Violent injuries among women in an urban area

BACKGROUND: Although the rate of death from injuries due to violent acts is much higher among black women than among white women in the United States, little is known about the nature and correlates of violent injuries among black women living in urban areas. METHODS: In this case-control study conducted at three emergency departments in one inner-city community (in west Philadelphia), we studied 405 adolescent girls and women who had been intentionally injured and 520 adolescent girls and women (control subjects) who had health problems not related to violent injury. Data were collected by conducting standardized interviews with use of questionnaires and by screening urine for illicit drugs. Individual logistic-regression models were constructed to identify factors associated with violent injuries inflicted by partners and those inflicted by persons other than the partners of the victims. RESULTS: The male partners of the injured women were much more likely than the male partners of control subjects to use cocaine (odds ratio, 4.4; 95 percent confidence interval, 2.3 to 8.4) and to have been arrested in the past (odds ratio, 3.1; 95 percent confidence interval, 1.8 to 5.2). Fifty-three percent of violent injuries to the women had been perpetrated by persons other than their partners. Women's use of illicit drugs and alcohol abuse were factors associated with both violence on the part of partners and violence on the part of other persons. Neighborhood characteristics, including low median income, a high rate of change of residence, and poor education, were independently associated with the risk of violent injuries among women. CONCLUSIONS: Women in this urban, low-income community face violence from both partners and other persons. Substance abuse, particularly cocaine use, is a significant correlate of violent injuries. Standard Census data may help identify neighborhoods where women are at high risk for such violence and that would benefit from community-level interventions.     

Intimate partner violence during pregnancy in Vietnam: role of husbands

Intimate partner violence (IPV) perpetrators are often husbands. Understanding factors pertaining to women’s male partners is essential for programming interventions against IPV. The objective of the study was to describe husband-related social and behavioural risk factors and assess how they are associated with IPV during pregnancy. Cross-sectional data were collected among 1309 pregnant women with husbands in Dong Anh district, Vietnam. Information on sociodemographic characteristics of husbands, the husband’s behaviour and the husband’s involvement in pregnancy care was indirectly collected via women’s report at first antenatal care visit. Data on exposure to intimate partner violence during pregnancy were collected when the women returned for antenatal care in 30–34 gestational weeks. Logistic regression analyses were used to measure the relationships between IPV during pregnancy and risk factors from the husband. Pregnant women who had husbands who were younger or blue-collar worker/farmer/unemployed had more likelihood to be exposed to IPV. Women with husbands who drank alcohol before sexual intercourse and gambled were more likely to be exposed to IPV repeated times. Those with husbands who had intentions of having a child had over three times increased OR to be exposed to IPV once (AOR = 3.2, 95% CI 1.1–9.7). If the husband had a preference for sons, the woman had 1.5 times increased OR (AOR = 1.5; 95% CI 1.1–1.9) to be exposed to IPV repeated times during pregnancy. This study highlights significant associations between IPV and maternal perceptions of husbands’ behaviours and involvement in pregnancy. Findings may help to identify at-risk pregnant women to IPV and guide the development of targeted interventions to prevent IPV from husbands.

     

Smoking and mortality among older men and women in three communities

BACKGROUND. Although cigarette smoking is the leading avoidable cause of premature death in middle age, some have claimed that no association is present among older persons. METHODS. We prospectively examined the relation of cigarette-smoking habits with mortality from all causes, cardiovascular causes, and cancer among 7178 persons 65 years of age or older without a history of myocardial infarction, stroke, or cancer who lived in one of three communities: East Boston, Massachusetts; Iowa and Washington counties, Iowa; and New Haven, Connecticut. At the time of the initial interview, prevalence rates of smoking in the three communities ranged from 5.2 to 17.8 percent among women and from 14.2 to 25.8 percent among men. During five years of follow-up there were 1442 deaths, 729 due to cardiovascular disease and 316 due to cancer. RESULTS. In both sexes, rates of total mortality among current smokers were twice what they were among participants who had never smoked. Relative risks, as adjusted for age and community, were 2.1 among the men (95 percent confidence interval, 1.7 to 2.7) and 1.8 among the women (95 percent confidence interval, 1.4 to 2.4). Current smokers had higher rates of cardiovascular mortality than those who had never smoked (as adjusted for age and community, the relative risk was 2.0 [95 percent confidence interval, 1.4 to 2.9] among the men and 1.6 [95 percent confidence interval, 1.1 to 2.3] among the women), as well as increased rates of cancer mortality (relative risk, 2.4 [95 percent confidence interval, 1.4 to 4.1] among the men and 2.4 [95 percent confidence interval, 1.4 to 3.9] among the women). In both sexes, former smokers had rates of cardiovascular mortality similar to those of the participants who had never smoked, regardless of age at cessation, whereas the rates for all cancers, as well as smoking-related cancers, remained elevated among men who had once smoked. CONCLUSIONS. Our prospective findings indicate that the mortality hazards of smoking extend well into later life, and suggest that cessation will continue to improve life expectancy in older people.     

Deaths and injuries from house fires.

BACKGROUND: We sought to define the factors associated with house fires and related injuries by analyzing the data from population-based surveillance. METHODS: For 1991 through 1997, we linked the following data for Dallas: records from the fire department of all house fires (excluding fires in apartments and mobile homes), records of patients transported by ambulance, hospital admissions, and reports from the medical examiner of fatal injuries. RESULTS: There were 223 injuries (91 fatal and 132 nonfatal) from 7190 house fires, for a rate of 5.2 injured persons per 100,000 population per year. Rates of injury related to house fires were highest among blacks (relative risk, 2.8; 95 percent confidence interval, 2.1 to 3.6) and in people 65 years of age or older (relative risk, 2.6; 95 percent confidence interval, 1.9 to 3.5). Census tracts with low median incomes had the highest rates of injury related to house fires (relative risk as compared with census tracts with high median incomes, 8.1; 95 percent confidence interval, 2.5 to 32.0). The rate of injuries was higher for fires that began in bedrooms or living areas (relative risk, 3.7); that were started by heating equipment, smoking, or children playing with fire (relative risk, 2.6); or that occurred in houses built before 1980 (relative risk, 6.6). Injuries occurred more often in houses without functioning smoke detectors (relative risk, 1.5; 95 percent confidence interval, 1.0 to 2.4). The prevalence of functioning smoke detectors was lowest in houses in the census tracts with the lowest median incomes (P<0.001). CONCLUSIONS: Rates of injuries related to house fires are highest in elderly, minority, and low-income populations and in houses without functioning smoke detectors. Efforts to prevent injuries and deaths from house fires should target these populations.     

Sexual violence against adult women primary care attenders in east London.

BACKGROUND: Sexual violence against women is common. The prevalence appears to be higher in north America than Europe. However, not all surveys have differentiated the experience of forced sex by a current or former partner. Few women are thought to report these experiences to their general practitioner (GP). AIM: To measure the prevalence of rape, sexual assault, and forced sexual intercourse by a partner among women attending general practices, to test the association between these experiences of sexual violence and demographic factors, and to assess the acceptability to women of screening for sexual violence by GPs. DESIGN OF STUDY: Cross-sectional survey. METHOD: A self-administered questionnaire survey of 1207 women aged over 15 years was carried out in 13 general practices in Hackney, east London. RESULTS: Eight per cent (95% confidence interval [CI] = 6.2 to 9.6) of women have experienced rape, 9% (95% CI = 7.0 to 10.6) another type of sexual assault, and 16% (95% CI = 13.6 to 18.1) forced sex by a partner in adulthood: 24% (95% CI = 21.2 to 26.5) have experienced one or more of these types of sexual violence. Experiences of sexual violence demonstrated high levels of lifetime co-occurrence. Women forced to have sex by partners experienced the most severe forms of domestic violence. One in five women would object to routine questioning about being raped and/or sexually assaulted, and one in nine about being forced to have sex by a partner. CONCLUSION: Experiences of sexual violence are common in the lives of adult women in east London, and they represent a significant public health problem. Those women who have one experience appear to be at risk of being victims again. A substantial minority object to routine questions about sexual violence.     

Postmenopausal estrogen therapy and cardiovascular disease. Ten-year follow-up from the nurses' health study

BACKGROUND. The effect of postmenopausal estrogen therapy on the risk of cardiovascular disease remains controversial. Our 1985 report in the Journal, based on four years of follow-up, suggested that estrogen therapy reduced the risk of coronary heart disease, but a report published simultaneously from the Framingham Study suggested that the risk was increased. In addition, studies of the effect of estrogens on stroke have yielded conflicting results. METHODS. We followed 48,470 postmenopausal women, 30 to 63 years old, who were participants in the Nurses' Health Study, and who did not have a history of cancer or cardiovascular disease at base line. During up to 10 years of follow-up (337,854 person-years), we documented 224 strokes, 405 cases of major coronary disease (nonfatal myocardial infarctions or deaths from coronary causes), and 1263 deaths from all causes. RESULTS. After adjustment for age and other risk factors, the overall relative risk of major coronary disease in women currently taking estrogen was 0.56 (95 percent confidence interval, 0.40 to 0.80); the risk was significantly reduced among women with either natural or surgical menopause. We observed no effect of the duration of estrogen use independent of age. The findings were similar in analyses limited to women who had recently visited their physicians (relative risk, 0.45; 95 percent confidence interval, 0.31 to 0.66) and in a low-risk group that excluded women reporting current cigarette smoking, diabetes, hypertension, hypercholesterolemia, or a Quetelet index above the 90th percentile (relative risk, 0.53; 95 percent confidence interval, 0.31 to 0.91). The relative risk for current and former users of estrogen as compared with those who had never used it was 0.89 (95 percent confidence interval, 0.78 to 1.00) for total mortality and 0.72 (95 percent confidence interval, 0.55 to 0.95) for mortality from cardiovascular disease. The relative risk of stroke when current users were compared with those who had never used estrogen was 0.97 (95 percent confidence interval, 0.65 to 1.45), with no marked differences according to type of stroke. CONCLUSIONS. Current estrogen use is associated with a reduction in the incidence of coronary heart disease as well as in mortality from cardiovascular disease, but it is not associated with any change in the risk of stroke.     

Identification of women at unsuspected risk of primary infection with herpes simplex virus type 2 during pregnancy.

BACKGROUND. Primary infections with herpes simplex virus type 2 (HSV-2) acquired by women during pregnancy account for about half of the morbidity and mortality from HSV-2 among neonates. The other half results from reactivation of old infections. Better methods are needed to identify which women are at risk for primary HSV-2 infection. METHODS. We prospectively studied HSV-2 infections among pregnant women who were patients in private obstetrical practices. Using an enzyme-linked immunosorbent assay that detects type-specific antibodies to HSV-2 glycoprotein G, we determined the prevalence at base line of HSV-2 infections among pregnant women and their husbands, the frequency of discordance for infection between partners, and the risk of seroconversion during pregnancy among the seronegative women whose husbands were seropositive. RESULTS. The seroprevalence of HSV-2 was 32 percent among the 277 women followed throughout their pregnancies and 25 percent among the 190 husbands studied. Two thirds of the HSV-2-seropositive women had no history of genital herpes. Of the 190 couples, 139 (73 percent) were serologically concordant for HSV-2 antibodies (57 percent being seronegative and 16 percent being seropositive), whereas 51 couples (27 percent) were discordant, despite having been sexually intimate for a mean of 6.1 years. Eighteen women who were seronegative for HSV-2 (9.5 percent) had seropositive partners, of whom 10 (56 percent) had no history of genital herpes. Thus, approximately 5 percent of these pregnant women had an unsuspected risk of contracting a primary HSV-2 infection. One of the 18 seronegative women with a seropositive husband seroconverted to HSV-2 during pregnancy; none of the other women seroconverted. CONCLUSIONS. In this study about 10 percent of pregnant women were at risk of contracting a primary HSV-2 infection from their HSV-2-seropositive husbands. In addition, about a third of these women were seropositive for HSV-2 and thus at risk for asymptomatic, reactivated infections. Serologic testing of couples can identify women who are at risk for primary or reactivated HSV-2 infections during pregnancy.     

Weight, diet, and the risk of symptomatic gallstones in middle-aged women

To assess the risk factors for symptomatic gallstones, 88,837 women in the Nurses' Health Study cohort (age range, 34 to 59 years) were followed for four years after completing a detailed questionnaire about food and alcohol intake in 1980. A total of 433 cholecystectomies and 179 cases of newly symptomatic, unremoved gallstones, diagnosed by ultrasonographic examination or x-ray films, were reported during the four-year follow-up. The age-adjusted relative risk for very obese women, who had a Quetelet index of relative weight (weight in kilograms divided by the square of the height in meters) of more than 32 kg per square meter, was 6.0 (95 percent confidence interval, 4.0 to 9.0), as compared with women whose relative weight was less than 20 kg per square meter. For slightly overweight women (relative weight, 24 to 24.9 kg per square meter), the relative risk was 1.7 (95 percent confidence interval, 1.1 to 2.7). Overall, we observed a roughly linear relation between relative weight and the risk of gallstones. Among the 59,306 women whose relative weight was less than 25 kg per square meter, a high energy intake (greater than 8200 J per day), as compared with a low energy intake (less than 4730 J per day), was associated with an increased incidence of symptomatic gallstones (relative risk, 2.1; 95 percent confidence interval, 1.4 to 3.3), and an alcohol intake of at least 5 g per day was associated with a decreased incidence as compared with abstention (relative risk, 0.6; 95 percent confidence interval, 0.4 to 0.8). Parity did not appear to be an important risk factor after an adjustment was made for relative weight. These data support a strong association between obesity and symptomatic gallstones and suggest that even moderate overweight may increase the risk.     

Risk factors for human immunodeficiency virus infection in intravenous drug users

To identify risk factors for human immunodeficiency virus (HIV) infection in intravenous drug users, we undertook a study of the seroprevalence of HIV antibody in 452 persons enrolled in a methadone-treatment program in the Bronx, New York. The seroprevalence of HIV was 39.4 percent overall, 49.1 percent in blacks, 41.8 percent in Hispanics, and 17.2 percent in non-Hispanic whites (P less than 0.001 for all comparisons). The presence of HIV antibody was associated with the number of injections per month (P less than 0.001), the percentage of injections with used needles (P less than 0.001), the average number of injections with cocaine per month (P less than 0.001), and the percentage of injections with needles that were shared with strangers or acquaintances (P less than 0.001), a practice that was more common among blacks and Hispanics than among whites. The number of heterosexual sex partners who used intravenous drugs was associated with HIV infection in women (P less than 0.004) and was the only risk factor found for users who had not injected drugs after 1982 (P less than 0.05). The presence of HIV antibody was independently associated with being black or Hispanic (adjusted odds ratio, 4.56; 95 percent confidence interval, 2.65 to 8.14), a more recent year of the last injection of drugs (adjusted odds ratio, 1.24; 95 percent confidence interval, 1.13 to 1.35), the percentage of injections of drugs that took place in "shooting galleries" (adjusted odds ratio, 1.49; 95 percent confidence interval, 1.19 to 1.88), having sex partners who used intravenous drugs (adjusted odds ratio 1.24; 95 percent confidence interval, 1.06 to 1.45), and low income (adjusted odds ratio, 1.55; 95 percent confidence interval, 1.10 to 2.17). We conclude that differences in both the social setting of drug use and behavior related to injection carry different risks for infection with HIV and may explain, in part, the higher seroprevalence of HIV among blacks and Hispanics. In addition, we found that heterosexual activity was an independent risk factor for drug users.     

Sexual practices, sexually transmitted diseases, and the incidence of anal cancer

To elucidate the risk factors for anal cancer, we interviewed and obtained blood specimens from 148 persons with anal cancer and from 166 controls with colon cancer in whom these diseases were diagnosed during 1978-1985. We found that in men, a history of receptive anal intercourse (related to homosexual behavior) was strongly associated with the occurrence of anal cancer (relative risk, 33.1; 95 percent confidence interval, 4.0 to 272.1). Anal intercourse was only weakly associated with the risk of anal cancer in women (relative risk, 1.8; 95 percent confidence interval, 0.7 to 4.2). Among the subjects with squamous-cell anal cancer, 47.1 percent of homosexual men, 28.6 percent of heterosexual men, and 28.3 percent of women gave a history of genital warts, as compared with only 1 to 2 percent of controls and no patients with transitional-cell anal cancer. In patients without a history of warts, anal cancer was associated with a history of gonorrhea in heterosexual men (relative risk, 17.2; 95 percent confidence interval, 2.0 to 149.4) and with seropositivity for herpes simplex type 2 (relative risk, 4.1; 95 percent confidence interval, 1.9 to 8.8) and Chlamydia trachomatis (relative risk, 2.3; 95 percent confidence interval, 1.1 to 4.8) in women. Current cigarette smoking was a substantial risk factor in both women (relative risk, 7.7; 95 percent confidence interval, 3.5 to 17.2) and men (relative risk, 9.4; 95 percent confidence interval, 2.3 to 38.5). We conclude that homosexual behavior in men is a risk factor for anal cancer, and that squamous-cell anal cancer is also associated with a history of genital warts, an association suggesting that papillomavirus infection is a cause of anal cancer. Certain other genital infections and cigarette smoking are also associated with anal cancer.     

Thiazide diuretic agents and the incidence of hip fracture

Thiazide diuretic agents lower the urinary excretion of calcium. Their use has been associated with increased bone density, but their role in preventing hip fracture has not been established. We prospectively studied the effect of thiazide diuretic agents on the incidence of hip fracture among 9518 men and women 65 years of age or older residing in three communities. At base line, 24 to 30 percent of the subjects were thiazide users. In the subsequent four years, 242 subjects had hip fractures. The incidence rates of hip fracture were lower among thiazide users than nonusers in each community; the Mantel-Haenszel relative risk of hip fracture, adjusted for community and age, was 0.63 (95 percent confidence interval, 0.46 to 0.86). The protective effect of the use of thiazides was independent of sex, age, impaired mobility, body-mass index, and current and former smoking status; the multivariate adjusted relative risk of hip fracture was 0.68 (95 percent confidence interval, 0.49 to 0.94). Furthermore, the protective effect was specific to thiazide diuretic agents, since there was no association between the use of antihypertensive medications other than thiazides and the risk of hip fracture. These prospective data suggest that in older men and women the use of thiazide diuretic agents is associated with a reduction of approximately one third in the risk of hip fracture.     

Decline in the risk of myocardial infarction among women who stop smoking

To assess the relation of smoking cessation to the risk of a first myocardial infarction in women, we compared the smoking habits of 910 patients who had had their first myocardial infarction with those of 2375 controls in a hospital-based case-control study of women from 25 to 64 years of age. The estimate of relative risk among current smokers as compared with women who had never smoked was 3.6 (95 percent confidence interval, 3.0 to 4.4). Among exsmokers overall, the corresponding estimate of relative risk was 1.2 (95 percent confidence interval, 1.0 to 1.7). Among exsmokers, the estimate of relative risk was significantly elevated among women who had stopped smoking less than two years previously (relative risk, 2.6; 95 percent confidence interval, 1.8 to 3.8). Most of the increase in the risk had dissipated among the women who had stopped smoking two to three years previously, and the estimate of relative risk among the women who had not smoked for three or more years was virtually indistinguishable from that among the women who had never smoked. The same pattern of decline was apparent regardless of the amount smoked, the duration of smoking, the age of the women, or the presence of other predisposing factors. These data suggest that in women, as in men, the increase in the risk of a first myocardial infarction among cigarette smokers declines soon after the cessation of smoking and is largely dissipated after two or three years.     

Mutations in coagulation factors in women with unexplained late fetal loss

BACKGROUND: Factor V and prothrombin-gene mutations are independent risk factors for venous thrombosis; it is debated whether a mutation in the gene encoding methylenetetrahydrofolate reductase, an enzyme involved in homocysteine metabolism, also increases the risk of venous thrombosis. Whether any of these mutations is associated with an increased risk of late fetal death is not known. METHODS: We studied 67 women with a first episode of unexplained late fetal loss (fetal death after 20 weeks or more of gestation) and 232 women who had had one or more normal pregnancies and no late fetal losses. All the women were tested for the presence of three gene mutations. Women with other thrombophilic conditions were excluded from the study. RESULTS: Eleven of the 67 women with late fetal loss (16 percent) and 13 of the 232 control women (6 percent) had either the factor V or the prothrombin mutation. The relative risks of late fetal loss in carriers of the factor V and prothrombin mutations were 3.2 (95 percent confidence interval, 1.0 to 10.9) and 3.3 (95 percent confidence interval, 1.1 to 10.3), respectively. Thirteen percent of the women whose fetuses died and 20 percent of the control women were homozygous for the mutation in the methylenetetrahydrofolate reductase gene (relative risk, 0.8; 95 percent confidence interval, 0.5 to 1.2). CONCLUSIONS: Both the factor V and the prothrombin mutations are associated with an approximate tripling of the risk of late fetal loss.     

Prothrombin and factor V mutations in women with a history of thrombosis during pregnancy and the puerperium

BACKGROUND: Venous thromboembolism is a leading cause of morbidity and mortality during pregnancy and the puerperium. However, the role of mutations in the prothrombin and factor V genes and other thrombophilic abnormalities as risk factors for thromboembolism in women during pregnancy and the pueperium is not known. METHODS: In a study of 119 women with a history of venous thromboembolism during pregnancy and the puerperium and 233 age-matched normal women, we measured the activity of antithrombin, protein C, protein S, and lupus anticoagulant. We also performed genetic analyses to detect the G1691A mutation in the factor V gene (factor V Leiden), the G20210A mutation in the prothrombin gene, and the C677T mutation in the methylenetetrahydrofolate reductase gene. Blood samples were obtained at least three months post partum or after the cessation of lactation. RESULTS: Among the women with a history of venous thromboembolism, the prevalence of factor V Leiden was 43.7 percent, as compared with 7.7 percent among the normal women (relative risk of venous thromboembolism, 9.3; 95 percent confidence interval, 5.1 to 16.9); that of the G20210A prothrombin-gene mutation, 16.9 percent as compared with 1.3 percent (relative risk, 15.2; 95 percent confidence interval, 4.2 to 52.6); and that of both factor V Leiden and the G20210A prothrombin-gene mutation 9.3 percent as compared with 0 (estimated odds ratio, 107). Assuming an overall risk of 1 in 1500 pregnancies, the risk of thrombosis among carriers of factor V Leiden was 0.2 percent, among carriers of the G20210A prothrombin-gene mutation, 0.5 percent, and among carriers of both defects, 4.6 percent, as calculated in a multivariate analysis. CONCLUSIONS: The G20210A prothrombin-gene mutation and factor V Leiden individually are associated with an increased risk of venous thromboembolism during pregnancy and the puerperium, and the risk among women with both mutations is disproportionately higher than that among women with only one mutation.     

Risk of uterine rupture during labor among women with a prior cesarean delivery.

BACKGROUND: Each year in the United States, approximately 60 percent of women with a prior cesarean delivery who become pregnant again attempt labor. Concern persists that a trial of labor may increase the risk of uterine rupture, an uncommon but serious obstetrical complication. METHODS: We conducted a population-based, retrospective cohort analysis using data from all primiparous women who gave birth to live singleton infants by cesarean section in civilian hospitals in Washington State from 1987 through 1996 and who delivered a second singleton child during the same period (a total of 20,095 women). We assessed the risk of uterine rupture for deliveries with spontaneous onset of labor, those with labor induced by prostaglandins, and those in which labor was induced by other means; these three groups of deliveries were compared with repeated cesarean delivery without labor. RESULTS: Uterine rupture occurred at a rate of 1.6 per 1000 among women with repeated cesarean delivery without labor (11 women), 5.2 per 1000 among women with spontaneous onset of labor (56 women), 7.7 per 1000 among women whose labor was induced without prostaglandins (15 women), and 24.5 per 1000 among women with prostaglandin-induced labor (9 women). As compared with the risk in women with repeated cesarean delivery without labor, uterine rupture was more likely among women with spontaneous onset of labor (relative risk, 3.3; 95 percent confidence interval, 1.8 to 6.0), induction of labor without prostaglandins (relative risk, 4.9; 95 percent confidence interval, 2.4 to 9.7), and induction with prostaglandins (relative risk, 15.6; 95 percent confidence interval, 8.1 to 30.0). CONCLUSIONS: For women with one prior cesarean delivery, the risk of uterine rupture is higher among those whose labor is induced than among those with repeated cesarean delivery without labor. Labor induced with a prostaglandin confers the highest risk.     

Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study

A pattern of left ventricular hypertrophy evident on the electrocardiogram is a harbinger of morbidity and mortality from cardiovascular disease. Echocardiography permits the noninvasive determination of left ventricular mass and the examination of its role as a precursor of morbidity and mortality. We examined the relation of left ventricular mass to the incidence of cardiovascular disease, mortality from cardiovascular disease, and mortality from all causes in 3220 subjects enrolled in the Framingham Heart Study who were 40 years of age or older and free of clinically apparent cardiovascular disease, in whom left ventricular mass was determined echocardiographically. During a four-year follow-up period, there were 208 incident cardiovascular events, 37 deaths from cardiovascular disease, and 124 deaths from all causes. Left ventricular mass, determined echocardiographically, was associated with all outcome events. This relation persisted after we adjusted for age, diastolic blood pressure, pulse pressure, treatment for hypertension, cigarette smoking, diabetes, obesity, the ratio of total cholesterol to high-density lipoprotein cholesterol, and electrocardiographic evidence of left ventricular hypertrophy. In men, the risk factor-adjusted relative risk of cardiovascular disease was 1.49 for each increment of 50 g per meter in left ventricular mass corrected for the subject's height (95 percent confidence interval, 1.20 to 1.85); in women, it was 1.57 (95 percent confidence interval, 1.20 to 2.04). Left ventricular mass (corrected for height) was also associated with the incidence of death from cardiovascular disease (relative risk, 1.73 [95 percent confidence interval, 1.19 to 2.52] in men and 2.12 [95 percent confidence interval, 1.28 to 3.49] in women). Left ventricular mass (corrected for height) was associated with death from all causes (relative risk, 1.49 [95 percent confidence interval, 1.14 to 1.94] in men and 2.01 [95 percent confidence interval, 1.44 to 2.81] in women). We conclude that the estimation of left ventricular mass by echocardiography offers prognostic information beyond that provided by the evaluation of traditional cardiovascular risk factors. An increase in left ventricular mass predicts a higher incidence of clinical events, including death, attributable to cardiovascular disease.     

Hip fracture and the use of estrogens in postmenopausal women. The Framingham Study

To assess the effect of postmenopausal use of estrogens on the subsequent risk of hip fracture, we performed a retrospective cohort study of 2873 women in the Framingham Heart Study. Information obtained at routine biennial examinations about the use of estrogens, body weight, age at menopause, smoking, and alcohol consumption was used to evaluate the risk of hip fracture among postmenopausal women who received estrogens. Hip fractures occurred in 179 postmenopausal women, at a rate that increased exponentially after the age of 50. The risk of fracture was inversely related to weight at all ages. The relative risk of hip fracture in subjects who had taken estrogens at any time was 0.65 after adjustment for age and weight (95 percent confidence interval, 0.44 to 0.98). The adjusted relative risk in women who had taken estrogens within the previous two years was further reduced, to 0.34 (95 percent confidence interval, 0.12 to 0.98). Taking estrogens within four years of menopause also protected against fracture. The number of women in each age group who took estrogens was insufficient for a definitive evaluation of risk, but recent use of estrogens appeared to be protective in women under the age of 65 (no fractures among those who took estrogens) and those 65 to 74. We cannot exclude some degree of selection bias among the women who received estrogen-replacement therapy. Nevertheless, this large cohort study supports the hypothesis that postmenopausal use of estrogens protects against subsequent hip fracture in women.     

Cigarette smoking and risk of stroke in middle-aged women

It is known that cigarette smoking is associated with increased risk of both thrombotic and hemorrhagic stroke among men. To test for such an association among women, we examined the incidence of stroke in relation to cigarette smoking in a prospective cohort study of 118,539 women 30 to 55 years of age and free from coronary heart disease, stroke, and cancer in 1976. During eight years of follow-up (908,447 person-years), we identified 274 strokes, comprising 71 subarachnoid hemorrhages, 26 intracerebral hemorrhages, 122 thromboembolic strokes, and 55 strokes about which information was insufficient to permit classification. The number of cigarettes smoked per day was associated positively with the risk of stroke. Compared with the women who had never smoked, those who smoked 1 to 14 cigarettes per day had an age-adjusted relative risk of 2.2 (95 percent confidence interval, 1.5 to 3.3), whereas those who smoked 25 or more cigarettes per day had a relative risk of 3.7 (95 percent confidence interval, 2.7 to 5.1). For women in this latter group, the relative risk of subarachnoid hemorrhage was 9.8 (95 percent confidence interval, 5.3 to 17.9), as compared with those who had never smoked. Adjustment for the effects of relative weight, hypertension, diabetes, history of high cholesterol, previous use of oral contraceptives, postmenopausal estrogen therapy, and alcohol intake did not appreciably alter the association between cigarette use and incidence of stroke. These prospective data support a strong causal relation between cigarette smoking and stroke among young and middle-aged women.     

Siblings, day-care attendance, and the risk of asthma and wheezing during childhood

BACKGROUND: Young children with older siblings and those who attend day care are at increased risk for infections, which in turn may protect against the development of allergic diseases, including asthma. However, the results of studies examining the relation between exposure to other children and the subsequent development of asthma have been conflicting. METHODS: In a study involving 1035 children followed since birth as part of the Tucson Children's Respiratory Study, we determined the incidence of asthma (defined as at least one episode of asthma diagnosed by a physician when the child was 6 to 13 years old) and the prevalence of frequent wheezing (more than three wheezing episodes during the preceding year) in relation to the number of siblings at home and in relation to attendance at day care during infancy. RESULTS: The presence of one or more older siblings at home protected against the development of asthma (adjusted relative risk for each additional older sibling, 0.8; 95 percent confidence interval, 0.7 to 1.0; P=0.04), as did attendance at day care during the first six months of life (adjusted relative risk, 0.4; 95 percent confidence interval, 0.2 to 1.0; P=0.04). Children with more exposure to other children at home or at day care were more likely to have frequent wheezing at the age of 2 years than children with little or no exposure (adjusted relative risk, 1.4; 95 percent confidence interval, 1.1 to 1.8; P=0.01) but were less likely to have frequent wheezing from the age of 6 (adjusted relative risk, 0.8; 95 percent confidence interval, 0.6 to 1.0; P=0.03) through the age of 13 (adjusted relative risk, 0.3; 95 percent confidence interval, 0.2 to 0.5; P<0.001). CONCLUSIONS: Exposure of young children to older children at home or to other children at day care protects against the development of asthma and frequent wheezing later in childhood.     

Domestic violence against women in Sivas, Turkey: survey study

Aim

To determine the self-reported prevalence of domestic violence and associated risk factors in the Sivas province of Turkey.

Method

Five hundred and eighty-three households were chosen by the method of stratified random sampling. The average age among women was 28.65 ± 4.64. A total of 45.3% of women were in 30-34 age-group, 76.5% were housewives, and 91.2% were married. The data were gathered by performing face-to-face interviews in participants’ homes. Demographic data were obtained by fill-in forms.

Results

We found a statistically significant relationship among the types of violence and annual income, type of family, education and occupation level of women, education level of perpetrators, watching violent films, and childhood experience of emotional abuse or negligence. Fifty-two percent of women were exposed to at least one type of violence. Verbal violence was the most frequent type of violence (53.8%), followed by physical violence (38.3%). About 45% of women exposed to violence were in the 30-34 age group, 41.6% completed only primary schools, 73.6% were housewives, 91.7% were married, 71.0% had been exposed to violence during their childhood, and 45.2%, had been exposed to violence several times in a month. Economic problems were reported as the most important reason for domestic violence (31.4%).

Conclusion

Our study found higher prevalence of domestic violence than expected. As an important public health problem, domestic violence requires multidisciplinary approach to understand its causes and plan preventive measures.Domestic violence against women is a serious public health concern in every community and culture (1). Domestic violence against women has drawn attention from the medical community because it has a negative and harmful impact on the mental, physical, and social health of women (2-5). World Health Organization (WHO) has defined domestic violence as “the range of sexually, psychologically, and physically coercive acts used against adult and adolescent women by current or former male intimate partners” (6,7). It is often difficult to conduct research on violence against women, since most women are reluctant to disclose information they consider confidential and intimate. They often feel shame, fear, guilt, and do not want to be disloyal to their partners (8). Besides this, differences in prevalence patterns can occur, because of different survey methods.Violence cannot be attributed to a single cause. According to the ecological model, factors related to violence are covered under four subtitles: 1) biological and personal factors; 2) close relationships, intimate partner; 3) the community context; and 4) the broad societal factors (3,9,10). However, this model only is not sufficient to explain violence and its characteristics.There is a number of studies highlighting the problem of domestic violence in the developing countries (8,10-13). Some studies showed a strong association between socioeconomic status and domestic violence, indicating a significant inverse relation between the income or education level of the male partner and violence (14). Some studies reported that women with greater autonomy, higher educational level, and control over economical resources are more protected against violence (3). However, in many families the husband is the sole decision-maker and the only one in control over financial matters (2,3,15,16). Experiencing abuse or witnessing domestic violence in childhood often turns individuals into either victims or perpetrators, thus closing the vicious circle of domestic violence. According to some studies, large families or larger number of children is associated with a reduced risk of domestic violence (11,17).It has been reported that one out of five women in South Australia has been exposed to domestic violence in forms of physical and/or sexual abuse (18). Violence against women in North America is still prevalent, with lifetime prevalence of 40%-51% (19). The rate of physical violence is higher in developing than in developed countries. The rate of women who are exposed to violence by their husbands is 45% in India, 47% in Philippines, 52% in Kenya (20). In Arab and Islamic countries, domestic violence is not yet considered a major concern, although its frequency is quite high. Surveys carried out in those countries have shown that the ratio of women who have been exposed to violence by their husbands is at least one in three women (21).Domestic violence is an increasingly important issue in Turkey as in the rest of the world. It has gained its importance since 1970, and in the mid 1980s it was brought to the public agenda for discussion. The first collective reaction of women against violence was the march of “No Violence” campaign performed in 1987. This was followed by reactions in “Kariye Women Festival” in 1987. In Turkey, violence is perceived as a discipline tool, which lead to legitimization of violence within the family and society that reproduces and camouflages violence. There are legal provisions accepting the legitimacy of domestic violence. In Turkish Criminal Law, there is no special provision for domestic violence. It is easier for a woman to complain to the formal authorities about violence in the street than about domestic violence.A study including 300 married women treated in the psychiatric outpatient clinic of the Hospital of Cumhuriyet University showed that domestic violence against women was highly prevalent and that women were trying to hide it (22). The study determined that 57% of women in the 16-29 age group were exposed to physical violence. The prevalence of emotional violence was 36%, economical 32%, sexual 30.7%, and verbal 29.3%.According to data from the Institution of Family Research (23), 35% of women in Turkey experienced physical violence from their husbands. According to the research, domestic violence was common to all socio-economical levels both in urban and rural areas. Among the causes of domestic violence reported, there were economical difficulties, temperament of the husbands, and provocation of husbands by their relatives. However, we do exactly not know which factors affect the prevalence of domestic violence in Turkey. As far as we know, there is no study investigating the relationship between domestic violence and childhood traumas. In this study, we aimed to determine the self-reported prevalence of domestic violence and the associated risk factors in the Sivas province in Turkey.