Sex differences in mortality: results from a population-based study of 12 longitudinal cohorts

A critique and examination of the polysocial risk score approach: predicting cognition in the Health and Retirement Study

Polysocial risk scores were recently proposed as a strategy for improving the clinical relevance of knowledge about social determinants of health. Our objective in this study was to assess whether the polysocial risk score model improves prediction of cognition and all-cause mortality in middle-aged and older adults beyond simpler models including a smaller set of key social determinants of health. We used a sample of 13 773 individuals aged ≥50 years at baseline from the 2006-2018 waves of the Health and Retirement Study, a US population-based longitudinal cohort study. Four linear mixed models were compared: 2 simple models including a priori-selected covariates and 2 polysocial risk score models which used least absolute shrinkage and selection operator (LASSO) regularization to select covariates among 9 or 21 candidate social predictors. All models included age. Predictive accuracy was assessed via R2 and root mean-squared prediction error (RMSPE) using training/test split validation and cross-validation. For predicting cognition, the simple model including age, race, sex, and education had an R2 value of 0.31 and an RMSPE of 0.880. Compared with this, the most complex polysocial risk score selected 12 predictors (R2 = 0.35 and RMSPE = 0.858; 2.2% improvement). For all-cause mortality, the simple model including age, race, sex, and education had an area under the receiver operating characteristic curve (AUROC) of 0.747, while the most complex polysocial risk score did not demonstrate improved performance (AUROC = 0.745). Models built on a smaller set of key social determinants performed comparably to models built on a more complex set of social "risk factors."

COVID-19 Increased Existing Gender Mortality Gaps in High Income More than Middle Income Countries

OJECTIVE

To analyze how patterns of excess mortality varied by sex and age groups across countries during the COVID-19 pandemic and their association with country income level.

METHODS

We used World Health Organization excess mortality estimates by sex and age groups for 75 countries in 2020 and 62 countries in 2021, restricting the sample to estimates based on recorded all-cause mortality data. We examined patterns across countries using country-specific Poisson regressions with observations consisting of the number of excess deaths by groups defined by sex and age.

FINDINGS

Men die at higher rates in nearly all places and at all ages beyond age 45. In 2020, the pandemic amplified this gender mortality gap for the world, but with variation across countries and by country income level. In high-income countries, rates of excess mortality were much higher for men than women. In contrast, in middle-income countries, the sex ratio of excess mortality was similar to the sex ratio of expected all-cause mortality. The exacerbation of the sex ratio of excess mortality observed in 2020 in high-income countries, however, declined in 2021.

CONCLUSION

The COVID-19 pandemic has killed men at much higher rates than women, as has been well documented, but these gender differences have varied by country income. These differences were the result of some combination of variation in gender patterns of infection rates and infection fatality rates across countries. The gender gap in mortality declined in high-income countries in 2021, likely as a result of the faster rollout of vaccination against COVID-19.

Assessing survival outcomes of patients with oral tongue squamous cell carcinoma: Focus on age, sex, and stage

BACKGROUND

The purpose of this study was to provide further insights into whether age and/or sex are associated with prognosis in oral tongue squamous cell carcinoma.

METHODS

This was a retrospective cohort study utilizing hospital registry data from 2006 to 2016 obtained from the National Cancer Database. Identified patients were divided into various cohorts based on age, sex, and staging. A descriptive analysis was performed using chi-square tests and overall survival rates were estimated using Kaplan-Meier method.

RESULTS

A total of 17 642 patients were included in the study. The 5-year overall survival rates were 82.0% (95% CI: 79.8%-84.0%) in younger patients versus 67.5% (95% CI: 66.7%-68.3%, p-value <0.0001) older patients. The median overall survival for females was 143.4 months (95% CI: 133.2-NA) versus 129.8 (95% CI: 125.4-138.7, p-value <0.0001) in males.

CONCLUSIONS

Our analysis suggests that younger age and female sex are both predictors of improved survival in oral tongue squamous cell carcinoma.

Association of Cognitive Frailty With Subsequent All-Cause Mortality Among Middle-Aged and Older Adults in 17 Countries

OBJECTIVES

Cognitive frailty refers to the co-occurrence of cognitive impairment and frailty without concurrent Alzheimer's disease or dementia. Studies of cognitive frailty and mortality have been limited to single country or older people. However, frailty and cognitive decline may occur much earlier. We aimed to examine the association between different cognitive frailty status and subsequent all-cause mortality among middle-aged and older people in 17 countries.

METHODS

Participants aged 50 and over were drawn from six prospective cohorts of aging. We classified participants according to their cognitive impairment and frailty status into the following groups: none, only cognitive impairment, only frailty and cognitive frailty. Competing-risks regression models were used to evaluate the association of different cognitive frailty status at baseline with subsequent all-cause mortality.

RESULTS

The cognitive frailty group had a higher mortality risk compared to those without cognitive impairment and frailty groups. Meta-analysis results showed participants with cognitive frailty (pooled subhazard ratio [SHR] = 2.34, 95% confidence interval [CI]: 2.01-2.72, I2 = 68.0%) had a higher mortality risk compared with those with only cognitive impairment status (pooled SHR = 1.36, 95% CI: 1.25-1.48, I2 = 3.0%) or only frailty status (pooled SHR = 1.83, 95% CI: 1.72-1.95, I2 = 31.0%). The association between cognitive frailty and mortality were stronger among those who were aged 70 years and older, males, single and nonconsumers of alcohol.

CONCLUSIONS

Cognitive frailty, frailty or cognitive impairment alone, is associated with an increased risk of all-cause mortality in Asian, European and American countries. Physical and cognitive function screening should be conducted as early as possible in middle-aged and older people, and targeted intervention approaches should be developed to reduce the incidence of adverse health outcomes.

Sex differences in all-cause mortality and life span between women with premature menopause and men: propensity score matching analysis

OBJECTIVE

This study investigated sex differences in all-cause mortality and life span between women undergoing premature menopause and men using propensity score matching analysis.

METHODS

Data were from the National Health and Nutrition Examination Survey (1999-2018) and the National Health and Nutrition Examination Survey III (1988-1994). We included 3,214 women experiencing premature menopause and 23,067 men. The participants were all older than 40 years. Propensity score matching analysis created matched cohorts of women and men using a 1:1 ratio. We employed Cox proportional hazard models to estimate unadjusted and adjusted hazard ratios (HR) (95% confidence interval [CI]) for the association between sex and both all-cause mortality and survival up to the 75th percentile of life span. A subgroup analysis examined the effects of hormone therapy on mortality and life span.

RESULTS

Compared with men in the matched cohorts, the adjusted HR values (95% CI) for all-cause mortality in women with age at menopause at <35, 35 to 39, and <40 years were 0.65 (0.54-0.78), 0.72 (0.59-0.87), and 0.67 (0.60-0.76), respectively. However, the adjusted HR values (95% CI) for women and men to survive to the 75th percentile of life span were not statistically significant. Besides, there was no significant difference in the mean life span between deceased women and men in the matched cohorts. In the subgroup analysis, the mean life span did not differ significantly between deceased women taking hormone therapy and men. However, the average life span of women never using hormone therapy was significantly longer than that of men (78.3 ± 11.6 vs 76.6 ± 11.9 years, P = 0.0154).

CONCLUSIONS

Women experiencing premature menopause had lower risks of all-cause mortality than men, but the advantage that women had in terms of life span was insignificant.

Quantitative Analysis of Factors of Attrition in a Double-blind rTMS Study for Alzheimer Treatment

Attrition is a particular concern in studies examining the efficacy of a treatment for Alzheimer disease. Analyzing reasons for withdrawal in Alzheimer studies is crucial to ruling out attrition bias, which can undermine a study's validity. In contrast, attrition in studies using repetitive transcranial magnetic stimulation (rTMS) has received much less attention. Our goal was to identify any commonalities between participants who withdrew for the same reasons. Three independent coders rated each response concerning the reasons for withdrawal, and frequency tables were generated to characterize the participants within each category. This study was conducted on the 28 withdrawn cases from a 7-month study investigating the short-term and long-term therapeutic effects of rTMS for Alzheimer disease among 156 participants across 3 sites of the study. Seven reasons for withdrawal were identified, with health and medical changes being the most commonly reported reason (7 participants). Personal issues involving family or caregivers were the next most common (5 participants), and the remaining 5 categories consisted of 3 participants each. Although the limited sample size prevented the use of inferential statistics, our findings highlight the need for more transparent reporting of attrition rates and withdrawal reasons by rTMS researchers.

Educational inequalities and self-reported health among men and women aged 18-49 years in Yangon Region, Myanmar: analysis of a population-based, cross-sectional study

OBJECTIVES

To estimate the prevalence of good self-reported health (SRH) in subpopulations based on the social determinants of health and to investigate the association between education (measured in years of schooling) and good SRH among men and women aged 18-49 years in Yangon Region, Myanmar.

DESIGN

Analysis of data from a population-based, cross-sectional study conducted in Yangon, Myanmar, from October to November 2016. A multistage sampling procedure was employed, and structured face-to-face interviews were conducted with standardised questions adapted from the Myanmar Demographic and Health Survey. Prevalence ratios (PRs) with 95% CIs were estimated using Poisson regression analyses by sex.

SETTING

Urban and rural areas of Yangon Region, Myanmar.

PARTICIPANTS

The sample included 2,506 participants (91.8% response rate) aged 18-49 years and excluded nuns, monks, soldiers, institutionalised people and individuals deemed too ill physically and/or mentally to participate.

RESULTS

The prevalence of good SRH was 61.2% (95% CI 59.3 to 63.1), with higher rates among men (72.0%, 95% CI 69.3 to 74.5), younger individuals (69.2%, 95% CI 66.2 to 72.1), urban residents (63.6%, 95% CI 60.8 to 66.3), extended family dwellers (66.6%, 95% CI 63.7 to 69.4) and those with a higher level of education (66.0%, 95% CI 61.3 to 70.5). After adjusting for confounders (age and area of residence), the association between years of schooling and SRH (PR) was 1.01 (95% CI 1.01 to 1.02, p=0.002) in men and 1.01 (95% CI 0.99 to 1.02, p=0.415) in women.

CONCLUSIONS

Good SRH was more prevalent among men than among women. Additionally, a 1-year increase in education was associated with a 1% increase in the prevalence of good SRH among men, whereas the association was not statistically significant among women. In order to enhance the educational benefits of health in Myanmar, we recommend a higher focus on the length of education and addressing gender inequalities in wage return from education.

Trends in cardiovascular disease among Inuit in Greenland from 1994 to 2021

Background and aims

Cardiovascular disease (CVD) poses significant health challenges globally. While substantial data exists for most populations, the Arctic Inuit's CVD incidence rates remain understudied. This research aimed to change this by estimating CVD incidence and mortality rates in Greenland from 1994 to 2021.

Methods

Using nationwide registers, a retrospective observational study was conducted, focusing on individuals born in Greenland to Greenlandic-born parents. Data were sourced from the Greenlandic Hospital Discharge Register and the nationwide electronic medical record.

Results

A total of 65,824 individuals were included. the age- and sex-specific incidence rates (IR) of ischemic heart disease, stroke, and heart failure (HF) declined from 1994 to 2021, with the most substantial decline observed for HF among women. Conversely, the IR of atrial fibrillation/flutter increased in both men and women, while the IR of myocardial infarction rose among men. The IR for stroke was particularly elevated compared to other CVD subgroups. Mortality rates for those diagnosed with CVD were 2.4 times higher than those without. Men exhibited a 40 % elevated mortality risk relative to women.

Conclusion

The study provides pivotal insights into CVD trends within the Arctic Inuit population, highlighting both positive developments and areas of concern. Given the increasing elderly demographic in Greenland, proactive health strategies are crucial. Emphasizing primary prevention and addressing specific CVD risks, particularly the elevated stroke IR, is imperative for future public health efforts.

Development and validation of a frailty index for use in the osteoarthritis initiative

BACKGROUND

The Osteoarthritis Initiative (OAI) evaluates the development and progression of osteoarthritis. Frailty captures the heterogeneity in aging. Use of this resource-intensive dataset to answer aging-related research questions could be enhanced by a frailty measure.

OBJECTIVE

To: (i) develop a deficit accumulation frailty index (FI) for the OAI; (ii) examine its relationship with age and compare between sexes, (iii) validate the FI versus all-cause mortality and (iv) compare this association with mortality with a modified frailty phenotype.

DESIGN

OAI cohort study.

SETTING

North America.

SUBJECTS

An FI was determined for 4,755/4,796 and 4,149/4,796 who had a valid FI and frailty phenotype.

METHODS

Fifty-nine-variables were screened for inclusion. Multivariate Cox regression evaluated the impact of FI or phenotype on all-cause mortality at follow-up (up to 146 months), controlling for age and sex.

RESULTS

Thirty-one items were included. FI scores (0.16 ± 0.09) were higher in older adults and among females (both, P < 0.001). By follow-up, 264 people had died (6.4%). Older age, being male, and greater FI were associated with a higher risk of all-cause mortality (all, P < 0.001). The model including FI was a better fit than the model including the phenotype (AIC: 4,167 vs. 4,178) and was a better predictor of all-cause mortality than the phenotype with an area under receiver operating characteristic curve: 0.652 vs. 0.581.

CONCLUSION

We developed an FI using the OAI and validated it in relation to all-cause mortality. The FI may be used to study aging on clinical, functional and structural aspects of osteoarthritis included in the OAI.

Investigating the "sex paradox" in pulmonary arterial hypertension: Results from the Pulmonary Hypertension Association Registry (PHAR)

BACKGROUND

Female sex is a significant risk factor for pulmonary arterial hypertension (PAH), yet males with PAH have worse survival - a phenomenon referred to as the "sex paradox" in PAH.

METHODS

All adult PAH patients in the Pulmonary Hypertension Association Registry (PHAR) with congruent sex and gender were included. Baseline differences in demographics, hemodynamics, functional parameters, and quality of life were assessed by sex. Kaplan-Meier survival analysis was used to evaluate survival by sex. Mediation analysis was conducted with Cox proportional hazards regression by comparing the unadjusted hazard ratios for sex before and after adjustment for covariates. The plausibility of collider-stratification bias was assessed by modeling how large an unmeasured factor would have to be to generate the observed sex-based mortality differences. Subgroup analysis was performed on idiopathic and incident patients.

RESULTS

Among the 1,891 patients included, 75% were female. Compared to men, women had less favorable hemodynamics, lower 6-minute walk distance, more PAH therapies, and worse functional class; however, sex-based differences were less pronounced when accounting for body surface area or expected variability by gender. On multivariate analysis, women had a 48% lower risk of death compared to men (Hazard Ratio 0.52, 95% Confidence interval 0.36 - 0.74, p < 0.001). Modeling found that under reasonable assumptions collider-stratification could account for sex-based differences in mortality.

CONCLUSIONS

In this large registry of PAH patients new to a care center, men had worse survival than women despite having more favorable baseline characteristics. Collider-stratification bias could account for the observed greater mortality among men.

Long-term inequalities in health among older Mexican adults: An outcome-wide analysis

The relationship between socioeconomic level and health outcomes in older people has been widely studied, but less information about health inequalities associated with gender and place of residence exists. Also, there is scarce evidence of longitudinal inequalities, particularly in countries from the global south. This study aimed to describe the longitudinal patterns of health inequalities associated with wealth, gender, and residence area among older Mexican adults. We used data from two longitudinal studies in Mexico: The Study on Global AGEing and Adult Health (SAGE) and the Mexican Health and Aging Study (MHAS). Three domains to characterize health inequities were used: wealth, gender, and rurality. We conducted an outcome-wide analysis with nine health indicators assessing older adults' physical and cognitive function. The Slope Index of Inequality and the Relative Index of Inequality were used as inequality measurements. Our results indicate that the greatest inequalities are observed in relation to wealth and gender. Older adults with lower socioeconomic status demonstrated higher rates of depression, sarcopenia, falls, and limitations in both basic and instrumental activities of daily living compared to their wealthier counterparts, with increasing trends in physical functionality over time. Furthermore, women experienced higher rates of depression, sarcopenia, frailty, and physical limitations compared to men. The only significant difference related to rurality was a lower rate of frailty among rural older adults. Longitudinal trajectories revealed an increase in the gap of inequality for various health indicators, especially in terms of wealth and gender. Health inequalities in old age are one of the greatest challenges facing health systems globally. Actions like universal coverage of health services for older people and the empowerment of individuals and their communities to have control over their lives and circumstances must be guaranteed.

Correlation between allostatic load index and cumulative mortality: a register-based study of Danish municipalities

OBJECTIVES

The aim of this study was to examine population-based allostatic load (AL) indices as an indicator of community health across 14 municipalities in Denmark.

DESIGN

Register-based study.

SETTING

Data derived from: the Lolland-Falster Health Study, the Copenhagen General Population Study and the Danish General Suburban Population Study. Nine biomarkers (systolic blood pressure, diastolic blood pressure, pulse rate, total serum cholesterol, high-density lipoprotein cholesterol, waist-to-hip ratio, triglycerides, C-reactive protein and serum albumin) were divided into high-risk and low-risk values based on clinically accepted criteria, and the AL index was defined as the average between the nine values. All-cause mortality data were obtained from Statistics Denmark.

PARTICIPANTS

We examined a total of 106 808 individuals aged 40-79 years.

PRIMARY OUTCOME MEASURE

Linear regression models were performed to investigate the association between mean AL index and cumulative mortality risk.

RESULTS

Mean AL index was higher in men (range 2.3-3.3) than in women (range 1.7-2.6). We found AL index to be strongly correlated with the cumulative mortality rate, correlation coefficient of 0.82. A unit increase in mean AL index corresponded to an increase in the cumulative mortality rate of 19% (95% CI 13% to 25%) for men, and 16% (95% CI 8% to 23%) for women but this difference was not statistically significant. The overall mean increase in cumulative mortality rate for both men and women was 17% (95% CI 14% to 20%).

CONCLUSIONS

Our findings indicate the population-based AL index to be a strong indicator of community health, and suggest identification of targets for reducing AL.

The impact of diabetes on mortality rates after lower extremity amputation

OBJECTIVE

To assess the impact of diabetes, amputation level, sex and age on mortality rates after lower extremity amputation (LEA) in Belgium, and to assess temporal trends in one-year survival rates from 2009 to 2018.

METHODS

Nationwide data on individuals who underwent minor and major LEA from 2009 to 2018 were collected. Kaplan-Meier survival curves were constructed. A Cox regression model with time-varying coefficients was used to estimate the likelihood of mortality after LEA in individuals with or without diabetes. Matched amputation-free individuals with or without diabetes were used for comparison. Time trends were analysed.

RESULTS

Amputations 41,304 were performed: 13,247 major and 28,057 minor. Five-year mortality rates in individuals with diabetes were 52% and 69% after minor and major LEA, respectively (individuals without diabetes: 45% and 63%, respectively). In the first six postoperative months, no differences in mortality rates were found between individuals with or without diabetes. Later, hazard ratios (HRs) for mortality in individuals with diabetes (compared with no diabetes) after minor LEA ranged from 1.38 to 1.52, and after major LEA from 1.35 to 1.46 (all p ≤ 0.005). Among individuals without LEA, HRs for mortality in diabetes (versus no diabetes) were systematically higher compared to the HRs for mortality in diabetes (versus no diabetes) after minor and major LEA. One-year survival rates did not change for individuals with diabetes.

CONCLUSIONS

In the first six postoperative months, mortality rates after LEA were not different between individuals with or without diabetes; later, diabetes was significantly associated with increased mortality. However, as HRs for mortality were higher in amputation-free individuals, diabetes impacts mortality less in the minor and major amputation groups relative to the comparison group of individuals without LEA.

Association Between Metabolic Syndrome and Mortality: Prospective Cohort Study

BACKGROUND

Metabolic syndrome (MetS) is a common metabolic disorder that results from the increasing prevalence of obesity, which has been an increasing concern in recent years. Previous evidence indicated that MetS was associated with mortality; however, different definitions of MetS were used. In 2005, the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III updated the definition of MetS, which has since been widely adopted. Therefore, it is necessary to conduct a novel study among other populations and countries with a larger sample size using the updated definition of MetS and death code to examine the association of MetS with all-cause and cause-specific mortality.

OBJECTIVE

We aimed to examine the associations of MetS with all-cause and cause-specific mortality.

METHODS

A total of 36,414 adults were included in this study, using data from the National Health and Nutrition Examination Survey (NHANES) III (1988-1994) and the continuous NHANES (1999-2014) in the United States. Death outcomes were ascertained by linkage to National Death Index records through December 31, 2015. MetS was defined by the NCEP ATP III-2005 criterion. Complex survey design factors including sample weights, clustering, and stratification were considered for all analyses with instructions for using NHANES data. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs for mortality from all causes, heart disease, diabetes, and cancer.

RESULTS

We observed 8494 deaths during the 16.71 years of follow-up. Compared with those without MetS, individuals with MetS were associated with a significantly elevated multiadjusted HR of 1.24 (95% CI 1.16-1.33), 1.44 (95% CI 1.25-1.66), and 5.15 (95% CI 3.15-8.43) for all cause, heart diseases, and diabetes mellitus, respectively, whereas no significant association was found for cancer mortality (HR 1.17, 95% CI 0.95-1.43).

CONCLUSIONS

Our study provides additional evidence that MetS and its components are significantly associated with all-cause, heart disease, and diabetes mortality, but not with cancer mortality. Health care professionals should pay more attention to MetS and its individual component.

Sex-specific population attributable risk factors for cardiovascular and all-cause mortality in the general population: Findings from the China PEACE million persons project

Little evidence exists regarding the sex-specific population attributable risk factors for cardiovascular and all-cause mortality in the Chinese general population. We used a sub-cohort of the China Patient-Centered Evaluative Assessment of Cardiac Events million persons project to evaluate the overall and sex-specific associations and population attributable fractions (PAFs) of twelve risk factors for cardiovascular and all-cause mortality. 95,469 participants were included between January 2016 and December 2020. The twelve risk factors (including four socioeconomic status and eight modifiable risk factors) were collected or measured at baseline. The outcomes of the study were all-cause mortality and cardiovascular mortality. Overall, 60.7% (N = 57,971) were women, and the mean age was 54.3 ± 10.2 years. After a median of 3.52 years of follow-up, 1311 (1.4%) people died, and 362 (0.4%) people died of cardiovascular causes. Majorities of risk factors were significantly associated with all-cause and cardiovascular mortality, and suboptimal blood pressure and low educational attainment were the two leading attributable risk factors for all-cause and cardiovascular mortality. The twelve risk factors collectively explained 72.4% (95% confidence interval (CI): 63.5, 79.2) and 84.0% (95% CI: 71.1, 91.1) of PAFs for all-cause and cardiovascular mortality. When stratified by sex, men had more risk factors that were significantly attributable to mortality than women, whereas low educational attainment had a more pronounced impact on female cardiovascular health. This study found that the twelve risk factors collectively explained a significant proportion of PAFs for all-cause and cardiovascular mortality. Several sex-related disparities in the associations between risk factors and mortality were noted.

Mortality Patterns Associated with Central Sleep Apnea among Veterans: A Large, Retrospective, Longitudinal Report

Rationale: Central sleep apnea (CSA) is associated with high mortality. Current knowledge stems from studies with limited sample size (fewer than 100 subjects) and in homogeneous populations such as heart failure (HF). Objectives: To address this knowledge gap, we compared the mortality pattern and time to death between the CSA and obstructive sleep apnea (OSA) patients in the large Veterans Health Administration patient population using the big data analytic approach. Methods: This is a retrospective study using national Veterans Health Administration electronic medical records from October 1, 1999, through September 30, 2020. We grouped the patients with underlying sleep disorders into CSA and OSA, using the International Classification of Diseases, Ninth and Tenth Revision codes. We applied Cox regression analysis to compare the mortality rate and hazard ratio (HR) among the two groups and adjusted HR by gender, race, body mass index (BMI), age, and Charlson Comorbidity Index. In CSA groups, a machine-learning algorithm was used to determine the most important predictor of time to death. Further subgroup analysis was also performed in patients that had comorbid HF. Results: Evaluation of patients resulted in 2,961 grouped as CSA and 1,487,353 grouped as OSA. Patients with CSA were older (61.8 ± 15.6 yr) than those with OSA (56.7 ± 13.9 yr). A higher proportion of patients with CSA (25.1%) died during the study period compared with the OSA cohort (14.9%). The adjusted HR was 1.53 (95% confidence interval [CI], 1.43-4.65). Presence of HF history of cerebrovascular disease, hemiplegia, and having a BMI less than 18.5 were among the highest predictors of mortality in CSA. The subgroup analysis revealed that the presence of HF was associated with increased mortality both in CSA (HR, 7.4; 95% CI, 6.67-8.21) and OSA (HR, 4.3; 95% CI, 4.26-4.34) groups. Conclusions: Clinically diagnosed CSA was associated with a shorter time to death from the index diagnostic date. Almost one-fifth of patients with CSA died within 5 years of diagnosis. The presence of HF, history of cerebrovascular disease and hemiplegia, male sex, and being underweight were among the highest predictors of mortality in CSA. CSA was associated with higher mortality than OSA, independent of associated comorbidity.

Long-Term Effects of Cognitive Training on All-Cause Mortality in US Older Adults

Objectives: Cognitive abilities have been implicated as predictors of mortality in older adults. This study examines the effects of cognitive training on mortality 20 years post-intervention. Methods: Data come from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) randomized control trial (N = 2802). Participants were cognitively and physically healthy, community-dwelling adults aged 65 and older. Cox proportional hazard models were used to investigate (1) the association between baseline cognition and mortality risk and (2) the effect of ACTIVE cognitive training (memory, reasoning, and speed of processing) on mortality risk 20 years post-intervention. Results: Higher baseline cognition predicted lower mortality risk 20 years post-intervention. No significant effects of ACTIVE cognitive training in memory, reasoning, or speed of processing on mortality risk were observed. Discussion: More work is needed to identify cognitive training interventions that may lead to lower mortality risks in later adulthood.

Differences by Sex in the Presentation of Multimorbidity: Longitudinal Study in Mexican Adults Living in the Community, 2001-2018

Background: Multimorbidity represents a challenge for public health because as populations age, its prevalence increases. The objectives were to describe by sex the multimorbidity patterns from 2001 to 2018 in a cohort of people ≥50 years and in a subcohort with multimorbidity to describe the trajectories and transitions. Materials and Methods: Secondary analysis of the cohort of adults ≥50 years in the Mexican Health and Aging Study. Sociodemographic, health, functionality, and mortality were analyzed. Descriptive analysis was performed, estimation of prevalence by sex and trajectories, and transitions of the multimorbidity patterns with alluvial diagrams. Results: In the full cohort, 53.3% were women and in the subcohort with multimorbidity 66.1%. In both sexes, more cases with multimorbidity were observed among people without schooling, without a job, with a fair or bad economic situation, and with fair or bad self-perception of their health. The chronic diseases (CDs) with the highest prevalence were diabetes mellitus (DM), hypertension (HT), and arthritis and the most prevalent multimorbidity patterns were HT+arthritis and DM+HT. Higher proportion of men transited early to death and the women to other patterns more complex. Conclusion: Women always had higher prevalence of multimorbidity from an early age and with more complex combinations of CDs, but men with multimorbidity died prematurely. It is important to analyze multimorbidity not only from a biological approach but also from a perspective that considers sex inequalities and allows for the development of specific interventions adapted to the particular needs of men and women.

Higher Lead and Lower Calcium Levels Are Associated with Increased Risk of Mortality in Malaysian Older Population: Findings from the LRGS-TUA Longitudinal Study

The main objective of this study is to determine the association of various trace elements’ status with the 5-year mortality rate among community-dwelling older adults in Malaysia. This study was part of the Long-term Research Grant Scheme—Towards Useful Ageing (LRGS-TUA). The participants were followed up for five years, and their mortality status was identified through the Mortality Data Matching Service provided by the National Registration Department, Malaysia. Of the 303 participants included in this study, 34 (11.2%) participants had died within five years after baseline data collection. As compared to the survivors, participants who died earlier were more likely (p < 0.05) to be men, smokers, have a lower intake of total dietary fiber and molybdenum, higher intake of manganese, lower zinc levels in toenail samples, lower calcium and higher lead levels in hair samples during baseline. Following the multivariate Cox proportional hazard analysis, lower total dietary fiber intake (HR: 0.681; 0.532−0.871), lower calcium (HR: 0.999; 95% CI: 0.999−1.000) and higher lead (HR: 1.309; 95% CI: 1.061−1.616) levels in hair samples appeared as the predictors of mortality. In conclusion, higher lead and lower calcium levels are associated with higher risk of mortality among community-dwelling older adults in Malaysia. Our current findings provide a better understanding of how the trace elements’ status may affect older populations’ well-being and mortality rate.

Premature mortality in a population-based cohort of autistic adults in Canada

Research from different countries suggests that autistic adults are more likely to die prematurely than non-autistic adults, but these studies do not always investigate male and female individuals separately and do not consider whether this pattern is unique to autistic people or is also an issue for people with other developmental disabilities. We examined premature mortality in autistic males and females (assigned at birth) in a population-based cohort, compared to males and females with and without other developmental disabilities. Using linked administrative health and social services population data from Ontario, Canada, age-matched males and females aged 19-65 years were followed between 2010 and 2016, and causes of death were determined. Over the 6-year observation period, 330 of 42,607 persons (0.77%) in the group without developmental disabilities had died compared to 259 of 10,646 persons (2.43%) in the autism group and 419 of 10,615 persons (3.95%) in the other developmental disabilities group. Autistic males and females were more likely to die than non-autistic males (adjusted risk ratio, RR 3.13, 95%CI 2.58-3.79) and non-autistic females (adjusted RR 3.12, 95%CI 2.35-4.13) without developmental disabilities, but were less likely to die than adults with other developmental disabilities (males: adjusted RR 0.66, 95%CI 0.55-0.79; females: adjusted RR 0.55, 95%CI 0.43-0.71). Most common causes of death varied depending on a person's sex and diagnosis. Given the greater likelihood of premature mortality in adults with developmental disabilities including autism, greater attention and resources directed toward their health and social care are needed, tailored to their sex and diagnosis-informed needs. LAY SUMMARY: This study looked at how many autistic men and women died over 6 years (2010-2016), along with how they died, and compared this to adults who did not have autism living in Ontario, Canada. It found that autistic men and women were more than three times as likely to die as people of the same age who did not have a developmental disability. However, adults with other developmental disabilities besides autism were even more likely to die than autistic adults. This means that we have to pay more attention and invest in better social and health care for autistic people, along with people who have other types of developmental disabilities.

The association between BDNF C270T genetic variants and smoking in patients with mental disorders and in healthy controls

Studies investigating the association between smoking and the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism have reported inconclusive results, while the studies on the association of smoking status with BDNF C270T polymorphism are missing. We aimed to determine the association of smoking and BDNF Val66Met and C270T genetic variants in control subjects and patients with mental disorders. This study included 3502 Caucasian subjects: 918 healthy controls and 2584 patients with mental disorders (519 individuals with posttraumatic stress disorder (PTSD), 419 patients with depression, 996 patients with schizophrenia, and 650 patients with alcohol dependence). The frequency of the BDNF Val66Met and C270T variants were presented in codominant, dominant and recessive models. BDNF C270T, but not BDNF Val66Met polymorphism, was significantly associated with smoking in all groups, since the presence of the C270T T allele was more frequently found in smokers compared to non-smokers. Significant predictors of smoking were sex, age and BDNF C270T genetic variants. However, after detailed analysis of the separate diagnostic entities, the significant association of BDNF C270T polymorphism was confirmed only in healthy subjects, but not in patients with mental disorders; and was not related to number of cigarettes smoked per day. In patients with alcohol dependence, the severity of smoking was significantly associated with BDNF Val66Met variants. This is a first report of the significant association between the BDNF C270T polymorphism and smoking status in the large groups of Caucasian cases/controls.

Association of Surgeon-Patient Sex Concordance With Postoperative Outcomes

Importance

Surgeon sex is associated with differential postoperative outcomes, though the mechanism remains unclear. Sex concordance of surgeons and patients may represent a potential mechanism, given prior associations with physician-patient relationships.

Objective

To examine the association between surgeon-patient sex discordance and postoperative outcomes.

Design, Setting, and Participants

In this population-based, retrospective cohort study, adult patients 18 years and older undergoing one of 21 common elective or emergent surgical procedures in Ontario, Canada, from 2007 to 2019 were analyzed. Data were analyzed from November 2020 to March 2021.

Exposures

Surgeon-patient sex concordance (male surgeon with male patient, female surgeon with female patient) or discordance (male surgeon with female patient, female surgeon with male patient), operationalized as a binary (discordant vs concordant) and 4-level categorical variable.

Main Outcomes and Measures

Adverse postoperative outcome, defined as death, readmission, or complication within 30-day following surgery. Secondary outcomes assessed each of these metrics individually. Generalized estimating equations with clustering at the level of the surgical procedure were used to account for differences between procedures, and subgroup analyses were performed according to procedure, patient, surgeon, and hospital characteristics.

Results

Among 1 320 108 patients treated by 2937 surgeons, 602 560 patients were sex concordant with their surgeon (male surgeon with male patient, 509 634; female surgeon with female patient, 92 926) while 717 548 were sex discordant (male surgeon with female patient, 667 279; female surgeon with male patient, 50 269). A total of 189 390 patients (14.9%) experienced 1 or more adverse postoperative outcomes. Sex discordance between surgeon and patient was associated with a significant increased likelihood of composite adverse postoperative outcomes (adjusted odds ratio [aOR], 1.07; 95% CI, 1.04-1.09), as well as death (aOR, 1.07; 95% CI, 1.02-1.13), and complications (aOR, 1.09; 95% CI, 1.07-1.11) but not readmission (aOR, 1.02; 95% CI, 0.98-1.07). While associations were consistent across most subgroups, patient sex significantly modified this association, with worse outcomes for female patients treated by male surgeons (compared with female patients treated by female surgeons: aOR, 1.15; 95% CI, 1.10-1.20) but not male patients treated by female surgeons (compared with male patients treated by male surgeons: aOR, 0.99; 95% CI, 0.95-1.03) (P for interaction = .004).

Conclusions and Relevance

In this study, sex discordance between surgeons and patients negatively affected outcomes following common procedures. Subgroup analyses demonstrate that this is driven by worse outcomes among female patients treated by male surgeons. Further work should seek to understand the underlying mechanism.

Midlife Cardiovascular Health and Robust versus Frail Late-Life Status: The Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

We examined the relationship of midlife cardiovascular health (CVH) with late-life robustness among men and women and the impact of survivorship bias on sex-differences in robustness.

METHODS

Prospective analysis of 15,744 participants aged 45-64 (Visit 1 median age: 54 years, 55% female, 27% Black) in 1987-1989 from the population-based ARIC Study. CVH was operationalized according to the Life's Simple 7 (LS7) metric of health behaviors (smoking, weight, physical activity, diet, cholesterol, blood pressure, and glucose); each behavior was scored as ideal (2 points), intermediate (1 point), or poor (0 points) and summed. Late-life robust/pre-frail/frailty was defined at Visit 5 (2011-2013). Multinomial regression estimated relative prevalence ratios (RPR) of late-life robustness/pre-frailty/frailty/death across overall midlife LS7 score and components, for the full Visit 1 sample. Separate analyses considered Visit 5 survivors only.

RESULTS

For each one-unit greater midlife LS7 score, participants had a 37% higher relative prevalence of being robust versus frail (overall RPR=1.37, [95% CI: 1.30-1.44]; women=1.45 [1.36-1.54]; men=1.24 [1.13-1.36]). Among the full Visit 1 sample, women had a similar one-level higher robustness category prevalence (RPR=1.35 [95% CI: 1.32-1.39]) than men (RPR=1.31 [95% CI: 1.27-1.35]) for every one-unit higher midlife LS7 score. Among survivors, men were more likely to be robust than women at lower LS7 levels; differences were attenuated and not statistically different at higher midlife LS7 levels.

CONCLUSIONS

Midlife CVH is positively associated with robustness in late-life among men and women. Accounting for mortality in part explains documented sex-differences in robustness across all levels of LS7.