Association of Marital Status With Total and Cause-Specific Mortality in Asia

Does partnership predict mortality? Evidence from a twin fixed effects study design

This study examines the association between partnership status and mortality, addressing methodological concerns such as selection effects and unobserved heterogeneity. Utilizing Norwegian administrative data on birth cohorts from 1955 to 1975, we analyze mortality outcomes using Kaplan-Meier survival analyses and Cox proportional hazards regression models. The dataset includes over 1.2 million individuals and distinguishes between partnered and non-partnered individuals. While results for the general population show that non-partnered individuals face significantly higher mortality risks, with hazard ratios of 1.59 for men and 1.47 for women, twin fixed effects models reveal no significant relationship between partnership status and mortality. This finding suggests that much of the observed association may be due to shared genetic and environmental factors rather than a direct causal effect of partnership status. By leveraging the twin fixed effects research design, this study provides a robust test of the partnership-mortality hypothesis, highlighting the importance of controlling for unobserved heterogeneity in observational research. Our results underscore the complexity of the partnership-health nexus and call for caution in interpreting simple associations as evidence of causality.

Social factors, health policy, and environment: implications for cardiovascular disease across the globe

Cardiovascular disease (CVD) is the leading cause of deaths worldwide, with 80% occurring in low- and middle-income countries. These countries are characterized by rapid urbanization, poorly funded health systems, poor access to prevention and treatment strategies, and increasing age and a higher prevalence of chronic disease. Rapid urbanization has contributed to the significant environmental and societal changes affecting daily life habits and cardiovascular health. There is growing awareness that environmental and social exposures and policies can influence CVD directly or through behavioural risk factors. However, much of this knowledge comes from studies in high-income countries and is applied to low- and middle-income countries without evidence to indicate this is appropriate. This state-of-the-art review will present and synthesize key findings from the Prospective Urban Rural Epidemiology study and related studies that have aimed to understand the environmental, social, and policy determinants of cardiovascular health in countries across varying levels of economic development through an urban/rural lens. Emerging from these findings are future policy and research recommendations to accelerate the reduction of the global burden of CVD.

Sex differences in the impact of marital status on coronary artery disease outcomes in Korea

BACKGROUND

Coronary artery disease (CAD) outcomes are influenced by social determinants, including marital status. However, research on the sex-specific effects of marital status on CAD outcomes is limited. This study aimed to evaluate the relationship between marital status and clinical outcomes of patients with CAD stratified according to sex in Korea.

METHODS

A total of 3476 patients with CAD who underwent percutaneous coronary intervention (PCI) were enrolled in this retrospective observational study. Patients were categorized into married and nonmarried groups based on demographic data at the time of admission. The primary endpoint was all-cause mortality.

RESULTS

Among the study population, 20.7% of women and 11.5% of men who underwent PCI for CAD were nonmarried. For 87.1% of nonmarried women, the cause of being nonmarried was the death of a spouse, whereas for 48.3% of unmarried men, the most common cause was being unmarried. During a median follow-up of 53.3 months, in analysis using the Cox proportional hazard regression model, nonmarried status was associated with higher all-cause [adjusted hazard ratio (HR): 2.24, 95% confidence interval (CI): 1.22-4.09, P = 0.009] and cardiovascular (adjusted HR: 2.63, 95% CI: 19.91-5.80, P = 0.017) deaths in men but not in women.

CONCLUSION

Marital status independently predicted the adverse outcomes in men with CAD but not in women, highlighting the importance of sex-specific approaches to the assessment of social determinants in cardiovascular care. Future studies should explore broader social and economic factors to inform targeted interventions.

Interactive and joint effects of toxic metals and oxidative balance score on the risk of mortality in adults with NAFLD

BACKGROUND

High oxidative balance score (OBS) may mitigate inflammation levels and thereby alleviate the adverse health effects induced by toxic metals. We assessed the independent, joint effects as well as their interactions of toxic metals and OBS on mortality among individuals with non-alcoholic fatty liver diseases (NAFLD).

METHODS

Participants with NAFLD from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 were included. Mortality and underlying causes of death were certain by National Death Index records through 31 December 2019. Cox regression models were used to estimate hazard ratios (HRs) for all-cause and disease-specific mortality. Additionally, we assessed multiplicative and additive interactions of OBS and toxic metals on mortality.

RESULTS

Among 5263 patients with NAFLD, 1097 deaths occurred during a mean follow-up of 10.27 years. Compared with those in the OBS tertile 1, participants in tertile 3 had lower risk of all-cause mortality (HR=0.79, 95 %CI: 0.64, 0.96). Compared with individuals in the lowest lead concentration in blood, those in the highest had an increased risk of mortality, with the HRs (95 %CIs) being 1.23 (1.01, 1.51), 1.53(1.06, 2.20) and 1.94(1.25, 3.01) for all-cause, CVD and cancer mortality, respectively. Similar results were also found for blood cadmium level. Joint associations analyses found that individuals with low lead and high-OBS levels had the lowest risk of all-cause, CVD and cancer mortality, with the HRs(95 %CIs) being 0.58(0.40, 0.85), 0.45(0.21, 0.93) and 0.35(0.15, 0.81), respectively. Multiplicative interactions between OBS and blood cadmium on all-cause death (HR=0.87, 95 %CI: 0.78, 0.97) and CVD death (HR=0.81, 95 %CI: 0.67, 0.99) were found.

CONCLUSIONS

High OBS and low exposure to toxic metals were associated with lower risk of mortality among participants with NAFLD. Adopting anti-oxidative lifestyle could alleviate the harmful effects of toxic metals in NAFLD patients. Comprehensive strategies are essential to decrease the risk of mortality and potentially mitigate the overall burden of NAFLD.

Evaluating the Hypertension Cascade of Care in Adults in Urban Lao PDR: Evidence From the VITERBI Cohort Study

Background

Hypertension (HT) is a major risk factor for adult morbidity and mortality in low- and middle-income countries and little is known regarding the distribution of HT risk and treatment access within urban areas.

Patients and methods

We used data from the Vientiane Multi-Generational Birth Cohort in urban Lao PDR to assess the prevalence of loss and retention across five stages of HT care for 40+ year old adults: i) prevalence of hypertension, ii) hypertensives who ever had their BP measured by a health care professional, iii) hypertensives ever diagnosed with HT by a professional, iv) patients currently treated with HT medication, and v) patients with currently controlled BP. We estimated associations between sociodemographic and lifestyle predictors and the proportion of participants who reached each care cascade step using mutually adjusted Poisson regression modeling.

Results

Among the 3196 participants aged 40 to 99 years, the overall prevalence of HT was 16.3%, with higher rates for women, people over 60 years, peripheral district residents, low educated, widowed, and obese. Among people with HT, 90.2% ever had their BP measured by a health care professional, 69.3% ever received a HT diagnosis, 60.9% HT were currently on (drug) treatment, and 39.5% had currently controlled BP. The largest cascade of care losses occurred at the diagnosis and control stages with better outcomes for women. While central districts showed higher rates of diagnosis, control levels were lower than in peripheral districts, but there these differences appeared to be explained by adjusting for sociodemographic and lifestyle factors.

Conclusion

While HT prevalence in Lao PDR is lower than reported for other LMICs, more than 16% over the age of 40 years suffer from HT, and 60% of these cases are currently not controlled. Major policy efforts are needed to support this population and to prevent HT-driven excess mortality.

The impact of social determinants of health on chronic kidney disease risk: evidence from the CHARLS study

Background

Empirical evidence regarding the relationship between social determinants of health (SDH) and renal outcomes remains limited. Consequently, the objective of this study was to investigate the potential association between SDH and the development of chronic kidney disease (CKD) across various levels.

Methods

Data were sourced from the 2011 China Health and Retirement Longitudinal Study (CHARLS), which included 6,290 Chinese participants aged 40 years and older. Among these participants, 4,115 underwent a follow-up assessment in the 2015 survey. The primary outcome measure was the incidence of CKD, operationally defined as a reduction in estimated glomerular filtration rate to <60 ml/min/1.73 m2. To analyze the association between varying levels of SDH and renal outcomes, a Cox proportional hazards regression model was employed.

Results

The findings indicate that, in comparison to individuals with a pension, higher education, and no need for family support, the risk of developing CKD increased by 43, 49, and 52%, respectively. Furthermore, the combination of requiring family support, being unmarried, and lacking medical insurance was associated with an elevated incidence of CKD. Utilizing the counting model of adverse SDH indicators, it was observed that when the number of adverse SDH was equal to or greater than four, there was a significant increase in the risk of CKD. The incidence density of CKD was found to rise in correlation with the severity of adverse SDH, with the incidence density in the adverse SDH group being 0.06 per person-year higher than that in the favorable SDH group. After adjusting for multiple variables, the hazard ratio (HR) for incident CKD was 2.47 [95% confidence interval (CI): 1.46-4.16] in the adverse SDH group compared to the favorable SDH group, a finding that persisted across various subgroups.

Conclusion

Research indicates that financial support, pensions, education, marital status, and health insurance significantly impact CKD risk. Higher income, pension coverage, education, marital stability, and insurance lower this risk. Evaluating adverse SDH indicators helps assess individual SDH levels and CKD risk, with four or more indicators suggesting high risk. Therefore, adverse SDH measures can predict CKD.

Marital status and risk of dementia over 18 years: Surprising findings from the National Alzheimer's Coordinating Center

INTRODUCTION

Marital status is a potential risk/protective factor for adverse health outcomes. This study tested whether marital status was associated with dementia risk in older adults.

METHODS

Participants (N = 24,107; Meanage = 71.79) were from the National Alzheimer's Coordinating Center. Cox regressions tested the association between baseline marital status and clinically ascertained dementia over up to 18 years of follow-up.

RESULTS

Compared to married participants, widowed (hazard ratio [HR] = 0.73, 95% confidence interval [95% CI] = 0.67-0.79), divorced (HR = 0.66, 95% CI = 0.59-0.73), and never-married participants (HR = 0.60, 95% CI = 0.52-0.71) were at lower dementia risk, including for Alzheimer's disease and Lewy body dementia. The associations for divorced and never married remained significant accounting for demographic, behavioral, clinical, genetic, referral source, participation, and diagnostic factors. The associations were slightly stronger among professional referrals, males, and relatively younger participants.

DISCUSSION

Unmarried individuals may have a lower risk of dementia compared to married adults. The findings could indicate delayed diagnoses among unmarried individuals or challenge the assumption that marriage protects against dementia.

HIGHLIGHTS

Widowed, divorced, and never-married older adults had a lower dementia risk, compared to their married counterparts. Unmarried older adults were also at a lower risk of Alzheimer's disease and Lewy body dementia, with a pattern of mixed findings for frontotemporal lobar degeneration, and no associations with risk of vascular dementia or mild cognitive impairment. All unmarried groups were at a lower risk of progression from mild cognitive impairment to dementia. There was some evidence of moderation by age, sex, and referral source. However, stratified analyses showed small differences between groups, and most interactions were not significant, suggesting that the role of marital status in dementia tends to be similar across individuals at different levels of dementia risk due to education, depression, and genetic vulnerability.

Tooth loss trajectories and their association with all-cause mortality among older Chinese adults

Background

The association between tooth loss trajectories and all-cause mortality has not been sufficiently explored. This study aims to examine the relationship between tooth loss trajectories and all-cause mortality in Chinese adults aged 65 years and older.

Methods

This study included 3,726 participants from the Chinese Longitudinal Healthy Longevity Study (CLHLS). The inclusion criteria required participants to be aged 65 years or older, with complete data on tooth count at baseline and at least one follow-up survey. Participants were excluded if they had missing data on death, time to death, or if their they reported tooth count showed an abnormally high increase. The mean age of participants was 85.16 ± 10.7 years. To identify distinct trajectories of tooth loss, growth mixture models (GMM) were employed. Cox regression analysis was utilized to assess the association between tooth loss trajectories and all-cause mortality. Sensitivity analyses were conducted to test the robustness of the findings, while subgroup analyses were performed to explored potential variations in association across different demographic groups.

Results

The prevalence of edentulism at baseline was 37.13%, with a cumulative incidence of 15.8% over 10-year period. Three distinct tooth loss trajectories were identified during follow-up of 9.41 years: (1) progressively mild loss: comprising 312 participants (8.37%); (2) progressively severe loss, comprising 505 participants (13.55%); and (3) edentulism group, comprising 2,909 participants (78.07%). The median follow-up times for each group were 5.91 years, 3.44 years, and 1.84 years, respectively. During the follow-up period, the number of deaths were 114 (36.54%) in the progressively mild loss group, 274 (54.26%) in the progressively severe loss group, and 2,284 (78.51%) in the edentulism group. Compared to the progressively mild loss group, the hazard ratio (HR) for all-cause mortality was 1.29 (95% CI, 1.01-1.64) in the progressively severe loss group, and 1.60 (95% CI, 1.28-1.99) in the edentulism group.

Conclusions

This study identified three distinct tooth loss trajectories among older Chinese adults, with the edentulism group exhibiting the strongest association with all-cause mortality. These findings highlight the crucial importance of maintaining oral health and preserving natural teeth to promote longevity and improve overall health outcomes in older adults.

Effect of healthy lifestyle score trajectory on all-cause mortality in the late middle-aged and older population: Finding from 17-year retrospective cohort study

PURPOSE

Recently, the World Health Organization has emphasized the importance of a healthy lifestyle in reducing severe illnesses and premature mortality. To evaluate this, the Healthy Lifestyle Score (HLS), which focuses on health protecting behaviors (e.g., smoking, alcohol consumption, physical activity, body mass index), is widely used. However, as HLS may fluctuate over time, there is increasing focus on monitoring HLS trends. Accordingly, this study aims to track HLS trajectories (HLST) and examine their association with mortality among middle-aged and older Koreans.

METHODS

After excluding missing values, data from 6249 participants were analyzed using the group-based trajectory model (GBTM) to classify HLST, based on the first to fourth waves of the Korean Longitudinal Study of Aging (KLoSA). The chi-square test and Cox proportional hazards model were employed to examine the association between HLST and all-cause mortality over a 10-year follow-up period (December 31, 2012, to December 31, 2022; 3650 days).

RESULTS

Three HLST groups were identified in the GBTM analysis. These were the Poor HLST (17.8 %), Average HLST (42.9 %), and Good HLST (39.4 %) groups. Compared to the good HLST, the poor HLST had higher mortality at 1 year (hazard ratio [HR]: 1.98, p: 0.029), 3 years (HR: 1.78, p: 0.001), 5 years (HR: 1.52, p: 0.002), 7 years (HR: 1.39, p: 0.002), and 10 years (HR: 1.40, p: 0.000). Furthermore, stratified analysis by sex, age, marital status and residential region showed that male, ≥65 years, single and urban area groups had a strong association between HLST and all-cause mortality.

CONCLUSION

The findings of this study underscore the necessity of policies and institutional measures grounded in community networks to mitigate the risk of all-cause mortality among vulnerable groups with persistently poor HLST.

Inpatient autopsy rate and associated factors in a Chinese megacity: a population-based retrospective cohort study

OBJECTIVES

This study investigated the autopsy rate of hospital deaths in Shenzhen megacity and identified factors that may impact the decision to perform an autopsy in hospital deaths.

DESIGN

This is a population-based retrospective cohort study.

SETTING

Shenzhen is a megacity in China with a population of more than 17 million and a total of 151 hospitals. The official dataset of the inpatient medical record home page was used. Demographic, clinical and hospital information was extracted.

PARTICIPANTS

All the 35 272 inpatient deaths between 2016 and 2022 with known autopsy status were included to calculate the overall autopsy rate. Among them, a total of 34 577 cases with complete data, classified hospital and Chinese nationality, were included for further multivariable rare events logistic regression and Poisson pseudo maximum likelihood regression.

OUTCOME MEASURES

Whether the inpatient death was autopsied or not.

RESULTS

The autopsy procedure was performed in 0.9% (319/35 272) of hospital deaths. The autopsy decision was significantly and positively associated with being married (OR= 1.60, 95% CI: 1.16 to 2.21), self-paying (OR=1.56, 95% CI: 1.07 to 2.26), death due to external causes of injury and poisoning (OR=1.69, 95% CI: 1.02 to 2.81) and pregnancy (OR=13.58, 95% CI: 4.94 to 37.36), but negatively associated with age (OR=0.97, 95% CI: 0.96 to 0.98), emergency admission (OR=0.66, 95% CI: 0.49 to 0.88), referral (OR=0.47, 95% CI: 0.25 to 0.88), neoplasms (OR=0.35, 95% CI: 0.22 to 0.56), respiratory diseases (OR=0.49, 95% CI: 0.26 to 0.95) and for-profit hospitals (OR=0.45, 95% CI: 0.23 to 0.91). There were no statistically significant differences in autopsy rates between large teaching hospitals and other hospitals.

CONCLUSIONS

The autopsy rate of hospital deaths was extremely low, largely due to healthcare providers. Even large teaching hospitals do not request more autopsies compared with other hospitals, after controlling for the patient characteristics. More efforts are urged to encourage hospitals and healthcare providers to proactively request autopsies, helping to revive this important procedure.

Evaluation of Treatment Outcomes Among Individuals on Highly Active Antiretroviral Therapy in KwaZulu-Natal, South Africa

Despite access to antiretroviral therapy (ART), South Africa has a high human immunodeficiency virus (HIV) burden. Treatment outcomes among individuals on highly active ART (HAART) in KwaZulu-Natal, with a higher incidence of HIV, are not fully known. This study evaluated the impact of HAART outcomes and identified and analyzed the factors associated with the outcomes in people living with HIV and AIDS (PLWHA) in the high-incidence region of KwaZulu-Natal Province, South Africa. This retrospective medical record review was conducted at King Edward VIII Hospital in South Africa. Data analysis was performed using STATA software Version 18.0 and Microsoft Excel 2021. The estimates used were 95% confidence intervals, and a p value < 0.05 was considered statistically significant. A total of 707 clinical records of PLWHA were examined and analyzed; less than half of them (44.98%, n = 318) achieved the benchmark of two consecutive instances of suppressed viral loads. The CD4 greater than or equal to 500 cells/mm3 at baseline average of 22.91% (n = 162) registered an increase to 48.94% (n = 346) in the 6th month and further escalated to 79.49% (n = 562) by the 12th month following ART initiation. A total of 160 deaths (mortality rate of 22.63%) were recorded within the study period. The percentage of HIV-infected patients attaining viral suppression at 6 and 12 months after initiating the treatment was respectively 44.98% and 67.04%, below the 90% target established by the Joint United Nations Program on HIV/AIDS (UNAIDS). The proportion of favorable immunological responses for individuals on ART increased over time.

Association and causal mediation between marital status and depression in seven countries

Depression represents a significant global public health challenge, and marital status has been recognized as a potential risk factor. However, previous investigations of this association have primarily focused on Western samples with substantial heterogeneity. Our study aimed to examine the association between marital status and depressive symptoms across countries with diverse cultural backgrounds using a large-scale, two-stage, cross-country analysis. We used nationally representative, de-identified individual-level data from seven countries, including the USA, the UK, Mexico, Ireland, Korea, China and Indonesia (106,556 cross-sectional and 20,865 longitudinal participants), representing approximately 541 million adults. The follow-up duration ranged from 4 to 18 years. Our analysis revealed that unmarried individuals had a higher risk of depressive symptoms than their married counterparts across all countries (pooled odds ratio, 1.86; 95% confidence interval (CI), 1.61-2.14). However, the magnitude of this risk was influenced by country, sex and education level, with greater risk in Western versus Eastern countries (β = 0.36; 95% CI, 0.16-0.56; P < 0.001), among males versus females (β = 0.25; 95% CI, 0.003-0.47; P = 0.047) and among those with higher versus lower educational attainment (β2 = 0.34; 95% CI, 0.11-0.56; P = 0.003). Furthermore, alcohol drinking causally mediated increased later depressive symptom risk among widowed, divorced/separated and single Chinese, Korean and Mexican participants (all P < 0.001). Similarly, smoking was as identified as a causal mediator among single individuals in China and Mexico, and the results remained unchanged in the bootstrap resampling validation and the sensitivity analyses. Our cross-country analysis suggests that unmarried individuals may be at greater risk of depression, and any efforts to mitigate this risk should consider the roles of cultural context, sex, educational attainment and substance use.

Association between long-term exposure to PM2.5 chemical components and metabolic syndrome in middle-aged and older adults

Background

Previous studies indicated that exposure to ambient fine particulate matter (PM2.5) could increase the risk of metabolic syndrome (MetS). However, the specific impact of PM2.5 chemical components remains uncertain.

Methods

A national cross-sectional study of 12,846 Chinese middle-aged and older adults was conducted. Satellite-based spatiotemporal models were employed to determine the 3-year average PM2.5 components exposure, including sulfates (SO4 2-), nitrates (NO3 -), ammonia (NH4 +), black carbon (BC), and organic matter (OM). Generalized linear models were used to investigate the associations of PM2.5 components with MetS and the components of MetS, and restricted cubic splines curves were used to establish the exposure-response relationships between PM2.5 components with MetS, as well as the components of MetS.

Results

MetS risk increased by 35.1, 33.5, 33.6, 31.2, 32.4, and 31.4% for every inter-quartile range rise in PM2.5, SO4 2-, NO3 -, NH4 +, OM and BC, respectively. For MetS components, PM2.5 chemical components were associated with evaluated risks of central obesity, high blood pressure (high-BP), high fasting glucose (high-FBG), and low high-density lipoprotein cholesterol (low-HDL).

Conclusion

This study indicated that exposure to PM2.5 components is related to increased risk of MetS and its components, including central obesity, high-BP, high-FBG, and low-HDL. Moreover, we found that the adverse effect of PM2.5 chemical components on MetS was more sensitive to people who were single, divorced, or widowed than married people.

Nationwide Increasing Incidence of Nontuberculous Mycobacterial Diseases Among Adults in Denmark: Eighteen Years of Follow-Up

BACKGROUND

The epidemiology of nontuberculous mycobacteria (NTM) infections is not well described. In this study, we sought to determine the incidence and prevalence of NTM infections and focus on social risk factors. In addition, we describe people with pulmonary and extrapulmonary NTM.

RESEARCH QUESTION

What are the incidence and prevalence of NTM in Denmark, and what are the characteristics of the affected patients?

STUDY DESIGN AND METHODS

This is a nationwide retrospective register-based cohort study in Denmark. Adult patients in the Danish national registers who received a diagnosis of NTM disease from 2000 to 2017 were classified as having either pulmonary or extrapulmonary NTM disease.

RESULTS

We identified 1,146 adults with an NTM diagnosis. Of these, 661 patients had pulmonary NTM, of whom 50.4% were male, whereas 485 had extrapulmonary NTM, of whom 59.6% were male. The median age (interquartile range) was 66 (18) years and 57 (32) years, respectively. The yearly incidence rate per 100,000 increased between 2000 and 2017 for both pulmonary NTM (0.4 to 1.3) and extrapulmonary NTM (0.3 to 0.6). The annual prevalence per 100,000 inhabitants increased from 0.4 to 3.5 for pulmonary NTM and from 0.3 to 1.0 for extrapulmonary NTM. The incidence rate increased with age. The incidence of pulmonary NTM was highest among those who were aged 70 years or older (19.3 per 100,000 inhabitants). Compared with patients with pulmonary NTM, patients with extrapulmonary NTM were more likely to be employed and had a higher educational level.

INTERPRETATION

This study indicates that the prevalence of NTM disease in Denmark increased between 2000 and 2017. We found that patients with pulmonary NTM and patients with extrapulmonary NTM represent two distinct groups that differ in age, sex, education, and employment status. Increased suspicion of pulmonary NTM disease is warranted in older adults after exclusion of more common lung infections.

The effect of residential greenness on cardiovascular mortality from a large cohort in South China: An in-depth analysis of effect modification by multiple demographic and lifestyle characteristics

BACKGROUND

The potential for residential greenness to improve cardiovascular health through both physical and psychological mechanisms is well recognized. However, evidence from rapidly urbanizing developing countries and cohort-based causal inference approaches, remains limited. We aim to examine the effect of residential greenness and time to cardiovascular mortality in South China.

METHODS

We utilized data from a community-based population survey involving 748,209 participants at baseline from 2009 to 2015, followed up until 2020. Residential greenness exposure was assessed by the annual Normalized Difference Vegetation Index (NDVI) in the 500 m radius of each participant's residence. We used time-varying proportional hazard Cox models coupled with inverse probability weighting to fit marginal structural models and obtain hazard ratios (HRs) for cardiovascular disease (CVD) mortality after adjusting for confounders. Multiple effect modifiers on both additive and multiplicative scales were further explored.

RESULTS

A total of 15,139 CVD-related deaths were identified during a median of 7.9 years of follow-up. A protective effect was found between higher greenness exposure and reduced CVD mortality, with a 9.3 % lower rate of total CVD mortality (HR 0.907, 95 % CI 0.859-0.957) based on a 0.1 increase in annual average NDVI. Demographic (age, marital status) and lifestyle factors (smoking, drinking status) were found to modify the association between residential greenness and CVD mortality (all P interaction values < 0.05 or 95 %CI for RERI excluded the value 0). Notably, this effect was more pronounced among older adults, married, and individuals having healthier lifestyles, indicating a greater benefit from greenness for these subgroups.

CONCLUSIONS

Our findings support a causal link between increased residential greenness exposure and a reduced risk of CVD mortality in South China with marked heterogenous effects, which has public health implications for cultivating greener urban environments to mitigate the impact of CVD within the context of rapid urbanization.

Correlation between marital status and the prognosis of older patients with cerebrovascular disease in intensive care units: A retrospective cohort study

Background and Aims

Marital status has been shown to be associated with mortality, but evidence in critically ill elder intensive care unit (ICU) patients with cerebrovascular diseases (CeVD) is limited. This study was to explore the correlation between marital status and the prognosis of patients with CeVD aged 65 years and over in the ICU.

Methods

In the present study, 3564 patients were enrolled in the Medical Information Mart for Intensive Care IV database (version 2.2). Patients were divided into four groups based on marital status: married, single, divorced, and widowed. The primary outcome was all-cause mortality as patients were followed up for 3-, 6-, 9-, and 12-month. All-cause mortality risk for patients with different marital status was compared. Univariate and multivariable logistic regression analyses, survival curves and stratified analyses were performed to determine the correlation between marital status and mortality in critically ill patients with CeVD aged ≥65 years.

Results

Of the patients, 51.2% (1825/3564) were married, followed by 23.8% (847/3564) were widowed, 18.2% (647/3564) were single, and 6.9% (245/3567) were divorced. Compared with the married, the unmarried had a higher proportion of female (p < 0.001), older (p < 0.001), and less proportion of mechanical ventilation (p = 0.045). Multivariate analyses showed that no differences were observed for mortality risk among different marital statuses (p > 0.05), while at late follow-up, widowed had a significance higher mortality risk than the married (9-month: odds ratio [OR]: 1.30, 95% confidence interval [CI]: 1.05-1.61, p = 0.02; 12-month: OR: 1.38, 95% CI: 1.12-1.71, p = 0.003). Stratified analyses indicated a stable correlation between marital status and 12-month mortality rate in sub-analysis for gender (p = 0.46) and age (p = 0.35).

Conclusion

Marital status is associated with long-term prognosis in older patients with CeVD admitted to ICU. Widowed people should receive more societal attention irrespective of sex or age.

Development and validation of a nomogram integrating marital status for 5-year overall survival of chondrosarcoma: a population-based study

OBJECTIVES

The objective of this study was to evaluate the influence of marital status on overall survival (OS) and develop a nomogram for predicting 5-year OS in chondrosarcoma (CHS) patients.

METHODS

We utilized the Surveillance, Epidemiology, and End Results (SEER) database to identify CHS patients diagnosed between 2010 and 2018. Survival rates were calculated using Kaplan-Meier analysis. Prognostic factors were identified through univariate and multivariate analyses. An independent cohort was used for external validation of the nomogram. Performance evaluation of the nomogram was conducted using Harrell's concordance index (C-index), calibration plot, and decision curve analysis (DCA).

RESULTS

In the SEER cohort, Kaplan-Meier analysis showed significant differences in OS among CHS patients with different marital statuses (P < 0.001), with widowed patients having the lowest OS. In terms of gender, there were significant survival differences based on marital status in females (P < 0.001), but not in males (P = 0.067). The OS of married and single females is significantly higher than that of married (P < 0.001) and single male (P = 0.006), respectively. Kaplan-Meier curves showed no significant difference in OS between groups stratified by either gender or marital status in the external cohort. Univariate and multivariate analyses confirmed that age at diagnosis, gender, marital status, tumor size, histological type, tumor grade, SEER stage, and surgery were independent prognostic factors for OS. The nomogram demonstrated high internal and external validation C-indexes of 0.818 and 0.88, respectively. Calibration plots, DCA curve, and Kaplan-Meier curve (P < 0.001) confirmed the excellent performance and clinical utility of the nomogram.

CONCLUSIONS

Marital status was an independent factor influencing OS in CHS patients, with widowed patients having the worst prognosis. The OS of both married and single females is significantly higher than that of their male counterparts. However, these findings require further validation in a large independent cohort. While the contribution of marital status on predicting OS appears modest, our nomogram accurately predicted 5-year OS and identified high-risk groups, providing a valuable tool for clinical decision-making.

Prevalence and risk factors of cognitive impairment in Chinese patients with hypertension: a systematic review and meta-analysis

Background

Cognitive impairment is prevalent in Chinese patients with hypertension; however, current evidence on prevalence and risk factors is required to be synthesized.

Objectives

This systematic review and meta-analysis aimed to evaluate the prevalence and risk factors of cognitive impairment in Chinese patients with hypertension.

Methods

Two reviewers independently searched PubMed, Web of Science, Embase, The Cochrane Library, CNKI, CBM, the Wanfang database, and the VIP database from their inception to 7 June 2023. The gray literature and the reference lists of the included studies were also retrieved manually. Moreover, we also independently performed the eligibility screening, data extraction, and data synthesis. The primary outcome was the prevalence of cognitive impairment in Chinese patients with hypertension, and the secondary outcomes were the risk factors for cognitive impairment in patients with hypertension. R (version 4.0.3) was used for data synthesis.

Results

In total, 82 studies involving 53,623 patients with hypertension were included in this meta-analysis. The pooled prevalence of cognitive impairment in patients with hypertension was 37.6% (95% CI: 33.2-42.2%). A total of 12 risk factors, including advanced age (r = -0.34, 95% CI: -0.45, -0.21), female sex (OR = 1.15, 95% CI: 1.01-1.32), BMI > 24 Kg/m2 (OR = 1.76, 95% CI: 1.04-3.00), lower educational level (OR = 2.01, 95% CI: 1.10-3.67), single status (OR = 1.63, 95% CI: 1.32-2.02), complications with diabetes (OR = 1.44, 95% CI: 1.14-1.80), coronary heart disease (OR = 1.49, 95% CI: 1.12-1.97), higher stage of hypertension [stage 3 vs. stage 1, OR = 3.08, 95% CI: 1.82-5.22; stage 2 vs. stage 1, OR = 1.83, 95% CI: 1.29-2.60], no regular physical activity (OR = 0.40, 95% CI: 0.21-0.77), higher levels of systolic blood pressure (r = -0.25, 95% CI: -0.42, -0.08), Hcy (r = -0.39, 95% CI: -0.63, -0.09), and IL-6 (r = -0.26, 95% CI: -0.48, -0.02) were detected.

Conclusion

Cognitive impairment is prevalent in Chinese patients with hypertension, and the increased prevalence was associated with several demographic characteristics, complicated disease, no regular physical activity, worse hypertension status (higher stages and SBP), and high levels of biomarkers. Therefore, more attention should be paid to the early identification and treatment of patients with hypertension who are at high risk for cognitive impairment in clinical practice. In addition, relevant risk factors should be controlled to reduce the incidence of cognitive impairment.

Systematic review registration

http://www.crd.york.ac.uk/PROSPERO, identifier [CRD42023410437].

A wide landscape of morbidity and mortality risk associated with marital status in 0.5 million Chinese men and women: a prospective cohort study

Background

A comprehensive depiction of long-term health impacts of marital status is lacking.

Methods

Sex-stratified phenome-wide association analyses (PheWAS) of marital status (living with vs. without a spouse) were performed using baseline (2004-2008) and follow-up information (ICD10-coded events till Dec 31, 2017) from the China Kadoorie Biobank (CKB). We estimated adjusted hazard ratios (aHRs) to evaluate the associations of marital status with morbidity risks of phenome-wide significant diseases or sex-specific top-10 death causes in China documented in 2017. Additionally, the association between marital status and mortality risks among participants with major chronic diseases at baseline was assessed.

Findings

During up to 11.1 years of the median follow-up period, 1,946,380 incident health events were recorded among 210,202 men and 302,521 women aged 30-79. Marital status was found to have phenome-wide significant associations with thirteen diseases among men (p < 9.92 × 10-5) and nine diseases among women (p < 9.33 × 10-5), respectively. After adjusting for all disease-specific covariates in the final model, participants living without a spouse showed increased risks of schizophrenia, schizotypal and delusional disorders (aHR [95% CI]: 2.55, [1.83-3.56] for men; 1.49, [1.13-1.97] for women) compared with their counterparts. Additional higher risks in overall mental and behavioural disorder (1.31, 1.13-1.53), cardiovascular disease (1.07, 1.04-1.10) and cancer (1.06, 1.00-1.12) were only observed among men without a spouse, whereas women living without a spouse were at lower risks of developing genitourinary diseases (0.89, 0.85-0.93) and injury & poisoning (0.93, 0.88-0.97). Among 282,810 participants with major chronic diseases at baseline, 39,166 deaths were recorded. Increased mortality risks for those without a spouse were observed in 12 of 21 diseases among male patients and one of 23 among female patients. For patients with any self-reported disease at baseline, compared with those living with a spouse, the aHRs (95% CIs) of mortality risk were 1.29 (1.24-1.34) and 1.04 (1.00-1.07) among men and women without a spouse (pinteraction<0.0001), respectively.

Interpretation

Long-term associations of marital status with morbidity and mortality risks are diverse among middle-aged Chinese adults, and the adverse impacts due to living without a spouse are more profound among men. Marital status may be an influential factor for health needs.

Funding

The National Natural Science Foundation of China, the Kadoorie Charitable Foundation, the National Key R&D Program of China, the Chinese Ministry of Science and Technology, and the UK Wellcome Trust.

Marital status and cause-specific mortality: A population-based prospective cohort study in southern Sweden

The aim was to investigate associations between marital status and mortality with a prospective cohort study design. A public health survey including adults aged 18-80 was conducted with a postal questionnaire in southern Sweden in 2008 (54.1% participation). The survey formed a baseline that was linked to 8.3-year follow-up all-cause, cardiovascular (CVD), cancer and other cause mortality. The present investigation entails 14,750 participants aged 45-80. Associations between marital status and mortality were investigated with multiple Cox-regression analyses. A 72.8% prevalence of respondents were married/cohabitating, 9.1% never married, 12.2% divorced and 5.9% widows/widowers. Marital status was associated with age, sex, socioeconomic status (SES) by occupation, country of birth, chronic disease, Body Mass Index (BMI), health-related behaviors and generalized trust covariates. Never married/single, divorced, and widowed men had significantly higher hazard rate ratios (HRRs) of all-cause mortality than the reference category married/cohabitating men throughout the multiple analyses. For men, CVD and other cause mortality showed similar significant results, but not cancer. No significant associations were displayed for women in the multiple analyses. Associations between marital status and mortality are stronger among men than women. Associations between marital status and cancer mortality are not statistically significant with low effect measures throughout the multiple analyses among both men and women.

A Cross-Sectional Study on the Knowledge and Awareness of Lung Cancer and Screening in Jazan Region, Saudi Arabia

BACKGROUND

Lung cancer (LC) is the most common cause of cancer-related deaths worldwide. With lung cancer often diagnosed at advanced stages, understanding the local population's awareness levels is crucial for designing effective preventive strategies. By identifying gaps in knowledge, the research aims to inform targeted health education efforts, optimize resource allocation, influence policy development, and contribute to the limited body of research on lung cancer awareness in the region, ultimately fostering improved public health outcomes.

METHODS

This was a cross-sectional observational study conducted in Jazan region, Saudi Arabia, from July 2022 to June 2023, 671 participants over 18 years old, encompassing both genders, were gsurveyed. Data was collected through a questionnaire covering sociodemographic characteristics and LC-related awareness. SPSS 23 was used for analysis. Factors associated with knowledge scores were explored using independent t-tests and ANOVA, with the Tukey post-hoc test identifying specific group differences.

RESULTS

The study included 671 participants, most participants were between 18 and 35 years (73.5%), with 38.5% males and 61.5% females. Lung cancer (LC) awareness was high (95.1%), with 4.9% reporting a family history. Knowledge assessment revealed a mean score of 14.66, with 41.6% having low, 49.5% moderate, and 8.9% high knowledge levels. Correct responses were notable for recognizing LC as a common cancer, a leading cause of death, and associating smoking and shisha with risk. Symptoms were well identified. Screening awareness was at 63.5%, with 78.8% willing to undergo tests if at risk. Age, marital status, and occupation were associated with knowledge, while factors like gender, nationality, residency, education, income, and smoking status showed no significant associations.

CONCLUSION

The findings indicate that there are knowledge gaps related to LC and its screening in Jazan region in Saudi Arabia. Effective awareness programs targeting specific sociodemographic groups are needed to improve the early detection and outcomes.

Impacts of exposure to humidex on cardiovascular mortality: a multi-city study in Southwest China

BACKGROUND

Many studies have reported the association between ambient temperature and mortality from cardiovascular disease (CVD). However, the health effects of humidity are still unclear, much less the combined effects of temperature and humidity. In this study, we used humidex to quantify the effect of temperature and humidity combined on CVD mortality.

METHODS

Daily meteorological, air pollution, and CVD mortality data were collected in four cities in southwest China. We used a distributed lag non-linear model (DLNM) in the first stage to assess the exposure-response association between humidex and city-specific CVD mortality. A multivariate meta-analysis was conducted in the second stage to pool these effects at the overall level. To evaluate the mortality burden of high and low humidex, we determined the attributable fraction (AF). According to the abovementioned processes, stratified analyses were conducted based on various demographic factors.

RESULTS

Humidex and the CVD exposure-response curve showed an inverted "J" shape, the minimum mortality humidex (MMH) was 31.7 (77th percentile), and the cumulative relative risk (CRR) was 2.27 (95% confidence interval [CI], 1.76-2.91). At extremely high and low humidex, CRRs were 1.19 (95% CI, 0.98-1.44) and 2.52 (95% CI, 1.88-3.38), respectively. The burden of CVD mortality attributed to non-optimal humidex was 21.59% (95% empirical CI [eCI], 18.12-24.59%), most of which was due to low humidex, with an AF of 20.16% (95% eCI, 16.72-23.23%).

CONCLUSIONS

Low humidex could significantly increase the risk of CVD mortality, and vulnerability to humidex differed across populations with different demographic characteristics. The elderly (> 64 years old), unmarried people, and those with a limited level of education (1-9 years) were especially susceptible to low humidex. Therefore, humidex is appropriate as a predictor in a CVD early-warning system.

Quantitative measurement of empathy and analysis of its correlation to clinical factors in korean patients with chronic diseases

BACKGROUND

Empathy is the core of the physician-patient relationship. The Consultation and Relational Empathy (CARE) measure is a useful tool for assessing patient-rated empathy. There have been scarce data on empathy in chronic disease patients in Korea. We aim to evaluate empathy using the Korean CARE measure in patients from various clinical environments and the factors influencing the degree of empathy in patients with chronic disease.

METHODS

Data were collected from patients with chronic diseases. Patients were from primary, secondary, and tertiary clinics. Characteristics of the patients, physicians, and disease status were collected. The difference in CARE score was studied according to the clinical factors.

RESULTS

A total of 162 patients with chronic diseases were included. About 60% of patients were male. The mean age was 62 years. They had an average number of 2.6 diseases. More than half of patients experienced overt cardiovascular disease. About half of them had a history of hospitalization due to cardiovascular disease. The overall average CARE score was 45.6 ± 7.0. The CARE score was not significantly different according to the characteristics of the patient, physician, or disease status. Regarding marital status, the CARE score was significantly lower for the small number of patients (n = 4, 2.5%) who refused to provide their marital status than for other groups. Except for four patients, there was no significant difference in the CARE score among married, unmarried, or divorced groups. This trend was maintained in hypertensive patients.

CONCLUSIONS

The Korean CARE measure could assess patient-rated empathy in various clinical practices. The empathy of patients was high regardless of multiple factors.

Prevalence and Associations of Type 2 Diabetes Risk and Sociodemographic Factors in Saudi Arabia: A Web-Based Cross-Sectional Survey Study

Type 2 diabetes mellitus (T2DM) is a chronic disease with ever-increasing prevalence worldwide. In our study, we evaluated the prevalence of the risk of developing T2DM in Saudi Arabia and investigated associations between that risk and various sociodemographic characteristics. To those ends, a web-based cross-sectional survey of Saudi nationals without diabetes, all enrolled using snowball sampling, was conducted from January 2021 to January 2022. The risk of developing T2DM was evaluated using a validated risk assessment questionnaire (ARABRISK), and associations of high ARABRISK scores and sociodemographic variables were explored in multivariable logistic regression modeling. Of the 4559 participants, 88.1% were 18 to 39 years old, and 67.2% held a college or university degree. High ARABRISK scores were observed in 7.5% of the sample. Residing in a midsize city versus a large city was associated with a lower ARABRISK risk score (p = 0.007), as were having private instead of governmental insurance (p = 0.005), and being unemployed versus employed (p < 0.001). By contrast, being married (p < 0.001), divorced or widowed (p < 0.001), and/or retired (p < 0.001) were each associated with a higher ARABRISK score. A large representative study is needed to calculate the risk of T2DM among Saudi nationals.

The Widowhood Effect on Mortality in Older Patients with Hip Fracture

Objective

Widowed people have increased mortality than married people of the same age, a phenomenon known as the widowhood effect. This study aimed to investigate whether this effect exists in older patients with hip fracture.

Methods

Using our own hip fracture database, a total of 1101 hip fracture patients were consecutively included from January 2014 to December 2021. Marital status was stratified as married (n = 793) and widowed (n = 308). Patients survival status was obtained from medical records or telephone follow-ups, and the outcomes were all-cause mortality at 30 days, 1 year and at latest follow-up. Univariate and multivariate Cox proportional hazard models were used to assess the association between marital status and mortality, and subgroup analyses according to sex were also conducted.

Results

Compared with married patients, widowed patients were more likely to be older, female and intertrochanteric fracture, and were less likely to be urban area, smoking, drinking, and surgical treatment (P < 0.05). After a median follow-up of 37.1 months, the 30-day mortality was 4.3% (n = 47), 1-year mortality was 19.3% (n = 178), and total mortality was 34.2% (n = 376). Multivariate Cox analysis showed that widowed marital status remained an independent risk factor for 1-year mortality (HR = 1.437, 95% CI: 1.054–1.959, P = 0.022), and total mortality (HR = 1.296, 95% CI: 1.038–1.618, P = 0.022), whereas this association was not found in 30-day mortality (HR = 1.200, 95% CI: 0.607–2.376, P = 0.599). Moreover, subgroup analyses also found that the widowhood effect on mortality was present in both male and female.

Conclusion

Widowed marital status seems to be an independent risk factor for long-term mortality in older patients with hip fracture.