The Lancet Regional Health - Europe

Population ageing increases the importance of cognitive capacity for making decisions about retirement and living independently beyond it. We tested whether post-war educational expansion and working-life social mobility eliminate the association between social class of origin and cognition in early old age using the 1958 National Child Development Study. Two outcomes were analysed at age 62: standard episodic memory (immediate + delayed word recall) and long-term episodic memory, capturing accurate half-century recall of childhood household facts (rooms and people at age 11 validated against mothers' responses). Social mobility trajectories derived in prior work were classified into predominantly manual versus non-manual class trajectories. Models were estimated separately for women and men across three specifications: (i) social origin and controls, (ii) adding social mobility, and (iii) adding weighting to address healthy survivor bias. Education was consistently associated with both outcomes. For long-term episodic memory, social origin gradients were clearer than for short-term episodic memory, with men from service/professional origins showing a 13 percentage-point higher probability of accurate half-century recall than men from manual origins. These findings indicate that education expansion and working-life social mobility failed to release the grip of social origin on long-term episodic memory.

Background Hospital admissions for mental health (MH) and stress related presentations (SRP; symptoms without a clear medical cause which may be psychosomatic in nature) among children and young people (CYP) have risen over time. Rehospitalisation contributes to service costs, may indicate gaps in community based care, and can also disrupt education and social development. Methods This retrospective cohort study used NHS Hospital Episode Statistics to identify all CYP aged 10 to 25 with >1 MH/SRP related hospital admissions in England between 1 April 2014 and 31 March 2018, with follow up until 31 March 2019. Admissions were classified from ICD10 codes into internalising, externalising, personality, and eating disorders, psychosis, self-harm, substance use, postpartum, or potentially psychosomatic diagnostic groups. Outcomes included 30 day all cause readmission, 1 year all cause readmission, and 1 year MH/SRP-specific rehospitalisation. Time to rehospitalisation, and number of MH/SRP readmissions were also evaluated. Clinical and sociodemographic characteristics associated with rehospitalisation were assessed using regression models, time to rehospitalisation using Kaplan Meier analyses, and diagnostic transitions were visualised using Sankey diagrams. Results Of 492,061 CYP with hospital admission for MH/SRP, approximately one third were rehospitalised within one year. Females, older CYP and those from more deprived areas had higher odds of all cause readmission. The odds of MH/SRP rehospitalisation were highest among those aged 14 to 15 years. Co occurring chronic physical health conditions, personality and eating disorders were associated with higher odds, and shorter time, to readmission. Conclusions Rehospitalisation following MH/SRP admissions is common and socioeconomically patterned among CYP. Targeted discharge planning and continuity of care interventions are needed, particularly for high risk CYP admitted with eating and personality disorders.

Background: Ethnic minorities and socioeconomically disadvantaged populations in the UK are at increased risk of obesity. We modelled longitudinal body mass index (BMI) trajectories through infancy, childhood, and adolescence to identify at-risk groups and modifiable risk factors. Methods: This cohort sampled 10,350 White and South Asian children born in Leicestershire, 1985-1997. We included 5,571 participants with [≥]3 BMI measurements between 0-18 years collected from healthcare records, questionnaires, and study visits. We used Group-Based Trajectory Modelling of BMI, separately by sex and ethnicity, and combined. We identified at-risk groups and modifiable risk factors using multinomial logistic regression, with inverse probability weighting to reduce selection bias. Results: We identified similar five BMI trajectories across sex and ethnicity: stable normal BMI (47%); persistent low BMI (30%); early overweight resolving (8%); childhood onset obesity (4%); and adolescent onset overweight (11%). Childhood onset obesity deviated from stable normal BMI at 2-4 years of age, adolescent onset overweight at 4-6 years. South Asians were at higher risk of childhood onset obesity (aOR: 1.66 [95%CI 1.08-2.53]) and adolescent onset overweight (1.29 [0.98-1.71]) than Whites. Children from deprived backgrounds (1.66 [0.92-2.82], most vs least deprived quintile) and those with less educated parents (1.67 [1.08-2.63], compulsory vs higher education) were at increased risk of childhood onset obesity. Smoking during pregnancy (1.50 [0.88-2.54]) and absence of breastfeeding (1.56 [1.07-2.29]) increased risk of childhood onset obesity. Physical activity decreased risk of childhood onset obesity (0.64 [0.44-0.93], [≥]4 vs 0-3 hours/week) and adolescent onset overweight (0.75 [0.59-0.94]). Conclusion: BMI trajectories diverge as early as age 2 years, revealing ethnic and social inequalities. Obesity strategies in the UK should intervene during critical windows in early life and prioritise South Asian children and those from socioeconomically deprived backgrounds.

Background. Vietnam's disease burden has shifted from communicable, maternal, neonatal, and nutritional (CMNN) causes to non-communicable diseases (NCDs), but the tempo, drivers, and regional positioning of this transition have not been jointly quantified. We characterised Vietnam's epidemiological transition 1990-2023 against ten Southeast-Asian (SEA) peers. Methods. Using Global Burden of Disease 2023 data, we computed joinpoint-regression AAPC with 95% CI (BIC-penalised, up to three break-points) for age-standardised DALY rates and cause-composition shares. We applied Das Gupta three-factor decomposition to 1990-2023 absolute DALY change (population-size, age-structure, age-specific-rate effects) and benchmarked Vietnam's NCD share against an SDI-conditional peer trajectory via leave-one-out quadratic regression. Premature mortality was quantified as WHO 30q70 under both broad NCD and strict SDG 3.4.1 definitions, using Chiang II life-table adjustment identically across all eleven countries. Findings. The CMNN age-standardised DALY rate fell from 13,295.9 to 4,022.1 per 100,000 (AAPC -4.63%/year; 95% CI -4.80 to -4.46); the NCD rate fell only from 21,688.2 to 19,282.8 (AAPC -0.37; -0.45 to -0.30). NCD share of total DALYs rose from 52.99% to 70.67% (+17.67 pp; AAPC +1.09). Vietnam ranked fourth of eleven SEA countries in 2023 (up from sixth in 1990) and sat 5.3% above the SDI-expected trajectory. Das Gupta decomposition attributed the +10.63 million NCD DALY increase to population growth (+6.26 M) and ageing (+6.08 M); rate change removed only 1.71 M. Premature NCD mortality fell from 25.02% to 21.80% (broad, 12.9% reduction) and from 22.17% to 19.50% (SDG 3.4.1, 12.0%; Vietnam sixth of eleven) - far short of the SDG 3.4 one-third-reduction target. Interpretation. Vietnam has entered a disability- and ageing-dominated NCD phase. Meeting SDG 3.4 by 2030 requires population-scale primary prevention sized to demographic momentum.

HighlightsO_LIHealth inequalities have widened over 15 years, favouring high-income groups C_LIO_LIInequality in physical activity & mental health widened the most pre-intervention C_LIO_LIPost-intervention, inequalities persisted but stayed relatively unchanged. C_LIO_LILong-term illness and unemployment were key drivers of inequality C_LIO_LIThe greenway may have slowed down the inequality widening but the impact is limited C_LI BackgroundEvidence concerning health inequalities following urban green and blue space UGBS) interventions is limited. This study examined the changes in health inequalities after a major urban regeneration project, the Connswater Community Greenway (CCG), in Belfast, UK. MethodCross-sectional household surveys were conducted in 2010/11 (baseline), 2017/18 (immediately after completion), and 2023/24 (long-term follow-up) with a sample of approximately 1,000 adults each wave. Using concentration indices (CI), income-related health inequalities for three outcomes (physical activity, mental wellbeing and quality of life) were measured. A regression-based decomposition of concentration index examined the contribution of sociodemographic factors to the observed inequalities underpinning each outcome over time. ResultsAcross three waves, there was widening of inequalities over the 15-year period across all three health outcomes, with those from high-income groups reported higher levels of physical activity (CI=0.33, SE=0.026), better mental wellbeing (CI=0.03, SE=0.003), and better quality of life (CI=0.09, SE=0.008). The widening inequalities mainly occurred during the construction phase of CCG (2010-2017) and remained stable post-intervention (2017-2023). Decomposition analysis revealed that the pro-poor concentration of long-term illness and unemployment was the key driver that together explained approximately 51%-76% of the inequalities. ConclusionThe CCG was limited in reducing health inequalities which were mainly driven by long-term illness and unemployment - factors beyond the direct scope of the UGBS intervention - resulting in low-income groups likely to fall further behind the wealthier groups. The widening of inequality is consistent with findings from other public interventions that did not have a primary equity focus.

Background: The two-child benefit cap, implemented in April 2017, restricted Universal Credit and Child Tax Credit to the first two children in households with three or more children. We evaluate the impact of the two-child benefit cap on parental mental, general, and financial health, as well as investigate how this may differ in particular sociodemographic and economic subgroups based on sex, ethnicity and income. Methods: Data was obtained from parents (youngest child aged 5 or under) in the UK Household Longitudinal Survey from 2009 to 2023. Outcomes included parental mental health (psychological distress and life satisfaction), general health (health-related quality of life (HRQoL), self-rated health and health satisfaction), and financial health (current financial situation and financial outlook). We used complementary policy evaluation methods with different strengths and assumptions to triangulate evidence and strengthen inference: interrupted time series (ITS), difference-in-differences (DiD) and controlled time series analysis (CITS). Subgroup analyses were stratified by sex, ethnicity, and income. Findings: Across methods, findings consistently indicate that the policy worsened life satisfaction, self-rated health, health satisfaction, and financial health for parents of 3+ children. Findings were less consistent across methods for psychological distress and HRQoL. For instance, for psychological distress ITS and CITS indicate adverse impacts of the policy; however, one DiD model did not support this conclusion due to greater average worsening in the control group between the pre- and post-periods. Subgroup analyses indicate greater mental health and general health impacts in lower income, male and ethnic minority parents; while financial health was negatively impacted in all subgroups examined. Conclusions: Using repeated cross-sectional panel data and triangulating across causal inference methods, we conclude that the two-child benefit cap in the UK had a measurable adverse impact on most health outcomes examined, with worse outcomes for male, lower income and ethnic minority parents.

Background Heatwaves increasingly threaten public health in the Mediterranean region, and Greece is among the hardest hit countries. Yet evidence on long-term adaptation, spatial vulnerability, and the contribution of human-induced climate change to heatwave-related mortality in Greece remains limited. Methods We analysed 2,144,957 all cause deaths in Greece during 2000 and 2019 using a time stratified case crossover design. We derived population weighted daily maximum temperatures at NUTS3 level from ERA5 reanalysis and WorldPop. We applied six heatwave definitions (HD1-HD6) varying by duration (2 or 3 consecutive days or more) and thresholds (90th, 95th, 99th percentiles). We fitted Bayesian hierarchical Poisson models to estimate heatwave-mortality associations varying by space and time. We additionally adjusted for relative humidity and national. We then combined these estimates with probabilistic climate attribution methods to quantify the number and proportion of heatwave-related deaths attributable to human induced climate change. Results Heatwaves raised mortality consistently, with relative risks from 1.08 (95% CrI (Credible Interval): 1.07- 1.09; HD1) to 1.15 (1.11- 1.20; HD6). Risks increased with heatwave intensity and duration and peaked among females and adults aged 85 years and older. We did not detect a consistent temporal decline in risk or marked spatial heterogeneity. Human induced climate accounted for 51-94% of heatwave related deaths across definitions. The proportion attributable to climate change rose over time. Conclusions Heatwaves already impose a major mortality burden in Greece, with more than half driven by anthropogenic climate change and little evidence of population level adaptation. These findings call for rapid emissions reductions and targeted adaptation, including stronger heat health warning systems and protection of vulnerable groups.

Objective To examine ethnic differences in the incidence and age-related trajectories of childhood health conditions from birth to adolescence within a UK birth cohort. Design Longitudinal population-based birth cohort with linkage to primary care electronic health records. Setting Born in Bradford (BiB), a multi-ethnic birth cohort in Bradford, UK. Participants 13,282 children (36% White British, 44% Pakistani British, 20% other ethnicity) born 2007 to 2011 with linked primary care records and over 1 year follow-up. Main outcome measures Incident diagnoses of atopic conditions (asthma, eczema, allergic rhinoconjunctivitis), overweight/obesity, common mental health disorders (anxiety, depression), and neurodevelopmental disorders (including ADHD and autism). Incidence rates, Kaplan-Meier cumulative incidence, and Cox regression hazards ratios (HRs) were estimated. Results Atopic conditions emerged early (median onset 5 to 6 years) and were more common among Pakistani British children, with higher hazards of eczema (HR 2.29, 95% CI 2.01 to 2.61), allergic rhinoconjunctivitis (HR 2.27, 2.00 to 2.58), and asthma (HR 1.35, 1.22 to 1.50). Overweight/ obesity developed later (median 9 to 10 years) and were also more frequent in Pakistani British children (HR 1.25, 1.16 to 1.35). In contrast, common mental health disorders emerged predominantly in early adolescence (median around 13 years), and both mental health and neurodevelopmental diagnoses were more frequently recorded among White British children; Pakistani British children had lower hazards of neurodevelopmental diagnoses (HR 0.28, 0.23 to 0.35) and mental health disorders (HR 0.53, 0.41 to 0.70). Conclusions Ethnic differences in childhood health are condition-specific and vary by age of onset, emerging at distinct stages. These findings inform the timing of prevention, service planning, and research into underlying mechanism.

Background Education outcomes predict life chances. However, poverty, ill-health and disability are barriers to achievement. We examined determinants of academic attainment of children with and without major congenital anomalies in state-funded mainstream schools at ages 11 and 16 (key stages [KS] 2 and 4). Methods and Findings Routinely collected electronic records for children born in Wales 01/01/1998-31/12/2007 until 31/12/2019 were linked in the Secure Anonymised Information Linkage (SAIL) Databank. Education outcomes were explored using logistic regression, adjusting for: anomalies, maternal and child deprivation, prescribing, hospitalisation, gestation length, childs sex, and special education needs (SEN) provision. Children with anomalies were less likely to achieve academic standards: however, attainment was more closely associated with affluence. At age 11, 81.87% (7167/8754) with and 93.80% (232,450/247,814) without anomalies passed (odds ratio [OR] 0.30, 95% confidence intervals [CI] 0.28-0.32). At age 16, 46.76% (2070/4427) with and 56.10% (69,732/124,300) without anomalies achieved 5 General Certificates of Secondary Education (GCSEs) at grades C-A* including English/Welsh, Maths and Science (EWMS) (OR 0.69, 0.65-0.73). Discrepancies narrowed in adjusted analyses, particularly when SEN provision was accounted: aOR 0.72 (0.66-0.78) at KS2, and aOR 0.93, (0.87-1.00) for 5 GCSEs C-A* with EWMS. These GCSEs were achieved by 29.65% (307/1034) children with anomalies and 38.42% (10,875/28,305) of unaffected children in the most deprived quintile{dagger}: in the most affluent quintile, figures were 67.57% (547/810) and 74.98% (16,978/22,644). Children with anomalies, receiving maximum SEN support, eligible for Free School Meals (FSM) were the least successful: 5/192 (2.6%) passed 5 GCSEs C-A* with EWMS, as did 37/354 (10.4%) ineligible for FSM. The strongest associations with these GCSEs were SEN statements (aOR 0.07, 0.06-0.07), FSM eligibility (aOR 0.39, 0.37-0.41), and epilepsy (aOR 0.60, 0.45-0.80). However, data were unavailable for 15-18% of children, mainly those educated outside mainstream schools, and some co-morbidities. Generalisation of findings to other countries rests with readers. Conclusions Many children with anomalies from affluent households succeeded. The children left behind lived with poverty and ill-health from congenital anomalies and/or epilepsy. SEN provision mitigated the impact of disadvantage, but poor children with anomalies were unlikely to succeed. {dagger}taking maternal Welsh Index of Multiple Deprivation (WIMD) 2014 at birth.

Background: Understanding the underlying mechanisms for differences in vaccine uptake between migrants and non-migrants is crucial in order to design targeted interventions encouraging vaccination and to ensure vaccine-related equity. Therefore, this study examined to what extent migration-related disparities in COVID-19 vaccination were associated with psychological factors, based on the established 5C model of vaccine behaviour (Confidence, Complacency, Constraints, Calculation, Collective Responsibility). Methods: Data were obtained from the German study "Corona Monitoring Nationwide - Wave 2" (RKI-SOEP-2 study), which was carried out between November 2021 and March 2022. The association between COVID-19 vaccination and migration status, while considering the psychological factors, was investigated using multivariable binary logistic regressions. A decomposition analysis (Karlson-Holm-Breen method) was conducted to examine the extent to which migration-related disparities in vaccine uptake were associated with the psychological factors of the 5C framework. Results: Migrants were less likely to be vaccinated against COVID-19 compared to non-migrants, especially participants from the Middle East and North Africa (MENA) region. Our decomposition showed that almost two-thirds of the disparities in COVID-19 vaccine uptake between migrants and non-migrants were associated with the psychological factors (first-generation: 61.2%, second-generation: 64.2%). Confidence in safety of the vaccine was the most relevant factor in the 5C framework. Furthermore, the results highlighted the importance of a differentiated analysis regarding country of origin: While the 5C model accounted for only 19.4% of the difference between participants from the MENA region and non-migrants, the proportion for participants from Eastern Europe was 73.5%, suggesting that the underlying mechanisms for the lower uptake in the MENA group need further investigation. Conclusions: Overall, migration-related disparities in COVID-19 vaccination were significantly associated with differences in psychological factors of vaccine behaviour. To increase vaccine acceptance within the heterogeneous group of migrants in general, tailored and proactive health communication interventions are needed.

Previous research links Adverse Childhood Experiences (ACEs) with problem gambling, but most studies rely on retrospective reporting and focus narrowly on maltreatment, overlooking adversities such as parental mental health issues. Using data on 3794 young adults in the Avon Longitudinal Study of Parents and Children, we examined longitudinal associations between 10 prospectively measured ACEs (individually and cumulatively), and moderate-risk/problem gambling (Problem Gambling Severity Index >=3) at ages 17, 20 and 24, adjusted for socioeconomic and other background factors. Population attributable fractions (PAFs) estimated proportions of cases potentially attributable to ACEs. Most ACEs were associated with higher odds of moderate-risk/problem gambling across ages (24/30 estimates) after adjustment, though effect sizes were generally small (median adjusted odds ratio [aOR] 1.31, interquartile range 1.24-1.59), and confidence intervals (CIs) wide. Sexual abuse showed the strongest association (aORs 2.4-4.2, CIs 0.5-10.5), while bullying and parental conviction were associated at ages 17 and 20 only, parental separation age 24 only. Evidence for a dose-response relationship was weak. PAFs suggested ACEs accounted for up to 12% of moderate-risk/problem gambling cases. These findings highlight potential impacts of ACEs on later gambling behaviour, but imprecise estimates suggest findings should be interpreted cautiously and strengthened through larger datasets and meta-analyses.

Aims Type 2 diabetes mellitus (T2DM) increases risks of stroke and dementia, yet these risks vary across individuals. We hypothesized that clinically derived diabetes subtypes contribute to this heterogeneity. We aimed to identify data-driven subtypes using routine clinical features and examine their associations with dementia, stroke, mortality, and brain structure. Methods K-means clustering was applied to 14,353 UK Biobank participants with prevalent T2DM using age at diagnosis, body mass index, glycated hemoglobin, insulin resistance (triglyceride/HDL ratio), systolic blood pressure, and C-reactive protein. Cox models assessed associations with incident dementia (all-cause, Alzheimers disease [AD], vascular dementia [VaD]), stroke (all-cause, ischemic [IS], intracerebral hemorrhage [ICH]), and mortality. Brain MRI outcomes were analyzed in 779 participants using inverse probability-weighted linear regression. Results Three subtypes were identified: severe obesity-related inflammatory diabetes (SOID), mild metabolic diabetes (MMD, reference), and mild age-related hypertension-predominant diabetes (MARD-H). Compared with MMD, SOID showed higher risks of dementia (HR 1.24), VaD (HR 1.42), stroke (HR 1.38), IS (HR 1.48), all-cause mortality (HR 1.59), and cardiovascular death (HR 1.88). MRI showed lower gray matter volume and greater white matter hyperintensity burden in SOID. Conclusions Data-driven subtyping revealed heterogeneity in neurological risk in T2DM, with the obesity-inflammation subtype showing elevated vascular and neuroimaging risk.

BackgroundIn England, the burden of respiratory infections varies by ethnicity, contributing to health inequalities, but the role of additional demographic factors remains underexplored. We quantified how differences in social mixing and demographic characteristics between ethnic groups cause inequalities in transmission dynamics. MethodsWe analysed the association between the ethnicity and the number of contacts of 12,484 participants in the 2024-2025 Reconnect social contact survey, using a negative binomial regression model. We simulated respiratory pathogen epidemics using a compartmental model stratified by age, ethnicity, and contact levels, at a national level and in major cities in England. FindingsAfter adjusting for demographic variables, participants of Black and Mixed ethnicities had more contacts than those of White ethnicity (rate ratios (RR): 1.18 [95% Credible Interval (CI): 1.11-1.26], and 1.31 [95% CI: 1.14-1.52]). Participants of Asian ethnicity had fewer contacts (RR: 0.85 [95% CI: 0.79-0.91]). In national-level simulations, individuals of White ethnicity had the lowest attack rates due to demographic differences and mixing patterns. Local demographic structures changed simulated dynamics: attack rates in individuals of Black and Mixed ethnicities were approximately double those of White ethnicity in Birmingham, but less than 60% higher in Liverpool. InterpretationDemographic characteristics and mixing patterns create inequalities in transmission dynamics between ethnicities, while local demographic characteristics and pathogen infectiousness change the expected relative burden. To ensure mitigation strategies are effective and equitable, their evaluation must explicitly account for inequalities arising from local context. FundingMedical Research Council, National Institute for Health and Care Research, Wellcome Trust Research in context Evidence before this studyWe searched PubMed for population-based studies quantifying differences in respiratory infections between ethnic groups, up to 1 April 2026, with no language restrictions. Keywords included: (respiratory pathogens OR influenza OR COVID-19) AND (ethnic* OR race) AND (inequ*) AND (compartmental model OR incidence rate ratio OR hazard ratio). We excluded studies that focused on non-respiratory pathogens (e.g. looking at consequences of COVID-19 on incidence of other pathogens). A population-based cohort study showed that influenza infection risk was higher in South Asian, Black, and Mixed ethnic groups compared to White ethnicity in England. Another population-based cohort study highlighted that during the first wave of COVID-19 in England, the South Asian, Black, and Mixed ethnic groups were more likely to test positive and to be hospitalised than the White ethnic group. Census data in England showed that the distributions of age, household size, household income and employment status differed between ethnic groups, and the recent Reconnect social contact surveys highlighted the impact of each demographic factor on the participants number of contacts. Added value of this studyOur study shows that social contact patterns, mixing, and demographic structure all lead to unequal infection risk between ethnic groups in respiratory pathogen epidemics. Using the largest available social contact survey in England, we show that both the average number of contacts and the proportion of high-contact individuals varied by ethnic group, even after adjusting for participants demographics. These differences, together with mixing patterns and age structure, led to lower expected incidence among individuals of White ethnicity than in all other ethnic groups in simulated outbreaks. The level of inequality between ethnic groups changed when we used different values of pathogen transmissibility. Finally, as ethnic composition and population structure differ between cities in England, our results show differences in expected inequalities at a local level. Implications of all the available evidenceInequalities in infection risk between ethnic groups are context- and pathogen-dependent. They arise from both local population structure and contact patterns. Detailed information on mixing between groups and population structure is needed to accurately measure group-specific infection risk. These findings indicate that public health interventions based only on national-level estimates conceal regional variation in risk and may ultimately increase inequalities. Public health interventions need to be tailored to local contexts to be equitable and effective. Finally, our findings provide a foundation for understanding the progression from infection-risk inequalities to disparities in disease presentation and clinical outcomes.

Objectives: Longer lifespans lead to longer time on retirement, despite the efforts to raise the retirement age. Therefore, it is important to study how the retirement years can be spent without diseases. This study examined socioeconomic and sociodemographic differences in healthy years spent on retirement. Methods: We followed a cohort of retired Finnish municipal employees (N=4231, average follow-up 15.4 years) on national administrative registers for major chronic diseases: cancer, coronary heart disease, cerebrovascular disease, diabetes, asthma or chronic obstructive pulmonary disease, dementia, mental disorders, and alcohol-related disorders. Median healthy years on retirement and age at first occurrence of illness (ICD-10 and ATC-based) in each combination of sex, occupational class, and age of retirement were predicted using Royston-Parmar models. Prevalence rates for each diagnostic group were calculated. Results: Most healthy years on retirement were spent by women having worked in semi-professional jobs who retired at age 60-62 (median predicted healthy years 11.6, 95% CI 10.4-12.7). The least healthy years on retirement were spent by men having worked in routine non-manual jobs who retired after age 62 (median predicted healthy years 6.5, 95% CI 4.4-9.5). Diabetes was slightly more common among lower occupational class women, and dementia among manual working women having retired at age 60-62. Discussion: Healthy years on retirement are not enjoyed equally by women and men and those who retire early or later. Policies aiming to increase the retirement age should consider the effects of these gaps on retirees and the equitability of those effects.

Background: Potassium is involved in multiple physiological processes in the body, and hyperkalemia is a common, potentially life-threatening condition. Objective: The aim of our study was to examine the association between plasma potassium levels, and 30-day mortality in patients presenting to an emergency department with normo- or hyperkalemia. Design: Retrospective Cohort study. Setting: Emergency Departments in the Capital region of Denmark Participants: Persons attending Emergency Departments in the Capital Region of Denmark from 2017--2021 with a plasma potassium level of at least 3.5 mM measured within 4 hours after arrival. Measurements: The study was based on data from Danish National Registries and electronic patient records. We performed Kaplan-Meier survival analyses and unadjusted and adjusted cox regression analyses utilizing plasma [K+] 3.5--4.4 mM as the reference group for 30-day mortality hazard ratios (HRs). Results: A total of 248,453 patients were included with a median age of 60 years (Q1;Q3 42;75), and 6,959 (2.8%) died within 30 days. Mortality was 2.2% for potassium level 3.5--4.4 mM, 6.9% for 4.5--4.9 mM, 17.1% for 5.0--5.9 mM, and 26.9% for [≥] 6.0 mM. Unadjusted 30-day HRs were 3.2 (95%CI: 3.0--3.4) for [K+] 4.5--4.9 mM, 8.6 (95%CI: 7.9--9.3) for [K+] 5.0--5.9 mM, and 14.7 (95%CI: 12.5--17.0) for [K+] [≥]6.0 mM. Adjusted HRs were 1.4 (1.3--1.5), 2.10 (1.9--2.3), and 2.4 (2.0--2.8), respectively. Limitations: Risk of residual confounding. Missing data. No access to data regarding in-hospital treatment. Conclusion: Plasma potassium levels above 4.4 mM were associated with increased 30-day mortality among patients presenting to emergency departments. Primary funding source: Department of Emergency Medicine, Copenhagen University hospital, Bispebjerg and Frederiksberg Hospital.

BackgroundIn England, individuals with chronic liver disease (CLD) are among those with the lowest seasonal influenza vaccine uptake despite being at elevated risk of severe influenza. We examined the relationship between CLD severity and aetiology, and influenza vaccine uptake in England. MethodsA retrospective cohort study of adults (18-115 years) using Clinical Practice Research Datalink Aurum primary care data was conducted for five seasons (2019/20-2023/24). Poisson regression was used to estimate rates of uptake by CLD severity (clinical diagnoses categorised as low, moderate, or severe) and aetiology (alcohol-related, viral-related, and diagnoses in the Green Book guidelines). FindingsThere were 182,174-277,470 with CLD per cohort. Among those who were additionally age-eligible for vaccination, uptake was 71{middle dot}1-79{middle dot}7% compared to 30{middle dot}9-40{middle dot}5% in those not additionally age-eligible. Among individuals below age eligibility without other comorbidities, severity was associated with higher uptake (incidence rate ratio [IRR] moderate 1{middle dot}80, 95% CI 1{middle dot}69-1{middle dot}90; severe 1{middle dot}95, 95% CI 1{middle dot}84-2{middle dot}08 in 2023/24); there was no effect in those with at least one additional comorbidity (moderate 1{middle dot}05, 95% CI 0{middle dot}99-1{middle dot}10; severe 1{middle dot}05, 95% CI 1{middle dot}01-1{middle dot}09). Alcohol- and viral-related aetiology were also associated with increased uptake in those not additionally age-eligible. Among individuals meeting age eligibility without additional comorbidities, severity was associated with a reduced uptake (moderate 0{middle dot}81, 95% CI 0{middle dot}73-0{middle dot}90; severe 0{middle dot}79, 95% CI 0{middle dot}74-0{middle dot}85), with attenuation in those with additional comorbidities (moderate 0{middle dot}99, 95% CI 0{middle dot}94-1{middle dot}04; severe 0{middle dot}91, 95% CI 0{middle dot}89-0{middle dot}94). InterpretationCLD severity and aetiology were important determinants of uptake in the absence of additional indications for influenza vaccination. Future research should prioritise understanding facilitators and barriers to vaccine uptake in individuals with CLD, particularly for those at highest risk of severe infection. FundingNIHR Health Protection Research Unit in Vaccines and Immunisation (NIHR200929/NIHR207408). Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed up to June 2025 using the terms "chronic liver disease", "cirrhosis", "hepatitis", "influenza vaccination", "seasonal influenza", and "vaccine uptake". Previous research, including national data from England, has shown that people with chronic liver disease tend to have lower seasonal influenza vaccine uptake than individuals with other medical comorbidities which qualify for vaccination such as diabetes, chronic kidney disease or immunosuppression. The reasons for low influenza vaccine uptake in people with chronic liver disease are not well understood, and it is therefore difficult for vaccination providers, principally primary care services in England, to tailor interventions aimed to increase uptake. Qualitative research involving individuals aged less than 65 years living in England with clinical risk comorbidities, most commonly diabetes, found that chronic disease management pathways inconsistently provided information about the importance of influenza vaccination as part of chronic disease management. Individuals with long-term conditions reported low perceived risk of influenza infection and limited awareness of vaccine benefits as important reasons for non-uptake. We hypothesised that the severity and aetiology of chronic liver disease may be important determinants of uptake. Added value of this studyWe conducted a population-based study to examine how chronic liver disease severity and aetiology influence seasonal influenza vaccine uptake in adults in England. Using primary care electronic health record data from five consecutive influenza seasons (2019/20-2023/24), we found that more severe chronic liver disease was associated with a substantial increase in vaccine uptake in those without additional indications for seasonal influenza vaccination (age-based eligibility or other qualifying clinical risk comorbidities). Alcohol- and viral-related aetiology were also associated with increased uptake in those who were not additionally age-eligible for vaccination. In contrast, severity, alcohol- and viral-related underlying aetiology were associated with a modest reduction in uptake for individuals with chronic liver disease who also qualified for vaccination due to age. Implications of all the available evidenceDespite clear clinical vulnerability to infection and a substantially elevated risk of morbidity and mortality following infection, a large proportion of adults with chronic liver disease, particularly those aged under 65 years, remain unvaccinated against seasonal influenza each year. This study suggests that chronic liver disease severity and underlying aetiology are important determinants of uptake in individuals not meeting age-based vaccine eligibility, particularly in those without additional clinical risk comorbidities. This could be because of differing perceptions of influenza risk, or due to varying degrees of interaction with healthcare specialists as part of chronic disease management. In individuals who met age-based vaccination eligibility, the negative effect of severity on influenza vaccine uptake may reflect greater barriers to accessing vaccination services by those with more complex health needs, or competing medical priorities for long-term condition management during consultations. To inform targeted vaccination strategies, future research should aim to understand the specific facilitators and barriers to influenza vaccination experienced by individuals with chronic liver disease. This should include perspectives of individuals with different disease severity, across different age groups, in those with and without additional co-morbidities.

Socioeconomic inequalities in health and well-being are a major public health concern, particularly in ageing populations. Education is a key determinant shaping multiple aspects of health outcomes. We used cross-sectional data from wave 9 of the German sample (n=4,148) of the Survey of Health, Ageing and Retirement in Europe (SHARE) to test whether formal education is associated with well-being in later adulthood, with health literacy, self-rated health, and preventive health behaviours as possible mediators. Our results showed that education was positively associated with greater well-being, but only via indirect pathways. Specifically, self-rated health, health literacy, and fruit and vegetable consumption mediated the relationship between education and well-being accounting for 54.7, 24.7, and 12.6 percent of the total effect, respectively. In addition, there were significant positive correlations between education and health literacy, as well as high-intensity physical activity, daily fruit and vegetable consumption, more preventive health check-ups, and less smoking. In contrast, alcohol consumption was more common among those with higher levels of education. All health behaviours and health literacy were correlated directly or indirectly (i.e., mediated by health) with well-being. These findings highlight the importance of examining indirect pathways linking education to well-being in later life. Interventions aimed at improving health literacy and promoting healthy behaviours may help reduce educational inequalities in quality of life among older adults.

Context: In the UK, and in other countries, people living with a terminal illness are eligible for financial support to help with the costs of serious illness and to support their dignity and independence. This study investigates the take-up of benefits in the last year of life and identifies sociodemographic, clinical, and geographical factors associated with underclaiming. Methods: Retrospective cohort study using linked mortality, Census and benefits data for all people who died aged 16+ from chronic illnesses in England and Wales between 1 May 2018 and 30 April 2021. Outcome was receipt of non-means tested disability benefits in the last 12 months of life. We describe geographical variation in take up, and association with sociodemographic, clinical and geographical exposures using Poisson models. Findings: Our population included 1,049,493 eligible decedents, with an overall take-up rate of 65.9%. After adjusting for sociodemographic factors, variation in take-up by cause of death was wide: liver disease 44% (95% CI 43, 45%), heart failure 52% (51, 52%), cancer 62% (61, 62%), dementia 75% (74, 75%), and neurodegenerative diseases 90% (88, 91%). Across Local Authorities, the age-and-sex-standardised take-up varied from 53% to 78%; rates were generally higher in more deprived areas, but not uniformly. Conclusions: In England and Wales, 1 in 3 people who die from expected causes (120,000 each year) do not receive the benefits for which they are eligible. Our analysis uses novel data linkages and highlights clinical and sociodemographic groups and geographical areas that could be targeted with proactive take-up initiatives.

Background: Despite optimal lipid-lowering and antithrombotic therapy, substantial residual cardiovascular risk persists in established atherosclerotic cardiovascular disease (ASCVD), partly driven by chronic vascular inflammation. Methods: Systematic review and meta-analysis of RCTs comparing colchicine to placebo or no treatment in adults with established ASCVD. Searches on March 21, 2026 (PubMed, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP). PROSPERO CRD420261346516. Primary outcome: 4-point MACE (CV death, MI, stroke, urgent revascularization). DerSimonian-Laird random-effects with HKSJ adjustment. Exploratory trial-level meta-regression: time-to-initiation (TTI) and cumulative dose as continuous moderators. Results: DL pooled HR for 4-point MACE: 0.68 (95% CI 0.51-0.89; p=0.0060). HKSJ-adjusted HR: 0.68 (95% CI 0.27-1.70; p=0.3018). Substantial heterogeneity (I2=81.4%; 95% prediction interval 0.29-1.57, crossing 1.0). Exploratory meta-regression: TTI (beta=-0.00187/day, p=0.003) and cumulative dose (beta=-0.00163/mg-day, p=0.0003; k=5, explicitly underpowered). Non-CV mortality: HR 1.07 (0.76-1.50; p=0.694). GI discontinuation: pooled RR 1.95 (1.09-3.48; p=0.024). GRADE certainty: Moderate (4-point MACE). Conclusions: Low-dose colchicine is associated with reduced 4-point MACE in ASCVD (DL HR 0.68; HKSJ HR 0.68). The substantial heterogeneity and wide prediction interval indicate that effect size varies substantially across clinical settings. The divergence between CLEAR SYNERGY (acute; HR 0.99) and sub-acute/chronic trials (HR 0.33-0.77) drives heterogeneity. Meta-regression suggests TTI and cumulative exposure may be key moderators but is underpowered. The non-CV mortality signal is not confirmed. This analysis informs precision anti-inflammatory prescribing in ASCVD.

Childhood weight development, especially overweight and obesity, has been associated with mental health, but their dynamic, causal relationships, and whether these differ by sex, remain unclear. We applied causal discovery to data from the Danish National Birth Cohort (n=67,593) spanning six periods from pregnancy to late adolescence and considering 67 variables related to child and parental weight, mental health, lifestyle, and socio-economic factors. We found no statistically significant difference between the causal graphs for boys and girls (P=0.079). The data-driven models found causal influence of childhood weight on subsequent weight status. Mental health pathways were exclusively within or across adjacent periods and centered on early adolescent stress. We examined the interplay between a subset of mental health variables, containing information on externalizing and internalizing problems, and weight, and found no direct causal pathway between the two processes. These findings suggest that observed links between weight and these mental health measures may be attributable to confounding. Our findings demonstrate the value of data-driven causal discovery in large cohort studies and how to test for differences in causal mechanisms across subgroups. Results are available in an interactive application, enabling future research to further explore the interplay between weight and mental health.