Impact of Statin Adherence on Cardiovascular Morbidity and All-Cause Mortality in the Primary Prevention of Cardiovascular Disease: A Population-Based Cohort Study in Finland

ObjectivesTo assess the extent to which adherence to statins is associated with the incidence of cardiovascular (CV) events and all-cause mortality in the primary prevention of CV diseases and whether different analytical approaches influence the observed associations.MethodsThis population-based cohort study used data from Finnish registers. The cohort included 97,575 new statin users aged 45 to 75 years in 2001 to 2004 with no CV diseases at baseline. Exposure was defined as adherence to statins (proportion of days covered [PDC]). The primary outcome was any CV event or death during a 3-year follow-up. Different analytical approaches, including multivariable-adjusted Cox regression, inverse probability weighting with time-varying adherence, and propensity score calibration, were used.ResultsDuring the first year of follow-up, 53% displayed good (PDC ≥80%), 26% had intermediate (PDC 40%–79%), and 21% exhibited poor (PDC <40%) adherence. After adjustment for sociodemographic and clinical covariates, a 25% relative risk reduction (hazard ratio [HR] 0.75; 95% confidence interval [CI] 0.71–0.79) was observed in the rate of any CV event or death among good versus poor adherers. Good adherers also had a lower incidence than poor adherers of acute coronary syndrome (HR 0.56; 95% CI 0.49–0.65) and acute cerebrovascular disease events (HR 0.67; 95% CI 0.60–0.76). The different analytical approaches achieved comparable results for all the outcomes.ConclusionsThe incidence of CV events and mortality was higher in poor versus good adherers. Different analytical methods that took into account changes in adherence and confounding at baseline did not appreciably affect the results.     

Can combining different risk interventions into a single formulation contribute to improved cardiovascular disease risk reduction? The single pill of amlodipine/atorvastatin

In order to prevent cardiovascular events, it is essential to effectively manage overall risk of cardiovascular disease. However, despite guideline recommendations to this effect, current management of the major, modifiable cardiovascular risk factors such as hypertension and dyslipidemia is disconnected and patient adherence to therapy is poor. This is particularly important for patients with multiple cardiovascular risk factors, who are often prescribed multiple medications. The JEWEL study program investigated the use of single-pill amlodipine/atorvastatin as a strategy to improve management of these patients. The JEWEL program consisted of two 16-week, international, open-label, multicenter, titration-to-goal studies in patients with hypertension and dyslipidemia. The two studies differed based on country of enrollment and certain tertiary endpoints, but the overall designs were very similar. Patients were enrolled from 255 centers across Canada and 13 European countries. The study was designed to assess the efficacy, safety, and utility of amlodipine/atorvastatin single-pill therapy in a real-world setting. Patients were initiated at a dose of amlodipine 5 mg/atorvastatin 10 mg, unless previously treated, and were uptitrated as necessary. The primary efficacy parameter was the percentage of patients, at different levels of cardiovascular risk, achieving country-specific guideline-recommended target levels for blood pressure and lipids. A secondary analysis of efficacy measured attainment of the same single goal for blood pressure across all study participants (JEWEL I and II) and the same single goal for LDL-C across all study participants (JEWEL I and II). The program utilized a newly developed questionnaire to gain better understanding of participants' beliefs and behaviors towards medical treatment of their multiple risk factors. Approximately 2850 patients were enrolled in the program, which was completed in August 2005. The JEWEL program assessed the effectiveness of a single pill (amlodipine/atorvastatin) in targeting the two principal risk factors for cardiovascular disease simultaneously to achieve nationally applicable treatment targets in a routine clinical practice setting.     

Statin Use and COVID-19 Infectivity and Severity in South Korea: Two Population-Based Nationwide Cohort Studies

BackgroundBasic studies suggest that statins as add-on therapy may benefit patients with COVID-19; however, real-world evidence of such a beneficial association is lacking.ObjectiveWe investigated differences in SARS-CoV-2 test positivity and clinical outcomes of COVID-19 (composite endpoint: admission to intensive care unit, invasive ventilation, or death) between statin users and nonusers.MethodsTwo independent population-based cohorts were analyzed, and we investigated the differences in SARS-CoV-2 test positivity and severe clinical outcomes of COVID-19, such as admission to the intensive care unit, invasive ventilation, or death, between statin users and nonusers. One group comprised an unmatched cohort of 214,207 patients who underwent SARS-CoV-2 testing from the Global Research Collaboration Project (GRCP)-COVID cohort, and the other group comprised an unmatched cohort of 74,866 patients who underwent SARS-CoV-2 testing from the National Health Insurance Service (NHIS)-COVID cohort.ResultsThe GRCP-COVID cohort with propensity score matching had 29,701 statin users and 29,701 matched nonusers. The SARS-CoV-2 test positivity rate was not associated with statin use (statin users, 2.82% [837/29,701]; nonusers, 2.65% [787/29,701]; adjusted relative risk [aRR] 0.97; 95% CI 0.88-1.07). Among patients with confirmed COVID-19 in the GRCP-COVID cohort, 804 were statin users and 1573 were matched nonusers. Statin users were associated with a decreased likelihood of severe clinical outcomes (statin users, 3.98% [32/804]; nonusers, 5.40% [85/1573]; aRR 0.62; 95% CI 0.41-0.91) and length of hospital stay (statin users, 23.8 days; nonusers, 26.3 days; adjusted mean difference –2.87; 95% CI –5.68 to –0.93) than nonusers. The results of the NHIS-COVID cohort were similar to the primary results of the GRCP-COVID cohort.ConclusionsOur findings indicate that prior statin use is related to a decreased risk of worsening clinical outcomes of COVID-19 and length of hospital stay but not to that of SARS-CoV-2 infection.     

Association Between Medication Adherence and Healthcare Costs Among Patients Receiving the Low-Income Subsidy

ObjectivesSignificant literature exists on the effects of medication adherence on reducing healthcare costs, but less is known about the effect of medication adherence among Medicare low-income subsidy (LIS) recipients. This study examined the effects of medication adherence on healthcare costs among LIS recipients with diabetes, hypertension, and/or heart failure.MethodsThis retrospective study analyzed Medicare claims data (2012-2013) linked to the Area Health Resources Files. Using measures developed by the Pharmacy Quality Alliance, adherence to 11 medication classes was studied among patients with 7 possible combinations of the diseases mentioned. Adherence was measured in 8 categories of proportion of days covered (PDC): ≥95%, 90% to <95%, 85% to <90%, 80% to <85%, 75% to <80%, 50% to <75%, 25% to <50%, and <25%. Annual Medicare costs were compared across adherence categories. A generalized linear model was used to control for patient/community characteristics.ResultsAmong patients with only one disease, such as diabetes, patients with the lowest adherence (PDC < 25%) had $3152/year higher Medicare costs than patients with the highest adherence (PDC ≥ 95%; $11 101 vs $7949; P < .05). The adjusted costs among patients with PDC < 25% was $1893 higher than patients with PDC ≥ 95% ($9919 vs $8026; P < .05). Among patients with multiple chronic conditions, patients’ adherence to medications for fewer diseases had higher costs.ConclusionsGreater medication adherence is associated with lower Medicare costs in the Medicare LIS population. Future policy affecting the LIS program should encourage better medication adherence among patients with chronic diseases.     

Statin and statin-fibrate use was significantly associated with increased myositis risk in a managed care population

OBJECTIVE: We quantified the risk of myositis associated with statin and fibrate drug use with other covariates within a managed care organization (MCO) population. STUDY DESIGN AND SETTING: The study spanned the years 1999-2003. Myositis cases had creatine kinase (CK) >or=10x upper limit of normal and a myopathy diagnosis. Exposures of statins, fibrates, and other drugs were assessed with age, gender, and indicators of suspected myopathy risk. Exposures were first analyzed within a cohort with CK monitoring and then within a more general secondary cohort. Adjusted relative risks (RRs) and incidence rates of myositis were generated by Poisson regression. RESULTS: Myositis was significantly associated with statin monotherapy (RR 2.8 [95% confidence interval, CI=1.3-5.9]), statin-fibrate combination therapy (9.1 [95% CI=3.5-23]), comorbid liver disease (4.3 [95% CI=1.5-13], and/or renal disease (2.5 [95% CI=1.3-5.0]). Myositis rates per covariate pattern ranged from 33 to 6,400 per 100,000 person-years. The mean time to event was 1.7 years for statin-fibrate use, 2.0 years for statins alone, and 2.1 years for unexposed. Within the secondary cohort, RRs increased up to 10 times further away from the null. CONCLUSION: Statins, with or without fibrates, and liver and renal disease were significantly associated with increased myositis risk in an MCO population.     

Effects of Statins on Relative Risk of Fractures for Older Adults: An Updated Systematic Review With Meta-Analysis

ObjectivesBasic and translational studies have found statin treatment may have beneficial effects on bone metabolism; however, whether statins reduce the risk of fractures in older adults is still in debate. Therefore, we aimed to summarize the up-to-date evidence on risk of fracture among older individuals with statin use.DesignSystematic literature review and meta-analysis.Setting and ParticipantsTwenty-one observational studies and 2 randomized controlled trials (RCTs) comprising 1,783,123 participants aged at least 50 years were retrieved from PubMed, Embase, and the Cochrane Library.MeasuresWe estimated summary relative risks (RRs) with 95% confidence intervals (CIs) using the random-effects model. Subgroup analysis was performed to explore the potential source of heterogeneity.ResultsMeta-analysis of observational studies suggested that statin treatment was significantly associated with reduced risk of all fractures (RR 0.80, 95% CI 0.72–0.88), among which hip fracture (RR 0.73, 95% CI 0.64–0.82) and lower extremity fracture (RR 0.69, 95% CI 0.54–0.88) showed consistent results, whereas no significant decreased risk was observed with respect to other fracture sites. Subgroup analyses showed that among the statin users, fracture risk was reduced in both genders, older adults ≥50 years old, those with short drug duration (< year) or medium to high statin dose (>90 defined daily dose), those taking atorvastatin, and in Europeans and Americans. Meta-analysis of RCTs revealed no significant effect of statin treatment on the risk of fractures (RR 1.00, 95% CI 0.87–1.15).Conclusions and ImplicationsOverall, the findings of this updated meta-analysis indicated no solid evidence supporting that statins have a beneficial effect associated with reduced risk of fractures for older adults. Our findings should be further confirmed in future larger population-based prospective cohort studies or well-designed RCTs.     

Alcohol consumption and the risk of breast cancer: a report from the Tecumseh Community Health Study

The relationship between prior alcohol consumption and the risk of breast cancer was studied in 1954 women in the Tecumseh Community Health Study (TCHS) who entered the cohort in 1959-1960 and were followed potentially for 28 years. The mean alcohol consumption at baseline was 0.89 (SD 2.2) oz/week for premenopausal women and 0.85 (SD 2.2) oz/week for postmenopausal women. Only 25% of the cohort consumed more than 0.5 oz of ethanol/week or about 1.6 g/day. The adjusted relative risks (RRs) for breast cancer associated with the use of ethanol vs never drinking were 0.93 (95% CI, 0.40-2.18) for ex-drinkers, 1.08 (95% CI, 0.64-1.82) for 0- less than 1 drink/day, 1.23 (95% CI, 0.49-3.10) for 1- less than 2 drinks/day and 1.12 (95% CI, 0.25-5.01) for greater than or equal to 2 drinks/day. There were only 37 subjects in the group at the highest level of consumption (greater than or equal to 2 drinks/day). There was no significant interaction between alcohol and the period of onset of breast cancer (premenopausal or postmenopausal). In the TCHS, alcohol consumption generally at levels not exceeding 2 drinks/day, was not significantly associated with an increased risk of breast cancer. Although we have found little excess risk associated with alcohol consumption, the wide confidence intervals summarized above are not inconsistent with previously published reports that have suggested a modest positive association.     

Alcohol, tobacco, and diet in relation to esophageal cancer: the Shanghai Cohort Study

Prospective data on environmental exposures, especially with respect to alcohol, tobacco, and diet, in relation to the risk of esophageal cancer in high-risk populations are sparse. We analyzed data from a population-based cohort of 18,244 middle-aged and older men in Shanghai to identify risk factors for esophageal cancer in this high-risk population. The cohort was followed through 2006, and 101 incident esophageal cancer cases were identified. Cox proportional hazards models were used to estimate hazard ratios (HR) and their corresponding 95% confidence intervals (CI) for associations between exposures and esophageal cancer risk. With adjustment for tobacco use and other potential confounders, regular drinkers vs. nondrinkers of alcoholic beverages had a twofold risk of developing esophageal cancer (HR=2.02, 95% CI=1.31-3.12). With adjustment for alcohol and other potential confounders, long-term smokers (40+ yr) vs. nonsmokers of cigarettes showed a twofold risk of developing esophageal cancer (HR=2.06, 95% CI=1.11-3.82). Increased consumption of fruits (including oranges/tangerines), seafood, and milk were found to be protective against the development of esophageal cancer; HRs were decreased by 40-60% for high vs. low consumers after adjustment for cigarette smoking, alcohol drinking, and other confounders.     

Risk factors for colonization with extended-spectrum beta-lactamase-producing bacteria and intensive care unit admission

Extended-spectrum beta-lactamase (ESBL)-producing bacteria are emerging pathogens. To analyze risk factors for colonization with ESBL-producing bacteria at intensive care unit (ICU) admission, we conducted a prospective study of a 3.5-year cohort of patients admitted to medical and surgical ICUs at the University of Maryland Medical Center. Over the study period, admission cultures were obtained from 5,209 patients. Of these, 117 were colonized with ESBL-producing Escherichia coli and Klebsiella spp., and 29 (25%) had a subsequent ESBL-positive clinical culture. Multivariable analysis showed the following to be statistically associated with ESBL colonization at admission: piperacillin-tazobactam (odds ratio [OR] 2.05, 95% confidence interval [CI] 1.36-3.10), vancomycin (OR 2.11, 95% CI 1.34-3.31), age > 60 years (OR 1.79, 95% CI 1.24-2.60), and chronic disease score (OR 1.15; 95% CI 1.04-1.27). Coexisting conditions and previous antimicrobial drug exposure are thus predictive of colonization, and a large percentage of these patients have subsequent positive clinical cultures for ESBL-producing bacteria.     

Effects of Statins for Secondary Prevention on Functioning and Other Outcomes Among Nursing Home Residents

ObjectivesStudies examining the effects of statins after acute myocardial infarction (AMI) excluded frail older adults, especially nursing home (NH) residents, and few examined functional outcomes. Older NH residents may benefit less from statins and be particularly susceptible to adverse drug events like myopathy-related functional decline. We evaluated the effects of statins on 1-year functional decline, rehospitalization, and death in NH residents.DesignWe conducted a retrospective cohort study using 2007-2010 linked national data from Minimum Data Set (MDS) assessments, Medicare claims, and Online Survey Certification and Reporting System records.Setting and ParticipantsWe included US NH residents 65 years and older who were statin nonusers, were hospitalized for AMI between May 2007 and March 2010, and returned to the NH.MeasuresOutcomes were functional decline, death, and rehospitalization in the first year after post-AMI NH admission. New statin users were 1:1 propensity-score matched to nonusers to adjust for 92 characteristics. We estimated hazard ratios (HRs) and restricted mean survival time differences with 95% confidence intervals (CIs) comparing individuals who did vs did not initiate statin therapy after AMI hospitalization.ResultsPropensity-score matching yielded a cohort of 5440 residents. Mean age was 83 years and 69% were female. Statin use was associated with a reduction in mortality (HR 0.80, 95% CI 0.73-0.87), corresponding to a mean of 15.9 (95% CI 9.9-22.0) days of extended life expectancy. No overall differences in rehospitalization (HR 1.06, 95% CI 0.98-1.14) or functional decline (HR 1.00, 95% CI 0.88-1.14) were observed.Conclusions and ImplicationsStatins may reduce 1-year mortality by 20% without affecting function among older NH residents who wish to live longer after AMI. During shared decision making with these patients or their representatives, clinicians should consider communicating that the average benefit of statins is 16 days of additional survival over 1 year.     

Consumption of alcohol and risk of cancer among men: a 30 year cohort study in Lithuania

Studies have indicated hazardous consumption of large quantities of alcohol among adults in Lithuania. We assessed the associations of alcohol consumption at baseline with cancer incidence among men in a population-based cohort study, using Cox models adjusted for smoking, education and body mass index. Attained age was used as a time-scale. During follow-up (1978–2008) 1,698 men developed cancer. A higher amount of alcohol consumption (≥140.1 g/week vs. 0.1–10.0 g/week) was positively associated with increased risk of total cancer [hazard ratio (HR) = 1.36, 95 % confidence interval (95 % CI) 1.11, 1.65], upper aerodigestive tract cancer (HR = 2.79, 95 % CI 1.23, 6.34) and alcohol-related cancers (i.e. oral cavity, pharynx, larynx, oesophagus, colorectal and liver cancer) (HR = 1.88, 95 % CI 1.25, 2.85). Compared to occasional drinkers (a few times/year), drinkers 2–7 times/week showed an increased risk of total (HR = 1.45, 95 % CI 1.16, 1.83), alcohol-related (HR = 1.83 95 % CI 1.14, 2.93) and other cancers (HR = 1.35, 95 % CI 1.04, 1.76). Our results showed no statistically significant associations between quantity of alcohol intake per one occasion and risk of cancer. About 13 % of total, 35 % of upper aerodigestive tract, 22 % of alcohol-related and 10 % of other cancer cases were due to alcohol consumption in this cohort of men.     

The effect of smoke-free homes on smoking behavior in the U.S

BACKGROUND: Evidence from longitudinal population surveys is needed to establish whether smoke-free homes might influence smoking behavior. METHODS: The Tobacco Use Supplement of the nationally representative U.S. Current Population Survey (TUS-CPS) interviewed 3292 adult recent smokers in 2002 and again 12 months later. Both surveys measured smoking status, rules on smoking in the home, and the number of cigarettes smoked per day (cpd). For the main study outcome, an early marker of successful cessation (>/=90 days quit) was used. Analysis was completed in 2008. RESULTS: In the 12 months ending February 2003, the prevalence of smoke-free homes among recent smokers increased from 33% to 39%. A smoke-free home at baseline was associated with >/=90 days cessation at follow-up (10.9% vs 6.2%, AOR=1.44; 95% CI=0.97, 2.21), and those who maintained a smoke-free home were more likely to be >/=90 days quit than those who did not (12.9% vs 5.7%, AOR=1.99; 95% CI=0.93, 4.25). However, adopting a smoke-free home during the year was associated with a nearly fivefold increase in the percentage of >/=90 days quit (AOR=4.81; 95% CI=3.06, 7.59). This increase was seen among all smokers, including moderate-to-heavy smokers (>/=90 days quit: a smoke-free home=13.0% vs no smoke-free home=2.9%, p<0.001). Among continuing smokers with a smoke-free home at baseline, maintenance of the smoke-free home was associated with a decline in consumption (mu=-2.18; 95% CI=-1.24; -3.10 cpd). Among continuing smokers with no smoke-free home at baseline, adoption of that status was also associated with a decline in consumption (mu=-1.72; 95% CI=-0.58; -2.85 cpd). CONCLUSIONS: This study provides strong evidence that the adoption of a smoke-free home is associated with successful quitting among smokers in the U.S.     

低预后人群拮抗剂方案中不同扳机时机对临床结局的影响北大核心CSCD

目的探讨在拮抗剂方案中,低预后人群选择不同扳机时机对临床结局产生的影响。方法筛选2017年1月至2019年6月期间在河南省人民医院生殖中心进行拮抗剂方案助孕的波塞冬标准下的低预后患者资料共1613个周期进行回顾性队列研究,根据不同扳机时机分为3组,按照常规标准扳机为正常组(961个周期),提前1 d扳机为提前组(359个周期),推迟1 d扳机为推迟组(293个周期)。通过单因素分析、多元logistics回归分析等方法比较不同扳机时机对累积妊娠率、累积活产率等临床结局的影响。结果三组患者鲜胚移植妊娠率分别为提前组35.77%(44/123)、正常组39.16%(150/383)、推迟组34.01%(50/147)。三组患者累积妊娠率和累积活产率由低到高依次为提前组、正常组、推迟组,组间比较差异均有统计学意义[累积妊娠率为33.18%(72/217)、42.33%(276/652)、45.27%(91/201),P=0.024;累积活产率为22.97%(48/209)、31.96%(201/629)、35.90%(70/159),P=0.012]。经过多元logistics回归调整混杂因素后,结果显示提前和推迟扳机与正常扳机相比,对临床结局的影响无统计学意义[推迟组的鲜胚移植妊娠率OR(95%CI)=0.69(0.44~1.09),P=0.114;累积妊娠率OR(95%CI)=0.77(0.51~1.16),P=0.214;累积活产率OR(95%CI)=0.83(0.54~1.29),P=0.418;提前组的鲜胚移植妊娠率OR(95%CI)=0.98(0.60~1.60),P=0.934;累积妊娠率OR(95%CI)=0.87(0.58~1.30),P=0.513;累积活产率OR(95%CI)=0.86(0.54~1.35),P=0.515]。结论波塞冬低预后人群在拮抗剂方案中按照常规标准进行扳机可获得理想的临床结局,可以综合考虑患者的个体情况进行扳机。     

Assessing relationships between health-related quality of life and adherence to antiretroviral therapy

OBJECTIVE: To investigate associations between health-related quality of life (HRQoL), as assessed using the multidimensional quality of life-HIV (MQOL-HIV) questionnaire, and adherence to antiretroviral treatment in HIV-infected subjects. DESIGN: Multicentre cross-sectional study in three institutional tertiary hospitals in northwest Spain. PATIENTS AND METHODS: The MQOL-HIV was completed by 235 HIV-infected adults undergoing antiretroviral treatment. Adherence to antiretroviral therapy was assessed by using patient's self-report. Information about sociodemographic characteristics and clinical variables was also collected. RESULTS: Good adherence (> or = 95% of prescribed pills correctly taken) was reported by 131 patients (55.7%). Univariate analyses indicated that the sociodemographic and clinical variables associated with adherence were age, educational level, income, employment, home stability, transmission route, history of previous antiretroviral therapy, and number of prescribed pills/day. Subscales of MQOL-HIV associated with adherence were mental health, cognitive functioning, financial status, medical care, partner intimacy, and (in men only) sexual functioning. Stepwise logistic regression showed that good adherence was more frequent in patients aged > 40 years (odds ratio, OR: 2.50; 95% confidence interval, CI: 1.15-5.61) and in patients with high cognitive functioning (OR: 2.26; 95% CI: 1.19-4.30). Conversely, poor adherence was more frequent in patients without stable home (OR: 2.96; 95% CI: 1.39-6.32), in patients required to take 14 or more pills/day (OR: 2.17; 95% CI: 1.18-4.28), in patients with low financial status (OR: 3.42; 95% CI: 1.57-7.45), and in patients reporting low medical care (OR: 2.07; 95% CI: 1.07-3.98). CONCLUSIONS: HRQoL dimensions, notably cognitive functioning, financial status and medical care, are closely associated with antiretroviral therapy adherence.     

Frequency of patient-physician contact in chronic kidney disease care and achievement of clinical performance targets.

OBJECTIVE: To examine whether the frequency of physician contact is associated with accepted quality of care measures reflecting clinical performance in chronic kidney disease patients. DESIGN: Prospective cohort study of end-stage renal disease patients begun in 1995, followed for 2.5 years. SETTING: 76 not-for-profit US dialysis clinics. STUDY PARTICIPANTS: 678 incident hemodialysis patients for whom we had information on average frequency of patient-physician contact at each clinic (low, monthly or less frequent; intermediate, between monthly and weekly; high, more than weekly), determined by clinic survey. MAIN OUTCOME MEASURES: Achievement of accepted 6 month clinical performance targets of albumin (> or =3.5 g/dl), calcium-phosphate (Ca-P) product (<60 mg(2)/dl(2)), dialysis dose (Kt/V > or = 1.2), vascular access type (fistula), and hemoglobin (> or =11 g/dl). RESULTS: By logistic regression, patients treated at clinics reporting less frequent physician contact had lower odds of achieving most targets, statistically significantly for albumin [low, adjusted odds ratio (OR) = 0.83, 95% confidence interval (CI), 0.55-1.25; intermediate, adjusted OR = 0.62, 95% CI, 0.42-0.93; reference, high] and dialysis dose (low, adjusted OR = 0.26, 95% CI, 0.08-0.89; intermediate, adjusted OR = 0.67, 95% CI, 0.20-2.27); however, they had greater odds of achieving the hemoglobin target (low, adjusted OR = 1.94, 95% CI, 1.24-3.04; intermediate, adjusted OR = 1.89, 95% CI, 1.27-2.83). Additionally, the number of targets reached was statistically significantly lower in the monthly or less group (adjusted OR = 0.43, 95% CI, 0.20-0.94). CONCLUSIONS: More frequent patient-physician contact is positively associated with the achievement of clinical performance targets in chronic kidney disease care.     

Alcohol,Tobacco, and Diet in Relation to Esophageal Cancer: The Shanghai Cohort Study

Prospective data on environmental exposures, especially with respect to alcohol, tobacco, and diet, in relation to the risk of esophageal cancer in high-risk populations are sparse. We analyzed data from a population-based cohort of 18,244 middle-aged and older men in Shanghai to identify risk factors for esophageal cancer in this high-risk population. The cohort was followed through 2006, and 101 incident esophageal cancer cases were identified. Cox proportional hazards models were used to estimate hazard ratios (HR) and their corresponding 95% confidence intervals (CI) for associations between exposures and esophageal cancer risk. With adjustment for tobacco use and other potential confounders, regular drinkers vs. nondrinkers of alcoholic beverages had a twofold risk of developing esophageal cancer (HR = 2.02, 95% CI = 1.31–3.12). With adjustment for alcohol and other potential confounders, long-term smokers (40+ yr) vs. nonsmokers of cigarettes showed a twofold risk of developing esophageal cancer (HR = 2.06, 95% CI = 1.11–3.82). Increased consumption of fruits (including oranges/tangerines), seafood, and milk were found to be protective against the development of esophageal cancer; HRs were decreased by 40–60% for high vs. low consumers after adjustment for cigarette smoking, alcohol drinking, and other confounders.     

Effectiveness of the linkage of child care and maternity payments to childhood immunisation

In 1998, Australia enacted comprehensive national legislation making receipt of the maternity immunisation allowance (MIA) and the child care benefit (CCB) conditional on evidence of age-appropriate immunisation. We assessed the impact of this policy on immunisation status using a nationally representative population-based case-control study of 589 fully immunised controls and 190 incompletely immunised cases, aged 28-31 months. Immunisation status was significantly associated with parent awareness of the MIA (adjusted odds ratio (aOR) = 3.34, 95% CI = 2.28 - 4.91) and CCB (aOR = 2.08, 95% CI = 1.30 - 3.34). Only 31% of the 219 control parents who were receiving the CCB reported that they could continue to afford child care without the assistance of the CCB. The use of legislated financial immunisation incentives for parents appears to be widely accepted among Australian parents and to have had an impact on immunisation uptake. The policy may serve as a model for other comparable countries.