Objective To estimate how much changes in the main risk factors of cardiovascular disease (smoking prevalence, serum cholesterol, and systolic blood pressure) can explain the reduction in coronary heart disease mortality observed among working aged men and women in eastern Finland.
Design Population based observational study.
Setting Eastern Finland.
Participants 34 525 men and women aged 30-59 years who participated in the national FINRISK studies between 1972 and 2012.
Interventions Change in main cardiovascular risk factors through population based primary prevention.
Main outcome measures Predicted and observed age standardised mortality due to coronary heart disease. Predicted change was estimated with a logistic regression model using risk factor data collected in nine consecutive, population based, risk factor surveys conducted every five years since 1972. Data on observed mortality were obtained from the National Causes of Death Register.
Results During the 40 year study period, levels of the three major cardiovascular risk factors decreased except for a small increase in serum cholesterol levels between 2007 and 2012. From years 1969-1972 to 2012, coronary heart disease mortality decreased by 82% (from 643 to 118 deaths per 100 000 people) and 84% (114 to 17) among men and women aged 35-64 years, respectively. During the first 10 years of the study, changes in these three target risk factors contributed to nearly all of the observed mortality reduction. Since the mid-1980s, the observed reduction in mortality has been larger than predicted. In the last 10 years of the study, about two thirds (69% in men and 66% in women) of the reduction could be explained by changes in the three main risk factors, and the remaining third by other factors.
Conclusion Reductions in disease burden and mortality due to coronary heart disease can be achieved through the use of population based primary prevention programmes. Secondary prevention among high risk individuals and treatment of acute events of coronary heart disease could confer additional benefit.
By Pekka Jousilahti et al, BMJ 2016;352:i721
Importance Few studies have evaluated the relationship between influenza vaccination and pneumonia, a serious complication of influenza infection.
Objective To assess the association between influenza vaccination status and hospitalization for community-acquired laboratory-confirmed influenza pneumonia.
Design, Setting, and Participants The Etiology of Pneumonia in the Community (EPIC) study was a prospective observational multicenter study of hospitalizations for community acquired pneumonia conducted from January 2010 through June 2012 at 4 US sites. In this case-control study, we used EPIC data from patients 6 months or older with laboratory-confirmed influenza infection and verified vaccination status during the influenza seasons and excluded patients with recent hospitalization, from chronic care residential facilities, and with severe immunosuppression. Logistic regression was used to calculate odds ratios, comparing the odds of vaccination between influenza-positive (case) and influenza-negative (control) patients with pneumonia, controlling for demographics, comorbidities, season, study site, and timing of disease onset. Vaccine effectiveness was estimated as (1−adjusted odds ratio)×100%. Exposure Influenza vaccination, verified through record review.
Main Outcomes and Measures Influenza pneumonia, confirmed by real-time reversetranscription polymerase chain reaction performed on nasal/oropharyngeal swabs. Results Overall, 2767 patients hospitalized for pneumonia were eligible for the study; 162 (5.9%) had laboratory-confirmed influenza. Twenty-eight of 162 cases (17%) with influenza-associated pneumonia and 766 of 2605 controls (29%) with influenza-negative pneumonia had been vaccinated. The adjusted odds ratio of prior influenza vaccination between cases and controls was 0.43 (95% CI, 0.28-0.68; estimated vaccine effectiveness, 56.7%; 95% CI, 31.9%-72.5%).
Conclusions and Relevance Among children and adults hospitalized with community acquired pneumonia, those with laboratory-confirmed influenza-associated pneumonia, compared with those with pneumonia not associated with influenza, had lower odds of having received influenza vaccination.
Association Between Hospitalization With Community-Acquired Laboratory Confirmed Influenza Pneumonia and Prior Receipt of Influenza Vaccination by Carlos G. Grijalva, et al. JAMA. 2015;314(14):1488-1497
Objective To examine the effect of the bivalent human papillomavirus (HPV) vaccine on
Design Observational long term follow-up of a randomized, double blinded trial combined
with an independent unvaccinated population based cohort.
Setting Single center study in Costa Rica.
Participants 7466 women in the trial and 2836 women in the unvaccinated cohort enrolled
at the end of the randomized trial and in parallel with the observational trial component.
Intervention Women in the trial were assigned to receive three doses of bivalent HPV
vaccine (n=3727) or the control hepatitis A vaccine (n=3739). Crossover bivalent HPV
vaccination occurred in the hepatitis A vaccine arm at the end of the trial. Women in the
unvaccinated cohort received (n=2836) no vaccination.
Main outcome measure Risk of miscarriage, defined by the US Centers for Disease
Control and Prevention as fetal loss within 20 weeks of gestation, in pregnancies exposed
to bivalent HPV vaccination in less than 90 days and any time from vaccination compared
with pregnancies exposed to hepatitis A vaccine and pregnancies in the unvaccinated
Results Of 3394 pregnancies conceived at any time since bivalent HPV vaccination, 381
pregnancies were conceived less than 90 days from vaccination. Unexposed pregnancies
comprised 2507 pregnancies conceived after hepatitis A vaccination and 720 conceived in
the unvaccinated cohort. Miscarriages occurred in 451 (13.3%) of all exposed pregnancies,
in 50 (13.1%) of the pregnancies conceived less than 90 days from bivalent HPV
vaccination, and in 414 (12.8%) of the unexposed pregnancies, of which 316 (12.6%) were
in the hepatitis A vaccine group and 98 (13.6%) in the unvaccinated cohort. The relative risk
of miscarriage for pregnancies conceived less than 90 days from vaccination compared with
all unexposed pregnancies was 1.02 (95% confidence interval 0.78 to 1.34, one sided
P=0.436) in unadjusted analyses. Results were similar after adjusting for age at vaccination
(relative risk 1.15, one sided P=0.17), age at conception (1.03, P=0.422), and calendar year
(1.06, P=0.358), and in stratified analyses. Among pregnancies conceived at any time from
bivalent HPV vaccination, exposure was not associated with an increased risk of
miscarriage overall or in subgroups, except for miscarriages at weeks 13-20 of gestation
(relative risk 1.35, 95% confidence interval 1.02 to 1.77, one sided P=0.017).
Conclusions There is no evidence that bivalent HPV vaccination affects the risk of
miscarriage for pregnancies conceived less than 90 days from vaccination. The increased
risk estimate for miscarriages in a subgroup of pregnancies conceived any time after
vaccination may be an artifact of a thorough set of sensitivity analyses, but since a genuine association cannot totally be ruled out, this signal should nevertheless be explored further in existing and future studies.
Effect of bivalent human papillomavirus vaccination on pregnancy outcomes: long term observational follow-up in the Costa Rica HPV Vaccine Trial by Orestis A Panagiotou, et al. on behalf of the Costa Rica HPV Vaccine Trial (CVT) Group
BMJ2015; 351 (Published 07 September 2015)
Objective To examine the association between warfarin treatment and longitudinal outcomes after ischemic stroke in patients with atrial fibrillation in community practice.
Design Observational study.
Setting Hospitals (n=1487) participating in the Get With The Guidelines (GWTG)-Stroke program in the United States, from 2009 to 2011.
Participants 12,552 warfarin naive atrial fibrillation patients admitted to hospital for ischemic stroke and treated with warfarin compared with no oral anticoagulant at discharge, linked to Medicare claims for longitudinal outcomes.
Main outcome measures Major adverse cardiovascular events (MACE) and home time, a patient centered outcomes measure defined as the total number of days free from institutional care after discharge. A propensity score inverse probability weighting method was used to account for all differences in observed characteristics between treatment groups.
Results Among 12,552 survivors of stroke, 11,039 (88%) were treated with warfarin at discharge. Warfarin treated patients were slightly younger and less likely to have a history of previous stroke or coronary artery disease but had similar severity of stroke as measured by the National Institutes of Health Stroke Scale. Relative to those not treated, patients treated with warfarin had more days at home (as opposed to institutional care) during the two years after discharge (adjusted home time difference 47.6 days, 99% confidence interval 26.9 to 68.2). Patients discharged on warfarin treatment also had a reduced risk of MACE (adjusted hazard ratio 0.87, 99% confidence interval 0.78 to 0.98), all cause mortality (0.72, 0.63 to 0.84), and recurrent ischemic stroke (0.63, 0.48 to 0.83). These differences were consistent among clinically relevant subgroups by age, sex, stroke severity, and history of previous coronary artery disease and stroke.
Conclusions Among ischemic stroke patients with atrial fibrillation, warfarin treatment was associated with improved long term clinical outcomes and more days at home.
Real world effectiveness of warfarin among ischemic stroke patients with atrial fibrillation: observational analysis from Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) study by Ying Xian, et al. BMJ 2015; 351 :h3786