Aspirin use and chronic diseases: a cohort study of the elderly.

OBJECTIVE--To evaluate the associations between the use of aspirin and the incidences of cardiovascular diseases, cancers, and other chronic diseases. DESIGN--Postal questionnaire survey to elicit details of aspirin use. SETTING--Californian retirement community. SUBJECTS--All 22,781 residents of the community (white, affluent, and well educated) were sent a questionnaire that included questions on medical history and the use of drugs such as analgesics, laxatives, and vitamin supplements. In all 61% responded (13,987, 8881 women and 5106 men; median age 73). They formed the cohort that was followed up for 6 1/2 years using discharge summaries from three hospitals serving the area and death certificates from the health department. Only 13 respondents were lost to follow up but seemed not to have died. MAIN OUTCOME MEASURES--Incidences of cardiovascular diseases, cancers, gastrointestinal bleeding, ulcers, and cataracts were compared in participants who did and did not take aspirin daily. RESULTS--Age adjusted incidences were computed with an internal standard and five age groups. By 1 January 1988 there had been 25 incident cases of kidney cancer among all participants; 341 incident cases of stroke, 253 of acute myocardial infarction, 220 of ischaemic heart disease, and 317 of other heart disease were reported among respondents without a reported history of angina, myocardial infarction, or stroke. The incidence of kidney cancer was raised among those who took aspirin daily compared with those who did not take it, although the increase was significant only in men (relative risks = 6.3, 95% confidence interval 2.2 to 17, for men and 2.1, 0.53 to 8.5, for women). Those who took aspirin daily showed no increased risk of any other cancer, except colon cancer for both sexes combined (relative risk = 1.5, 1.1 to 2.2). The risk of acute myocardial infarction was reduced slightly among regular users of aspirin in men but not women. The risk of ischaemic heart disease was almost doubled in those who took aspirin daily compared with non-users (relative risks = 1.9, 1.1 to 3.1, for men and 1.7, 1.1 to 2.7, for women). Small, non-significant increased risks of stroke were observed in both sexes. CONCLUSION--The daily use of aspirin increased the risk of kidney cancer and ischaemic heart disease.     

Depression as a risk factor for ischaemic heart disease in men: population based case-control study

Objective: To determine the relation between depression, anxiety, and use of antidepressants and the onset of ischaemic heart disease. Design: Population based case-control study. Setting: All 5623 patients registered with one general practice. Subjects: 188 male cases with ischaemic heart disease matched by age to 485 male controls without ischaemic heart disease; 139 female cases with ischaemic heart disease matched by age to 412 female controls. Main outcome measure: Adjusted odds ratios calculated by conditional logistic regression. Results: The risk of ischaemic heart disease was three times higher among men with a recorded diagnosis of depression than among controls of the same age (odds ratio 3.09; 95% confidence interval 1.33 to 7.21; P=0.009). This association persisted when smoking status, diabetes, hypertension, and underprivileged area (UPA(8)) score were included in a multivariate model (adjusted 2.75; 1.13 to 6.69; P=0.03). Men with depression within the preceding 10 years were three times more likely to develop ischaemic heart disease than were the controls (3.13; 1.27 to 7.70; P=0.01). Men with ischaemic heart disease had a higher risk of subsequent ischaemic heart disease than men without ischaemic heart disease (adjusted 2.34; 1.34 to 4.10; P=0.003). Depression was not a risk factor for ischaemic heart disease in women on multivariate analysis (adjusted 1.34; 0.70 to 2.56; P=0.38). Anxiety and subsequent ischaemic heart disease were not significantly associated in men or women. Conclusion: Depression may be an independent risk factor for ischaemic heart disease in men, but not in women.

Key messages

• So far, research into whether depression precedes myocardial infarction has been limited
• This case-control study examined the relation between ischaemic heart disease and depression and the differences in this relation between men and women
• Depression may be a risk factor for ischaemic heart disease in men but not women
• This is independent of diabetes, hypertension, deprivation score, and smoking status

     

Decline in cardiovascular mortality in North Karelia and other parts of Finland.

The trends in mortality from ischaemic heart disease, cerebrovascular stroke, and all cardiovascular diseases were analysed for the province of North Karelia and for the rest of Finland. Linear trends in mortality were computed for the population aged 35 to 64 for the period from 1969 to 1982, and changes in mortality between the three year means of 1969-71 and 1980-2 were calculated. In North Karelia, where a community based preventive programme has been carried out since 1972, the annual decline in mortality from ischaemic heart disease in men was on average 2.9%, whereas in the rest of Finland it was 2.0%. For women the respective average annual declines in mortality were 4.9% and 3.0%. The net decline from 1969-71 to 1980-2 in North Karelia was 100 deaths/100,000 men. The annual mortality from all cardiovascular disease in men decreased by 2.9% in North Karelia and by 2.6% in the rest of Finland; in women the decreases were 6.0% and 5.0% a year, respectively. The net decline in North Karelia was 71 deaths/100,000 men. The decline in mortality from all causes was also appreciable in both sexes in North Karelia, but it did not differ significantly from national trends.     

By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease?

OBJECTIVE--To estimate by how much and how quickly a given reduction in serum cholesterol concentration will reduce the risk of ischaemic heart disease. DESIGN--Data on the incidence of ischaemic heart disease and serum cholesterol concentration were analysed from 10 prospective (cohort) studies, three international studies in different communities, and 28 randomised controlled trials (with mortality data analysed according to allocated treatment to ensure the avoidance of bias). MAIN OUTCOME MEASURE--Decrease in incidence of ischaemic heart disease or mortality for a 0.6 mmol/l (about 10%) decrease in serum cholesterol concentration. RESULTS--For men results from the cohort studies showed that a decrease of serum cholesterol concentration of 0.6 mmol/l (about 10%) was associated with a decrease in incidence of ischaemic heart disease of 54% at age 40 years, 39% at age 50, 27% at 60, 20% at 70, and 19% at 80. The combined estimate from the three international studies (for ages 55-64 years) was 38% (95% confidence interval 33% to 42%), somewhat greater than the cohort study estimate of 27%. The reductions in incidence of ischaemic heart disease in the randomised trials (for ages 55-64 years) were 7% (0 to 14%) in the first two years, 22% (15% to 28%) from 2.1-5 years, and 25% (15% to 35%) after five years, the last estimate being close to the estimate of 27% for the long term reduction from the cohort studies. The data for women are limited but indicate a similar effect. CONCLUSIONS--The results from the cohort studies, international comparisons, and clinical trials are remarkably consistent. The cohort studies, based on half a million men and 18,000 ischaemic heart disease events, estimate that a long term reduction in serum cholesterol concentration of 0.6 mmol/l (10%), which can be achieved by moderate dietary change, lowers the risk of ischaemic heart disease by 50% at age 40, falling to 20% at age 70. The randomised trials, based on 45,000 men and 4000 ischaemic heart disease events show that the full effect of the reduction in risk is achieved by five years.     

Changes in incidence and prognosis of ischaemic heart disease in Finland: a record linkage study of data on death certificates and hospital records for 1972 and 1981.

The components of the decline in mortality from ischaemic heart disease in Finland were studied by analysing the changes in incidence and prognosis between 1972 and 1981. Using personal identification numbers, hospital discharge records and death certificates were linked for all men and women aged 40-64. During this period mortality decreased 15.9% in men and 23.5% in women, incidence 14.2% in men and 19.3% in women, being greatest among 40-49 year olds living in urban areas, and case fatality 7.3% in men and 10.3% in women, owing primarily to a decrease in patients dying of ischaemic heart disease without being admitted to hospital; survival was also better among patients admitted to hospital. Factors explaining these changes remain unknown because data on risk factors and factors influencing prognosis are limited and largely ecological.     

Contribution of deaths related to alcohol use of socioeconomic variation in mortality: register based follow up study.

OBJECTIVE: To estimate the contribution of excessive alcohol use to socioeconomic variation in mortality among men and women in Finland. DESIGN: Register based follow up study. SUBJECTS: The population covered by the 1985 and 1990 censuses, aged > or = 20 in the follow up period 1987-93. MAIN OUTCOME MEASURES: Total mortality and alcohol related mortality from all causes, from diseases, and from accidents and violence according to socioeconomic position. The excess mortality among other classes compared with upper non-manual employees and differences in life expectancy between the classes were used to measure mortality differentials. RESULTS: Alcohol related mortality constituted 11% of all mortality among men aged > or = 20 and 2% among women and was higher among manual workers than among other classes. It accounted for 14% of the excess all cause mortality among manual workers over upper non-manual employees among men and 4% among women and for 24% and 9% of the differences in life expectancy, respectively. Half of the excess mortality from accidents and violence among male manual workers and 38% among female manual workers was accounted for by alcohol related deaths, whereas in diseases the role of alcohol was modest. The contribution of alcohol related deaths to relative mortality differentials weakened with age. CONCLUSIONS: Class differentials in alcohol related mortality are an important factor in the socioeconomic mortality differentials in Finland, especially among men, among younger age groups, and in mortality from accidents and violence.     

Change in alcohol consumption and risk of death from all causes and from ischaemic heart disease.

OBJECTIVE--To examine the association between alcohol consumption and mortality from all causes and from ischaemic heart disease with a focus on differentiating between long term abstainers and more recent non-drinkers. DESIGN--Cohort study of changes in alcohol consumption from 1965 to 1974 and mortality from all causes and ischaemic heart disease during 1974-84. SETTING--Population based study of adult residents of Alameda County, California. SUBJECTS--2225 women and 1845 men aged 35 and over in 1965. MAIN OUTCOME MEASURES--Alcohol consumption in 1964 and 1974 and mortality from all causes and from ischaemic heart disease during 1974-84. RESULTS--There was a significantly higher risk of death from all causes and from ischaemic heart disease in women who gave up drinking between 1965 and 1974 than in women who continued to drink (relative risk 1.72, 95% confidence interval 1.11 to 2.66, and 2.75, 1.44 to 5.23, for all causes and ischaemic heart disease respectively). A significant increase in risk was not seen in men who gave up drinking (1.32, 0.87 to 2.01, and 0.95, 0.41 to 2.20, respectively). Among men, long term abstainers compared with drinkers were at increased risk of death from all causes and from ischaemic heart disease, though the associations were not significant (1.40, 0.98 to 2.00, and 1.40, 0.76 to 2.58, for all causes and ischaemic heart disease respectively). CONCLUSION--Some of the increased risk of death from all causes and from ischaemic heart disease associated with not drinking in women seems to be accounted for by higher risks among those who gave up drinking. Men who are long term abstainers may also be at an increased risk of death. The heterogeneity of the non-drinking group should be considered when comparisons are made with drinkers.     

Decline in ischaemic heart disease in Iceland and change in risk factor levels.

OBJECTIVE--To monitor trends in mortality and morbidity due to ischaemic heart disease and compare these with observed levels of risk factors from population surveys. DESIGN--Analysis of trends in death rates from ischaemic heart disease in Iceland compared with expected rates computed from population surveys. Risk factor levels together with beta factors obtained from Cox''s regression analysis were used to compute expected death rates. Trends in morbidity due to acute myocardial infarction were assessed and secular trends in dietary consumption compared with trends in cholesterol concentrations. SETTING--Reykjavik, Iceland (total population 250,000; over half the population live in Reykjavik). SUBJECTS--12,814 randomly selected residents in the Reykjavik area aged 45-64 (6623 men, 6191 women; 72% and 80% of those invited). MAIN OUTCOME MEASURES--Age adjusted rates of myocardial infarction and deaths from ischaemic heart disease. Expected risk from risk factor levels (smoking, total serum cholesterol concentration, systolic blood pressure) at each unique survey visit. RESULTS--Mortality from ischaemic heart disease has decreased by 17-18% since 1970. During 1981-6 the myocardial infarction attack rate in men under 75 decreased by 23%. A decrease occurred in the level of all three major risk factors after 1968. The fall in the serum cholesterol concentration coincided with a reduction in consumption of dairy fat and margarine. The calculated reduction in risk for the age group 45-64 was about 35%, which was closely similar to the observed decrease in mortality due to ischaemic heart disease in that age group. CONCLUSION--The reduction in mortality from ischaemic heart disease was substantially due to a decreased incidence of myocardial infarction and could be attributed largely to the reduction in risk factors.     

Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland.

OBJECTIVES--To estimate the extent to which changes in the main coronary risk factors (serum cholesterol concentration, blood pressure, and smoking) explain the decline in mortality from ischaemic heart disease and to evaluate the relative importance of change in each of these risk factors. DESIGN--Predicted changes in ischaemic heart disease mortality were calculated by a logistic regression model using the risk factor levels assessed by cross sectional population surveys, in 1972, 1977, 1982, 1987, and 1992. These predicted changes were compared with observed changes in mortality statistics. SETTING--North Karelia and Kuopio provinces, Finland. SUBJECTS--14,257 men and 14,786 women aged 30-59 randomly selected from the national population register. MAIN OUTCOME MEASURES--Levels of the risk factors and predicted and observed changes in mortality from ischaemic heart disease. RESULTS--The observed changes in the risk factors in the population from 1972 to 1992 predicted a decline in mortality from ischaemic heart disease of 44% (95% confidence interval 37% to 50%) in men and 49% (37% to 59%) in women. The observed decline was 55% (51% to 58%) and 68% (61 to 74) respectively. CONCLUSION--An assessment of the data on the risk factors for ischaemic heart disease and mortality suggests that most of the decline in mortality from ischaemic heart disease can be explained by changes in the three main coronary risk factors.     

Impaired lung function and mortality risk in men and women: findings from the Renfrew and Paisley prospective population study.

OBJECTIVE: To assess the relation between forced expiratory volume in one second (FEV1) and subsequent mortality. DESIGN: Prospective general population study. SETTING: Renfrew and Paisley, Scotland. SUBJECTS: 7058 men and 8353 women aged 45-64 years at baseline screening in 1972-6. MAIN OUTCOME MEASURE: Mortality from all causes, ischaemic heart disease, cancer, hung and other cancers, stroke, respiratory disease, and other causes of death after 15 years of follow up. RESULTS: 2545 men and 1894 women died during the follow up period. Significant trends of increasing risk with diminishing FEV1 are apparent for both sexes for all the causes of death examined after adjustment for age, cigarette smoking, diastolic blood pressure, cholesterol concentration, body mass index, and social class. The relative hazard ratios for all cause mortality for subjects in the lowest fifth of the FEV1 distribution were 1.92 (95% confidence interval 1.68 to 2.20) for men and 1.89 (1.63 to 2.20) for women. Corresponding relative hazard ratios were 1.56 (1.26 to 1.92) and 1.88 (1.44 to 2.47) for ischaemic heart disease, 2.53 (1.69 to 3.79) and 4.37 (1.84 to 10.42) for lung cancer, and 1.66 (1.07 to 2.59) and 1.65 (1.09 to 2.49) for stroke. Reduced FEV1 was also associated with an increased risk for each cause of death examined except cancer for lifelong nonsmokers. CONCLUSIONS: Impaired lung function is a major clinical indicator of mortality risk in men and women for a wide range of diseases. The use of FEV1 as part of any health assessment of middle aged patients should be considered. Smokers with reduced FEV1 should form a priority group for targeted advice to stop smoking.     

Eveningness has the increased odds for spinal diseases but the decreased odds for articular diseases with prospective hospital treatments

Eveningness has been associated with multiple health risks, including articular and spinal diseases. Here, we analyzed if higher risks for articular and spinal diseases among Evening-types are also seen as increased treatments severe enough to require hospitalization. Our sample consists of 5696 Finnish adults from the general population with information on treatments during 1987–2010 based on the national hospital discharge register (HILMO). Their chronotype was assessed as part of the national health examination study (FINRISK) in 2007. From 2007 to 2010, the risk for dorsopathies was significantly higher (OR = 1.8, p < 0.05) but that for arthropathies was significantly lower (OR = 0.5, p < 0.05) for Evening-types than for Morning-types, after controlling for a range of potential confounding factors. Based on the clinical diagnoses assessed during hospital treatment, our study demonstrates that the eveningness associates significantly with the increased odds for dorsopathies.     

Access to coronary catheterisation: fair shares for all?

OBJECTIVE--To determine the effects of patient''s sex and area''s material deprivation on utilisation rates of coronary catheterisation and angiography in the investigation of ischaemic heart disease. DESIGN--Retrospective analysis of routinely collected hospital statistics. SETTING--Acute hospitals throughout Northern Ireland. SUBJECTS--24,179 episodes of patients discharged from hospital with a primary diagnosis of ischaemic heart disease and 1270 episodes relating to patients with an underlying diagnosis of ischaemic heart disease who had either coronary catheterisation or angiography. MAIN OUTCOME MEASURES--Age standardised admission rates for heart disease and age standardised utilisation rates for catheterisation or angiography, or both, for 566 electoral wards ranked by Townsend "deprivation" scores. RESULTS--Catheterisation-angiography rates in men were over fivefold those of women, ranging from 85.5/100,000 v 16/100,000 in patients from "well off" areas to 123/100,000 v 22/100,000 for patients from deprived areas. After admission rates for heart disease were controlled for, the overall rate ratio for women was 0.48 (95% confidence interval 0.38 to 0.60). After differential admission rates for heart disease and other potential clinical confounders were controlled for, the investigation rates of patients from the least and most "deprived" areas were not significantly different (rate ratio 1.04 (0.87 to 1.25)). CONCLUSION--Although investigation rates were significantly lower in women than in men, further clinical data would be required before labelling this underutilisation as evidence of bias. There was no significant difference in invasive investigation rates for heart disease in areas of varying deprivation or affluence.     

Prevalence and five-year cumulative incidence of psychological distress: the CroHort study

The aims of this paper are to investigate the change in prevalence of psychological distress (PD), to investigate the cumulative incidence of the psychological distress and to indicate are there any differences between genders and various age groups in Croatian adult population. Psychological distress status was measured by the five-item Mental Health Scale (MHI-5) of the Short Form questionnaire (SF-36). Psychological distress was present in 28.5% (95% CI 25.7%-31.2%) of men and 32.1% (95% CI 30.1%-34.0%) of women in 2003. In 2008 PD was present in 33.0% (95% CI 30.1%-35.9%) of men and 34.1% (95% CI 32.1%-36.0%) of women. The highest incidence of PD, both for men and women, was in the oldest age group (> 65 years). Results of this study demonstrating the fact that every third adult men and woman in Croatia are in psychological distress, the fact that there is an increase in PD prevalence for men and women should be taken into account in the future mental health policy planning.     

Community study of the causes of "natural" sudden death.

Three hundred and fifty cases of "natural" sudden death within six hours of onset of symptoms in people ranging in age from 18 to 69 years in Wandsworth were studied using a detailed necropsy protocol to determine the cause of death. Sudden death occurred in 28 (8%) Asians and blacks, but because of the small number they were excluded from the study, leaving 322 cases. Ischaemic heart disease accounted for 189 (59%) of the 322 sudden deaths (155 (65%) men; 34 (41%) women) and no proportional increase in instantaneous compared with non-instantaneous sudden death was found. Non-ischaemic cardiac disease was the cause of sudden death in 24 cases (7.5%). Non-cardiac disease included pulmonary emboli, aortic aneurysms, and intracerebral haemorrhage and caused 89 (27.6%) deaths. Alcohol was the cause of nine deaths (2.8%) and in 11 (3.4%) cases (six men and five women) no cause of death was found. This study shows that although ischaemic heart disease is the single largest cause of sudden natural death there are other major causes.     

Geographic variation in vascular mortality in eurasia: Relationship between mortality variables and risk factors

This study was based on a sample of 68 populations from 42 countries of Eurasia. Most of the data were from the MONICA Project, while additional information was from the abundant literature. Mortality rates (from cardiovascular, cerebrovascular and ischaemic heart diseases, and death rate from all causes) and related to them potential risk factors (systolic and diastolic blood pressure, total serum cholesterol and body mass index) were described for men and women, separately for 5 age cohorts, ranging between 25 and 64 years. The results showed that, in contrast to the studies carried out on theintrapopulational level, in our work risk factors did not demonstrate any strong association with mortality rate variables. Moreover, it was found that the vascular mortality on theinterpopulational level explains between 57% and 71% in total mortality and could serve as a quite fair indicator of the populational well-being in general. Although mortality rate from vascular diseases in women was much lower than in man of equal ages, geographic variation of the above mentioned death rates has showed a very similar pattern in the two sexes: the death rate is high in women when it is high in men.     

The value of needle aspiration cytology of the breast, with an emphasis on the diagnosis of breast disease in young women below the age of 30

Our experience with 4,739 needle aspirations of the breast was reviewed, with an emphasis on the diagnosis of carcinoma in young women under the age of 30 years. Among benign diseases, fibroadenomas were most frequently seen in younger women (24.3% of 919 cases) while cysts were most frequently seen in women 30 years of age and older (20.0%). Fibrocystic conditions were identified in approximately 30% of the women in each group. All younger women with suspicious diagnoses had fibrocystic disease at biopsy; in older women, 75% of the suspicious cases proved to be carcinomas while 25% proved to be fibrocystic diseases. Carcinomas were diagnosed cytologically in 1.3% of younger women and in 9.7% of older women. In young women, in whom breast carcinoma is a rare disorder, it is important that carcinoma be diagnosed without delay so that an appropriate plan of management can be adopted. These findings suggest that needle aspiration cytology can accurately make that diagnosis.     

Mortality in relation to smoking: 22 years' observations on female British doctors.

A total of 6194 female doctors who in 1951 replied to a questionnaire about their smoking habits were followed up prospectively for 22 years. During that time 1094 died. Ischaemic heart disease, lung cancer, and chronic obstructive lung disease were all significantly (p < 0.001) related to smoking, though the absolute excess risks were lower than in male doctors smoking equivalent amounts. Female smokers born before the first world war were less likely to describe themselves as inhalers or as having started to smoke while young than were female smokers who were born later. In these respects this younger group resembled male smokers, and as they move into their 60s and 70s their absolute risk of lung disease and relative risk of ischaemic heart disease will probably come to resemble the risks for men smoking the same numbers of cigarettes. These findings show only that cigarette smoking causes lung cancer, chronic obstructive lung disease, and heart disease in women as in men. Whether the proportional increase in mortality from these diseases is as great in women as in men might be estimated directly from new case-control studies on men and women born since 1920.     

Type A behaviour and ischaemic heart disease in middle aged British men.

The Bortner questionnaire, which measures aspects of type A (coronary prone) behaviour was completed by 5936 men aged 40-59 selected at random from one general practice in each of 19 British towns. The presence of ischaemic heart disease was determined at initial examination and the men were followed up for an average of 6.2 years for morbidity and mortality from myocardial infarction and for sudden cardiac death. Non-manual workers had significantly higher scores (more type A) than manual workers and the score decreased (less type A) with increasing age. After adjustment for social class and age men with higher scores had higher prevalences of ischaemic heart disease less marked for electrocardiographic evidence and more marked for response to a chest pain questionnaire (angina or possible myocardial infarction). A man''s recall of a doctor''s diagnosis of ischaemic heart disease, however, did not relate to his Bortner score. There was no significant relation between the Bortner score and the attack rate or incidence of major ischaemic heart disease events. In this study type A behaviour, as measured by the Bortner questionnaire, did not predict major ischaemic heart disease events in British middle aged men.     

Characteristics affecting fibrinolytic activity and plasma fibrinogen concentrations.

As part of a study to determine the extent to which the haemostatic system is implicated in the onset of clinically manifest ischaemic heart disease, characteristics influencing fibrinolytic activity (FA) and plasma fibrinogen concentrations were examined in 1601 men aged 18-64 and 707 women aged 18-59 in several occupational groups in North-west London. In men FA noticeably decreased till the age of about 58, when there was a small rise. In women a small increase in FA between 18 and about 40 was followed by a slightly larger fall between 40 and 59. There was a pronounced negative association of FA with obesity. FA was significantly less in smokers than non-smokers, though the effect was not large. FA increased with alcohol consumption. FA in men appeared to be greatest in the lower social classes, and men on night shift had poorer FA than those on day work. FA was greater in women using oral contraceptives than in those not using these preparations. In both sexes FA increased with exercise, but there were no associations between any of the characteristics studied and the increase. Plasma fibrinogen concentrations increase with age and obesity, are higher in smokers than non-smokers, and fall with alcohol consumption. In women the concentrations are higher in those using oral contraceptives. The general epidemiology of FA and plasma fibrinogen concentrations suggests that they may well be implicated in the pathogenesis of ischaemic heart disease.     

Diet and inequalities in health in three English towns

The diets of 2340 middle aged men and women living in three English towns were recorded. Consumption of fat and the other main nutrients was lowest in the northern industrial town, which had the highest death rates from ischaemic heart disease and from all causes combined.The findings suggest that differences in diet in middle age are not a major cause of differences in adult mortality between one part of Britain and another.