6). In multivariable analyses, increased CVD mortality after chemotherapy was confined to the first year after TC diagnosis (hazard ratio, 4.86; 95% CI, 1.25 to 32.08); distant disease (P<.05) and older age at diagnosis (P<.01) were independent risk factors.

CONCLUSION

This is the first population-based study, to our knowledge, to quantify short- and long-term CVD mortality after TC diagnosis. The increased short-term risk of CVD deaths should be further explored in analytic studies that enumerate incident events and can serve to develop comprehensive evidence-based approaches for risk stratification and application of preventive and interventional efforts.

Changes in self-perceived economic satisfaction and mortality at old ages: evidence from a survey of middle-aged and elderly adults in Taiwan

Experiencing a low socioeconomic status (SES) throughout the life course has been reported to be correlated with poor health outcomes. Several studies have suggested that income, wealth, and perceptions of economic status are associated with increased risk of death among elderly people. Few studies have investigated the association between lifetime SES and mortality among elderly adults. The analysis in this study was based on 2310 elderly adults for whom SES data from the four phases of the longitudinal survey of Health and Living Status of the Elderly in Taiwan (1989, 1993, 1996, and 1999) were available, and who were alive in 1999. The SES measures included in the analysis were annual income, the household wealth, and the self-perceived economic satisfaction. A group-based trajectory modelling approach was employed to create SES trajectories. Cox proportional hazard models were employed to examine the association between SES trajectories and 8-year all-cause mortality (1999-2007). Irrespective of whether income, wealth, or self-perceived economic satisfaction was used, the elderly adults with consistently low SES trajectory throughout early old age were independently and significantly associated with higher hazards of mortality than were those in a consistently high SES trajectory. Downward or upward mobility of income and wealth were associated with increased hazard of mortality. However, decreased self-perceived economic satisfaction was not significantly associated with increased hazard of mortality. According to the results, the strong distinction between trajectory patterns of income, wealth, and self-perceived economic satisfaction among elderly adults indicate that neither should be overlooked when investigating the role of SES mobility in mortality. Retirement policies or strategies for maintaining and promoting favorable SES in early old age may benefit the health of elderly adults later in life.

Cumulative socioeconomic disadvantage and cardiovascular disease mortality in the Alameda County Study 1965 to 2000

PURPOSE

Socioeconomic disadvantage is often evaluated at single points in the adult life course in health research. Social mobility models suggest that socioeconomic patterns may also influence disease risk. This study examines cumulative socioeconomic disadvantage (CSD) in relation to cardiovascular disease mortality (CVDM).

METHODS

Data were from the Alameda County Study (n = 2530). The CSD indices included father's education, the respondent's education, and either average or latent variable trajectory models of adulthood household income (1965-1994). Proportional hazards models were used to assess the associations between CSD and CVDM.

RESULTS

The CSD measures were not associated with CVDM in men. Among women, the magnitude of the association between CSD and CVDM was greater for the income trajectory (hazard ratio3 vs 0 = 4.73, 95% confidence interval = 2.20-10.18) compared with the average income (hazard ratio3 vs 0 = 3.78, 95% confidence interval = 1.67-8.53) CSD measure.

CONCLUSIONS

Measures of CSD that incorporate patterning of resources over the life course were associated with CVDM for women but not men. Patterning of available socioeconomic resources may differentially influence chronic disease risk and mortality by gender, and future work should continue to investigate how greater patterns variability in available resources influences health outcomes.

Low socioeconomic status over 12 years and subclinical cardiovascular disease: the study of women's health across the nation

BACKGROUND AND PURPOSE

The inverse relation between socioeconomic status and cardiovascular disease is well established. However, few studies have investigated socioeconomic status assessed repeatedly during adulthood in relation to subclinical atherosclerosis. We aimed to test whether consistently low socioeconomic status, as indexed by education, income, and financial strain, for 12 years of midlife was related to later carotid intima-media thickness and plaque among women.

METHODS

The Study of Women's Health Across the Nation is a multisite longitudinal study of midlife women. Education was assessed at the study baseline, income and financial strain were obtained yearly for 12 years, and a carotid ultrasound was obtained at study year 12 among 1402 women. Associations were tested in linear and multinomial logistic regression models adjusted for demographic, biological, and behavioral risk factors.

RESULTS

A high school education or less (odds ratio [OR] [95% confidence interval {CI}], 1.72 [1.15-2.59]; P<0.01), some college education (OR [95% CI], 1.65 [1.17-2.32]; P<0.01), consistently low income (OR [95% CI], 1.83 [1.15-2.89]; P<0.05), and consistent financial strain (OR [95% CI], 1.78 [1.21-2.61]; P<0.01) for 12 years were associated with higher carotid plaque, and consistent financial strain was associated with elevated maximal intima-media thickness (β [SE]=0.02 [0.01]; P<0.05) controlling for standard cardiovascular disease risk factors. When socioeconomic status indices were considered together, financial strain (β [SE]=0.02 [0.01]; P<0.05) and low education (high school education or less: OR [95% CI], 1.55 [1.01-2.37]; P<0.05; some college: OR [95% CI], 1.56 [1.09-2.21]; P<0.05) were most consistently associated with intima-media thickness and plaque, respectively, controlling for risk factors.

CONCLUSIONS

The findings indicate the importance of targeting economically disadvantaged women in efforts to prevent cardiovascular disease among women.

The impact of chronic kidney disease and cardiovascular comorbidity on mortality in a multiethnic population: a retrospective cohort study

OBJECTIVE

To assess the impact of chronic kidney disease (CKD) and cardiovascular comorbidity on mortality in a multiethnic primary care population.

DESIGN

Retrospective cohort study.

SETTING

Inner-city primary care trust in West Midlands, UK.

PARTICIPANTS

Individuals aged 40 years and older, of South Asian, black or white ethnicity, registered with a general practice and with their kidney function checked within the last 12 months (n=31 254).

OUTCOME MEASURE

All-cause mortality.

RESULTS

Reduced estimated glomerular filtration rate, higher albuminuria, older age, white ethnicity (vs South Asian or black ethnicity) and increasing cardiovascular comorbidities were independent determinants of a higher mortality risk. In the multivariate model including comorbidities and kidney function, the HR for mortality for South Asians was 0.697 (95% CI 0.56 to 0.868, p=0.001) and for blacks it was 0.533 (95% CI 0.403 to 0.704, p<0.001) compared to whites.

CONCLUSIONS

The HR for death is lower for South Asian and black individuals compared to white individuals. This is, in part, independent of age, gender, socioeconomic status, kidney function and comorbidities. Risk of death is higher in individuals with CKD and with a higher cumulative cardiovascular comorbidity.