Total cholesterol/HDL-C ratio versus non-HDL-C as predictors for ischemic heart disease: a 17-year follow-up study of women in southern Sweden.

BACKGROUND: A distorted blood lipid profile is an important risk factor for ischemic heart disease (IHD) but the predictive ability of the different lipid measures has rarely been studied. Our aim was to examine and compare, in a large sample of women, the predictive ability of total cholesterol/HDL cholesterol ratio (TC/HDL-C) and non-HDL-C in relation to IHD, adjusted for age, exercise, smoking, waist-hip ratio, blood pressure, and diabetes mellitus. METHODS: Between 1995 and 2000, a total of 6537 women aged 50-59 years from the Women's Health in Lund area (WHILA) study in southern Sweden were included and underwent a baseline examination. The women were followed through national registers for incidence of IHD during a mean follow-up of 17 years. The prediction accuracy was estimated through Harrell's C and Akaike Information Criterion (AIC). RESULTS: Increasing TC/HDL-C as well as non-HDL-C showed strong associations with IHD, with the highest risk in the 5th quintile, where the HR was 2.30 (95% CI: 1.70-3.11) for TC/HDL-C and 1.67 (95% CI: 1.25-2.24) for non-HDL-C, after adjustments. Comparisons using Harrell's C and AIC indicated that TC/HDL-C has a slightly higher predictive ability than that of non-HDL-C (Harrell's C 0.62 and 0.59 respectively, p = 0.003 for difference, age-adjusted model; AIC for TC/HDL-C < AIC for non-HDL-C). CONCLUSIONS: TC/HDL-C ratio and non-HDL-C are both clinical predictors for IHD in middle-aged women. The results indicate that the predictive ability of TC/HDL-C was higher than that of non-HDL-C; however, non-HDL-C was linearly related to IHD (p = 0.58) and may be easier to calculate and interpret in clinical practice, for early identification of future IHD in women.

The ratio of total cholesterol to high density lipoprotein cholesterol and myocardial infarction in Women's health in the Lund area (WHILA): a 17-year follow-up cohort study.

BACKGROUND: Identifying variables predictive of acute myocardial infarction (AMI) in women is important. The use of the ratio of total cholesterol-to-high density lipoprotein cholesterol (TC/HDL-C) is often overlooked. The aim was to study TC/HDL-C in relation to later AMI, in a large sample of women, adjusted for age, educational status, smoking, waist-hip ratio, blood pressure, and neighbourhood socioeconomic status. The hypothesis was that increasing TC/HDL-C is associated with an increased risk of later AMI. METHODS: From December 1995 to February 2000, 6147 women aged 50-59 years from the Womens' Health in Lund area (WHILA) study in southern Sweden underwent a physical examination, laboratory tests and filled in a questionnaire. The women were followed through national registers for incidence of AMI during a mean follow up of 17 years. RESULTS: An increasing TC/HDL-C showed a strong relationship with AMI, with the lowest hazard ratio (HR = 1) in women with a ratio of ≤3.5. The HR for AMI was 1.14 (95% CI: 0.73-1.78) for those with a ratio between 3.5 and 4.0; in those with a ratio between 4.0 and 5.0 the HR for AMI was 1.46 (95% CI: 1.00-2.13) and in those with a ratio > 5.0 the HR was 1.89 (95% CI 1.26-2.82), after adjusting for potential confounding factors. CONCLUSIONS: TC/HDL-C ratio is a powerful predictor of AMI in middle-aged women. The results indicate that this variable should be used in clinical practice and is important for early identification of individuals at risk of AMI.

Postnatal ER visits within 30 days-Pattern, risk factors and implications for care.

AIMS AND OBJECTIVES: To (i) reveal care-seeking patterns of emergency room visits within 30 days following childbirth (i.e., identify risk factors that trigger contact with emergency room, visit rate and diagnoses) and (ii) suggest clinical implications for postnatal follow-up. DESIGN: The study had a longitudinal design; it used anonymised data from a county council database on all women in Stockholm County, Sweden, who gave birth in 2013. METHODS: Descriptive and inferential data analysis methods were used. Cox regression was applied to these variables: age when giving birth, diagnostic codes at birth, care encounters and types (e.g., visits or hospital admissions), day of discharge and care organisation and type. The data covered the period from childbirth through a 30-day period following discharge from hospital. RESULTS: The database contained 28,963 births and 59,202 healthcare or medical care encounters. Of these encounters, 50.3% (n = 29,774) were planned visits to hospital postnatal care units within 7 days following discharge and 1.2% (n = 681) were admissions to hospitals. Of all women who gave birth, 12.2% (n = 3,533) visited the emergency room at least once. The number of visits peaked at day 6 following discharge. These factors significantly increased risk for emergency room visits: caesarean, assisted birth and sphincter injury. CONCLUSIONS: Emergency room visits occurred most commonly immediately following discharge when there were no routine check-ups. Greater risk of emergency room visits - following caesareans, assisted childbirths or sphincter injuries - indicated that early support for women with childbirth complications should be improved upon discharge from hospital. Other multiple risk factors for emergency room visits might exist. RELEVANCE TO CLINICAL PRACTICE: Many emergency room visits could be prevented through early, more qualified, appropriate follow-up via maternity care systems and effective midwifery interventions. These initiatives could enhance care continuity and facilitate postpartum recovery.

Association between antithrombotic treatment and hemorrhagic stroke in patients with atrial fibrillation-a cohort study in primary care.

OBJECTIVE: The objective of this study was to study the association between antithrombotic treatment and risk of hemorrhagic stroke (HS) in patients with atrial fibrillation (AF) treated in primary health care. METHODS: Study population included all adults (n = 12,215) 45 years and older diagnosed with AF at 75 primary care centers in Sweden 2001-2007. Outcome was defined as a first hospital episode with a discharge episode of HS after the AF diagnosis. Association between HS and persistent treatment with antithrombotic agents (warfarin, acetylsalicylic acid (ASA), clopidogrel) was explored using Cox regression analysis, with hazard ratios (HRs) and 95 % CIs. Adjustment was made for age, socioeconomic status, and co-morbid cardiovascular conditions. RESULTS: During a mean of 5.8 years (SD 2.4) of follow-up, 162 patients (1.3 %; 67 women and 95 men) with HS were recorded. The adjusted risk associated with persistent warfarin treatment compared to no antithrombotic treatment consistently showed no increased HS risk, HR for women 0.53 (95 % CI 0.23-1.27) and for men 0.55 (95 % CI 0.29-1.04); corresponding HRs for ASA were, for women, 0.45 (95 % CI 0.14-1.44) and, for men, 0.56 (95 % CI 0.24-1.29). CONCLUSIONS: In this clinical setting, we found no evidence pointing to an increased risk of HS with antithrombotic treatment.

Longitudinal trends in self-reported anxiety. Effects of age and birth cohort during 25 years.

BACKGROUND: Anxiety has been suggested to increase among young individuals, but previous studies on longitudinal trends are inconclusive. The aim of this study was to analyze longitudinally, the changes over time of prevalence of self-reported anxiety in the Swedish population between 1980/1981 and 2004/2005, in different birth cohorts and age groups. METHODS: A random sample of non-institutionalized persons aged 16-71 years was interviewed every eighth year. Self-reported anxiety was assessed using the question" Do you suffer from nervousness, uneasiness, or anxiety?" (no; yes, mild; yes, severe). Mixed models with random intercepts were used to estimate changes in rates of anxiety (mild or severe) within different age groups and birth cohorts and in males and females separately. In addition to three time-related variables - year of interview, age at the time of the interview, and year of birth -the following explanatory variables were included: education, urbanization, marital status, smoking, leisure time physical activity and body mass index. RESULTS: Overall prevalence of self-reported anxiety increased from 8.0 to 12.4% in males and from 17.8% to 23.6% in females, during the 25-year follow-up period. The increasing trend was found in all age groups except in the oldest age groups, and the highest increase was found in young adults 16-23 years, with more than a three-fold increase in females, and a 2.5-fold increase in males, after adjustments for covariates. CONCLUSIONS: Between 1980/81 and 2004/05, there was an increasing prevalence of self-reported anxiety in all age groups except in the oldest, which indicates increased suffering for a large part of the population, and probably an increased burden on the health care system. Clinical efforts should focus particularly on young females (16-23 years), where the increase was particularly large; almost one third experienced anxiety at the end of the 25-year follow-up.

Anxiety Is Linked to New-Onset Dyspepsia in the Swedish Population: A 10-Year Follow-up Study.

BACKGROUND & AIMS: Functional dyspepsia (FD) is associated with anxiety but it is not clear if one causes the other. We investigated whether anxiety and depression precede the onset of FD (based on the modified Rome III criteria) and gastroesophageal reflux symptoms (GERS) in a population-based follow-up study. METHODS: Participants from the Kalixanda study (n = 3000), randomly selected from the national population register of Sweden, were given the validated Abdominal Symptom Questionnaire 1998-2001; 1000 of these participants then were selected randomly to undergo esophagogastroduodenoscopy and were given the Abdominal Symptom Questionnaire along with the Hospital Anxiety and Depression Scale questionnaire. All eligible subjects who underwent endoscopy (n = 887) were invited to participate in a follow-up study in June-August 2010 and were given the same questionnaires. Data were analyzed by logistic regression. RESULTS: Of the 703 subjects who completed the follow-up questionnaires (79.3%); 110 were found to have FD at baseline (15.6%) and 93 at the follow-up examination (13.3%); 48 of these were new cases of FD. GERS without organic disease was reported by 273 individuals (38.8%) at baseline and by 280 at follow-up examination (39.8%); 93 cases were new. Major anxiety was associated with FD at the follow-up evaluation (odds ratio [OR], 6.30; 99% confidence interval [CI], 1.64-24.16). Anxiety was associated with postprandial distress syndrome at baseline (OR, 4.83; 99% CI, 1.24-18.76) and at the follow-up examination (OR, 8.12; 99% CI, 2.13-30.85), but not with epigastric pain syndrome. Anxiety at baseline was associated with new-onset FD at the follow-up examination (OR, 7.61; 99% CI, 1.21-47.73), but not with GERS. CONCLUSIONS: In a study of the Swedish population, anxiety at baseline, but not depression, increased the risk for development of FD by 7.6-fold in the next 10 years. Anxiety did not affect risk for GERS.

High Serum Insulin-Like Growth Factor-Binding Protein 1 (IGFBP-1) is Associated with High Fracture Risk Independent of Insulin-Like Growth Factor 1 (IGF-I).

High serum levels of IGFBP-1 are related both to low body mass index (BMI) and to low insulin-like growth factor 1 (IGF-I), which both in turn are related to low bone mineral density (BMD) and to increased fracture risk. However, we have found no previous prospective studies on IGFBP-1 and fracture risk. Despite its name, IGFBP-1 is not only just a binding protein but also has its own IGF-independent effects, e.g., stimulating osteoclast differentiation. IGFBP-1 might have an IGF-related and/or an IGF-independent association to fracture risk. This is a population-based prospective cohort study with a ten-year follow-up of 351 women aged 69-79 at inclusion. Fracture and mortality data were collected from national health care registers. IGFBP-1 had a positive linear relation to the risk of both hip fractures and "major osteoporotic fractures" including fractures of the hip, spine, shoulder, and wrist. The age-adjusted hazard ratio (HR) for a hip fracture was 1.46 (95 % CI 1.08-1.99) for one SD increase in IGFBP-1. The corresponding age-adjusted HR for major osteoporotic fractures was 1.33 (95 % CI 1.05-1.69). The relation between IGFBP-1 and fracture risk was not confounded by either IGF-I or BMI. Femoral neck BMD, however, mediated 56 % of the total "effect" of IGFBP-1 on hip fracture risk. In conclusion, IGFBP-1 had a positive linear relation to fracture risk, partly mediated by BMD but not related to IGF-I or BMD. This implies that IGFBP-1 might be an important factor in bone turnover and that further studies on this would be valuable.

How to best assess quality of drug treatment in patients with heart failure.

BACKGROUND: The proportion of patients with heart failure (HF) treated with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) is frequently used as quality indicator. This study aimed to compare agreement between different methods of calculating this quality indicator. In addition, characteristics for patients and care providers associated with a high proportion treated with ACEI or ARB were analyzed. METHODS: This Swedish cross-sectional register-based study was conducted in the Stockholm region (2.1 million inhabitants). The proportion of patients with HF treated with ACEI or ARB was calculated by different methods applied on an administrative database on healthcare consumption, diagnoses, and dispensed drugs and by self-reported data from all primary care centers in the region. RESULTS: A total of 32,677 patients recorded with a HF diagnosis 2008-2012 and alive July-December 2012 were identified. The proportion treated with ACEI or ARB varied depending on observation period and care provider included (range register 52-74 %). There was a large variation between different primary care centers (range register 36-88 %, range self-reported 8-100 %) and a poor agreement between methods (Bland-Altman; rhoc range 0.07-0.23). Predictors for high proportion treated were low age, high socioeconomic status, cardiovascular comorbidity, and diagnosis recorded both in primary care and in hospitals. CONCLUSIONS: There is poor agreement between different methods to evaluate adherence to guidelines for drug treatment in HF. Differences between practices concerning patient age, socioeconomic status, comorbidity, and care given by different providers should be taken into account in quality assessment.

Warfarin treatment and risk of stroke among primary care patients with atrial fibrillation.

OBJECTIVE: Our aim was to study the risk of a first ischaemic stroke (IS) in patients with atrial fibrillation (AF) treated in primary healthcare. DESIGN: The study population included all adults (n = 11,517), 45 years and older diagnosed with AF, from 75 primary care centres in Sweden between 2001 and 2007. IS was defined as a hospital care event of stroke between 2001 and 2010. Association between incident stroke and warfarin treatment was explored using Cox regression analysis, with hazard ratios (HRs), and 95% confidence intervals (95%CIs). Adjustment was made for age, socioeconomic factors and co-morbidity. RESULTS: Persistent treatment with warfarin was present among 33.7% of women and 40.0% among men. Persistent warfarin treatment, compared to no persistent treatment, was associated with a stroke preventing effect with fully adjusted HRs of 0.25 (95%CI 0.18-0.36) in women, and 0.25 (95%CI 0.19-0.32) in men. A CHA2DS2-VASc score of at least two among women, and three among men, was associated with a stroke risk exceeding 18% during a mean follow-up of 5.4 years. Risk of haemorrhagic stroke was not increased. CONCLUSIONS: Warfarin is effective in preventing stroke in AF patients in primary healthcare.

Women's health in the Lund area (WHILA)--Alcohol consumption and all-cause mortality among women--a 17 year follow-up study.

BACKGROUND: Alcohol consumption contributes to many negative health consequences and is a risk factor for death. Some previous studies however suggest a J-shaped relationship between the level of alcohol consumption and all-cause mortality. These findings have in part been suggested to be due to confounders. The aim of our study was to analyze the relationship between self-reported alcohol intake and all-cause mortality in women, adjusted for sociodemographic, lifestyle factors and diseases such as diabetes and previous ischemic heart disease. METHODS: All women aged 50-59 years (born between 1935 and 1945) that lived in any of the five municipalities in southern Sweden were invited to participate in a health survey. From December 1995 to February 2000 a total of 6916 women (out of 10,766, the total population of women in 1995) underwent a physical examination and answered a questionnaire. We followed the women from the day of screening until death, or if no event occurred until May 31st 2015. Mortality was ascertained through the national cause-of-death register. RESULTS: In this study a total of 6353 women were included. Alcohol consumption showed a J-formed relationship with mortality, when adjusted for education, marital status, smoking, BMI, physical fitness, diabetes and ischemic heart disease before screening. Non consumption of alcohol was associated with increased mortality as well as higher levels of consumption, from 12 grams per day and upwards. CONCLUSIONS: There was a clear J-shaped relation between the amount of alcohol consumption and all-cause mortality even after controlling for sociodemography, lifestyle factors and diseases such as diabetes and previous ischemic heart disease. The observed protective effect of light drinking (1-12 grams/day) could thus not be attributed to any of these known confounders.

The longitudinal age and birth cohort trends of regular exercise among adults aged 16-63 years in Sweden: a 24-year follow-up study.

BACKGROUND: The aim of this study is to analyze longitudinally, based on four measurements at intervals of eight years, the annual effect of age group and birth cohort on regular exercise in the Swedish population from 1980-1981 to 2004-2005. METHODS: We followed a randomly drawn subsample of individuals aged 16-63 years, interviewed by professional interviewers, from the Swedish Annual Level of Living Survey. We applied a mixed model with a random intercept and a random slope in order to analyze the annual effects. RESULTS: The prevalence of regular exercise increased annually by 0.3 % among men and 0.7 % among women. For every one-unit increase in BMI, the odds of regular physical activity decreased by 6 % among men and 5 % among women. While the female birth cohorts all increased over time the male birth cohorts showed a different pattern, as only the three oldest birth cohorts (1926-1933, 1934-1941, 1942-1949) showed an increase in regular exercise. The three youngest birth cohorts (1958-1965, 1966-1973, 1974-1981) instead showed a decreased prevalence of regular exercise. There was an inverse relationship between regular exercise and age, although the differences between age groups tended to decrease over time. Differences related to educational level increased over time as the prevalence of exercise among those with higher educational attainment increased more than among those with lower educational attainment. The most dramatic relative increase in exercise over time (almost two-fold) was found among those who were obese or who reported a poor health status. CONCLUSIONS: The prevalence of regular exercise increased in all studied sub-groups. However, the increased difference related to education level is worrying. To reduce the risk for ill health in these groups, there is a need for targeted interventions.

Pharmacotherapy and mortality in atrial fibrillation--a cohort of men and women 75 years or older in Sweden.

BACKGROUND: Atrial fibrillation (AF) is a common cardiovascular morbidity, not least among elderly people, and is treated with different classes of cardiovascular pharmacotherapies. HYPOTHESIS: Cardiovascular drugs may have a different impact on survival in elderly patients with AF in primary health care. METHODS: A cohort of 3,020 men and 3,749 women aged ≥75 and diagnosed with AF were selected from 75 primary care centres in Sweden. Laplace regression was used with years to death of the first 10% of the participants as the outcome. Independent variables were prescribed cardiovascular drugs. Regression models were adjusted for a propensity score comprising age, cardiovascular co-morbidities, socio-economic factors and other cardiovascular pharmacotherapies. RESULTS: Overall, mortality was 18.2%. The main finding of this study was survival increases associated with anticoagulants versus no treatment and versus antiplatelets of 1.95 years (95% confidence interval (CI) 1.43-2.48) and 0.78 years (95% CI 0.38-1.18), respectively, and survival increases associated with thiazides and calcium channel blockers of 0.81 years (95% CI 0.43-1.18) and 0.83 years (95% CI 0.47-1.18), respectively, in men and women together (results from sex-adjusted models). CONCLUSION: Our findings suggest that anticoagulants, thiazides and calcium channel blockers may lead to longer survival in elderly patients with AF.

Support and continuity during the first 2 weeks postpartum.

OBJECTIVES: To investigate mothers' perceived satisfaction with support from antenatal care (AC), postpartum care (PC) and child health care (CHC), respectively, during the first two weeks after childbirth. DESIGN: Cross-sectional survey, mixed-method design. ETHICAL ISSUES: The study was approved by the Regional Research and Ethics Committee at the Karolinska Insititutet, Sweden. METHODS: Data were collected using a study-specific questionnaire that focused on mothers' satisfaction with support from AC, PC and CHC during the first 2 weeks after childbirth. All mothers in Stockholm County (n = 546) who gave birth to a live infant during a 1-week period in 2009 were invited to participate. Descriptive and logistic regression analyses and a content analysis were performed. RESULTS: A large discrepancy was found between levels of satisfaction with AC, PC and CHC. Mothers were satisfied with the support from CHC healthcare nurses, but missed follow-up contact from AC and PC midwives. Nearly 40% of all mothers commented on insufficient support including that continuity in the chain of care was lacking and support for mothers' physical and emotional health was insufficient. Delivery at <37 weeks of gestation was associated with reduced satisfaction with both AC and CHC, but not with PC. Mothers who made emergency visits during the first two weeks were more likely to be dissatisfied with support from PC. CONCLUSION: All links in the chain of care are important for the support of mothers during the first 2 weeks after childbirth, but continuity needs to be improved to raise the quality of care for mothers.

Effect of cardiovascular drugs on mortality in atrial fibrillation and chronic heart failure.

OBJECTIVES: To study mortality rates among men and women with atrial fibrillation (AF) and concomitant chronic heart failure (CHF) prescribed different classes of cardiovascular drugs in primary health care. DESIGN: A cohort of men (n = 1159) and women (n = 1155) aged 45 years or above and diagnosed with both AF and CHF from patient records from 75 primary care centers in Sweden were included in the study. Regression models with mortality as the outcome were used, with adjustment for a propensity score comprising age, cardiovascular co-morbidities, education, marital status, and pharmacotherapy. We analysed using Cox regression with hazard ratio (HR), and Laplace regression with years until 10% of the patients had died, with 95% confidence intervals (95% CI). Independent variables were prescribed cardiovascular drugs. RESULTS: Individuals prescribed anticoagulants versus no treatment gained 1.95 years (95% CI 0.47-3.43), anticoagulants versus antiplatelets 1.26 years (95% CI 0.42-2.10), calcium channel blockers 1.17 years (95% CI 0.21-2.14), and statins 1.49 years (95% CI 0.39-2.59). Among patients 80 years or above no significant effect by anticoagulants was seen, HR 0.73 (95% CI 0.43-1.23). CONCLUSIONS: Our findings suggest that life may be prolonged in patients with AF and concomitant CHF in primary care prescribed anticoagulants, calcium channel blockers, and statins.

The longitudinal exercise trend among older Swedes aged 53-84 years - a 16-year follow-up study.

BACKGROUND: Many older adults are physically inactive and inactivity increases with age. This knowledge comes from cross-sectional studies. Cross-sectional studies may miss important trajectories within the older adults as a result of retirements, and poor health impact of promotional efforts. The aim of this study was to analyse, longitudinally, the annual effects of age group and birth cohort on self-reported regular exercise in the Swedish population aged 53-84 years during a 16-year period, for each sex separately. METHODS: A random sample of non-institutionalized persons was interviewed three times from 1988 to 2004 by professional interviewers. In addition to three time-related variables - year of interview, age at the time of the interview, and year of birth - we included the following explanatory variables in the analyses: educational level, body mass index, smoking, and self-reported health status. The data were analysed by a mixed model with a random intercept. RESULTS: The total prevalence of self-reported regular exercise increased between 1988/89 and 2004/05 among both men and women, from 27.1 to 43.1% and from 21.1 to 41.1%, respectively. There was a mean annual change in all age-groups in exercise of between 0.76 and 1.24% among men and between 0.86 and 1.38% among women. Low prevalence of self-reported regular exercise was associated with low educational level, obesity, smoking, and poor self-reported health, although those with poor self-reported health the greatest increase of physical activity. CONCLUSIONS: There was a steady, albeit inadequate, increase in self-reported regular exercise in older adults between 1988 and 2004. Physical activity promotion in older adults should be of high priority for both primary and secondary prevention of diseases, especially among groups with known risk factors for low levels of exercise.

Professional support and emergency visits during the first 2 weeks postpartum.

OBJECTIVES: The aim of the study was to assess mothers' perceived satisfaction with professional support during the first 2 weeks after childbirth and the extent to which mothers seek emergency care during the same period. DESIGN: A cross-sectional study was conducted of all mothers (n = 546) in Stockholm County, Sweden, who gave birth to a live baby during the same week in 2009. ETHICAL ISSUES: The study was approved by the regional Research and Ethics Committee at the Karolinska Insititutet, Sweden. METHODS: The mothers responded to a study-specific questionnaire on perceived satisfaction with professional support and the sense of coherence scale, which measures coping strategies. The mothers also provided information about their socio-demographic background, obstetric and infant data, and visits to hospital emergency departments. Descriptive and logistic regression analyses were performed. RESULTS: Fifty-three percent of the mothers rated the support received as sufficient or more than sufficient, 29.7% as neither sufficient nor insufficient and 17.7% as insufficient or completely insufficient. The results indicate a lack of continuity in postpartum care. As many as 17% of the mothers in the study population visited hospital emergency departments during the first 2 weeks after childbirth, as a result of problems related to delivery, breastfeeding or infant health. A higher frequency of such emergency visits was associated with poor perception of professional support, low sense of coherence and delivery complications. CONCLUSIONS: Relative to otherwise comparable mothers, mothers who experience complications with delivery are less satisfied with professional support and turn more frequently to hospital emergency departments for support.

Neighbourhood socioeconomic status and pain among older adults-A cross-sectional study.

BACKGROUND: Pain is associated with falls, disability and a poor quality of life among older adults. It is highly prevalent in many societies, and studies have shown that pain could be preventable or managed more effectively at the population level. However, few studies have investigated who is at higher risk of pain in the general population, which is important for development of effective interventions. The purpose of this study was to investigate, by using nationally representative samples in Sweden, whether neighbourhood socioeconomic status (SES) is associated with pain among older adults after considering other important risk factors. METHODS: The study used the Statistics on Income and Living Conditions (EU-SILC), which is a nationwide annual survey of the living conditions of residents in Sweden. We used the data of individuals who were over 65 years of age between 2008 and 2013. Multivariable logistic regression was conducted to investigate the association between neighbourhood SES and severe pain. RESULTS: Those who resided in low SES neighbourhoods had a 30% higher odds of having severe pain than those who resided in high SES neighbourhoods after controlling for individual risk factors, such as the sex, age, individual SES, smoking, exercise habits and body mass index. Exercise was protective against severe pain. CONCLUSION: Given the high prevalence of pain across populations, interventions targeting geographic areas (such as those in the current study) in combination with individual risk factors could be effective to reduce the burden of pain at the population level. SIGNIFICANCE: Those who reside in neighbourhoods with low SES may have higher risks of pain due to a lack of health-promoting resources as well as psychological stress. Further studies identifying the specific mechanisms behind the association between neighbourhood SES and pain would be useful in order to develop effective interventions.

Impact of feed, light and access to manipulable material on tail biting in pigs with intact tails.

BACKGROUND: Tail biting (TB) is a welfare issue with economic consequences due to infections and ill-thrift. This study aimed to reduce tail injuries in a high-performing non-tail-docking pig herd. RESULTS: During eleven years preceding the trial, the annual incidence of tail injuries registered at slaughter in pigs from the herd increased from 3% (equivalent to the national mean) to 10%. It was positively correlated to a high weight gain and negatively correlated to daylight length. The overall incidence of tail injuries during the four years preceding the trial was 9.2% with significant differences between four identically structured buildings for fatteners (I < II < III < IV). The feed was enriched with amino acids, minerals and fibres. The buildings used different illumination strategies, I: standard fluorescent tubes with an invisible flickering light of 30-40% for 14 h daily, II: non-flickering led light for 14 h daily, III (control) and IV: standard fluorescent tubes for 2 h daily. IV had free access to manipulable material (hay-silage), while I-III was offered 100-200 g daily. During the adaptation period (6 months), the incidence of tail injuries decreased significantly in all buildings to a mean of 5.4%. The largest decrease (from 11.4 to 4.3%) was obtained in IV. During the trial period (12 months), the mean incidence of tail injuries decreased in all groups to a mean of 3.0%. There were no differences in treatment incidences of individual pigs due to TB between groups, but the use of enriched pellets due to TB in pens was lowest in II. The low incidence of tail injuries was retained during the post-trial period (6 months) when all buildings used artificial illumination for two hours per day. CONCLUSIONS: The incidence of TB in fast growing non-tail-docked pigs in the herd was successfully reduced by supplementing the feed with amino acids, minerals, vitamins and fibres. Additional manipulable material accelerated that process and non-flickering illumination may have had an impact in preventing TB. The results obtained do not support the need for tail-docking of pigs, provided that the needs of the pigs in terms of feed ingredients, stocking density and access to manipulable materials are fulfilled.

Differences and time trends in drug treatment of atrial fibrillation in men and women and doctors' adherence to warfarin therapy recommendations: a Swedish study of prescribed drugs in primary care in 2002 and 2007.

BACKGROUND: Little is known about prescription trends in atrial fibrillation (AF) in primary health care in Sweden. OBJECTIVE: The aim was to study time trends in pharmacotherapy, in men and women with AF. We also aimed at studying doctors' adherence to CHADS2 for prescribing warfarin. CHADS2 assesses stroke risk by presence of known risk factors, i.e., congestive heart failure, hypertension, age >75 years, diabetes, previous stroke and transient ischemic attack. METHODS: Data were obtained from primary health care records that contained individual clinical data. In total, 371,036 patients were included in the sample from 2002, and 424,329 patients were included in the sample from 2007. The study population consisted of individuals aged 45+ years who were diagnosed with AF in 2002 (1,330 men and 1,096 women) and 2007 (2,748 men and 2,234 women). The pharmacotherapies prescribed in 2002 and 2007 were analyzed separately in men and women. Logistic regression was used to calculate the association between the CHADS2 score and prescribed warfarin treatment. RESULTS: Selective beta-blockers, anti-coagulant therapy and lipid-lowering drugs were prescribed more frequently in 2007 than in 2002. In 2007, antithrombotic and RAS-blocking agents were prescribed more frequently to men, whereas beta-1 selective beta-blockers were prescribed more frequently to women. There was no consistent association between the CHADS2 score and prescribed warfarin treatment. CONCLUSIONS: Pharmacotherapy of AF has improved over time, though CHADS2 guidelines need to be implemented systematically in primary health care in Sweden to decrease the risk of stroke and improve quality of life in patients with AF.

Effect of cardiovascular drug classes on all-cause mortality among atrial fibrillation patients treated in primary care in Sweden: a cohort study.

BACKGROUND: Risk factors for stroke are well known in atrial fibrillation (AF) patients, while less is known on the effect of these factors on total mortality. OBJECTIVE: Our aim was to study the impact of cardiovascular drug classes on mortality in AF patients treated in primary care. METHODS: The study population was chosen based on patient data from 75 primary care centres in Sweden compiled in a database. Individuals diagnosed with AF who were older than 45 years were enrolled (n = 12,302, of whom 6,660 were men). Cox regression analysis with mortality (years to death) as outcome was conducted in the men and women separately, as well in the age categories <80 and ≥ 80 years, with cardiovascular drugs as independent factors, and age, cardiovascular diagnoses and educational level as covariates. RESULTS: Lower mortality was shown for anticoagulant treatment among men, both younger (<80 years) [adjusted hazard ratio (HR) 0.43, 95 % confidence interval (CI) 0.31-0.61] and older (≥ 80 years) (adjusted HR 0.47, 95 % CI 0.32-0.69), and among younger women (adjusted HR 0.46, 95 % CI 0.29-0.74), and for antiplatelet treatment in older men (adjusted HR 0.51, 95 % CI 0.35-0.74). Treatment with thiazides was associated with lower mortality among younger men (adjusted HR 0.68, 95 % CI 0.48-0.96), older men (adjusted HR 0.67, 95 % CI 0.46-0.98) and older women (adjusted HR 0.70, 95 % CI 0.52-0.94). Statins were associated with lower mortality among younger patients, in both men (adjusted HR 0.47, 95 % CI 0.32-0.68) and women (adjusted HR 0.54, 95 % CI 0.35-0.82). CONCLUSIONS: The differences in age and gender patterns need further exploration.