Trends in intentional and unintentional poisonings among older adults - A national register-based study in Sweden.

BACKGROUND: Among older people intentional poisoning outnumber unintentional ones. While there are indications that time trends differ by poisoning intent, studies are scarce. We assessed how the annual prevalence of intentional and unintentional poisoning changed over time, overall and by demographic groups. METHODS: We conducted a national open cohort study of individuals aged 50-100 years, resident in Sweden during 2005-2016. Individuals were followed up in population-based registers for their demographic and health attributes from 2006-2016. Annual prevalence of hospitalization and death by poisoning intent (unintentional vs. intentional or undetermined; ICD-10 definitions) were compiled for the categories of four demographic attributes (age, sex, marital status, and birth cohort "baby boomers"). The time trends were assessed by multinomial logistic regression with year as an independent variable. RESULTS: The annual overall prevalence of hospitalization and death by intentional poisonings consistently exceeded that of unintentional poisonings. There was a significant downward trend in intentional poisonings but not in unintentional ones. This difference in trends also applied when considering men and women separately, married and unmarried people, the young-old individuals (but not the older- or oldest-old ones), and the baby boomers and non-baby boomers. The largest demographic differences within intent were found between married and unmarried people, and the smallest one between men and women. CONCLUSION: As expected, the annual prevalence of intentional poisonings considerably exceed that of unintentional ones among Swedish older people. The recent trends reveal a significant reduction of intentional poisonings, consistent across a range of demographic attributes. The scope for action regarding this preventable cause of mortality and morbidity remains considerable.

Snus (Swedish smokeless tobacco) use and risk of stroke: pooled analyses of incidence and survival.

BACKGROUND: Snus is a moist smokeless tobacco product with high nicotine content. Its use has a short-term effect on the cardiovascular system, but the relationship between snus use and stroke is unclear. OBJECTIVE: The aim of this study was to assess the associations between use of snus and incidence of and survival after stroke, both overall and according to subtypes. METHODS: Pooled analyses of eight Swedish prospective cohort studies were conducted, including 130 485 men who never smoked. We estimated hazard ratios (HRs) with 95% confidence intervals (CIs) of incidence and death after diagnosis using Cox proportional hazard regression models and case fatality and survival using logistic regression and Kaplan-Meier methods, respectively. RESULTS: No associations were observed between the use of snus and the risk of overall stroke (HR 1.04, 95% CI 0.92-1.17) or of any of the stroke subtypes. The odds ratio (OR) of 28-day case fatality was 1.42 (95% CI 0.99-2.04) amongst users of snus who had experienced a stroke, and the HR of death during the follow-up period was 1.32 (95% CI 1.08-1.61). CONCLUSION: Use of snus was not associated with the risk of stroke. Hence, nicotine is unlikely to contribute importantly to the pathophysiology of stroke. However, case fatality was increased in snus users, compared with nonusers, but further studies are needed to determine any possible causal mechanisms.

School performance and the risk of suicide attempts in young adults: a longitudinal population-based study.

BACKGROUND: Poor school performance is strongly associated with attempted suicide, but the mechanisms underlying this association are uncertain. We examined this relationship and the extent to which it is explained by (i) adult health behaviours and (ii) social conditions. Furthermore, we examined the potential modifying role of previous suicidal thoughts in the relationship. METHOD: We conducted a longitudinal cohort study of 6146 individuals aged 18-33 years, recruited in 2002 and 2006 in Stockholm and resurveyed in 2007 and 2010 respectively. We estimated the risk of reported lifetime suicide attempts at follow-up among individuals without a history of suicide attempts at baseline and in relation to compulsory school-leaving grades, controlling for possible confounders and mediators. RESULTS: There were 91 cases of self-reported suicide attempts during the follow-up (5-year incidence of 1.5%). ORs ranged from 3.35 [95% confidence interval (CI) 1.88-5.96] for those in the lowest grade quartile to 2.60 (95% CI 1.48-4.57) and 1.76 (95% CI 0.99-3.13) for those in the second and third quartiles respectively. The relationship between school performance and risk of suicide attempts did not differ by sex. Adult health behaviours and social conditions marginally attenuated, but did not explain, the relationship. The gradient varied with baseline history of suicidal thoughts, and was found only among individuals without such a history. CONCLUSIONS: Poor school performance was found to predict suicide attempts among young adults without a history of suicidal thoughts. Adult health behaviours and social conditions did not explain this relationship. Instead, other factors linked with poor school performance, such as poor coping ability, may increase the risk of suicide attempts.

Steroid-sparing properties of sargramostim in patients with corticosteroid-dependent Crohn's disease: a randomised, double-blind, placebo-controlled, phase 2 study.

OBJECTIVE: Although treatment with corticosteroids induces remission in Crohn's disease, prolonged exposure to corticosteroids is undesirable. This randomised clinical trial evaluated the efficacy of recombinant human granulocyte-macrophage colony-stimulating factor (sargramostim), an activator of innate immunity, in corticosteroid-dependent patients with Crohn's disease. DESIGN: Patients were randomised in a 2:1 ratio, to sargramostim 6 microg/kg subcutaneously once daily or placebo for up to 22 weeks. The study consisted of (1) an adjunctive phase (weeks 1-4) in which patients received study drug plus corticosteroid therapy; (2) a forced corticosteroid tapering phase (weeks 4-14); and (3) an observation phase (4 weeks) in which patients received study drug plus prednisone < or =7.5 mg. The primary endpoint was corticosteroid-free remission (Crohn's Disease Activity Index (CDAI) < or =150) 4 weeks after corticosteroid elimination. Secondary endpoints were corticosteroid-free response (CDAI decreased by > or =100) and induction of remission in patients who reduced the dose of corticosteroid to 2.5-7.5 mg. RESULTS: Eighty-seven patients were randomised to sargramostim and 42 to placebo. Significantly more sargramostim-treated patients than placebo patients achieved corticosteroid-free remission (18.6% vs 4.9%; p = 0.03). Similar differences were seen for corticosteroid-free response and in patients who tapered corticosteroids to 2.5-7.5 mg/day. Sargramostim treatment was also associated with significant improvements in health-related quality of life. Patients who received sargramostim were more likely to experience musculoskeletal pain, injection site reactions and dyspnoea. CONCLUSIONS: Sargramostim was more effective than placebo for inducing corticosteroid-free remission in patients with Crohn's disease with corticosteroid dependence. Sargramostim may provide significant benefit in this population if these findings are confirmed.

A three-part study to investigate the incidence and potential etiologies of tadalafil-associated back pain or myalgia.

The potential mechanisms underlying back pain and/or myalgia experienced by men taking tadalafil were investigated. An integrated analysis of 10 placebo-controlled tadalafil clinical trials (N=1846) showed that the incidence of back pain and/or myalgia was 9.4% in patients receiving tadalafil 10 mg (N=394), 8.3% in patients receiving tadalafil 20 mg (N=883) and 3.7% in placebo-treated patients (N=569). One (0.3%) patient receiving tadalafil 10 mg, six (0.7%) patients receiving tadalafil 20 mg, and no patients receiving placebo discontinued treatment due to back pain and/or myalgia. In a prospective study in healthy volunteers, no substantial changes were observed in laboratory markers indicative of inflammation or muscle damage, and tadalafil did not affect renal plasma flow nor produce lumbar or gluteal myositis by positron emission tomography scan or magnetic resonance imaging. Although the mechanism of back pain and/or myalgia remains unknown, these events appear to be self-limiting and a general effect of phosphodiesterase 5 inhibition.

A 6-month study of the efficacy and safety of tadalafil in the treatment of erectile dysfunction: a randomised, double-blind, parallel-group, placebo-controlled study in Australian men.

The efficacy and safety of tadalafil for the treatment of erectile dysfunction (ED) were assessed in a 6-month, randomised, double-blind, placebo-controlled study. Australian men with mild, moderate or severe ED of organic, psychogenic or mixed aetiology were randomised to tadalafil 20 mg as needed (n = 93) or placebo (n = 47). Efficacy assessments included the international index of erectile function (IIEF) and the sexual encounter profile (SEP) diary. Tadalafil significantly improved erectile function compared with placebo (p < 0.001, all measures). At the end of the study, the mean per-patient proportion of successful sexual intercourse attempts (SEP question three) was 73.5% for patients treated with tadalafil and 26.8% for placebo-treated patients. Improved erections were reported by 78% of tadalafil-treated patients compared to 12.8% of placebo-treated patients. The most common treatment-emergent adverse events--headache and dyspepsia--were generally mild or moderate. Tadalafil was effective and well tolerated in Australian men with mild to severe ED.

Impact of diabetes mellitus on the severity of erectile dysfunction and response to treatment: analysis of data from tadalafil clinical trials.

AIMS/HYPOTHESIS: A retrospective analysis of pooled data from twelve placebo-controlled trials was conducted to characterise the efficacy and safety of tadalafil for the treatment of erectile dysfunction in men with diabetes compared with that in men without diabetes. METHODS: Patients were randomly allocated to tadalafil 10 mg, 20 mg, or placebo, taken as needed for 12 weeks. The study population comprised 637 men with diabetes (mean age 57 years) and 1681 men without diabetes (mean age 56 years). RESULTS: At baseline, patients with diabetes had more severe erectile dysfunction than patients without diabetes, with mean International Index of Erectile Function (IIEF) erectile function domain scores of 12.6 and 15.0 respectively (p<0.001). Compared with placebo, tadalafil 10 mg and 20 mg improved all primary efficacy outcomes in both patient groups (p<0.001). Men with diabetes receiving tadalafil 20 mg experienced a mean improvement of 7.4 in their IIEF erectile function domain score against baseline versus 0.9 for placebo (p<0.001). This group reported on average that 53% of their attempts at intercourse were successful, compared with 22% for placebo (p<0.001 for the change from baseline). Baseline IIEF erectile function domain scores correlated inversely with baseline HbA(1)c levels. The responses to tadalafil were similar regardless of levels of baseline glycaemic control, diabetic therapy received, or previous use of sildenafil. CONCLUSIONS/INTERPRETATION: Despite more severe baseline erectile dysfunction in men with diabetes, tadalafil was efficacious and well tolerated in this population. As reported for other phosphodiesterase 5 inhibitors, the response to tadalafil was slightly lower in men with diabetes than in men without diabetes.

A prospective study of fatal occupational accidents -- relationship to sleeping difficulties and occupational factors.

Very little is known about the association between sleep and (fatal) occupational accidents. This study investigated this relationship using register data of self-rated sleep difficulties, together with occupational and demographic characteristics. The variables were related to subsequent occupational fatal accidents. A national sample of 47,860 individuals was selected at regular intervals over a period of 20 years, and interviewed over the phone on issues related to work and health. The responses were linked to the cause of death register (suicides excluded) and the data set was subjected to a (multivariate) Cox regression survival analysis. One hundred and sixty six fatal occupational accidents occurred, and the significant predictors were: male vs. female: relative risk (RR)=2.30 with a 95% confidence interval (CI) of 1.56-3.38; difficulties in sleeping (past 2 weeks): RR=1.89 with CI=1.22-2.94; and non-day work: RR=1.63 with CI=1.09-2.45. No significant effect was seen for age, socio-economic group, hectic work, overtime (>50 h per week), or physically strenuous work. It was concluded that self-reported disturbed sleep is a predictor of accidental death at work, in addition to non-day work and male gender.

Self rated health: Is it as good a predictor of subsequent mortality among adults in lower as well as in higher social classes?

STUDY OBJECTIVE: To analyse the predictive power of self rated health for mortality in different socioeconomic groups. DESIGN, SETTING, PARTICIPANTS: Analysis of mortality rates and risk ratios of death during follow up among 170 223 respondents aged 16 years and above in the Swedish Survey of Living Conditions 1975-1997, in relation to self rated health stated at the interview, by age, sex, socioeconomic group, chronic illness and over time. MAIN RESULTS: There was a strong relation between poor self rated health and mortality, greater at younger ages, similar among men and women and among persons with and without a chronic illness. The relative relation between self rated health and subsequent death was stronger in higher than in lower socioeconomic groups, possibly because of the lower base mortality of these groups. However, the absolute mortality risk differences between persons reporting poor and good self rated health were similar across socioeconomic groups within each sex. The mortality risk difference between persons reporting poor and good self rated health was considerably higher among persons with a chronic illness than among persons without a chronic illness. The mortality risk among persons reporting poor health was increased for shorter (<2 years) as well as longer (10+ years) periods of follow up. CONCLUSIONS: The results suggest that poor self rated health is a strong predictor of subsequent mortality in all subgroups studied, and that self rated health therefore may be a useful outcome measure.

Decision latitude, job strain, and myocardial infarction: a study of working men in Stockholm. The SHEEP Study Group. Stockholm Heart epidemiology Program.

OBJECTIVES: This study examined the role of decision latitude and job strain in the etiology of a first myocardial infarction. METHODS: Eligible case patients were all full-time working men 45 to 64 years of age who suffered a first myocardial infarction during the period January 1992 to January 1993 in the greater Stockholm region. Referents were selected from the general population. Participation rates were 82% (case patients) and 75% (referents). RESULTS: Both inferred and self-reported low decision latitude were associated with increased risk of a first myocardial infarction, although this association was weakened after adjustment for social class. A decrease in inferred decision latitude during the 10 years preceding the myocardial infarction was associated with increased risk after all adjustments, including chest pain and social class. The combination of high self-reported demands and low self-reported decision latitude was an independent predictor of risk after all adjustments. CONCLUSIONS: Both negative change in inferred decision latitude and self-reported job strain are important risk indicators in men less than 55 years of age and in blue-collar workers.

Long-term psychosocial work environment and cardiovascular mortality among Swedish men.

OBJECTIVES: This study examined the effect of cumulative exposure to work organization--psychological demands, work control, and social support on prospectively measured cardiovascular disease mortality risk. METHODS: The source population was a national sample of 12517 subjects selected from the Swedish male population by Statistics Sweden in annual surveys between 1977 and 1981. Over a 14-year follow-up period, 521 deaths from cardiovascular disease were identified. A nested case-control design was used. Work environment exposure scores were assigned to cases and controls by linking lifetime job histories with a job exposure matrix. RESULTS: Conditional logistic regression analysis was used in examining cardiovascular mortality risk in relation to work exposure after adjustment for age, year last employed, smoking, exercise, education, social class, nationality, and physical job demands. In the final multi-variable analysis, workers with low work control had a relative risk of 1.83 (95% confidence interval [CI] = 1.19, 2.82) for cardiovascular mortality. Workers with combined exposure to low control and low support had a relative risk of 2.62 (95% CI=1.22, 5.61). CONCLUSIONS: These results indicate that long-term exposure to low work control is a risk factor for cardiovascular disease mortality.

PIP: The physical effects of aspects of work organization in Sweden is explored using data on a sample of 12,517 individuals. The data were drawn from official surveys carried out between 1977 and 1981 and followed up for 14 years. The results indicate that long-term exposure to such psychosocial factors as low levels of work control in the work place is associated with increased risk of mortality from cardiovascular disease.

Catamenial insulin reactions treated with a long-acting gonadotropin releasing hormone agonist.

Exacerbation of a variety of symptoms during the menstrual cycle is a well-described phenomenon. The exact causes of these changes are poorly understood, and no specific and efficacious therapy has been described. We successfully treated a patient with severe catamenial insulin reactions with a long-acting gonadotropin releasing hormone agonist to suppress menstrual function and added a combination of estrogen and progestin to offset any adverse effect of the resultant hypoestrogenemia for 1 year.

Lipid lowering through work stress reduction.

Swedish civil servants, who reported considerable stress while working in larger government authorities, were randomized into either a work stress reduction intervention or a control group. Four work units constituted the intervention group (n = 94). and one unit formed the control group (n = 35). Participants in the two groups were of similar age and two thirds were women. Psychosocial, lifestyle, and physiological assessments were made before, during, and after the 8-month intervention period. A significant decrease in apolipoprotein B/apolipoprotein A I ratio (p < 0.05) occurred in the intervention group but not in the control group. No changes were seen in either group in smoking, eating. exercise, relative weight, or other lifestyle factors. which could explain the lipid profile changes. Stimulation from and autonomy over work increased in the intervention group (p < 0.01) hut remained the same in the control group. Results have implications for the efficacy of work stress interventions in decreasing coronary risk.

Flocculation and loss of potency of human NPH insulin.

In late 1986, several vials of Humulin N (NPH human insulin, recombinant DNA origin) came to our attention because of a clumped, white coating on the inside of the vials. To determine the frequency of this phenomenon, we surveyed 100 consecutive patients who used Humulin N. Ten patients had encountered 21 vials of flocculated insulin in the previous 12 mo, reflecting an incidence of 1 per 72 vials. Insulin drawn from affected vials was markedly reduced in potency: 20.9 +/- 3.4 U/ml vs. the labeled potency of 100 U/ml. Several patients reporting flocculated insulin, including one hospitalized with ketoacidosis, experienced unusual and unexplained elevation in blood glucose concentration for several days before flocculation was observed. Patients who use NPH human insulin should be aware of this phenomenon and carefully inspect their vials for evidence of insulin precipitation before each injection.

Surveillance colonoscopy and biopsy in patients with ureterosigmoidostomy.

Colonoscopy with biopsy was included in the surveillance of 19 patients with ureterosigmoidostomy, because of the high incidence of colonic carcinoma reported in such cases. The patients were examined 1-6 times, at intervals of 1-2 years, 4-36 years after the urinary diversion. Random biopsies from the distal colon and rectum showed only discrete changes, and no dysplasia. Polyps with dysplastic changes were found close to ureteral anastomoses in three patients. For routine check-up of the rectosigmoid region and the ureteral implantation sites, examination with a flexible sigmoidoscope seems to be adequate and preferable, giving easy access to the risk zone for the development of cancer. Caution should be exercised, however, when performing biopsy close to the ureteral orifices.

Continent ileostomy. A follow-up study of 60 patients.

Sixty patients underwent proctocolectomy and received a continent ileostomy because of ulcerative colitis (50 cases) familial polyposis (7) or Crohn's disease (3), with no deaths at surgery or during follow-up (mean 4.5 years, range 3 months-10 years). Early complications were few and insignificant. Late complications (nipple-valve sliding and pouch ileitis) were more common, and 15 patients with valve sliding causing leakage had to undergo altogether 22 reoperations. Three reservoirs had to be removed because of refractory pouch ileitis. Modifications in nipple-valve construction in the last 40 cases diminished the problem of sliding. More than 90% of the patients reported improved quality of life after conversion of conventional to continent ileostomy. Continent ileostomy remains an excellent alternative to ileoanal anastomosis with proximal reservoir for patients who cannot accept conventional ileostomy or when an ileoanal anastomosis with reservoir functions unsatisfactorily or is otherwise unsuitable.

Long-term metabolic control with insulin pump therapy. Report of experience with 127 patients.

To determine the long-term efficacy of insulin-pump therapy, we analyzed trends in glycosylated hemoglobin concentrations in 127 patients with Type I diabetes using insulin pumps for periods ranging from 13 to 47 months. In the first year of pump therapy the average glycosylated hemoglobin concentration improved in 83 per cent of the patients, as compared with the value before pump therapy. Although only 11 of the 127 subjects had normal glycosylated hemoglobin values before pump therapy, 33 had a normal average value during the first full year of pump use (P = 0.0001). This favorable trend persisted for the three-year duration of the study. Seventeen of the 19 patients who subsequently discontinued insulin-pump therapy had improved glycosylated hemoglobin values during the period of pump use. Eleven of the 19 patients remained available for follow-up study; the glycosylated hemoglobin concentration became worse in 7 when they returned to conventional treatment. We conclude that the improvement in metabolic control repeatedly demonstrated in short-term studies with the insulin pump can be maintained for a period of years.