Serum uric acid and long-term mortality from stroke, coronary heart disease and all causes.

BACKGROUND: Increased serum uric acid (SUA) levels are linked to obesity, dyslipidemia, diabetes and hypertension. Whether SUA carries a risk for coronary heart disease (CHD) and stroke remains uncertain. DESIGN: A prospective cohort study. METHODS: Of an original cohort of middle-aged workers who were examined in 1963 and followed-up for 23 years, 9125 men, free of CHD at entry, are included in this study. Subjects were divided into quintiles according to baseline SUA levels. Hazard ratios (HR) for all-cause, CHD, and stroke mortality were estimated in SUA quintiles, with the third serving as a referent. RESULTS: During follow-up, 2893 deaths were recorded, including 830 ascribed to CHD and 292 to stroke. The HR for all death [1.22, 95% confidence interval (CI) 1.09-1.37] and CHD (1.29, 95% CI 1.05-1.58) were increased in the upper SUA quintile. Fatal stroke showed a U-shaped relationship as both the upper (HR 1.48, 95% CI 1.02-2.17) and bottom (HR 1.43, 95% CI 0.99-2.08) quintiles were associated with a higher risk. Adjustment for confounders reduced the HR of the upper quintile for all outcomes, but did not attenuate the association of the bottom quintile with stroke (HR 1.52, 95% CI 1.04-2.23). When analysed separately by stroke type, the latter association seemed to be stronger for hemorrhagic (HR 3.27, 95% CI 1.14-9.33) than for ischemic stroke (HR 1.34, 95% CI 0.87-2.05). CONCLUSION: In addition to findings supporting increased mortality among hyperuricemic subjects, we identified an association between low SUA levels and fatal stroke, which deserves further investigation.

Body fat distribution and long-term risk of stroke mortality.

BACKGROUND AND PURPOSE: Excess weight is an important determinant of cardiovascular disease, but the relationship between excess weight, its distribution, and stroke is yet unclear. We examined in a large prospective cohort study the association between body fat distribution and stroke mortality among middle-aged men. METHODS: A cohort of male civil servants and municipal employees free of cardiovascular disease in Israel (n=9151) were followed up for mortality over 23 years. The subscapular skinfold (SSF) was used as a measure of trunk and overall obesity and the ratio of subscapular to triceps skinfold thickness (SFR) as an indicator of trunk versus peripheral distribution of body fat. RESULTS: During the follow-up period, 316 died of stroke, and 865 died of coronary heart disease. The estimated age-adjusted hazard ratios (HRs) for stroke mortality, associated with 1 SD increment of SSF, was 1.12 (95% CI, 1.01 to 1.25) and for body mass index, 1.17 (1.06 to 1.30), but these associations were markedly weakened when adjusting for blood pressure. SFR was associated with an age-adjusted HR for stroke mortality of 1.14 (1.03 to 1.26). Further adjusting for systolic blood pressure, diabetes mellitus, cigarette smoking, and socioeconomic status (HR, 1.11; 1.01 to 1.23) as well as body mass index (HR, 1.11; 1.00 to 1.23) only mildly attenuated this association. Subjects with SFR in the upper quartile exhibited a approximately 1.5-fold higher adjusted HR (1.53; 1.10 to 2.12) compared with the lowest quartile. CONCLUSIONS: Indices of body fat and body fat distribution predict long-term stroke and coronary heart disease mortality among middle-aged men. SFR, an indicator of trunk versus peripheral distribution of body fat, is associated with stroke mortality, independent of main mediators of the effect of obesity on health and of body mass index.

Perceived family difficulties and prediction of 23-year stroke mortality among middle-aged men.

BACKGROUND/OBJECTIVE: To examine the association of indicators of family problems, support and coping style and prediction of stroke mortality among a large cohort of middle-aged men. METHODS: A cohort of 10,059 men aged > or =40 years at study inclusion that were tenured civil servants or municipal employees were followed for mortality over 23 years, for a total of about 200,000 person-years of follow-up. Mortality attributed to stroke and to CHD as underlying causes was determined. Subjects underwent a structured psychosocial questionnaire at baseline by trained interviewers, and associations between each indicator of perceived family difficulties, support and coping (9 indicators in total) and mortality from stroke and from CHD were estimated using the proportional hazard model by Cox. RESULTS: During the 23-year follow-up period, 364 men died of stroke, and 1,098 men died of CHD. Among the indicators, perceived serious family difficulties at baseline, adjusted for traditional risk factors, were associated with higher risk of dying from stroke (HR 1.34, 95% CI 1.04-1.72), as were wife and children not tending to listen (HR 1.29, 95% CI 1.00-1.65), and person tending to keep feelings to oneself when conflict with wife (HR 1.27, 95% CI 1.03-1.37), while other indicators had associated HRs nearer unity. None of the variables assessed predicted mortality from CHD over a long-term follow-up. CONCLUSION: Several indicators of perceived family problems, family support and coping style are related to risk of dying from stroke over a long-term follow-up among middle-aged men.

Gender differences in time spent during direct observation of doctor-patient encounters.

BACKGROUND: Despite increasing recognition of women's health needs, little is known about how primary care physicians spend time with women. Therefore, we examined differences in time use and preventive service delivery during outpatient visits by male and female patients. METHODS: As part of a multimethod study of 138 family physicians, 3384 outpatient visits by adults were directly observed, medical records were reviewed, and patient surveys were performed. Time use was assessed by the Davis Observation Code, which classifies every 15 seconds into 20 behavioral categories. Receipt of health habit counseling recommended by the U.S. Preventive Services Task Force was assessed by direct observation, and eligibility was determined by chart review. Logistic regression and multivariate analysis of variance (ANOVA) were used to compare time use and preventive service delivery in visits by women vs. men. RESULTS: Sixty-four percent of adult visits were from women. Women reported poorer physical health, had higher rates of anxiety (12.5% vs. 7.4% in men), and depression (21.9% vs. 8.4% in men), a higher percent of visits for well care (10.2% vs. 8.8% in men), and more drugs prescribed (64.8% vs. 61% in men) and raised more emotional issues than men (14.7% vs. 7.5%). After controlling for visit and patients characteristics, visits by women had a higher percent of time spent on physical examination, structuring the intervention, patient questions, screening, and emotional counseling. Visits by men involved a higher percent of time spent on procedures and health behavior counseling. More eligible men than women received exercise, diet, and substance abuse counseling. Patients of female physicians exhibited gender differences in only one category of how time was spent (substance abuse), whereas among patients of male physicians, gender differences were noted in 10 of the 20 categories. CONCLUSIONS: Outpatient visits by women differ from those of men in ways that reflect women's unique healthcare needs but also raise concern about unequal delivery of health habit counseling for diet and exercise.