Hip fractures in patients with primary aldosteronism - a Swedish nationwide study.

In this large population-based matched cohort study, patients with primary aldosteronism were at increased risk of hip fracture, particularly subgroups traditionally considered at higher risk of osteoporosis such as women, patients older than 56 years at diagnosis, patients with established cardiovascular disease at diagnosis, and patients treated with MRA. PURPOSE: Previous studies suggest that primary aldosteronism (PA) is associated with dysregulated bone homeostasis. The aim of this study was to evaluate the incidence of hip fractures in patients with PA. METHODS: We studied a nationwide cohort of 2419 patients with PA (1997-2019) and 24 187 age and sex matched controls from the general population. Hip fractures were identified by ICD codes in the Swedish National Patient Register. We estimated hazard ratios (HRs) for incident hip fractures, adjusted for prior fractures, socioeconomic factors, diabetes, osteoporosis, hyperparathyroidism, and cardiovascular disease (CVD). Pairwise subgroup comparisons were performed by age (18-56 and > 56 years), sex, CVD at baseline, and treatment for PA. RESULTS: During a mean follow up of 8 ± 5 years, 64 (2.6%) patients had a hip fracture after being diagnosed with PA, compared to 401 (1.7%) controls. After adjustments, PA was associated with a 55% increased risk of hip fracture compared to controls (HR 1.55 [1.18-2.03]). HRs were increased in women (HR 1.76 [95% CI 1.24-2.52]), patients aged > 56 years (HR 1.62 [95% CI 1.21-2.17]), and patients with CVD at diagnosis (HR 2.15 [95% CI 1.37-3.37]). PA patients treated with adrenalectomy did not have higher risk than controls (HR 0.84 [95% CI 0.35-2.0]), while patients treated with mineralocorticoid receptor antagonists (MRA) retained a greater risk (HR 1.84 [95% CI 1.20-2.83]). CONCLUSION: PA is associated with increased hip fracture risk, especially in women, patients diagnosed after the age of 56 years and patients with established CVD at diagnosis. Also, patients treated with MRA seem to have an increased risk of hip fractures, while adrenalectomy may be protective.

Heart Failure in Late Pregnancy and Postpartum: Incidence and Long-Term Mortality in Sweden From 1997 to 2010.

BACKGROUND: Heart failure (HF) in late pregnancy and postpartum (HFPP), of which peripartum cardiomyopathy (PPCM) constitutes the larger part, is still a rare occurrence in Sweden. Population-based data are scarce. Our aim was to characterize HFPP and determine the incidence and mortality in a Swedish cohort. METHODS AND RESULTS: Through merging data from the National Inpatient, Cause of Death, and Medical Birth Registries, we identified ICD-10 codes for HF and cardiomyopathy within 3 months before delivery to 6 months postpartum. Each case was assigned 5 age-matched control subjects from the Medical Birth Registry. From 1997 to 2010, 241 unique HFPP case subjects and 1063 matched control subjects were identified. Mean incidence was 1 in 5719 deliveries. HFPP was strongly associated with preeclampsia (odds ratio [OR] 11.91, 95% confidence interval [CI] 7.86-18.06), obesity (OR 2.5, 95% CI 1.7-3.7), low- and middle-income country (LMIC) of origin (OR 1.73, 95% CI 1.14-2.63), and twin deliveries (OR 4.39 CI 95% 2.24-8.58). By the end of the study period deaths among cases were >35-fold those of controls: 9 cases (3.7 %) and 1 control (0.1 %; P < .0001). Among control subjects, 17.9% of mortalities occurred within 3 years, of diagnosis compared with 100% among cases. CONCLUSIONS: The mean incidence and mortality among women with HFPP in Sweden from 1997 to 2010 was low but carried a marked excess risk of death compared with control subjects and was strongly linked to preeclampsia, obesity, multifetal births, and LMIC origin of the mother.

Twenty-year trends in long-term mortality risk in 17,149 survivors of ischemic stroke less than 55 years of age.

BACKGROUND AND PURPOSE: The purpose of the present study was to investigate the 4-year mortality risk among patients<55 years with a first ischemic stroke during 1987-2006. METHODS: A total of 17,149 cases (37.4% women) aged 18 to 54 years who survived≥28 days after a first ischemic stroke were identified in the Swedish Inpatient Register from 1987 to 2006. All patients were followed for 4 years or until death. The standardized mortality ratio was calculated by comparing the mortality rates with those of the general population of equivalent age, sex, and calendar year. RESULTS: During the period, there were 1265 deaths. Long-term survival improved over time in both men and women. Among men, the mortality risk decreased by 32% (hazard ratio=0.68 [95% confidence interval, 0.56-0.82]) from the first 5-year period to the last 5-year period (1987-1991 versus 2002-2006), and among women, the mortality risk decreased by 45% (0.55 [0.41-0.75]). Despite an overall decrease in mortality, the standardized mortality ratios for the last 5-year period remained high: 5.88 (95% confidence interval, 5.10-6.71) for men and 5.91 (4.68-7.29) for women with an absolute excess risk of 1.60 and 0.97 per 100 person-years, respectively, with nearly half of all deaths related to cardiovascular disease. CONCLUSIONS: During the 20-year period, 4-year mortality decreased by one third but was still 6-fold higher than that of the general population in the most recent period, emphasizing the importance of secondary prevention in young persons who have had a stroke.

Assessment of selection bias in a health survey of children and families - the IDEFICS Sweden-study.

BACKGROUND: A health survey was performed in 2007-2008 in the IDEFICS/Sweden study (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) in children aged 2-9 years. We hypothesized that families with disadvantageous socioeconomic and -demographic backgrounds and children with overweight and obesity were underrepresented. METHODS: In a cross-sectional study, we compared Swedish IDEFICS participants (N=1,825) with referent children (N=1,825) using data from Statistics Sweden population registers. IDEFICS participants were matched for age and gender with a referent child living in the same municipality. Longitudinal weight and height data from birth to 8 years was collected for both populations (n=3,650) from the children's local health services. Outcome measures included the family's socioeconomic and demographic characteristics, maternal body mass index (BMI) and smoking habits before pregnancy, the children's BMI standard deviation score (SDS) at the age of inclusion in the IDEFICS study (BMISDS-index), and the children's BMI-categories during the age-span. Comparisons between groups were done and a multiple logistic regression analysis for the study of determinants of participation in the IDEFICS study was performed. RESULTS: Compared with IDEFICS participants, referent families were more likely to have lower education and income, foreign backgrounds, be single parents, and have mothers who smoked before pregnancy. Maternal BMI before pregnancy and child's BMISDS-index did not differ between groups. Comparing the longitudinal data-set, the prevalence of obesity was significantly different at age 8 years n= 45 (4.5%) versus n= 31 (2.9%) in the referent and IDEFICS populations, respectively. In the multivariable adjusted model, the strongest significant association with IDEFICS study participation was parental Swedish background (odds ratio (OR) = 1.91, 95% confidence interval (CI) (1.48-2.47) followed by parents having high education OR 1.80, 95% CI (1.02-3.16) and being married or co-habiting OR 1.75 95% CI (1.38-2.23). CONCLUSION: Families with single parenthood, foreign background, low education and income were underrepresented in the IDEFICS Sweden study. BMI at inclusion had no selection effect, but developing obesity was significantly greater among referents.

A nationwide study of temporal trends of cause-specific hospital readmissions in patients with heart failure.

AIMS: The impact of hospital readmissions on the outcomes of heart failure (HF) patients is well known. However, data on temporal trends of cause-specific hospital readmissions in these patients are limited. METHODS AND RESULTS: From 1987 to 2014, we identified and followed up for 1 year 608 135 patients ≥18 years hospitalized with HF according to the International Classification of Diseases (ICD) 9 and 10 from the National Inpatient Register. Readmissions for cardiovascular (CVD) and non-CVD causes and co-morbidities were defined according to ICD-9 and ICD-10 codes. We analysed trends in the incidence rate of readmissions, the median time to the first rehospitalization, and the time to readmission, stratified by sex, age groups and cause of rehospitalization using linear regression. During our study, 1 year all-cause mortality decreased (ß = -4.93, P < 0.0001), but the incidence rate of readmissions per 1000 person-years remained unchanged. The readmission rate for CVD causes decreased; in contrast, the readmission rate increased across all age and sex groups for non-CVD causes. Analysing the patients by study periods (1987-1997, 1998-2007 and 2008-2014), CVD and non-CVD co-morbidities had a statistically significant increasing trend (P < 0.001). The median time in hospital decreased and the median time to the first readmission were almost unchanged. CONCLUSIONS: Contrary to a declining mortality rate, the incidence rate of readmissions saw no change, possibly because of divergent trends in cause-specific readmissions. An increasing rate of readmissions for non-CVD causes underscores the importance of optimising multimorbidity management to reduce the risk of readmissions in patients with HF.

Heart failure outcomes in low-risk patients with atrial fibrillation: a case-control study of 680 523 Swedish individuals.

AIMS: Knowledge of long-term outcomes in patients with atrial fibrillation (AF) remains limited. We sought to evaluate the risk of new-onset heart failure (HF) in patients with AF and a low cardiovascular risk profile. METHODS AND RESULTS: Data from the Swedish National Patient Register were used to identify all patients with a first-time diagnosis of AF without underlying cardiovascular disease at baseline between 1987 and 2018. Each patient was compared with two controls without AF from the National Total Population Register. In total, 227 811 patients and 452 712 controls were included. During a mean follow-up of 9.1 (standard deviation 7.0) years, the hazard ratio (HR) for new-onset HF was 3.55 [95% confidence interval (CI) 3.51-3.60] in patients compared with controls. Women with AF (18-34 years) had HR for HF onset 24.6 (95% CI 7.59-80.0) and men HR 9.86 (95% CI 6.81-14.27). The highest risk was within 1 year in patients 18-34 years, HR 103.9 (95% CI 46.3-233.1). The incidence rate within 1 year increased from 6.2 (95% CI 4.5-8.6) per 1000 person-years in young patients (18-34 years) to 142.8 (95% CI 139.4-146.3) per 1000 person-years among older patients (>80 years). CONCLUSIONS: Patients studied had a three-fold higher risk of developing HF compared with controls. Young patients, particularly women, carry up to 100-fold increased risk to develop HF within 1 year after AF. Further studies in patients with AF and low cardiovascular risk profile are needed to prevent serious complications such as HF.

Incident Gout: Risk of Death and Cause-Specific Mortality in Western Sweden: A Prospective, Controlled Inception Cohort Study.

Background: Excess mortality in gout has been attributed to cardiovascular diseases (CVD). Considering the decline in CVD mortality in the general population, we wanted to evaluate overall mortality in gout and cause-specific contributions to mortality beyond CVD and temporal trends. Methods: All incident cases of gout between 2006 and 2015 in western Sweden and 5 population controls per case matched for age, sex, and county were identified. Comorbidities were identified for 5 years preceding the index date. Follow-up ended at death, migration, or end of study on December 2017. Effect of gout on death risk was calculated using COX regression on the whole population and stratified by sex, adjusted for demographics, and comorbidities. Death incidence rates were compared between the two time periods, 2006-2010 and 2011-2015. Results: We identified 22,055 cases of incident gout and 98,946 controls, median age (Q1, Q3) 69-68 (57, 79/56, 78) years and 67.6-66.5% males. Except for dementia, all comorbidities were significantly more common at baseline among gout cases. Overall, the risk for death in incident gout was neither increased overall nor in men, but women had a 10% elevated risk. In adjusted models for cause-specific mortality, death from CVD, renal disease, and digestive system diseases were significantly increased in the total gout population while death from dementia, cancer, and lung diseases were significantly decreased. There were no significant differences in overall incident death rate ratios between cases and controls in the two time periods examined. Conclusions: An increased risk for CVD, renal disease, and diseases of the digestive system in patients with gout highlights the importance of addressing CVD risk factors in gout management. Gout was associated with reduced mortality from dementia, which may have implications on urate lowering therapy and possible effects on dementia risk.

Trends in survival of Swedish men and women with heart failure from 1987 to 2014: a population-based case-control study.

AIMS: To compare trends in short-term and long-term survival of patients with heart failure (HF) compared with controls from the general population. METHODS AND RESULTS: We used data from the Swedish National Inpatient Registry to identify all patients aged ≥18 years with a first recorded diagnosis of HF between 1 January 1987 and 31 December 2014 and compared them with controls matched on age and sex from the Total Population Register. We included 702 485 patients with HF and 1 306 183 controls. In patients with HF aged 18-64 years, short-term (29 days to 6 months) and long-term mortality (>11 years) decreased from 166 and 76.6 per 1000 person-years in 1987 to 2000 to 99.6 and 49.4 per 1000 person-years, respectively, in 2001 to 2014. During the same period, mortality improved marginally, in those aged ≥65 years: short-time mortality from 368.8 to 326.2 per 1000 person-years and long-term mortality from 219.6 to 193.9 per 1000 person-years. In 1987-2000, patients aged <65 years had more than three times higher risk of dying at 29 days to 6 months, with an hazard ratio (HR) of 3.66 [95% confidence interval (CI) 3.46-3.87], compared with controls (P < 0.0001) but substantially higher in 2001-2014 with an HR of 11.3 (95% CI 9.99-12.7, P < 0.0001). HRs for long-term mortality (6-10 and >11 years) increased moderately from 2.49 (95% CI 2.41-2.57) and 3.16 (95% CI 3.07-3.24) in 1987-2000 to 4.35 (95% CI 4.09-4.63) and 4.11 (95% CI 3.49-4.85) in 2001-2014, largely because survival among controls improved more than that among patients with HF (P < 0.0001). CONCLUSIONS: Absolute survival improved in HF patients aged <65 years, but only marginally so in those aged ≥65 years. Compared with controls, both short-term and long-term relative risk of dying increased, especially in younger patients with HF.

Opioid consumption in patients undergoing Roux-en-Y bariatric surgery compared with population controls with and without obesity.

BACKGROUND: Patients with obesity are prescribed more opioids than the general population. OBJECTIVES: To compare opioid consumption in patients with obesity who underwent Roux-en-Y bariatric surgery (RYGB) with population controls with and without obesity, not undergoing bariatric surgery, and to identify characteristics associated with opioid use. SETTING: This study included all patients with a principal diagnosis of obesity, aged 18-72 years, with a RYGB surgical code in the Swedish Patient Register between 2007 and 2013. METHODS: RYGB patients (n = 23,898) were age- and sex-matched with 1 control patient with obesity (n = 23,898) and 2 population controls without obesity (n = 46,064). Participants were classified as nonconsumers and consumers based on their opioid dispensations during the 12 months before baseline. Opioid consumption was assessed for 24 months. RESULTS: Nonconsumers. Within 24 months, a significantly higher proportion of RYGB patients (16.6%) started using opioids compared with the controls with obesity (14.3%, P < .0001) and population controls (5.4%, P < .0001). RYGB patients and controls with obesity had higher median daily intake of opioid morphine equivalent (MEQ) (2.8 mg/d) than population controls (2.5 mg/d, P < .0001). Consumers. Within 24 months, the proportion of RYGB patients and controls with obesity that was using opioids were similar (53.1% and 53.4%), but higher compared to population controls (38.0%, P < .0001). The median daily opioid MEQ was higher among RYGB patients than in population controls (10.5 versus 7.8 mg/d, P < .0001). RYGB patients, overall, had higher incidence of bowel surgery and cholecystectomy compared with controls with obesity and population controls, leading to prolonged opioid use in this group. Opioid consumption in general was associated with chronic pain and psychiatric disorder, which were more common in patients with obesity than in the population controls. CONCLUSION: RYGB surgery increased the risk of prolonged opioid use in patients with obesity who were nonconsumers before surgery but had no effect on overall opioid use among prior consumers. RYGB-associated complications requiring surgery influenced opioid use for both nonconsumers and consumers. Regular reassessments of pain mechanisms and specific treatment owing to type of pain could prevent unnecessary opioid use in this patient group.

Trends in mortality risks among 94,328 patients surviving 30days after a first isolated coronary artery bypass graft procedure from 1987 to 2006: A population-based study.

BACKGROUND: Updated knowledge about survival after coronary artery bypass graft (CABG) surgery is needed. We examined 20-year trends in 4-year survival after a first isolated CABG procedure, compared with that of the general population. METHODS: We identified 94,328 patients surviving 30days after a first isolated CABG 1987-2006 from the Swedish Inpatient Register. RESULTS: Crude annual mortality rates remained stable at approximately 1% in patients aged 18-54years and at approximately 2% in those aged ≥55years. After adjustment for comorbidities, 4-year survival in men aged 18-54 and ≥55years improved by 37% (HR: 0.63, 95% CI, 0.46-0.88) and 31% (HR: 0.69, 95% CI, 0.63-0.76), respectively, (1987-1991 vs. 2002-2006). The corresponding estimate for women aged ≥55years was 38% (HR: 0.62, 95% CI, 0.52-0.75), with no significant change in survival in women aged <55years (HR: 1.02, 95% CI, 0.52-2.03). Men and women aged <55years had higher mortality than the general population, with standardized mortality ratios (SMR) of 1.76 (95% CI, 1.35-2.22) in men and 4.49 (95% CI, 2.74-6.68) in women during the last period (2002-2006). In contrast, patients aged ≥55years had better survival with a SMR of 0.74 (95% CI, 0.70-0.78) in men and 0.82 (95% CI, 0.74-0.91) in women during 2002-2006. CONCLUSION: During 1987-2006, there was a significant improvement in survival after CABG for all categories, except in women aged <55years. Men and women aged ≥55years who survived the first 30days after CABG had a lower mortality risk than the general population.

Non-prescribed use of psychoactive prescription drugs among drug-impaired drivers in Sweden.

AIMS: To determine the prevalence of non-prescribed drug use among subjects suspected of drug-impaired driving with a psychoactive prescription drug, and to identify associated factors. METHODS: Subjects investigated for drug-impaired driving in Sweden during 2006-2009 with a confirmed intake of diazepam, flunitrazepam, tramadol, zolpidem or zopiclone were identified using the Swedish Forensic Toxicology Database. Information on dispensed prescription drugs was retrieved from the Swedish Prescribed Drug Register. Non-prescribed use was our outcome, defined as a psychoactive prescription drug intake confirmed by toxicological analysis in a subject by whom it was not dispensed in the 12 months preceding the sampling. Prevalence proportions were calculated for each drug and logistic regression was used to identify associated factors. RESULTS: In total, 2225 subjects were included. The median age (range) was 34 (15-80) years and 1864 (83.8%) subjects were male. Non-prescribed use was found in 1513 subjects (58.7%); for flunitrazepam 103 (76.3%), diazepam 1098 (74.1%), tramadol 192 (40.3%), zopiclone 60 (29.7%), and zolpidem 60 (21.2%) subjects, respectively. Younger age and multiple-substance use were associated with non-prescribed use, whereas ongoing treatment with other psychoactive drugs was negatively associated with non-prescribed use. CONCLUSIONS: Non-prescribed use of psychoactive prescription drugs was common in subjects suspected of drug-impaired driving and was more frequent for benzodiazepines and tramadol compared to zolpidem and zopiclone. The young and multi-substance users were more likely, whereas subjects with ongoing prescribed treatment with other psychoactive drugs were less likely, to use non-prescribed drugs.