Preexisting cognitive impairment is associated with postoperative cognitive dysfunction after hip joint replacement surgery.

BACKGROUND: This study investigated the prevalence of cognitive impairment in elderly noncardiac surgery patients and any association between preoperative cognitive impairment and postoperative cognitive dysfunction (POCD). Additionally, the incidence of cognitive decline at 12 months after surgery was identified. METHODS: Three hundred patients for hip joint replacement and 51 nonsurgical controls aged 60 yr or older were studied in a prospective observational clinical trial. All study participants and controls completed a battery of eight neuropsychological tests before surgery and at 7 days, 3 months, and 12 months afterwards. Preoperative cognitive status was assessed using preexisting cognitive impairment (PreCI) defined as a decline of at least 2 SD on two or more of seven neuropsychological tests compared to population norms. POCD and cognitive decline were assessed using the reliable change index utilizing the results of the control group. RESULTS: PreCI was classified in 96 of 300 (32%) patients (95% CI, 23 to 43%). After surgery, 49 of 286 (17%) patients (95% CI, 13 to 22%) and 27 of 284 (10%) patients (95% CI, 6 to 13%) demonstrated POCD at 7 days and 3 months, respectively, while 7 of 271 (3%) patients (95% CI, 1 to 4%) demonstrated cognitive decline at 12 months. Patients with PreCI had a significantly increased incidence of POCD at 7 days and 3 months and cognitive decline at 12 months. CONCLUSIONS: Patients with PreCI have an increased incidence of POCD and cognitive decline. PreCI is a good predictor of subsequent POCD and cognitive decline. The incidence of cognitive decline after 12 months in this group of patients is low.

Validity of self-reported versus hospital-coded diagnosis of stroke: a cross-sectional and longitudinal study.

BACKGROUND: Population-based studies, as well as clinicians, often rely on self-report and hospital records to obtain a history of stroke. This study aimed to compare the validity of the diagnosis of stroke by self-report and by hospital coding according to their cross-sectional association with prevalent vascular risk factors, and longitudinal association with recurrent stroke and major cardiovascular outcomes in a large cohort of older Australian men. METHODS: Between 1996 and 1999, 11,745 older men were surveyed for a self-reported history of stroke as part of the Health in Men Study (HIMS). Previous hospitalization for stroke was obtained with consent from linked medical records via the Western Australian Data Linkage System (WADLS). Subjects were followed by WADLS until December 31, 2010, for hospitalization for stroke, cardiovascular events, and all-cause mortality. The primary outcome was hospitalisation for stroke during follow-up. Secondary outcomes included incident vascular events and composite vascular endpoints. RESULTS: At baseline, a history of stroke was reported by 903 men (7.7%), previous hospitalisation for stroke was recorded in 717 (6.1%), both self-report and hospitalisation in 467 (4.0%), and no history of stroke in 10,696 men (91.1%). Prevalent cardiovascular disease and peripheral arterial disease were more common among men with previous hospitalisation for stroke than a history of self-reported stroke (p < 0.001). In longitudinal analyses, incident aortic aneurysm was also more common among men with baseline history of hospitalization for stroke (adjusted hazard ratio (HR) 1.71, 95% CI 1.12-2.60) than among men with self-reported stroke (HR 0.88, 95% CI 0.56-1.36) compared to men with no history of stroke. With regard to the primary outcome, the rate of hospitalisation for stroke during follow-up was significantly higher among men with self-reported stroke (HR 2.44, 95% CI 2.03-2.94), hospital-coded stroke (adjusted HR 3.02, 2.42-3.78) and both self-reported and hospital-coded stroke (adjusted HR 3.33, 2.82-3.92) compared to participants with no previous stroke. Time to recurrent stroke was similar among different methods of initial stroke diagnosis (p = 0.067). CONCLUSIONS: Self-reported stroke and hospital-coded stroke have a similar prognostic value for predicting the risk of recurrent stroke. This supports the use of these ways of assessing a history of stroke for the clinical purposes of secondary prevention and for further epidemiological studies.

The LINKIN Health Census process: design and implementation.

This paper describes the first phase of the LINKIN Health Study, which aims to evaluate health system functioning within a rural population. Locally relevant data on the health status and service usage of this population, including non-users and users, health service providers traditionally omitted from health services research, and multiple socio-economic indicators, was collected using a self-complete health census. Household response was 75% (N = 4425). Response was greater when face-to-face contact was made at delivery compared to when questionnaires were left in the letterbox (89% vs 64%), falling to 26% when no face-to-face contact was made at either delivery or collection.

Are the national guidelines for health behaviour appropriate for older Australians? Evidence from the Men, Women and Ageing project.

AIM: To review findings from the Men, Women and Ageing (MWA) longitudinal studies and consider their implications for national health guidelines. METHODS: Guidelines for good health for older adults in the areas of body mass index (BMI), physical activity, alcohol consumption and smoking behaviours are compared with MWA findings. RESULTS: Findings from MWA suggest that current BMI guidelines may be too narrow because BMI in the overweight range appears to be protective for both older men and women. Across all levels of BMI, even low levels of physical activity decrease mortality risk compared with being sedentary. Our findings suggest that consideration should be given to having different alcohol guidelines for older men and women and should include recommendations for alcohol-free days. The benefit of quitting smoking at any age is apparent for both women and men. CONCLUSIONS: Current national guidelines in the areas discussed in this paper should be reviewed for older people.

Function after spinal treatment, exercise, and rehabilitation: cost-effectiveness analysis based on a randomized controlled trial.

STUDY DESIGN: Cost-effectiveness analysis alongside a factorial randomized controlled trial. OBJECTIVE: To assess the cost-effectiveness of a rehabilitation program and/or an education booklet each compared with usual care for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery. SUMMARY OF BACKGROUND DATA: There is little knowledge about the cost-effectiveness of postoperative management of patients after spinal surgery. METHODS: A total of 338 patients were recruited into the study between June 2005 and March 2009. Patients were randomized to rehabilitation only, booklet only, rehabilitation plus booklet, or usual care only. Interactions between booklet and rehabilitation were nonsignificant; hence, we compare booklet versus no booklet and rehabilitation versus no rehabilitation. We adopt an English National Health Service and personal social services perspective. Data on outcomes and costs are based on patient level data from the trial. A 1-year time horizon was used. Outcomes were measured in terms of quality-adjusted life years. Health-related quality of life was reported by patients using the EuroQol-5D (EQ-5D). A comprehensive range of health service contacts were included in the cost analysis. RESULTS: There were no significant differences in costs or outcomes associated with either intervention. Mean incremental costs and mean quality-adjusted life years gained per patient of booklet versus no booklet were -£87 (95% CI: -£1221 to £1047) and -0.023 (95% CI: -0.068 to 0.023), respectively. Figures for rehabilitation versus no rehabilitation were £160 (95% CI: -£984 to £1304) and 0.002 (95% CI: -0.044 to 0.048), respectively. Neither intervention was cost-effective when compared with the threshold range commonly used to judge whether or not an intervention is cost-effective in the English National Health Service. CONCLUSION: Cost-effectiveness evidence does not support use of booklet over no booklet or rehabilitation over no rehabilitation for the postoperative management of patients after spinal surgery.

Women who smoke like men die like men who smoke: findings from two Australian cohort studies.

BACKGROUND: There is controversy about whether men and women with similar smoking histories have similar incidence and mortality rates from smoking related diseases. OBJECTIVE: To compare mortality rates from all causes of death and various smoking related causes for men and women smokers categorised by numbers of cigarettes smoked and for ex-smokers by time since quitting. METHODS: This was a 10-year follow-up study with deaths identified from the National Death Index. The setting was two cohort studies in Australia established in 1996. Participants were: men (n=12,154) and women (n=11,707) aged (mean (SD)) 72.1 (4.4) and 72.5 (1.5) years, respectively, when recruited. The main outcome measure was HRs for men and women separately and RRs calculated from combined analyses using proportional hazards models (for deaths from all causes) and competing risks proportional hazards models (for specific causes). RESULTS: HRs for deaths from all causes for men (n=3549 deaths) and women (n=2665 deaths) among smokers increased with amount smoked and for ex-smokers decreased with time since quitting. Similar effects were found for various groups of smoking-related conditions with the dose-response effects largest for lung cancer and chronic obstructive pulmonary disease. The ratios of HRs for women relative to men were near unity and the 95% CIs included unity for almost all comparisons. CONCLUSIONS: The data provide strong evidence that men and women with similar patterns of smoking experience similar rates of death due to smoking.

ISSLS prize winner: Function After Spinal Treatment, Exercise, and Rehabilitation (FASTER): a factorial randomized trial to determine whether the functional outcome of spinal surgery can be improved.

STUDY DESIGN: This was a multicenter, factorial, randomized, controlled trial on the postoperative management of spinal surgery patients, with randomization stratified by surgeon and operative procedure. OBJECTIVE: This study sought to determine whether the functional outcome of two common spinal operations could be improved by a program of postoperative rehabilitation that combines professional support and advice with graded active exercise commencing 6 weeks after surgery and/or an educational booklet based on evidence-based messages and advice received at discharge from hospital, each compared with usual care. SUMMARY OF BACKGROUND DATA: Surgical interventions on the spine are increasing, and while surgery for spinal stenosis and disc prolapse have been shown to be superior to conservative management, functional outcome, and patient satisfaction are not optimal. METHODS: The study compared the effectiveness of a rehabilitation program and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery, each compared with "usual care" using a 2 × 2 factorial design, randomizing patient to four groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The primary outcome measure was the Oswestry Disability Index (ODI) at 12 months, with secondary outcomes including visual analog scale measures of back and leg pain. RESULTS: Three hundred thirty-eight patients were recruited into the study and measurements were obtained preoperatively and then repeated at 6 weeks, 3, 6, 9 and 12 months postoperatively. Twelve months postoperatively the observed effect of rehabilitation on ODI was -2.7 (95% CI: -6.8 to 1.5) and the effect of booklet was 2.7 (95% CI: -1.5 to 6.9). CONCLUSION: This study found that neither intervention had a significant impact on long-term outcome.

Body-mass index and cancer mortality in the Asia-Pacific Cohort Studies Collaboration: pooled analyses of 424,519 participants.

BACKGROUND: Excess bodyweight is an established risk factor for several types of cancer, but there are sparse data from Asian populations, where the proportion of overweight and obese individuals is increasing rapidly and adiposity can be substantially greater for the same body-mass index (BMI) compared with people from Western populations. METHODS: We examined associations of adult BMI with cancer mortality (overall and for 20 cancer sites) in geographic populations from Asia and from Australia and New Zealand (ANZ), within the Asia-Pacific Cohort Studies Collaboration, by use of Cox regression analysis. Pooled data from 39 cohorts (recruitment 1961-99, median follow-up 4 years) were analysed for 424,519 participants (77% Asian; 41% female; mean recruitment age 48 years) with individual data on BMI. FINDINGS: After excluding those with follow-up of less than 3 years, 4872 cancer deaths occurred in 401,215 participants. Hazard ratios for cancer sites with increased mortality risk in obese (BMI > or = 30 kg/m(2)) compared with normal weight participants (BMI 18.5-24.9 kg/m(2)) were: 1.21 (95% CI 1.09-1.36) for all-cause cancer (excluding lung and upper aerodigestive tract), 1.50 (1.13-1.99) for colon, 1.68 (1.06-2.67) for rectum, 1.63 (1.13-2.35) for breast in women 60 years or older, 2.62 (1.57-4.37) for ovary, 4.21 (1.89-9.39) for cervix, 1.45 (0.97-2.19) for prostate, and 1.66 (1.03-2.68) for leukaemia (all after left censoring at 3 years). The increased risk associated with a 5-unit increase in BMI for those with BMI of 18.5 kg/m(2) or higher was 1.09 (95% CI 1.04-1.14) for all cancers (excluding lung and upper aerodigestive tract). There was little evidence of regional differences in relative risk of cancer with higher BMI, apart from cancers of the oropharynx and larynx, where the association was inverse in ANZ and absent in Asia. INTERPRETATION: Overweight and obese individuals in populations across the Asia-Pacific region have a significantly increased risk of mortality from cancer. Strategies to prevent individuals from becoming overweight and obese in Asia are needed to reduce the burden of cancer that is expected if the obesity epidemic continues. FUNDING: National Health and Medical Research Council of Australia, Health Research Council of New Zealand, and Pfizer Inc.

Population-based observational study of claudication in older men: the Health in Men Study.

OBJECTIVES: To assess the prevalence of and risk factors for claudication and its association with subsequent cardiovascular events. DESIGN, SETTING AND PARTICIPANTS: Observational cohort study of 12 203 Western Australian men aged 65 years and over, recruited from 1996 to 1999, and followed up from 2001 to 2004. MAIN OUTCOME MEASURES: Prevalence of claudication and incidence of peripheral arterial disease (PAD); risk factors for claudication and its association with subsequent cardiovascular events. RESULTS: The prevalence of claudication was 5.3% (638 of 11 970 men). At follow-up, after exclusion of 148 men with claudication at baseline and 76 with missing data at follow-up, the crude average annual incidence of new PAD (claudication or procedure for PAD) was 0.85% (95% CI, 0.72%-0.96%). The risk factors for prevalent claudication and incident PAD were similar, with age, smoking, hypertension, diabetes and history of cardiovascular disease dominating. Of the men with claudication at baseline, nearly half (47.5%; 303 of 638) were not taking aspirin. At follow-up, 42.5% (82 of 193) of the men with incident PAD were not taking aspirin. Claudication at baseline was associated with twice the risk of cardiovascular death (hazard ratio, 2.00; 95% CI, 1.52-2.64). There was a J-shaped relationship between aortic diameter, and both prevalent claudication and subsequent cardiovascular events. CONCLUSIONS: Among older men, claudication is prevalent and is associated with factors that can still be modified in older age, including smoking, exercise and diet. Relatively few men with claudication or at risk of PAD use aspirin. Claudication is a significant predictor of cardiovascular outcome.

Alcohol use and mortality in older men and women.

AIMS: To compare the effect of alcohol intake on 10-year mortality for men and women over the age of 65 years. DESIGN, SETTING AND PARTICIPANTS: Two prospective cohorts of community-dwelling men aged 65-79 years at baseline in 1996 (n = 11 727) and women aged 70-75 years in 1996 (n = 12 432). MEASUREMENTS: Alcohol was assessed according to frequency of use (number of days alcohol was consumed per week) and quantity consumed per day. Cox proportional hazards models were compared for men and women for all-cause and cause-specific mortality. FINDINGS: Compared with older adults who did not consume alcohol every week, the risk of all-cause mortality was reduced in men reporting up to four standard drinks per day and in women who consumed one or two drinks per day. One or two alcohol-free days per week reduced this risk further in men, but not in women. Similar results were observed for deaths due to cardiovascular disease. CONCLUSIONS: In people over the age of 65 years, alcohol intake of four standard drinks per day for men and two standard drinks per day for women was associated with lower mortality risk. For men, the risk was reduced further if accompanied with 1 or 2 alcohol-free days per week.

Association between serum lipoproteins and abdominal aortic aneurysm.

The importance of dyslipidemia in the etiology of abdominal aortic aneurysm (AAA) is poorly defined, in part because previous association analyses have often not considered the use of current lipid-modifying medications. Medications targeted at altering the concentrations of circulating lipids have an established role in occlusive atherosclerosis but are of unknown value in the primary prevention of AAA. We examined the association between fasting serum levels of triglycerides low- and high-density lipoprotein and the presence of an AAA in a cohort of 3,327 men aged 65 to 83 years. The analyses were adjusted for established risk factors of AAA and the prescription of lipid-modifying agents using multiple logistic regression analysis. Of the 3,327 men, 1,043 (31%) were receiving lipid-modifying therapy at the fasting lipid measurement. The lipid-modifying therapy was statins in most cases (n = 1,023). The serum high-density lipoprotein concentrations were lower in patients with AAAs. The serum high-density lipoprotein concentration was independently associated with a reduced risk of having an AAA in men not receiving current lipid-modifying therapy (odds ratio 0.72, 95% confidence interval 0.56 to 0.93 per 0.4-mM increase) and in the total cohort (odds ratio 0.76, 95% confidence interval 0.63 to 0.91 per 0.4-mM increase, adjusted for lipid-modifying therapy). The concentrations of low-density lipoprotein and triglycerides were not associated with the presence of AAAs. In conclusion, high-density lipoprotein appeared to be the most important lipid in predicting the risk of AAA development, with potential value as a therapeutic target. Current cardiovascular strategies aimed at lowering low-density lipoprotein might not have any effect on the prevention of AAAs.

Attitudes to living and working in pandemic conditions among emergency prehospital medical care personnel.

INTRODUCTION: Little is known about the risk perceptions and attitudes of healthcare personnel, especially of emergency prehospital medical care personnel, regarding the possibility of an outbreak or epidemic event. PROBLEM: This study was designed to investigate pre-event knowledge and attitudes of a national sample of the emergency prehospital medical care providers in relation to a potential human influenza pandemic, and to determine predictors of these attitudes. METHODS: Surveys were distributed to a random, cross-sectional sample of 20% of the Australian emergency prehospital medical care workforce (n = 2,929), stratified by the nine services operating in Australia, as well as by gender and location. The surveys included: (1) demographic information; (2) knowledge of influenza; and (3) attitudes and perceptions related to working during influenza pandemic conditions. Multiple logistic regression models were constructed to identify predictors of pandemic-related risk perceptions. RESULTS: Among the 725 Australian emergency prehospital medical care personnel who responded, 89% were very anxious about working during pandemic conditions, and 85% perceived a high personal risk associated with working in such conditions. In general, respondents demonstrated poor knowledge in relation to avian influenza, influenza generally, and infection transmission methods. Less than 5% of respondents perceived that they had adequate education/training about avian influenza. Logistic regression analyses indicate that, in managing the attitudes and risk perceptions of emergency prehospital medical care staff, particular attention should be directed toward the paid, male workforce (as opposed to volunteers), and on personnel whose relationship partners do not work in the health industry. CONCLUSIONS: These results highlight the potentially crucial role of education and training in pandemic preparedness. Organizations that provide emergency prehospital medical care must address this apparent lack of knowledge regarding infection transmission, and procedures for protection and decontamination. Careful management of the perceptions of emergency prehospital medical care personnel during a pandemic is likely to be critical in achieving an effective response to a widespread outbreak of infectious disease.

Anticipated behaviors of emergency prehospital medical care providers during an influenza pandemic.

INTRODUCTION: Emergency prehospital medical care providers are frontline health workers during emergencies. However, little is known about their attitudes, perceptions, and likely behaviors during emergency conditions. Understanding these attitudes and behaviors is crucial to mitigating the psychological and operational effects of biohazard events such as pandemic influenza, and will support the business continuity of essential prehospital services. PROBLEM: This study was designed to investigate the association between knowledge and attitudes regarding avian influenza on likely behavioral responses of Australian emergency prehospital medical care providers in pandemic conditions. METHODS: Using a reply-paid postal questionnaire, the knowledge and attitudes of a national, stratified, random sample of the Australian emergency prehospital medical care workforce in relation to pandemic influenza were investigated. In addition to knowledge and attitudes, there were five measures of anticipated behavior during pandemic conditions: (1) preparedness to wear personal protective equipment (PPE); (2) preparedness to change role; (3) willingness to work; and likely refusal to work with colleagues who were exposed to (4) known and (5) suspected influenza. Multiple logistic regression models were constructed to determine the independent predictors of each of the anticipated behaviors, while controlling for other relevant variables. RESULTS: Almost half (43%) of the 725 emergency prehospital medical care personnel who responded to the survey indicated that they would be unwilling to work during pandemic conditions; one-quarter indicated that they would not be prepared to work in PPE; and one-third would refuse to work with a colleague exposed to a known case of pandemic human influenza. Willingness to work during a pandemic (OR = 1.41; 95% CI = 1.0-1.9), and willingness to change roles (OR = 1.44; 95% CI = 1.04-2.0) significantly increased with adequate knowledge about infectious agents generally. Generally, refusal to work with exposed (OR = 0.48; 95% CI = 0.3-0.7) or potentially exposed (OR = 0.43; 95% CI = 0.3-0.6) colleagues significantly decreased with adequate knowledge about infectious agents. Confidence in the employer's capacity to respond appropriately to a pandemic significantly increased employee willingness to work (OR = 2.83; 95% CI = 1.9-4.1); willingness to change roles during a pandemic (OR = 1.52; 95% CI = 1.1-2.1); preparedness to wear PPE (OR = 1.68; 95% CI = 1.1-2.5); and significantly decreased the likelihood of refusing to work with colleagues exposed to (suspected) influenza (OR = 0.59; 95% CI = 0.4-0.9). CONCLUSIONS: These findings indicate that education and training alone will not adequately prepare the emergency prehospital medical workforce for a pandemic. It is crucial to address the concerns of ambulance personnel and the perceived concerns of their relationship with partners in order to maintain an effective prehospital emergency medical care service during pandemic conditions.

Body mass index and survival in men and women aged 70 to 75.

OBJECTIVES: To examine in an older population all-cause and cause-specific mortality associated with underweight (body mass index (BMI)<18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), and obesity (BMI> or =30.0). DESIGN: Cohort study. SETTING: The Health in Men Study and the Australian Longitudinal Study of Women's Health. PARTICIPANTS: Adults aged 70 to 75, 4,677 men and 4,563 women recruited in 1996 and followed for up to 10 years. MEASUREMENTS: Relative risk of all-cause mortality and cause-specific (cardiovascular disease, cancer, and chronic respiratory disease) mortality. RESULTS: Mortality risk was lowest for overweight participants. The risk of death for overweight participants was 13% less than for normal-weight participants (hazard ratio (HR)=0.87, 95% CI=0.78-0.94). The risk of death was similar for obese and normal-weight participants (HR=0.98, 95% CI=0.85-1.11). Being sedentary doubled the mortality risk for women across all levels of BMI (HR=2.08, 95% CI=1.79-2.41) but resulted in only a 28% greater risk for men (HR=1.28 (95% CI=1.14-1.44). CONCLUSION: These results lend further credence to claims that the BMI thresholds for overweight and obese are overly restrictive for older people. Overweight older people are not at greater mortality risk than those who are normal weight. Being sedentary was associated with a greater risk of mortality in women than in men.

Higher luteinizing hormone is associated with poor memory recall: the health in men study.

Elevated levels of gonadotropins have been observed in patients with Alzheimer's disease and have been associated with poorer cognition in women, but not men. The aim of this study was to explore the relationship between gonadotropins and cognition in a cohort of 585 healthy, community-dwelling men aged 70-87 years. Cognitive function was assessed with the California Verbal Learning Test Second Edition (CVLT-II) and the Standardized Mini-Mental State Examination (SMMSE). Testosterone, sex hormone binding globulin, and luteinizing hormone levels were assayed from early morning sera. Free testosterone was calculated using mass action equations. In linear regression analyses, neither total nor free testosterone levels were associated with measures of immediate or delayed recall. Higher levels of luteinizing hormone were associated with poorer performance on a measure of immediate recall (CVLT-II trials 1-5 total score) independent of total and free testosterone levels. The association remained after adjustment for age, educational attainment, and depression. In contrast, only total and free testosterone levels were associated with SMMSE score. These findings suggest a role for both androgens and gonadotropins in differing cognitive domains, and that gonadotropins may influence cognition independent of sex steroids.

Differing risk factor profiles of ischemic stroke subtypes: evidence for a distinct lacunar arteriopathy?

BACKGROUND AND PURPOSE: Differences in risk factor profiles between lacunar and other ischemic stroke subtypes may provide evidence for a distinct lacunar arteriopathy, but existing studies have limitations. We overcame these by pooling individual data on 2875 patients with first-ever ischemic stroke from 5 collaborating prospective stroke registers that used similar, unbiased methods to define risk factors and classify stroke subtypes. METHODS: We compared risk factors between lacunar and nonlacunar ischemic strokes, altering the comparison groups in sensitivity analyses, and incorporated these data into a meta-analysis of published studies. RESULTS: Unadjusted and adjusted analyses gave similar results. We found a lower prevalence of cardioembolic source (adjusted odds ratio, 0.33; 95% CI, 0.24 to 0.46), ipsilateral carotid stenosis (odds ratio, 0.21; 95% CI, 0.14 to 0.30), and ischemic heart disease (odds ratio, 0.75; 95% CI, 0.58 to 0.97) in lacunar compared with nonlacunar patients but no difference for hypertension, diabetes, or any other risk factor studied. Results were robust to sensitivity analyses and largely confirmed in our meta-analysis. CONCLUSIONS: Hypertension and diabetes appear equally common in lacunar and nonlacunar ischemic stroke, but lacunar stroke is less likely to be caused by embolism from the heart or proximal arteries, and the lower prevalence of ischemic heart disease in lacunar stroke provides additional support for a nonatherosclerotic arteriopathy causing many lacunar ischemic strokes. Our findings have implications for how clinicians classify ischemic stroke subtypes and highlight the need for additional research into the specific causes of and treatments for lacunar stroke.

Erectile dysfunction as a predictor for subsequent atherosclerotic cardiovascular events: findings from a linked-data study.

INTRODUCTION: In spite of the mounting interest in the nexus between erectile dysfunction (ED) and cardiovascular (CV) diseases, there is little published information on the role of ED as a predictor for subsequent CV events. AIM: This study aimed to investigate the role of ED as a predictor for atherosclerotic CV events subsequent to the manifestation of ED. Method. The investigation involved the retrospective study of data on a cohort of men with ED linked to hospital morbidity data and death registrations. By using the linked data, the incidence rates of atherosclerotic CV events subsequent to the manifestation of ED were estimated in men with ED and no atherosclerotic CV disease reported prior to the manifestation of ED. The risk of subsequent atherosclerotic CV events in men with ED was assessed by comparing these incidence rates with those in the general male population. MAIN OUTCOME MEASURE: Standardized incidence rate ratio (SIRR), comparing the incidence of atherosclerotic CV events subsequent to the manifestation of ED in a cohort of 1,660 men with ED to the incidence in the general male population. RESULTS: On the basis of hospital admissions and death registrations, men with ED had a statistically significantly higher incidence of atherosclerotic CV events (SIRR 2.2; 95% confidence interval 1.9, 2.4). There were significantly increased incidence rate ratios in all age groups younger than 70 years, with a statistically highly significant downward trend with increase of age (P < 0.0001) across these age groups. Younger age at first manifestation of ED, cigarette smoking, presence of comorbidities and socioeconomic disadvantage were all associated with higher hazard ratios for subsequent atherosclerotic CV events. CONCLUSIONS: The findings show that ED is not only significantly associated with but is also strongly predictive of subsequent atherosclerotic CV events. This is even more striking when ED presents at a younger age.

IGF1 and its binding proteins 3 and 1 are differentially associated with metabolic syndrome in older men.

OBJECTIVE: Circulating IGF1 declines with age, and reduced circulating IGF1 is associated with increased cardiovascular mortality in some but not all studies. The relationship between IGF-binding proteins 3 and 1 (IGFBP3 and IGFBP1) with risk of cardiovascular disease remains unclear. We sought to examine associations between IGF1, IGFBP3 and IGFBP1 with metabolic syndrome in older men. DESIGN: Cross-sectional analysis of 3980 community-dwelling men aged >or=70 years. Methods Morning plasma levels of IGF1, IGFBP3 and IGFBP1 were assayed. Metabolic syndrome was defined according to National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATPIII) criteria. RESULTS: For IGF1 and IGFBP3, there was a U-shaped relationship, with middle quintiles possessing the lowest odds ratios (OR) for metabolic syndrome (reference Q1, Q3 IGF1: OR 0.74, 95% confidence intervals 0.57-0.96, Q3 IGFBP3: OR 0.67, 0.51-0.87). Increasing IGFBP1 was associated with reduced risk of metabolic syndrome with a dose-response gradient (reference Q1, OR for Q2 to Q5 IGFBP1: 0.56, 0.33, 0.22 and 0.12 respectively, P<0.001). IGF1 was associated with two, IGFBP1 with four and IGFBP3 with all five components of the metabolic syndrome. The ratio of IGF1/IGFBP3 was not associated with metabolic syndrome. CONCLUSIONS: In older men, both lower and higher IGF1 and IGFBP3 levels may be metabolically unfavourable. IGFBP1, as a marker of insulin sensitivity, is relevant in the assessment of metabolic syndrome, while the IGF1/IGFBP3 ratio is less informative. Longitudinal follow-up of this cohort would be needed to determine whether these distributions of IGF1, IGFBP3 and IGFBP1 predict incidence of cardiovascular events during male ageing.