Heredity of pregnancy-related pelvic girdle pain in Sweden.

INTRODUCTION: Pelvic girdle pain during and after pregnancy is a major public health problem with significant daily problems for affected women and their families. There is now accumulating evidence that pregnancy-related pelvic girdle pain originates from the sacroiliac joints and the pubic symphysis as well as their extra-articular ligaments. However, the heritability of the disease remains to be determined. We hypothesized that there is an increased familial risk of pregnancy-related pelvic girdle pain. MATERIAL AND METHODS: A population-based national database linkage registry study of approximately 9.3 million individuals within 4.2 million families in Sweden with a recruitment period from 1997 to 2018. The Swedish Multi-generation register was used to find female pairs of twins, full siblings, half-siblings and first cousins where both in the pairs had a completed pregnancy. The outcome measure was diagnosis of pregnancy-related pelvic girdle pain (International Classification of Diseases-10 O26.7 [1997-2018]) in the first pregnancy. Data was obtained from the Swedish Hospital Discharge Register, the Swedish Outpatient Care Register, the Swedish Medical Birth Register, the Primary Healthcare Register, and Medical Treatment Register. Cox regression analysis was used to calculate adjusted estimated effect of the exposure variable familial history of pregnancy-related pelvic girdle pain on the outcome variable pregnancy-related pelvic girdle pain at first birth. RESULTS: From the registers, 1 010 064 women pregnant with their first child within 795 654 families were collected. In total, 109 147 women were diagnosed with pregnancy-related pelvic girdle pain. The adjusted hazard ratio for a familial risk of pregnancy-related pelvic girdle pain was 2.09 (95% CI 1.85-2.37) among twins (monozygotic and dizygotic), 1.78 (95% CI 1.74-1.82) in full siblings, 1.16 (95% CI 1.06-1.28) in half-siblings from the mother, 1.09 (95% CI 1.024-1.16) in half-siblings from the father and 1.09 (95% CI 1.07-1.12) in first cousins. CONCLUSIONS: This nationwide observational study showed a familial clustering of pregnancy-related pelvic girdle pain. The hazard ratio for the condition was associated with the degree of relatedness, suggesting that heredity factors contribute to the development of pregnancy-related pelvic girdle pain. There is no causal treatment available for pregnancy-related pelvic girdle pain and further studies are now encouraged to clarify the specific genetic factors that contribute to the disease and for future targeted interventions.

How does social support shape the association between depressive symptoms and labour market participation: a four-way decomposition.

BACKGROUND: Little is known about factors that may explain the association between depressive symptoms and poor labour market participation (LMP). The aim of this study is to examine the mediation and interaction effects of social support on the association between depressive symptoms and LMP. METHODS: Data were used from 985 participants (91% of the initial cohort) of the Northern Swedish Cohort, a longitudinal study of Swedish participants followed from adolescence throughout adulthood. Depressive symptoms were measured at age 16, social support at age 21 and LMP from age 30 to 43. Poor LMP was defined as being unemployed for a total of 6 months or more between the ages of 30 and 43. A four-way decomposition approach was applied to identify direct, mediation and interaction effects, together and separately. RESULTS: Both depressive symptoms during adolescence and social support at young adulthood were associated with poor LMP [odds ratio (OR) = 1.70, 95% confidence interval (CI) 1.17-2.47 and OR = 2.56, 95% CI 1.78-3.68 respectively]. The association between depressive symptoms and poor LMP was partially mediated by a lack of social support. No interaction effect of a lack of social support was found. CONCLUSION: The results suggest that depressive symptoms influence not only later LMP but also the intermediary level of social support, and in turn influencing later LMP. Recommendations for public health are to detect and treat depressive symptoms at an early stage and to focus on the development of social skills, facilitating the increased availability of social support, thereby improving future LMP.

The making of a professional digital caregiver: personalisation and friendliness as practices of humanisation.

The aim of this paper is to explore how a digital caregiver, developed within a Swedish interdisciplinary research project, is humanised through health-enhancing practices of personalisation and friendliness. The digital caregiver is developed for being used in older patients' homes to enhance their health. The paper explores how the participants (researchers and user study participants) of the research project navigate through the humanisation of technology in relation to practices of personalisation and friendliness. The participants were involved in a balancing act between making the digital caregiver person-like and friend-like enough to ensure the health of the patient. Simultaneously, trying to make the patients feel like as if they were interacting with someone rather than something-while at the same time not making the digital caregiver seem like a real person or a real friend. This illustrates the participants' discursive negotiations of the degree of humanisation the digital caregiver needs in order to promote the health of the patient. A discursive conflict was identified between a patient discourse of self-determination versus a healthcare professional discourse of authority and medical responsibility: whether the digital caregiver should follow the patient's health-related preferences or follow the healthcare professionals' health rules. Hence, a possible conflict between the patient and the digital caregiver might arise due to different understandings of friendliness and health; between friendliness (humanisation) as a health-enhancing practice governed by the patient or by the healthcare professionals (healthcare professionalism).

Group activity participation at age 21 and depressive symptoms during boom and recession in Sweden: a 20-year follow-up.

BACKGROUND: Organized group activities (e.g. sports or arts clubs) have long been noted as important developmental settings for youth, yet previous studies on the relationships between participation and mental health outcomes have focused on short-term effects among school-aged adolescents. The subsequent period of life, emerging adulthood, has been largely overlooked despite being another important life stage where individuals face new existential challenges and may benefit from group activity participation. The potential for macroeconomic conditions to modify these relationships has also not been considered. METHODS: Participants (n = 1654) comprise two cohorts, born in either 1965 (n = 968) or 1973 (n = 686), from the same middle-sized industrial town in Northern Sweden. Both cohorts completed detailed questionnaires at age 21 (macroeconomic boom for Cohort 65, recession for Cohort 73) and approximately 20 years follow-up (age 43 for Cohort 65, age 39 for Cohort 73). General linear models were used to assess concurrent and prospective associations between regular group activity participation and depressive symptoms, as well as the potential interaction with boom/recession. RESULTS: After controlling for sociodemographic factors, regular group activity participation at age 21 was associated with lower depressive symptoms, both concurrently and at follow-up. Those exposed to recession at age 21 reported higher depressive symptoms at the time but there was no interaction between cohort (boom/recession) and group activity participation. CONCLUSIONS: Regular group activity participation during emerging adulthood is associated with lower depressive symptoms uniformly in times of boom and recession. Beneficial effects of such participation may contribute to better mental health over 20 years.

Gender differences in healthcare management of depression: aspects of sick leave and treatment with psychoactive drugs in a Swedish setting.

Purpose: To investigate whether women and men diagnosed with depressive disorder were managed equally in terms of being sick-leave certified and being prescribed psychoactive drugs. Materials and methods: Data from all patients diagnosed with depression during 2010-2015 in Uppsala county, Sweden (n = 19 448) were used to investigate associations between gender and issued sick-leave certificate, prescriptions of anti-depressants, anxiolytics, hypnotics and sedatives, and cognitive behavioral psychotherapy referrals, at different time points up till 180 days after diagnosis. Results: At diagnosis date, 50.1% were prescribed antidepressants; 14.2% anxiolytics; 13.3% hypnotics or sedatives. Corresponding proportion regarding issue of sick-leave certificate among working aged (18-64 years) was 16.6%. Men had higher odds than women of being prescribed antidepressants (OR 1.16; 95% CI 1.09-1.24); anxiolytics (1.10; 95% CI 1.02-1.21), hypnotics and sedatives (OR 1.09; 95% CI 1.00-1.19) and lower odds (among those aged 18-64 years) of being sick-leave certified (OR 0.90; 95% CI 0.82-0.98) in adjusted regression models. There were subtle changes in ORs for outcomes at 3- and 6-month follow-up periods. Conclusions: Men had somewhat higher odds of being prescribed psychoactive drugs and slightly lower odds of being sick-leave certified as compared to women at date when diagnosed with depression. The absolute differences were, however, small and the overall conclusion is that women and men with current diagnosed depressive episode/recurrent depressive disorder are generally managed likewise regarding sick leave and psychoactive treatment.

Case fatality of myocardial infarction among shift workers.

PURPOSE: Shift work has been associated with an excess risk of cardiovascular disease (CVD) and more specifically myocardial infarction (MI). The majority of the studies that found a positive association between shift work and CVD have been based on incidence data. The results from studies on cardiovascular-related mortality among shift workers have shown little or no elevated mortality associated with shift work. None of the previous studies have analysed short-term mortality (case fatality) after MI. Therefore, we investigated whether shift work is associated with increased case fatality after MI compared with day workers. METHODS: Data on incident cases with first MI were obtained from case-control study conducted in two geographical sites in Sweden (Stockholm Heart Epidemiology Program and Västernorrland Heart Epidemiology Program), including 1,542 cases (1,147 men and 395 women) of MI with complete working time information and 65 years or younger. Case fatality was defined as death within 28 days of onset of MI. Risk estimates were calculated using logistic regression. RESULTS: The crude odds ratios for case fatality among male shift workers were 1.63 [95 % confidence interval (CI) 1.12, 2.38] and 0.56 (95 % CI 0.26, 1.18) for female shift workers compared with day workers. Adjustments for established cardiovascular risk factors such as diabetes type II and socio-economic status did not alter the results. CONCLUSION: Shift work was associated with increased risk of case fatality among male shift workers after the first MI.

The Incidence of Problem Gambling in a Representative Cohort of Swedish Female and Male 16-24 Year-Olds by Socio-demographic Characteristics, in Comparison with 25-44 Year-Olds.

We aimed to estimate the incidence of a first episode of problem gambling among Swedish 16-24 year-olds by demographic and socio-economic characteristics, and to compare the incidence between 16-24 and 25-44 year-olds, and between young women and men. Other aims were to estimate the proportions of recovery and incidence in recurrent problem gambling, and prevalence of problem gambling among 16-44 year-olds in Sweden. We selected 4,358 participants aged 16-44 from the nationally representative Swedish Longitudinal Gambling Study in 2008/2009 and 2009/2010. The primary outcome measure was a first episode of problem gambling during 12 months before the follow-up as measured by the Problem Gambling Severity Index among participants without a history of problem gambling at baseline. The incidence proportion of a first episode of problem gambling among 16-24 year-olds was 2.26% (95% confidence interval 1.52-3.36); three times lower among females (1.14; 0.42-3.07%) than males (3.32; 2.19-5.01%). Young age and household financial problems were associated with first episode problem gambling among young women. Among 25-44 year-olds, the incidence proportion of a first episode of problem gambling was 0.81% (0.41-1.56). Recovery from problem gambling was high, in particular among females. Individual transitions from problem gambling to recovery and to recurrent problem gambling, between baseline and follow-up, were common regardless of age. This study adds further evidence to research suggesting that there is a high mobility in and out of problem gambling over time on an individual level. The high incidence of first episode problem gambling among youth in Sweden stresses the importance of prevention of problem gambling at an early age.

Use of Scandinavian moist smokeless tobacco (snus) and the risk of atrial fibrillation.

BACKGROUND: Snus is a smokeless tobacco product, widely used among Swedish men and increasingly so elsewhere. There is debate as to whether snus is an acceptable "harm-reduction" tobacco product. Since snus use delivers a dose of nicotine equivalent to cigarettes, and has been implicated in cardiac arrhythmia because of associations with sudden cardiovascular death, a relation with atrial fibrillation is plausible and important to investigate. METHODS: To assess the relation between use of snus and risk of atrial fibrillation, we carried out a pooled analysis of 7 prospective Swedish cohort studies. In total, 274,882 men, recruited between 1978 and 2004, were followed via the National Patient Register for atrial fibrillation. Primary analyses were restricted to 127,907 never-smokers. Relative risks were estimated using Cox proportional hazard regression. RESULTS: The prevalence of snus use was 25% among never-smokers. During follow-up, 3,069 cases of atrial fibrillation were identified. The pooled relative risk of atrial fibrillation was 1.07 (95% confidence interval = 0.97-1.19) in current snus users, compared with nonusers. CONCLUSION: Findings from this large national pooling project indicate that snus use is unlikely to confer any important increase in risk of atrial fibrillation.

Suicide or undetermined intent? A register-based study of signs of misclassification.

BACKGROUND: Several studies have concluded that some deaths classified as undetermined intent are in fact suicides, and it is common in suicide research in Europe to include these deaths. Our aim was to investigate if information on background variables would be helpful in assessing if deaths classified as undetermined intent should be included in the analyses of suicides. METHODS: We performed a register study of 31,883 deaths classified as suicides and 9,196 deaths classified as undetermined intent in Sweden from 1987 to 2011. We compared suicide deaths with deaths classified as undetermined intent with regard to different background variables such as sex, age, country of birth, marital status, prior inpatient care for self-inflicted harm, alcohol and drug abuse, psychiatric inpatient care, and use of psychotropics. We also performed a multivariate analysis with logistic regression. RESULTS: Our results showed differences in most studied background factors. Higher education was more common in suicides; hospitalization for self-inflicted harm was more common among female suicides as was prior psychiatric inpatient care. Deaths in foreign-born men were classified as undetermined intent in a higher degree and hospitalization for substance abuse was more common in undetermined intents of both sexes. Roughly 50% of both suicide and deaths classified as undetermined intent had a filled prescription of psychotropics during their last six months. Our multivariate analysis showed male deaths to more likely be classified as suicide than female: OR: 1.13 (1.07-1.18). The probability of a death being classified as suicide was also increased for individuals aged 15-24, being born in Sweden, individuals who were married, and for deaths after 1987-1992. CONCLUSION: By analyzing Sweden's unique high-validity population-based register data, we found several differences in background variables between deaths classified as suicide and deaths classified as undetermined intent. However, we were not able to clearly distinguish these two death manners. For future research we suggest, separate analyses of the two different manners of death.

Myocardial infarction and occupational exposure to motor exhaust: a population-based case-control study in Sweden.

There is a well-established association between particulate urban air pollution and cardiovascular disease, but few studies have investigated the risk associated with occupational exposure to particles from motor exhaust. This study investigated the risk of myocardial infarction (MI) after occupational exposure to motor exhaust, using elemental carbon (EC) as a marker of exposure. A population-based case-control study of first-time non-lethal MI was conducted among Swedish citizens in ages 45-70 living in Stockholm County 1992-1994, including 1,643 cases and 2,235 controls. Working histories and data on potential confounders were collected by questionnaire and medical examination. The exposure to EC was assessed through a job-exposure matrix. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were estimated by unconditional logistic regression. We investigated various exposure metrics: intensity, cumulative exposure and years since exposure. There was an exposure-response relation between the highest average exposure intensity during the work history and the risk of MI when adjusting for smoking and alcohol drinking (p for trend 0.034), with an OR of 1.30 (95% CI 0.99-1.71) in the highest tertile of exposure compared to the unexposed. An exposure-response pattern was observed in the analysis of years since exposure cessation among formerly exposed. Additional adjustments for markers of the metabolic syndrome reduced ORs and trends to non-significant levels, although this might be an over-adjustment since the metabolic syndrome may be part of the causal pathway. Occupational exposure to motor exhaust was associated with a moderately increased risk of MI.

The influence of self-reported leisure time physical activity and the body mass index on recovery from persistent back pain among men and women: a population-based cohort study.

BACKGROUND: There is limited knowledge about leisure time physical activity and the body mass index (BMI) as prognostic factors for recovery from persistent back pain. The aim of this study was to assess the influence of leisure time physical activity and BMI on recovery from persistent back pain among men and women in a general population. METHODS: The study population (n=1836) in this longitudinal cohort study consisted of participants reporting persistent back pain in the baseline questionnaire in 2002-2003. Data on leisure time physical activity, BMI and potential confounders were also collected at baseline. Information on recovery from persistent back pain (no back pain periods ≥ 7 days during the last 5 years) was obtained from the follow-up questionnaire in 2007. Log-binomial models were applied to calculate Risk Ratios with 95 percent Confidence Intervals (CI) comparing physically active and normal weight groups versus sedentary and overweight groups. RESULTS: Compared to a sedentary leisure time, all measured levels of leisure time physical activity were associated with a greater chance of recovery from persistent back pain among women. The adjusted Risk Ratios was 1.46 (95% CI: 1.06, 2.01) for low leisure time physical activity, 1.51 (95% CI: 1.02, 2.23) for moderate leisure time physical activity, and 1.67 (95% CI: 1.08, 2.58) for high leisure time physical activity. There were no indications that leisure time physical activity influenced recovery among men, or that BMI was associated with recovery from persistent back pain either among men or among women. CONCLUSIONS: Regular leisure time physical activity seems to improve recovery from persistent back pain among women.

Psychosocial health and gambling problems among men and women aged 16-24 years in the Swedish National Public Health Survey.

BACKGROUND: This study aimed to explore the association between psychosocial health, gambling and gambling problems in a nationally representative sample of Swedish youth aged 16-24 years. Another aim was to examine whether these associations were different between young men and women. METHODS: Data were from the cross-sectional Swedish National Public Health Survey in 2004-07. With a response rate of 60.1%, the sample consisted of 19 016 youth. Using a sex-stratified multinomial logistic regression, we estimated associations between psychosocial health variables and gambling and gambling problems. RESULTS: Among males, we found that the higher the alcohol consumption, the higher the likelihood of gambling and gambling problems. Men with high alcohol consumption had an almost four times higher likelihood of gambling problems than men with no or low alcohol consumption (OR 3.94, 95% CI: 2.17-7.14). Moreover, young male victims of violence were more than twice as likely to have gambling problems than non-victims (OR 2.35, 95% CI: 1.39-3.99). Among young women, we found an inverse association between high alcohol consumption and gambling problems (OR 0.15, 95% CI: 0.05-0.44), opposite that of the young men. Furthermore, psychological distress (OR 6.15, 95% CI: 2.15-17.60) and suicidality (OR 2.88, 95% CI: 1.16-7.17) were associated with higher probabilities of gambling problems among young women. CONCLUSION: Alcohol use, violence victimization and poor mental health are associated with gambling problems among Swedish youth, however, with important sex differences. Prevention of youth gambling should consider sex differences and psychosocial health in addition to gambling.

Early multidisciplinary assessment was associated with longer periods of sick leave: a randomized controlled trial in a primary health care centre.

OBJECTIVE: To study the effects on sick leave from an early multidisciplinary assessment at a primary health care centre. DESIGN: Randomized controlled trial. SETTING: Patients who saw GPs at a primary health care centre in mid-Sweden and asked for a sickness certificate for psychiatric or musculoskeletal diagnoses were invited to participate. Patients included were sick-listed for less than four weeks; 33 patients were randomized either to an assessment within a week by a physiotherapist, a psychotherapist, and an occupational therapist or to "standard care". The therapists used methods and tools they normally use in their clinical work. MAIN OUTCOME MEASURE: Proportion of patients still sick-listed three months after randomization, total and net days on sick leave, and proportion who were on part-time sick leave. Results. At follow-up after three months, in contrast to the pre-trial hypothesis, there was a trend toward a higher proportion of patients still sick-listed in the intervention group (7/18) as compared with the control group (3/15). The intervention group also had significantly longer sick-listing periods (mean 58 days) than the control group (mean 36 days) (p = 0.038). The proportion of patients who were part time sick-listed was significantly higher in the intervention group (10/18) than in the control group (2/15) (p = 0.027). CONCLUSIONS: In this study an early multidisciplinary assessment was associated with longer periods on sick leave and more individuals on part-time sick leave.

Knowing and accepting oneself: Exploring possibilities of self-awareness among working autistic young adults.

LAY ABSTRACT: When researchers and professionals talk about autism, they commonly point out problems and risks with autism or being autistic. Several interventions are based on the idea of the problems and risks of autism. Another way of talking about autism is to point out autistic people's strengths and strategies which they use to handle barriers and problems in their lives in order to live good lives on their own terms. In this article, the researchers explore how autistic young adults formulate their own difficulties, strengths and support needs in order to get right support from support people. To be able to formulate this, autistic people need to get to know oneself and one's own way of functioning. Autistic own self-knowledge must be central when formal support people, such as social workers, formulate support and interventions aimed at helping autistic people, in order for the support/intervention to be helpful.

Use of snus and acute myocardial infarction: pooled analysis of eight prospective observational studies.

The use of snus (also referred to as Scandinavian or Swedish moist smokeless tobacco), which is common in Sweden and increasing elsewhere, is receiving increasing attention since considered a tobacco smoke "potential reduction exposure product". Snus delivers a high dose of nicotine with possible hemodynamic effects, but its impact on cardiovascular morbidity and mortality is uncertain. The aim of this study was to investigate whether snus use is associated with risk of and survival after acute myocardial infarction (AMI). Data from eight prospective cohort studies set in Sweden was pooled and reanalysed. The relative risk of first time AMI and 28-day case-fatality was calculated for 130,361 men who never smoked. During 2,262,333 person-years of follow-up, 3,390 incident events of AMI were identified. Current snus use was not associated with risk of AMI (pooled multivariable hazard ratio 1.04, 95 % confidence interval 0.93 to 1.17). The short-term case fatality rate appeared increased in snus users (odds ratio 1.28, 95 % confidence interval 0.99 to 1.68). This study does not support any association between use of snus and development of AMI. Hence, toxic components other than nicotine appear implicated in the pathophysiology of smoking related ischemic heart disease. Case fatality after AMI is seemingly increased among snus users, but this relationship may be due to confounding by socioeconomic or life style factors.

International differences in self-reported health measures in 33 major metropolitan areas in Europe.

BACKGROUND: The increasing concentration of populations into large conurbations in recent decades has not been matched by international health assessments, which remain largely focused at the country level. We aimed to demonstrate the use of routine survey data to compare the health of large metropolitan centres across Europe and determine the extent to which differences are due to socio-economic factors. METHODS: Multilevel modelling of health survey data on 126,853 individuals from 33 metropolitan areas in the UK, Republic of Ireland, Sweden, Norway, Finland, Spain, Belgium and Germany compared general health, longstanding illness, acute sickness, psychological distress and obesity with the average for all areas, accounting for education and social class. RESULTS: We found some areas (Greater Glasgow; Greater Manchester, Cheshire and Merseyside; Northumberland, Tyne and Wear and South Yorkshire) had significantly higher levels of poor health. Other areas (West Flanders and Antwerp) had better than average health. Differences in individual socio-economic circumstances did not explain findings. With a few exceptions, acute sickness levels did not vary. CONCLUSION: Health tended to be worse in metropolitan areas in the north and west of the UK and the central belt and south east of Germany, and more favourable in Sweden and north west Belgium, even accounting for socio-economic composition of local populations. This study demonstrated that combining national health survey data covering different areas is viable but not without technical difficulties. Future comparisons between European regions should be made using standardized sampling, recruitment and data collection protocols, allowing proper monitoring of health inequalities.

The age- and sex-specific occurrence of bothersome neck pain in the general population--results from the Stockholm public health cohort.

BACKGROUND: Neck pain is very common but the occurrence of bothersome neck pain is not well described. Therefore our objective was to report on the prevalence and incidence of, as well as the rate of recovery from, bothersome neck pain in men and women of different ages in the general population. METHODS: We used data from a recently conducted population-based cohort study, comprising 23,794 individuals in Stockholm County, Sweden. Study participants were surveyed with a self-administered questionnaire in 2002/2003 and 2007, and information on episodes of neck pain was gathered at baseline and at follow-up. We then measured bothersome neck pain in 2005 and 2006 retrospectively in 2007 using the follow-up questionnaire. RESULTS: The one-year prevalence of bothersome neck pain for at least seven consecutive days was 25% (95% confidence interval (CI): 24-25) among women and 16% (95% CI: 15-16) among men, peaking in individuals aged 30-59 years. The one-year incidence proportion of bothersome neck pain was 7% (95% CI: 6-7) among women, and 4% (95% CI: 4-5) among men. Women recovered more infrequently than men. The one-year incidence proportion of recovery (of at least one year duration) was 11% (95% CI: 10-12) among women and 14% (95% CI: 12-16) among men. CONCLUSION: Bothersome neck pain is most common in middle-aged individuals. Women are more likely than men to have and to develop bothersome neck pain, and less likely to recover from such pain. Younger men and women have a higher incidence, but recover more often from bothersome neck pain than older individuals.

Influence of work ability and smoking on the prognosis of long-duration activity-limiting neck/back pain: a cohort study of a Swedish working population.

OBJECTIVES: Long-duration activity-limiting neck/back pain is common, but the knowledge of what work and lifestyle factors that influence the prognosis is sparse. The objective was therefore to evaluate if two factors, good self-perceived work ability and no daily smoking, are associated with a favourable prognosis of long-duration activity-limiting neck/back pain in a working population, and if these exposures have a synergistic prognostic effect. DESIGN: A prospective cohort study based on three subsamples from the Stockholm Public Health Cohort. SETTINGS: A working population in Stockholm County, Sweden. PARTICIPANTS: Individuals, 18-61 years old, reporting long-duration activity-limiting neck/back pain the previous 6 months at baseline in 2010 (n=5177). MEASURES: The exposures were: self-perceived work ability (categorised into good, moderate and poor) and daily smoking (no/yes). The outcome in 2014 was 'absence of long-duration activity-limiting neck/back pain' the previous 6 months representing a favourable prognosis of reported problems at baseline in 2010. Risk ratios (RRs) and risk differences (RDs) with 95% CI was estimated by general linear regressions, and the synergistic effect was estimated by the synergy index (SI) with 95% CI. RESULTS: Participants with moderate or good work ability, respectively, had an adjusted RR for a favourable prognosis of 1.37 (95% CI 1.11 to 1.69), and 1.80 (1.49 to 2.17) in comparison with participants with poor work ability. The corresponding adjusted RD were 0.07 (0.02 to 0.11) and 0.17 (0.12 to 0.22). Participants not smoking on daily basis had an adjusted RR of 1.21 (1.02 to 1.42), and an adjusted RD of 0.05 (0.01 to 0.10) for a favourable outcome compared with daily smokers. The adjusted SI was 0.92 (0.60 to 1.43). CONCLUSION: For participants with long-duration activity-limiting neck/back pain, moderate or good self-perceived work ability and not being a daily smoker were associated with a favourable prognosis but having both exposures seemed to have no synergistic prognostic effect.

Small birth size, adult overweight, and risk of acute myocardial infraction.

BACKGROUND: The association between small size at birth and increased risk of cardiovascular disease in adulthood is well established. This relationship is commonly interpreted according to the "thrifty phenotype hypothesis," which states that the association is generated by a mismatch between fetal and postnatal nutrition. Empirical support for an interaction between impaired fetal growth and later overnutrition is, however, sparse and partly conflicting. METHODS: The Stockholm Heart Epidemiology Program is a population-based case-control study of risk factors for acute myocardial infarction (MI); data were available for 1058 cases and 1478 controls. Using logistic regression, we studied the effect of size at birth, and its interactive effect with body mass index (BMI), at 3 occasions in adulthood, on the risk of MI. Biologic interaction was estimated with the synergy index. RESULTS: Very low birth weight for gestational age was associated with increased risk of MI (odds ratio [OR] = 2.0; 95% confidence interval [CI] = 1.4-2.9; attributable fraction = 5%). In nonfatal cases, adjustment for waist-hip ratio, insulin resistance, blood pressure, and lipids reduced the point estimate somewhat. Low birth weight for gestational age in combination with high BMI at the time of the MI produced an OR of 10.8 (3.6-31.8) for MI compared with normal birth weight and normal BMI; the synergy index was 6.5 (95% CI = 1.8-24.0). CONCLUSIONS: The synergism between small size at birth and high adult BMI supports the thrifty phenotype hypothesis. However, this mechanism seems to pertain to only a small fraction of the acute MI cases, implying minor public health importance.

Burden of type 2 diabetes attributed to lower educational levels in Sweden.

BACKGROUND: Type 2 diabetes is associated with low socioeconomic position (SEP) in high-income countries. Despite the important role of SEP in the development of many diseases, no socioeconomic indicator was included in the Comparative Risk Assessment (CRA) module of the Global Burden of Disease study. We therefore aimed to illustrate an example by estimating the burden of type 2 diabetes in Sweden attributed to lower educational levels as a measure of SEP using the methods applied in the CRA. METHODS: To include lower educational levels as a risk factor for type 2 diabetes, we pooled relevant international data from a recent systematic review to measure the association between type 2 diabetes incidence and lower educational levels. We also collected data on the distribution of educational levels in the Swedish population using comparable criteria for educational levels as identified in the international literature. Population attributable fractions (PAF) were estimated and applied to the burden of diabetes estimates from the Swedish burden of disease database for men and women in the separate age groups (30-44, 45-59, 60-69, 70-79, and 80+ years). RESULTS: The PAF estimates showed that 17.2% of the diabetes burden in men and 20.1% of the burden in women were attributed to lower educational levels in Sweden when combining all age groups. The burden was, however, most pronounced in the older age groups (70-79 and 80+), where lower educational levels contributed to 22.5% to 24.5% of the diabetes burden in men and 27.8% to 32.6% in women. CONCLUSIONS: There is a considerable burden of type 2 diabetes attributed to lower educational levels in Sweden, and socioeconomic indicators should be considered to be incorporated in the CRA.