Adjustment For Other Factors Research Articles

Differences in Presentation and Outcomes Between Children With Familial Dilated Cardiomyopathy and Children With Idiopathic Dilated Cardiomyopathy

Research comparing the survival of children with familial dilated cardiomyopathy (FDCM) to that of children with idiopathic dilated cardiomyopathy (IDCM) has produced conflicting results. We analyzed data from children with FDCM or IDCM using the National Heart, Lung, and Blood Institute-funded Pediatric Cardiomyopathy Registry. Compared to children with IDCM (n=647), children with FDCM (n=223) were older (mean 6.2 versus 4.5 years, P<0.001), less often had heart failure (64% versus 78%, P<0.001), had less-depressed mean left ventricular fractional shortening z scores (-7.85±3.98 versus -9.06±3.89, P<0.001) and lower end-diastolic dimension z scores (4.12±2.61 versus 4.91±2.57, P<0.001) at diagnosis. The cumulative incidence of death was lower for patients with FDCM compared with IDCM (P=0.04; hazard ratio 0.64, P=0.06), but no difference in risk of transplant or the combined death or transplant outcome. There was no difference in the proportion of children with echocardiographic normalization at 3 years of follow-up (FDCM, 30% versus IDCM, 26%; P=0.33). Multivariable analysis showed no difference in outcomes between FDCM and IDCM but for both groups older age, congestive heart failure, and increased left ventricular end-systolic dimension zscore at diagnosis were independently associated with an increased risk of death or heart transplantation (all Ps<0.001). There was no survival difference between FDCM and IDCM after adjustment for other factors. Older age, congestive heart failure, and greater left ventricular dilation at diagnosis were independently associated with increased risk of the combined end point of death or transplantation. URL: https://clinicaltrials.gov. Unique identifier: NCT00005391.

Risk factors for perinatal mortality in Murmansk County, Russia: a registry-based study

ABSTRACT Background: Factors contributing to perinatal mortality (PM) in Northwest Russia remain unclear. This study investigated possible associations between selected maternal and fetal characteristics and PM based on data from the population-based Murmansk County Birth Registry. Objective: This study investigated possible associations between selected maternal and fetal characteristics and PM based on data from the population-based Murmansk County Birth Registry. Methods: The study population consisted of all live- and stillbirths registered in the Murmansk County Birth Registry during 2006–2011 (n = 52,806). We excluded multiple births, births prior to 22 and after 45 completed weeks of gestation, infants with congenital malformations, and births with missing information regarding gestational age (a total of n = 3,666) and/or the studied characteristics (n = 2,356). Possible associations between maternal socio-demographic and lifestyle characteristics, maternal pre-pregnancy characteristics, pregnancy characteristics, and PM were studied by multivariable logistic regression. Crude and adjusted odds ratios with 95% confidence intervals were calculated. Results: Of the 49,140 births eligible for prevalence analysis, 338 were identified as perinatal deaths (6.9 per 1,000 births). After adjustment for other factors, maternal low education level, prior preterm delivery, spontaneous or induced abortions, antepartum hemorrhage, antenatally detected or suspected fetal growth retardation, and alcohol abuse during pregnancy all significantly increased the risk of PM. We observed a higher risk of PM in unmarried women, as well as overweight or obese mothers. Maternal underweight reduced the risk of PM. Conclusions: Our results suggest that both social and medical factors are important correlates of perinatal mortality in Northwest Russia.

Modeling The Underlying Tobacco Smoking Predictors Among 1st Year University Students In Iran.

Background:There are scant studies on the prevalence and determinants of tobacco smoking among 1st year university students in Iran. We aim to determine the prevalence of substance abuse and identify factors related with tobacco smoking in 1st year students of Qazvin University of Medical Sciences (QUMS).Methods:A self-administered questionnaire was used to collect information on sociodemographic, cigarette smoking, hookah smoking, and related risk factors among 521 1st year students in QUMS between January and February 2014. We used logistic regression to determine factors associated with substance abuse among students.Results:The descriptive statistics indicated that the prevalence of lifetime cigarette and hookah smoking was 8.6% (confidence interval [CI] 95%: 6.5–11.4) and 35.5% (CI 95%: 31.5–39.7), respectively. After adjustment for other factors, being male, the presence of any smoker in the family and having smoker friends were factors associated with cigarette and hookah smoking among students. Our findings also revealed the co-occurrence of risk-taking behaviors among students.Conclusions:Our study showed considerably low prevalence of tobacco smoking among 1st year students. Longitudinal studies are necessary to approve the observed results of this study and thus allow for a certain generalization of the observations.

The impact of red blood cell distribution width on outcome of elective percutaneous coronary intervention in non-anemia patients

Objective: Previous studies have revealed that the red blood cell distribution width (RDW) was associated with long-term prognosis in patients undergoing percutaneous coronary intervention (PCI). However, they did not exclude patients with anemia. This study, thus, investigated the association between RDW and prognosis in non-anemia patients. Methods: A total of 2 732 patients underwent elective PCI from July 2009 to September 2011 were enrolled in the study. These patients were divided into two groups based on their baseline median RDW levels: low RDW group (RDW<12.1%) and high RDW group (RDW≥12.1%). All the subjects were followed up for an average period of 18 months and the associations between baseline RDW levels and postoperative mortality were analyzed. Results: Patients in the high RDW group were elder and had more women than those in low RDW group. Most of them had prior history of hypertension, stroke, myocardial infarction, but few of them were current smokers. Subjects in the high RDW group had higher systolic blood pressure and total cholesterol levels, and lower erythrocyte mean corpuscular volume, hemoglobin level, estimated glomerular filtration rate level, and left ventricular ejection fraction. Moreover, more subjects in the high RDW group were combined with left main, ostial and chronic total occlusion lesion, and had a lower complete revascularization rate. The postoperative mortality was significantly higher in the high RDW group than that in the low RDW group (2.4% vs 0.6%, P<0.001). Multivariate Cox regression analysis revealed that preoperative high RDW level was an independent risk factor for postoperative mortality after adjustment of other factors (HR 3.930, 95%CI 1.600-9.656, P=0.003). Conclusion: High RDW might be a marker for the postoperative mortality in non-anemic patients undergoing elective PCI.

PM10 Air Pollution and Acute Hospital Admissions for Cardiovascular and Respiratory Causes in Ostrava.

The city of Ostrava and its surroundings belong to the most long-therm polluted areas in the Czech Republic and Europe. For identification of health risk, the World Health Organization recommends a theoretical estimation of increased short-term PM10 concentrations effect on hospital admissions for cardiac complaints based on a 0.6% increase per 10 µg.m-3 PM10 and 1.14% increase for respiratory causes. The goal of the present study is to verify the percentage increase of morbidity due to cardiovascular and respiratory causes, as per WHO recommendations for health risk assessment, in the population of Ostrava. The input data include data on PM10 air pollution, meteorological data, the absolute number of hospital admissions for acute cardiovascular and respiratory diseases in the period 2010-2012. To examine the association between air pollution and health outcomes the time series Poisson regression adjusted for covariates was used. A significant relationship was found between the cardiovascular hospital admissions (percentage increase of 1.24% per 10 µg.m-3) and values of PM10 less than 150 µg.m-3 in the basic model, although after adjustment for other factors, this relationship was no longer significant. A significant relationship was also observed for respiratory causes of hospital admissions in the basic model. Contrary to cardiovascular hospitalization, the relationship between respiratory hospital admissions and PM10 values below 150 µg.m-3 (percentage increase of 1.52%) remained statistically significant after adjustment for other factors. The observed significant relationship between hospital admissions for respiratory causes was consistent with the results of large European and American studies.

Impact of Donor Recipient Gender and Race Mismatch on Graft Outcomes in Patients With End-Stage Liver Disease Undergoing Liver Transplantation.

The discrepancy between donor supply and organ demand increased the possibility of gender and race mismatch between the donors and recipients. However, the findings of their impact on graft and patient survival are outdated and mixed. To estimate the effects of gender and race mismatch on graft survival and patient survival among adult patients (18 years and older) with end-stage liver disease. A total of 38 768 patients undergoing liver transplant between 2002 and 2011 were identified from United Network for Organ Sharing database. Kaplan-Meier curves, log-rank tests, and Cox proportional hazard regressions with backward elimination adopting a marginal approach with a working independence assumption and stratification on recipient hepatitis C virus status were used. Posttransplantation graft survival and patient survival. Both gender mismatch (hazard ratio [HR]: 1.14, 95% confidence interval [CI]: 1.09-1.12) and race mismatch (HR 1.08, 95%C: 1.04-1.12) had significantly adverse effects on graft survival and patient survival after controlling for other factors, especially among hepatitis C-positive female recipients with male donors (HR 1.13, 95%CI 1.03-1.24), black recipients with white donors (1.39, 1.29-1.49) or Hispanic donors (HR 1.48, 95%CI 1.27-1.72), and these effects were even worse among hepatitis C-positive recipients. Gender and race mismatch between donors and recipients adversely affected graft survival and patient survival among adult patients with end-stage liver disease, both independently and after the adjustment for other factors. Future research is recommended to explore other factors such as new model for end-stage liver disease sharing policy change and disparities in access to waiting-list or transplantation.

Modifiable lifestyle factors associated with risk of sessile serrated polyps, conventional adenomas and hyperplastic polyps

ObjectiveTo identify modifiable factors associated with sessile serrated polyps (SSPs) and compare the association of these factors with conventional adenomas (ADs) and hyperplastic polyps (HPs).DesignWe used data from the Tennessee...

Stroke Performance Measures Do Not Predict Functional Outcome.

Poststroke functional outcome is critical to stroke survivors. We sought to determine whether adherence to current stroke performance measures is associated with better functional outcome 90 days after an ischemic stroke. Utilizing the Brain Attack Surveillance in Corpus Christi cohort, we examined adherence to 7 ischemic stroke performance measures from February 2009 to June 2012. Adherence to the measures was analyzed in aggregate using a binary defect-free score and an opportunity score, representing the proportion of eligible measures met. The opportunity score ranges from 0 to 1, with values closer to 1 implying better adherence. Functional outcome, defined by an activities of daily living and instrumental activities of daily living (ADL/IADL) score (range 1-4, higher scores worse), was ascertained at 90 days poststroke. Tobit regression models were fitted to examine the associations between the performance measures and functional outcome, adjusting for demographic and clinical characteristics, including stroke severity. There were 565 patients with ischemic stroke included in the analysis. The median ADL/IADL score was 2.32 (interquartile range [IQR]: 1.41-3.41). The median opportunity score was 1 (IQR: 0.8-1), and 58.4% of the patients received defect-free care. After adjustment, the opportunity score (P = .67) and defect-free care (P = .92) were not associated with functional outcome. In this population, adherence to a composite of current stroke performance measures was not associated with poststroke functional outcome after adjustment for other factors. Performance measures that are associated with improved functional outcome should be developed and incorporated into stroke quality measures.

Management and Outcomes of Bleeding Events in Patients in the Emergency Department Taking Warfarin or a Non–Vitamin K Antagonist Oral Anticoagulant

BackgroundMost comparisons of bleeding patients who are taking warfarin or a non–vitamin K oral anticoagulant (NOAC) have been limited to admitted patients and major bleeding events in well-controlled, clinical trial settings. ObjectivesWe describe the clinical characteristics, interventions, and outcomes in patients who are taking warfarin or a NOAC who presented to the emergency department (ED) with any bleeding event. MethodsWe conducted a structured, retrospective, observational study of nonvalvular atrial fibrillation, pulmonary embolism, or deep vein thrombosis warfarin- or NOAC-treated patients presenting with any bleeding event to a large, academic ED between January 2012 and March 2015. We used descriptive statistics to summarize baseline characteristics, treatments, and outcomes and performed subgroup analyses based on the type of anticoagulant and site of bleeding. ResultsThe electronic search yielded 95 cases of patients taking a NOAC (i.e., dabigatran [33], rivaroxaban [32], or abixaban [30]) and 342 patients taking warfarin. Reversal agents were rarely used in all anticoagulant groups. Case fatality rates were similar among warfarin- and NOAC-treated patients for gastrointestinal bleeding (7% vs. 7%) and intracranial hemorrhage (18% vs. 4%), respectively. After adjustment for other factors, only intracranial hemorrhage (odds ratio 4.4; 95% confidence interval 1.4–13.3) was associated with mortality. ConclusionsDespite the rare use of reversal strategies, mortality was low and outcomes were comparable among patients with bleeding events presenting to the ED while taking a NOAC compared with warfarin.

Multiplicative interaction between mean corpuscular volume and red cell distribution width with target organ damagein hypertensive patients.

Accumulating evidence suggests that increased red cell distribution width (RDW) and mean corpuscular volume (MCV) were both poor prognostic factors for patients with cardiovascular diseases. Recently, the multiplicative interaction between RDW and MCV has been observed for predicting mortality in elderly patients without anemia; however, the relationship between the product of RDW-MCV and hypertension-induced target organ damage (TOD) has not been evaluated. We performed a cross-sectional study in 1115 hypertensive patients. RDW and MCV were determined using automated hematology analyzers. Prevalence of TOD was evaluated by estimated glomerular filtration rate, carotid intima-media thickness, and left ventricular mass index. The prevalence of TOD was observed to be increased with the RDW or product of RDW-MCV quartiles. Moreover, RDW, MCV and product of RDW-MCV were significantly higher in patients with TOD compared to those without TOD. According to two logistic regression models, the associations of RDW and MCV with TOD were lost after adjustment for other factors. However, product of RDW-MCV remains an independent predictor of TOD, with per 0.4fL increase in the product of RDW-MCV associated with a 16% increased risk of TOD (P=.012). The inclusion of MCV by calculating the product of RDW-MCV appears to enhance the association of RDW with TOD.

Time to follow-up of an abnormal mammogram in women with diabetes: a population-based study.

Women with diabetes have a higher breast cancer incidence and mortality. They are also significantly less likely to undergo screening mammography and present with more advanced stage than women without diabetes. The purpose of this study was to examine if women with diabetes are more likely to have delays in follow‐up of abnormal mammograms, compared to women without diabetes. Using population‐based health databases, this retrospective cohort study examined women between the ages of 50 and 74, with and without diabetes, living in the province of Ontario, Canada, who underwent screening through a centralized program and who had an abnormal mammogram between 2003 and 2012. We compared rates of follow‐up of a diagnostic test within 180 days, as well as likelihood of mastectomy or excision procedure and a diagnosis of breast cancer. Following an abnormal screening mammogram, 97.5% of women with diabetes had a diagnostic procedure within 180 days compared to 97.9% of women without diabetes. After adjustment for other factors, women with diabetes were only 3% less likely to have follow‐up testing after an abnormal mammogram than women without diabetes (hazard ratio [HR] 0.97, 95% CI: 0.96–0.99, P < 0.001). The majority of Ontario women who underwent screening mammography through a centralized screening program had timely follow‐up of an abnormal mammogram, with no meaningful delays in those who had diabetes. The results of this study suggest that diagnostic delays after screening do not significantly contribute to higher breast cancer mortality in women with diabetes.

Differential health effects of short-term exposure to source-specific particles in London, U.K.

BackgroundThere is ample evidence of adverse associations between short-term exposure to ambient particle mass concentrations and health but little is known about the relative contribution from various sources. MethodsWe used air particle composition and number networks in London between 2011 and 2012 to derive six source-related factors for PM10 and four factors for size distributions of ultrafine particles (NSD). We assessed the associations of these factors, at pre-specified lags, with daily total, cardiovascular (CVD) and respiratory mortality and hospitalizations using Poisson regression. Relative risks and 95% confidence intervals (CI) were expressed as percentage change per interquartile range increment in source-factor mass or number concentration. We evaluated the sensitivity of associations to adjustment for multiple other factors and by season. ResultsWe found no evidence of associations between PM10 or NSD source-related factors and daily mortality, as the direction of the estimates were variable with 95% CI spanning 0%. Traffic-related PM10 and NSD displayed consistent associations with CVD admissions aged 15–64years (1.01% (95%CI: 0.03%, 2.00%) and 1.04% (95%CI: −0.62%, 2.72%) respectively) as did particles from background urban sources (0.36% for PM10 and 0.81% for NSD). Most sources were positively associated with pediatric (0–14years) respiratory hospitalizations, with stronger evidence for fuel oil PM10 (3.43%, 95%CI: 1.26%, 5.65%). Our results did not suggest associations with cardiovascular admissions in 65+ or respiratory admissions in 15+ age groups. Effect estimates were generally robust to adjustment for other factors and by season. ConclusionsOur findings are broadly consistent with the growing evidence of the toxicity of traffic and combustion particles, particularly in relation to respiratory morbidity in children and cardiovascular morbidity in younger adults.

Fasting plasma glucose levels and coronary artery calcification in subjects with impaired fasting glucose.

BACKGROUNDPrediabetes is associated with an increased risk of cardiovascular disease (CVD). While the association of impaired glucose tolerance with CVD has been shown in many studies, the relationship between impaired fasting glucose (IFG) and CVD remains unclear.OBJECTIVESThe purpose of this study was to compare the coronary artery calcium (CAC) scores of participants with normal fasting glucose versus those with IFG, according to fasting plasma glucose (FPG) levels, and to assess whether differences in CAC scores were independent of important confounders.DESIGNRetrospective study.SETTINGHealth Promotion Center of the University Hospital (Gyeonggi-do, South Korea), during the period 2010–2014.PATIENTS AND METHODSParticipants were enrolled from the general population who visited for a medical check-up. CAC was assessed in asymptomatic individuals by multidetector computed tomography. Anthropometric parameters and metabolic profiles were also recorded. Subjects were divided into four fasting glucose groups. Participants with a history of CVD or diabetes mellitus were excluded.MAIN OUTCOME MEASURESCorrelation between FPG and CAC scores, CAC score categories, and association between CAC score and FPG categories.RESULTSOf 1112 participants, 346 (34.2%) had a CAC score >0. FPG values in the IFG patients were positively but weakly correlated with CAC scores (r=0.099, P=.001). The incidence of CAC differed according to FPG level (P<.001) and in Kruskal-Wallis test the mean CAC score differed by FPG group (P<.001). After adjustment for other factors in a multiple logistic regression analysis, those subjects with FPG ≥110 mg/dL had a significantly higher risk of CAC than did subjects with normal fasting glucose (110≤FPG [mg/dL] <120, OR=2.507, P=.002; 120≤FPG [mg/dL] <126, OR=3.568, P=.001 vs. <100 mg/dL)CONCLUSIONIFG (especially FPG≥110 mg/dL) could be an independent risk factor for CAC. These associations were not altered after adjustment for other possible confounders.LIMITATIONSPossible misclassification because data taken from a single blood test. No HbA1c tests or repeated FPG tests. No adjustment for other potentially important confounders.

The Registry of the International Society for Heart and Lung Transplantation: Nineteenth Pediatric Heart Transplantation Report—2016; Focus Theme: Primary Diagnostic Indications for Transplant

The Registry of the International Society for Heart and Lung Transplantation: Nineteenth Pediatric Heart Transplantation Report—2016; Focus Theme: Primary Diagnostic Indications for Transplant

Use of Estrogen-Containing Contraception Is Associated With Increased Concentrations of 25-Hydroxy Vitamin D

Small studies suggest exogenous estrogen may improve vitamin D status, but the etiology is unclear because women who use hormones may make lifestyle choices that differentially affect vitamin D status. Our objective was to investigate the association between use of hormonal contraception and 25-hydroxy-vitamin D (25(OH)D). We used linear regression modeling of cross-sectional data to estimate percent change in season-adjusted serum 25(OH)D with estrogen use after adjustment for other factors. At the enrollment clinic visit (2010-2012) into a cohort study of uterine fibroids, each subject provided a blood sample, had anthropomorphic variables and skin reflectance measured, and answered questionnaires on demographics, dietary and supplement intake, contraceptive use, reproductive and medical history, and behaviors. A total of 1662 African American women, community volunteers, 23-34 years old, living in the Detroit, Michigan, area were included. None. Serum 25(OH)D was measured. Serum 25(OH)D concentrations were low (70% <20 ng/ml). Current use of an estrogen-containing contraceptive was associated with a 20% (95% confidence interval: 14-27) increase in 25(OH)D after adjustment. There was no increase in 25(OH)D among participants who had used estrogen in the past, but were not current users, indicating that results were unlikely to be due to unmeasured confounding by factors related to contraceptive choice. The increase in 25(OH)D with use of estrogen-containing contraceptives raise mechanistic questions regarding the biological pathways involved, and highlights the need for studies that examine possible endogenous estrogen effects on vitamin D.

Prevalence, characteristics, and acute care utilization of disabled older adults with an absence of help for activities of daily living: Findings from a nationally representative survey

ObjectiveThe aim of this study was to investigate the prevalence, characteristics, and acute care utilization of community dwelling disabled older adults with an absence of help for activities of daily living (ADL). MethodsWe analyzed cross-sectional data from a nationally representative sample of people aged 65 years and over (n=2904) participating in the 2009 National Health Interview Survey in Taiwan. Disability was defined as self-reporting a lot of difficulty or complete inability to carry out one or more ADL tasks. Participants with disability were asked whether they received help in the form of personal assistance or assistive devices to complete ADL tasks, with a yes response indicating the presence of help and a no response indicating the absence of help. Hospitalization and emergency department visits was assessed as a dichotomous variable (any or none), respectively. ResultsAn absence of available help for ADL disability was reported in 16.6% of disabled older adults. Disabled older adults reporting an absence of help were more likely to be female. After adjustment for other factors, compared to older adults without disability, older adults with disability not receiving help for ADL tasks were highly related to hospitalization (OR=4.57; 95%CI=[1.51–13.82]) and emergency department visits (OR=3.52; 95%CI=[1.15–10.76]) during the past year, respectively. ConclusionsWe found that there is high prevalence of absence of help to perform ADL tasks in older adults with disability, and that this absence of help for ADL disability is associated with a greater burden of acute care utilization than those without disability.

HBsAg clearance rate in patients with HBeAg-positive chronic hepatitis B: a comparative effect analysis based on the real world

To investigate HBsAg clearance rate in previously untreated patients with HBeAg-positive chronic hepatitis B (CHB) treated with nucleos(t)ides and interferons and its influencing factors based on the clinical diagnosis and treatment dat. A retrospective cohort study was conducted in 1 767 previously untreated HBeAg-positive CHB patients who visited Beijing You'an Hospital from February 14, 2008 to December 31, 2012. HBsAg clearance rates were calculated for patients with different characteristics, and the Cox regression model was used to investigate the influencing factors for HBsAg clearance. The overall annual HBsAg clearance rate was 0.46% in 1767 patients, and in the patients treated with adefovir, entecavir, telbivudine, and common interferon, the annual HBsAg clearance rate was 0.52%, 0.47%, 0.45%, and 1.18%, respectively. No patients in the lamivudine and pegylated interferon-α groups experienced HBsAg clearance, which might be due to the small sample size. The univariate analysis showed that HBsAg clearance rate was associated with the patient's age when he/she visited the hospital and baseline HBsAg titer level. After adjustment for other factors, the patients treated with common interferon had a significantly higher possibility of HBsAg clearance than those treated with entecavir (HR = 8.33, 95% CI: 1.19-58.50, P = 0.0329), but the possibility of HBsAg clearance showed no significant difference between patients treated with other nucleos(t)ides and entecavir. The patients aged≥50 years had a probability of HBsAg clearance 4.92 times that of those aged < 50 years (HR = 4.92, 95% CI: 1.38-17.50, P = 0.0139) and the patients with baseline HBsAg titer level < 3 log10 IU/ml had a probability of HBsAg clearance 22.77 times higher than that of those with baseline HBsAg titer level≥3 log10 IU/ml (HR = 23.77, 95% CI: 6.17-91.51, P < 0.0001). The previously untreated CHB patients achieve a low annual HBsAg clearance rate under current antiviral therapeutic regimens, especially nucleos(t)ides. Baseline HBsAg titer level is closely associated with HBsAg clearance.

Impaired metabolic profile is a predictor of capillary rarefaction in a population of hypertensive and normotensive individuals

Capillary rarefaction is typically encountered in essential hypertension, yet identification of factors interfering with this phenomenon remains substantially underinvestigated. We examined whether components of metabolic profile (dyslipidemia, insulin resistance), inflammatory (high-sensitivity C-reactive protein, high-sensitivity C-reactive protein), and angiogenic (vascular endothelial growth factor) factors are implicated in this phenomenon in a population of newly diagnosed, never-treated hypertensive patients and normotensive controls. Nailfold capillary density was estimated with nailfold capillaroscopy using specifically designed software. A total of 159 individuals, 93 hypertensives, and 66 normotensives were included. Nailfold capillary density was lower among hypertensives compared to normotensives (146.4 ± 31.0 vs. 155.4 ± 26.9, respectively; P = .047). In the total population, capillary density significantly correlated with high-density lipoprotein (HDL) (r = 0.232; P = .003), HDL/low-density lipoprotein ratio (r = 0.175; P = .025), age (r = 0.236; P = .003), but neither with vascular endothelial growth factor or high-sensitivity C-reactive protein. An inverse association was found with body mass index (r = −0.174; P = .029), insulin levels (r = −0.200; P = .018), and homeostasis model assessment-insulin resistance (r = −0.223; P = .009). In the separate analysis for the hypertensive population, sex (P = .014) and homeostasis model assessment-insulin resistance (P = .011) were identified as significant predictors of capillary rarefaction after adjustment for other factors. On the contrary, only HDL levels (P = .036) predicted capillary density in the multiple regression model for the normotensive population. Different aspects of impaired metabolic profile, that is, insulin resistance and low HDL levels, but not angiogenic or inflammatory markers, appear to be independently associated with capillary rarefaction in hypertensive and normotensive individuals.

Risk factors for maternal death revisited.

For many years the UK Confidential Enquiry into Maternal Deaths (CEMD) has reported increased risks of pregnancy-associated death in certain groups of women, such as older mothers and substance abusers. The CEMD, however, lacks a control group, so these conclusions have had to be based on comparisons with data from other sources, e.g. the Office for National Statistics or Hospital Episode Statistics. Comparison between deaths and ‘near miss’ events became possible after the UK Obstetric Surveillance System (UKOSS) was established to study uncommon disorders of pregnancy. Conditions such as eclampsia and pulmonary embolism feature in reports from both CEMD and UKOSS, allowing researchers to compare women who died and those who survived. Kayem et al. (PLoS ONE 2011;6:e29077) found that the risk of death was increased by older age, black ethnicity, obesity and unemployment. In a similar, larger study, Nair et al. (BJOG. 2015;122:653-62) identified six risk factors, such as inadequate use of antenatal care, which together accounted for 70% of the increased risk of death. UKOSS also collects details on controls—one or more women delivering in the same hospital immediately before the near-miss case was delivered. These now provide an opportunity for the long-awaited comparison between women who died and women with uncomplicated pregnancies. In this issue, Nair et al. compare 383 maternal deaths reported to MBRRACE-UK in 2009–2013 and 1516 controls from UKOSS studies between 2010 and 2012. The two groups, drawn from the same national population over similar time periods, are as closely comparable as possible. This study is ground-breaking in several ways. First, it combines data from two well-established and accurate surveillance programmes. Their reliability contrasts with much of our global information on maternal mortality, which is derived either from estimates by international bodies or from national registers—notoriously subject to under-reporting. Secondly, the study includes maternal deaths from both direct and indirect causes. This is important because in the UK indirect deaths have outnumbered direct deaths since 1997. Worldwide, however, direct causes still account for 73% of maternal deaths (Say et al. Lancet Global Health. 2014;2:e323-33). This difference is one example of why lessons for reducing maternal mortality must be learned at a national level. Thirdly, the study challenges our ideas about risk factors. Of the 13 factors examined, only seven were found to be associated with maternal mortality. They include inadequate utilisation of antenatal care, medical comorbidities and, surprisingly for the UK, anaemia. Missing from the list are ethnicity, parity, body mass index and cigarette smoking, all of which were significant on initial analysis but not after adjustment for other factors. The clinical implications of this study are important. It confirms the risks associated with unemployment and increasing maternal age. The authors point out that women from black African backgrounds should still be considered high risk, but their analysis strongly suggests that the excess mortality in this and other at risk groups can be substantially reduced by targeted interventions, such as attention to medical co-morbidities and improved access to antenatal care. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Exercise adherence in a randomized trial of exercise on aromatase inhibitor arthralgias in breast cancer survivors: the Hormones and Physical Exercise (HOPE) study.

Up to 50% of postmenopausal breast cancer survivors taking aromatase inhibitors (AIs) experience AI-associated arthralgias, or joint pain, which causes many to stop taking AIs and may inhibit exercise, despite known health benefits. We thus evaluated exercise adherence and factors associated with better exercise adherence in breast cancer survivors experiencing AI-induced arthralgia in the (HOPE) year long randomized controlled trial. We included 61 HOPE women randomized to exercise (150min/week of moderate-intensity aerobic exercise and twice-weekly supervised strength training). Our main outcomes were aerobic exercise measured with daily activity logs, attendance at supervised exercise sessions, and changes in cardiorespiratory fitness, measured maximal oxygen consumption (VO2max). We examined means and standard deviations (SDs) for exercise adherence by demographic and medical characteristics and used the t test for mean differences. We also examined predictors of adherence using linear regression. On average, at the end of the year long trial, women reported 119 (SD 78) min/week of moderate-intensity aerobic exercise and participated in 70% of supervised exercise training sessions. After adjustment for other factors that influence adherence, at 6months postrandomization, only baseline VO2max was associated with higher aerobic exercise levels and at 12months, only older age predicted better supervised exercise training attendance. Breast cancer survivors taking AIs and experiencing arthralgia are able to initiate and maintain a year long exercise program, regardless of other factors that influence activity levels. Breast cancer survivors can exercise at levels that have been shown to improve AI-associated arthralgia.