Restrictive Spirometric Pattern and Preserved Ratio Impaired Spirometry in a Population 50-64 Years.

RATIONALE: Knowledge regarding prevalence and shared and unique characteristics of Restrictive spirometric pattern (RSP) and Preserved ratio impaired spirometry (PRISm) is lacking for a general population investigated with post-bronchodilator spirometry and computed tomography of the lungs. OBJECTIVES: To investigate shared and unique features for RSP and PRISm. METHODS: In the Swedish CArdioPulmonary bioImage Study (SCAPIS), a general population sample of 28,555 people aged 50 - 64 years (including 14,558 never-smokers) was assessed. The participants answered a questionnaire and underwent computed tomography of the lungs, post-bronchodilator spirometry, and coronary artery calcification score (CACS). Odds ratios (OR) with 95% confidence intervals (CI) were calculated using adjusted logistic regression. RSP was defined as FEV1/FVC≥0.70 and FVC<80%. PRISm was defined as FEV1/FVC≥0.70 and FEV1<80%. A local reference equation was applied. MEASUREMENTS AND RESULTS: The prevalence of RSP and PRISm were 5.1% (95% CI 4.9 - 5.4) and 5.1% (95% CI 4.8 - 5.3), respectively, with similar values seen in never-smokers. For RSP and PRISm, shared features were current smoking, dyspnea, chronic bronchitis, rheumatic disease, diabetes, ischemic heart disease (IHD), bronchial wall thickening, interstitial lung abnormalities (ILA), and bronchiectasis. Emphysema was uniquely linked to PRISm (OR 1.69, 1.36-2.10) vs 1.10 (0.84-1.43) for RSP. CACS≥300 was related to PRISm, but not among among never-smokers. CONCLUSIONS: PRISm and RSP have respiratory, cardiovascular, and metabolic conditions as shared features. Emphysema is only associated with PRISm. Coronary atherosclerosis may be associated with PRISm. Our results indicate that RSP and PRISm may share more features than not.

Plasma copeptin and markers of arterial disorder in patients with type 2 diabetes, a cross-sectional study.

OBJECTIVES: There is currently limited understanding of the relationship between copeptin, the midregional portion of proadrenomedullin (MRproADM) and the midregional fragment of the N-terminal of proatrial natriuretic peptide (MRproANP), and arterial disorders. Toe brachial index (TBI) and aortic pulse wave velocity (aPWV) are established parameters for detecting arterial disorders. This study evaluated whether copeptin, MRproADM, and MRproANP were associated with TBI and aPWV in patients with type 2 diabetes with no history of cardiovascular disease (CVD). METHODS: In the CARDIPP study, a cross-sectional analysis of 519 patients with type 2 diabetes aged 55-65 years with no history of CVD at baseline, had complete data on copeptin, MRproADM, MRproANP, TBI, and aPWV was performed. Linear regression analysis was used to investigate the associations between conventional CVD risk factors, copeptin, MRproADM, MRproANP, TBI, and aPWV. RESULTS: Copeptin was associated with TBI (ß-0.0020, CI-0.0035- (-0.0005), p = 0.010) and aPWV (ß 0.023, CI 0.002-0.044, p = 0.035). These associations were independent of age, sex, diabetes duration, mean 24-hour ambulatory systolic blood pressure, glycated hemoglobin A1c, total cholesterol, estimated glomerular filtration rate, body mass index, and active smoking. CONCLUSIONS: Plasma copeptin may be a helpful surrogate for identifying individuals at higher risk for arterial disorders. TRIAL REGISTRATION:  ClinicalTrials.gov identifier NCT010497377.

High prevalence of interstitial lung abnormalities in middle-aged never-smokers.

Background: Interstitial lung abnormalities (ILA) are incidental findings on chest computed tomography (CT). These patterns can present at an early stage of fibrotic lung disease. Our aim was to estimate the prevalence of ILA in the Swedish population, in particular in never-smokers, and find out its association with demographics, comorbidities and symptoms. Methods: Participants were recruited to the Swedish CArdioPulmonary BioImage Study (SCAPIS), a population-based survey including men and women aged 50-64 years performed at six university hospitals in Sweden. CT scan, spirometry and questionnaires were performed. ILA were defined as cysts, ground-glass opacities, reticular abnormality, bronchiectasis and honeycombing. Findings: Out of 29 521 participants, 14 487 were never-smokers and 14 380 were men. In the whole population, 2870 (9.7%) had ILA of which 134 (0.5%) were fibrotic. In never-smokers, the prevalence was 7.9% of which 0.3% were fibrotic. In the whole population, age, smoking history, chronic bronchitis, cancer, coronary artery calcium score and high-sensitive C-reactive protein were associated with ILA. Both ILA and fibrotic ILA were associated with restrictive spirometric pattern and impaired diffusing capacity of the lung for carbon monoxide. However, individuals with ILA did not report more symptoms compared with individuals without ILA. Interpretation: ILA are common in a middle-aged Swedish population including never-smokers. ILA may be at risk of being underdiagnosed among never-smokers since they are not a target for screening.

Consequences of Using Post- or Prebronchodilator Reference Values in Interpreting Spirometry.

Rationale: Postbronchodilator spirometry is used for the diagnosis of chronic obstructive pulmonary disease. However, prebronchodilator reference values are used for spirometry interpretation. Objectives: To compare the resulting prevalence rates of abnormal spirometry and study the consequences of using pre- or postbronchodilator reference values generated within SCAPIS (Swedish CArdioPulmonary bioImage Study) when interpreting postbronchodilator spirometry in a general population. Methods: SCAPIS reference values for postbronchodilator and prebronchodilator spirometry were based on 10,156 and 1,498 never-smoking, healthy participants, respectively. We studied the associations of abnormal spirometry, defined by using pre- or postbronchodilator reference values, with respiratory burden in the SCAPIS general population (28,851 individuals). Measurements and Main Results: Bronchodilation resulted in higher predicted medians and lower limits of normal (LLNs) for FEV1/FVC ratios. The prevalence of postbronchodilator FEV1/FVC ratio lower than the prebronchodilator LLN was 4.8%, and that of postbronchodilator FEV1/FVC lower than the postbronchodilator LLN was 9.9%, for the general population. An additional 5.1% were identified as having an abnormal postbronchodilator FEV1/FVC ratio, and this group had more respiratory symptoms, emphysema (13.5% vs. 4.1%; P < 0.001), and self-reported physician-diagnosed chronic obstructive pulmonary disease (2.8% vs. 0.5%, P < 0.001) than subjects with a postbronchodilator FEV1/FVC ratio greater than the LLN for both pre- and postbronchodilation. Conclusions: Pre- and postbronchodilator spirometry reference values differ with regard to FEV1/FVC ratio. Use of postbronchodilator reference values doubled the population prevalence of airflow obstruction; this was related to a higher respiratory burden. Using postbronchodilator reference values when interpreting postbronchodilator spirometry might enable the identification of individuals with mild disease and be clinically relevant.

Plasma mid-regional pro-atrial natriuretic peptide predicts cardiovascular events in patients with type 2 diabetes independently of subclinical organ damage.

AIM: The aim of this study was to investigate the association between plasma MR-proANP and cardiovascular disease (CVD) in a middle-aged population with type 2 diabetes. METHODS: MR-proANP was measured in 690 patients with type 2 diabetes participating in the epidemiological study CARDIPP (Cardiovascular Risk Factors in Patients with Diabetes-a Prospective Study in Primary Care). The outcome variables were incident major adverse cardiovascular events (MACE) and all-cause mortality. Patients were followed using the national Swedish Cause of Death Registry and the Inpatient Register. RESULTS: During the mean follow-up period of 10.8 years, MACE occurred in 111 patients and 102 patients died. The hazard ratio for an increment of MR-proANP of 1 pmol/l adjusted for sex, age, current smoking, previous CVD, HbA1c, serum cholesterol, eGFR, systolic blood pressure, C-reactive protein, aortic pulse wave velocity, left ventricular mass and intima media thickness in the carotid arteries was 1.007 (95% CI 1.000-1.013, P = 0.042) for MACE and 1.008 (95% CI 1.001-1.014, P = 0.017) for all-cause mortality. CONCLUSIONS: Elevated MR-proANP levels predict an increased risk for MACE and all-cause mortality in patients with type 2 diabetes independently of CVD risk factors and markers for subclinical organ damage.

Association of cardiometabolic risk factors with hospitalisation or death due to COVID-19: population-based cohort study in Sweden (SCAPIS).

OBJECTIVE: To assess the association of cardiometabolic risk factors with hospitalisation or death due to COVID-19 in the general population. DESIGN, SETTING AND PARTICIPANTS: Swedish population-based cohort including 29 955 participants. EXPOSURES: Cardiometabolic risk factors assessed between 2014 and 2018. MAIN OUTCOME MEASURES: Hospitalisation or death due to COVID-19, as registered in nationwide registers from 31 January 2020 through 12 September 2020. Associations of cardiometabolic risk factors with the outcome were assessed using logistic regression adjusted for age, sex, birthplace and education. RESULTS: Mean (SD) age was 61.2 (4.5) and 51.5% were women. 69 participants experienced hospitalisation or death due to COVID-19. Examples of statistically significant associations between baseline factors and subsequent hospitalisation or death due to COVID-19 included overweight (adjusted OR (aOR) vs normal weight 2.73 (95% CI 1.25 to 5.94)), obesity (aOR vs normal weight 4.09 (95% CI 1.82 to 9.18)), pre-diabetes (aOR vs normoglycaemia 2.56 (95% CI 1.44 to 4.55)), diabetes (aOR vs normoglycaemia 3.96 (95% CI 2.13 to 7.36)), sedentary time (aOR per hour/day increase 1.10 (95% CI 1.02 to 1.17)), grade 2 hypertension (aOR vs normotension 2.44 (95% CI 1.10 to 5.44)) and high density lipoprotein cholesterol (aOR per mmol/L increase 0.33 (95% CI 0.17 to 0.65)). Statistically significant associations were not observed for grade 1 hypertension (aOR vs normotension 1.03 (95% CI 0.55 to 1.96)), current smoking (aOR 0.56 (95% CI 0.24 to 1.30)), total cholesterol (aOR per mmol/L increase 0.90 (95% CI 0.71 to 1.13)), low density lipoprotein cholesterol (aOR per mmol/L increase 0.90 (95% CI 0.69 to 1.15)) and coronary artery calcium score (aOR per 10 units increase 1.00 (95% CI 0.99 to 1.01)). CONCLUSIONS: In a large population-based sample from the general population, several cardiometabolic risk factors were associated with hospitalisation or death due to COVID-19.

Circulating TNFrII levels predict incidence of ischemic heart disease and total mortality, independently of intima media thickness and pulse wave velocity in male with type 2 diabetes.

New and clinically useful markers of cardiovascular risk are of great importance in patients with type 2 diabetes since cardiovascular disease is a major cause of death in these patients. We analyzed inflammatory markers and other risk factors for heart disease in 761 patients who participated in the CARDIPP-study, Cardiovascular Risk factors in Patients with Diabetes-a Prospective study in Primary care. All participants had type 2 diabetes and were 55-66 years old at recruitment during the years 2005-2008. Patients were followed for incidence of stroke, myocardial infarction, or death from cardiovascular disease until the end of the year 2018 using the national Swedish Cause of Death and Hospitalization Registries. Besides traditional risk-markers for vascular disease, we also measured carotid-femoral pulse-wave velocity and intima-media thickness of carotid arteries. During a median period of 13 years, 165 men and 65 women died or were hospitalized for ischemic heart disease and stroke. TNFrII showed statistically significance as a risk factor for stroke, ischemic heart disease, and total mortality in male patients with diabetes type 2, independently of age, diabetes duration, BMI, Hba1c, systolic blood pressure, triglycerides, IMT and PWV (p = 0.002, HR 2.70, CI 1.42:5.13, p = 0.002). Circulating TNFrII levels failed to present a similar correlation in women (p = 0.48, CI 0.48:4.84). TNFrII stayed significant in males when HDL/LDL-ratio, CRP and smoking were added to the statistical analysis. Our data support the use of serum TNFrII in male type 2 diabetes patients to add independent prognostic information in terms of mortality and heart disease independently of other strong and well-established risk markers including cholesterol, inflammatory cytokines, PWV and IMT.Trial registration: ClinicalTrials.gov NCT01049737.

Chronic airflow limitation and its relation to respiratory symptoms among ever-smokers and never-smokers: a cross-sectional study.

BACKGROUND: The diagnosis of chronic obstructive pulmonary disease is based on the presence of persistent respiratory symptoms and chronic airflow limitation (CAL). CAL is based on the ratio of forced expiratory volume in 1 s to forced vital capacity (FEV1:FVC) after bronchodilation, and FEV1:FVC less than the fifth percentile is often used as a cut-off for CAL. The aim was to investigate if increasing percentiles of FEV1:FVC were associated with any respiratory symptom (cough with phlegm, dyspnoea or wheezing) in a general population sample of never-smokers and ever-smokers. METHODS: In a cross-sectional study comprising 15 128 adults (50-64 years), 7120 never-smokers and 8008 ever-smokers completed a respiratory questionnaire and performed FEV1 and FVC after bronchodilation. We calculated their z-scores for FEV1:FVC and defined the fifth percentile using the Global Lung Function Initiative (GLI) reference value, GLI5 and increasing percentiles up to GLI25. We analysed the associations between different strata of percentiles and prevalence of any respiratory symptom using multivariable logistic regression for estimation of OR. RESULTS: Among all subjects, regardless of smoking habits, the odds of any respiratory symptom were elevated up to the GLI15-20 strata. Among never-smokers, the odds of any respiratory symptom were elevated at GLI<5 (OR 3.57, 95% CI 2.43 to 5.23) and at GLI5-10 (OR 2.57, 95% CI 1.69 to 3.91), but not at higher percentiles. Among ever-smokers, the odds of any respiratory symptom were elevated from GLI<5 (OR 4.64, 95% CI 3.79 to 5.68) up to GLI≥25 (OR 1.33, 95% CI 1.00 to 1.75). CONCLUSIONS: The association between percentages of FEV1:FVC and respiratory symptoms differed depending on smoking history. Our results support a higher percentile cut-off for FEV1:FVC for never-smokers and, in particular, for ever-smokers.

The association between plasma proteomics and incident cardiovascular disease identifies MMP-12 as a promising cardiovascular risk marker in patients with chronic kidney disease.

BACKGROUND AND AIMS: Previous proteomics efforts in patients with chronic kidney disease (CKD) have predominantly evaluated urinary protein levels. Therefore, our aim was to investigate the association between plasma levels of 80 cardiovascular disease-related proteins and the risk of major adverse cardiovascular events (MACE) in patients with CKD. METHODS: Individuals with CKD stages 3-5 (eGFR below 60 ml min-1 [1.73 m]-2) from three community-based cohorts (PIVUS, ULSAM, SAVA), one diabetes cohort (CARDIPP) and one cohort with peripheral artery disease patients (PADVA) with information on 80 plasma protein biomarkers, assessed with a proximity extension assay, and follow-up data on incident MACE, were used as discovery sample. To validate findings and to asses generalizability to patients with CKD in clinical practice, an outpatient CKD-cohort (Malnutrition, Inflammation and Vascular Calcification (MIVC)) was used as replication sample. RESULTS: In the discovery sample (total n = 1316), 249 individuals experienced MACE during 7.0 ± 2.9 years (range 0.005-12.9) of follow-up, and in the replication sample, 71 MACE events in 283 individuals over a mean ± SD change of 2.9 ± 1.2 years (range 0.1-4.0) were documented. Applying Bonferroni correction, 18 proteins were significantly associated with risk of MACE in the discovery cohort, adjusting for age and sex in order of significance, GDF-15, FGF-23, REN, FABP4, IL6, TNF-R1, AGRP, MMP-12, AM, KIM-1, TRAILR2, TNFR2, CTSL1, CSF1, PlGF, CA-125, CCL20 and PAR-1 (p < 0.000625 for all). Only matrix metalloproteinase 12 (MMP-12) was significantly associated with an increased risk of MACE in the replication sample (hazard ratio (HR) per SD increase, 1.36, 95% CI (1.07-1.75), p = 0.013). CONCLUSIONS: Our proteomics analyses identified plasma MMP-12 as a promising cardiovascular risk marker in patients with CKD.

Toe brachial index predicts major acute cardiovascular events in patients with type 2 diabetes independently of arterial stiffness.

OBJECTIVE: Our aim was to analyze the predictive value of toe brachial index (TBI) as a risk marker for future major adverse cardiovascular events (MACE) and all-cause mortality in patients with type 2 diabetes (T2D). METHODS: TBI was measured in 741 patients with T2D in 2005-2008. Conventional risk factors for vascular disease as well as non-invasive measurements such as pulse-wave velocity (PWV) and intima-media thickness (IMT) of the carotid arteries were estimated. MACE was defined as cardiovascular death or hospitalization for non fatal myocardial infarction or non fatal stroke. Patients were followed for incidence of MACE using the national Swedish Cause of Death Registry and the Inpatient Register. RESULTS: During the follow-up for a period of 9 years MACE occurred in 97 patients and 85 patients died. TBI tertile, 1 versus 3, was significantly related to MACE (HR 2.67, 95%CI 1.60-4.50; p < 0.001) and to all-cause mortality (HR 1.98, 95%CI 1.16-3.83; p = 0.01). TBI tertile 1 as compared to TBI tertile 3 predicted MACE, but not all-cause mortality, independently of age, sex, diabetes duration and treatment, antihypertensive treatment, previous cardiovascular diseases, office systolic blood pressure, HbA1c, LDL cholesterol, estimated glomerular filtration rate, body mass index, current smoking PWV, IMT and carotid plaque presence (HR 3.39, 95%CI 1.53-7.51; p = 0.003 and HR 1.81, 95%CI 0.87-3.76; p = 0.1, respectively). CONCLUSIONS: Low TBI predicts an increased risk for MACE independently of arterial stiffness in patients with type 2 diabetes. TRIAL REGISTRATION: Clinical Trials.gov number NCT01049737. Registered January 14, 2010.

The association of body mass index, weight gain and central obesity with activity-related breathlessness: the Swedish Cardiopulmonary Bioimage Study.

INTRODUCTION: Breathlessness is common in the population, especially in women and associated with adverse health outcomes. Obesity (body mass index (BMI) >30 kg/m2) is rapidly increasing globally and its impact on breathlessness is unclear. METHODS: This population-based study aimed primarily to evaluate the association of current BMI and self-reported change in BMI since age 20 with breathlessness (modified Research Council score ≥1) in the middle-aged population. Secondary aims were to evaluate factors that contribute to breathlessness in obesity, including the interaction with spirometric lung volume and sex. RESULTS: We included 13 437 individuals; mean age 57.5 years; 52.5% women; mean BMI 26.8 (SD 4.3); mean BMI increase since age 20 was 5.0 kg/m2; and 1283 (9.6%) reported breathlessness. Obesity was strongly associated with increased breathlessness, OR 3.54 (95% CI, 3.03 to 4.13) independent of age, sex, smoking, airflow obstruction, exercise level and the presence of comorbidities. The association between BMI and breathlessness was modified by lung volume; the increase in breathlessness prevalence with higher BMI was steeper for individuals with lower forced vital capacity (FVC). The higher breathlessness prevalence in obese women than men (27.4% vs 12.5%; p<0.001) was related to their lower FVC. Irrespective of current BMI and confounders, individuals who had increased in BMI since age 20 had more breathlessness. CONCLUSION: Breathlessness is independently associated with obesity and with weight gain in adult life, and the association is stronger for individuals with lower lung volumes.

Risk factors and consequences of decreased kidney function in nursing home residents: A longitudinal study.

AIM: The aim of the present study was to study the renal function and the relationship of deterioration in renal function with major outcomes in elderly nursing home residents. A second aim was to compare the internationally recommended formulae for estimated glomerular filtration rate (eGFR) consisting of both creatinine and cystatin C in a nursing home population. METHODS: A total of 429 patients from 11 nursing homes were included during 2008-2011. GFR was estimated, from formulae based on both creatinine and cystatin C, at baseline and after 1 and 2 years. The patients were divided into groups based on chronic kidney disease level, and comparisons were made for mortality, morbidity, the use of medications and between the different formulae for eGFR. RESULTS: Survival was lower in the groups with lower renal function. Over 60% of the residents had impaired renal function. Those with impaired renal function were older, had a higher number of medications and a higher prevalence of heart failure. Higher number of medications was associated with a greater risk of rapid decline in renal function with an odds ratio of 1.2 (95% confidence interval 1.06-1.36, P = 0.003). The compared eGFR formulae based on both cystatin C and creatinine were in excellent concordance with each other. CONCLUSIONS: Decreased renal function was associated with increased mortality. A majority of nursing home residents had declining renal function, which should be considered when prescribing medications. The more medications, the higher the risk for rapidly declining renal function. Geriatr Gerontol Int 2017; 17: 791-797.

Prevalence and predictive importance of anemia in Swedish nursing home residents - a longitudinal study.

BACKGROUND: Anemia is common in elderly people and especially in nursing home residents. Few studies have been performed on the consequences of anemia in a nursing home population. This study explored the prevalence of anemia in nursing homes in Sweden, including risk factors and mortality associated with anemia or hemoglobin (Hb) decline. METHODS: Three hundred ninety patients from 12 nursing homes were included during 2008-2011. Information about medication, blood samples, questionnaire responses and information about physical and social activities was recorded. The baseline characteristics of the patients were compared for subjects with and without anemia. Vital status was ascertained during the following 7 years from baseline to compare the survival. Hb levels <120 g/L in women and <130 g/L in men were used to define anemia. For 220 of the subjects Hb change during one year was registered and the quartiles in Hb change were compared in terms of baseline characteristics and mortality. RESULTS: The prevalence of anemia at baseline was 52% among men and 32% among women. The men with anemia had a two-year mortality significantly higher (61%) than the men without anemia (29%, p = 0.001) but there was no statistical difference in two-year survival in women. In anemic men there was a higher mortality (Hazard Ratio = 1.58) during a total follow-up period of up to 7 years after adjustment for age, increased B-type natriuretic peptide (BNP) and decreased estimated Glomerular Filtration Rate (eGFR). Among men, but not women, we found baseline correlations between anemia and elevated BNP (>100 ng/L) and severely reduced eGFR (<30 ml/min). When the lowest quartile of Hb change (decline > 9 g/L) was compared with the highest (improvement > 6 g/L) the mortality was higher in the lowest quartile (p = 0.03). CONCLUSIONS: Anemia is common in nursing home residents in Sweden, especially among men for whom it is related to higher mortality. A rapid Hb drop is associated with higher mortality. Regardless of earlier Hb values, monitoring Hb regularly in a nursing home population seems important for catching rapid Hb decline correlated with higher mortality.

Aortic pulse wave velocity predicts incident cardiovascular events in patients with type 2 diabetes treated in primary care.

AIMS: The aim was to evaluate the predictive value of aortic pulse wave velocity (aPWV) on incident cardiovascular events in patients with type 2 diabetes without previous cardiovascular disease who were treated in primary care, after adjustment for traditional risk factors. METHODS: We measured aPWV in 627 patients who participated in the epidemiological study CARDIPP (Cardiovascular Risk Factors in Patients with Diabetes-a Prospective Study in Primary Care; ClinicalTrials.gov identifier NCT01049737) and who did not have previously known myocardial infarction or stroke. The outcome variable was a composite endpoint consisting of cardiovascular mortality, hospitalization for myocardial infarction and hospitalization for stroke. RESULTS: During a median follow-up time of almost eight years, the unadjusted HR per each increment of aPWV by 1m/s was 1.239 (95% CI 1.114-1.379, P<0.001) for the primary endpoint. Following adjustments for age, sex, diabetes duration, office systolic blood pressure, resting heart rate, total cholesterol, HbA1c, estimated glomerular filtration rate and smoking status, the adjusted hazard ratio was 1.142 (95% CI 1.003-1.301, P=0.044). CONCLUSIONS: In primary preventive patients with type 2 diabetes treated in primary care, aPWV predicted a composite outcome of incident cardiovascular events independently of diabetes-specific and traditional risk factors.

Association of soluble tumor necrosis factor receptors 1 and 2 with nephropathy, cardiovascular events, and total mortality in type 2 diabetes.

AIMS/HYPOTHESIS: Soluble tumor necrosis factor receptors 1 and 2 (sTNFR1 and sTNFR2) contribute to experimental diabetic kidney disease, a condition with substantially increased cardiovascular risk when present in patients. Therefore, we aimed to explore the levels of sTNFRs, and their association with prevalent kidney disease, incident cardiovascular disease, and risk of mortality independently of baseline kidney function and microalbuminuria in a cohort of patients with type 2 diabetes. In pre-defined secondary analyses we also investigated whether the sTNFRs predict adverse outcome in the absence of diabetic kidney disease. METHODS: The CARDIPP study, a cohort study of 607 diabetes patients [mean age 61 years, 44 % women, 45 cardiovascular events (fatal/non-fatal myocardial infarction or stroke) and 44 deaths during follow-up (mean 7.6 years)] was used. RESULTS: Higher sTNFR1 and sTNFR2 were associated with higher odds of prevalent kidney disease [odd ratio (OR) per standard deviation (SD) increase 1.60, 95 % confidence interval (CI) 1.32-1.93, p < 0.001 and OR 1.54, 95 % CI 1.21-1.97, p = 0.001, respectively]. In Cox regression models adjusting for age, sex, glomerular filtration rate and urinary albumin/creatinine ratio, higher sTNFR1 and sTNFR2 predicted incident cardiovascular events [hazard ratio (HR) per SD increase, 1.66, 95 % CI 1.29-2.174, p < 0.001 and HR 1.47, 95 % CI 1.13-1.91, p = 0.004, respectively]. Results were similar in separate models with adjustments for inflammatory markers, HbA1c, or established cardiovascular risk factors, or when participants with diabetic kidney disease at baseline were excluded (p < 0.01 for all). Both sTNFRs were associated with mortality. CONCLUSIONS/INTERPRETATIONS: Higher circulating sTNFR1 and sTNFR2 are associated with diabetic kidney disease, and predicts incident cardiovascular disease and mortality independently of microalbuminuria and kidney function, even in those without kidney disease. Our findings support the clinical utility of sTNFRs as prognostic markers in type 2 diabetes.

Factors associated with increased hospitalisation risk among nursing home residents in Sweden: a prospective study with a three-year follow-up.

BACKGROUND: Hospitalisation of nursing home residents might lead to deteriorating health. AIM: To evaluate physical and psychological factors associated with hospitalisation risk among nursing home residents. DESIGN: Prospective study with three years of follow-up. METHODS: Four hundred and twenty-nine Swedish nursing home residents, ages 65-101 years, from 11 nursing homes in three municipalities were followed during three years. The participants' physical and psychological status was assessed at baseline. A Cox proportional hazards model was used to evaluate factors associated with hospitalisation risk using STATA. RESULTS: Of the 429 participants, 196 (45.7%) were hospitalised at least once during the three-year follow-up period, and 109 (25.4%) during the first six months of the study. The most common causes of hospitalisation were cardiovascular diseases or complications due to falls. A Cox regression model showed that residents who have had previous falls (P < 0.001), are malnourished (P < 0.001), use a greater number of drugs (P < 0.001) and have more diseases (P < 0.001), are at an increased risk of hospitalisation. CONCLUSION: Nursing home residents are frequently hospitalised, often due to falls or cardiovascular diseases. Study results underscore the relationships between malnutrition, previous falls, greater numbers of drugs and diseases and higher risk of hospitalisation. IMPLICATIONS FOR PRACTICE: Preventive interventions aimed at malnutrition and falls at the nursing home could potentially reduce the number of hospitalisations. With improved education and support to nurses concerning risk assessment at the nursing homes, it may be possible to reduce the numbers of avoidable hospitalisation among nursing home residents and in the long run improve quality of life and reduce suffering.

Depression and use of antidepressants in Swedish nursing homes: a 12-month follow-up study.

BACKGROUND: The prescription of antidepressants in nursing homes has increased markedly since the introduction of SSRIs, while at the same time depressive symptoms often go unrecognized and untreated. The aim of this study was to examine whether depression among residents in nursing homes is treated adequately. METHODS: A sample of 429 participants from 11 Swedish nursing homes was selected and was assessed with the Cornell Scale for Depression in Dementia (CSDD) and using medical records and drug prescription data. For 256 participants a follow-up assessment was performed after 12 months. RESULTS: The prevalence of depression, according to medical records, was 9.1%, and the prevalence of CSDD score of ≥8 was 7.5%. Depression persisted in more than 50% of cases at the 12-month follow-up. Antidepressants were prescribed to 33% of the participants without a depression diagnosis or with a CSDD score of <8. 46.2% of all participants were prescribed antidepressants. 14% of the participants without a depression diagnosis or with a CSDD score of <8 had psychotropic polypharmacy. 15.2% of all participants had psychotropic polypharmacy, which persisted at the 12-month follow-up in three-quarters of cases. CONCLUSION: The prescription of antidepressants in frail elderly individuals is extensive and may be without clear indication. The clinical implication is that there is a need for systematic drug reviews at nursing homes, paying special attention to the subjects which are on antidepressants.

Healthy aging and age-adjusted nutrition and physical fitness.

Expected life span is gradually increasing worldwide. Healthy dietary and exercise habits contribute to healthy ageing. Certain types of diet can prevent or reduce obesity, and may reduce the risk of diseases (e.g., cardiovascular disease). Exercise also reduces the risk of diseases (e.g., cardiovascular disease, osteoporosis, some cancers and some mental disturbances). A less sedentary life style seems at least as important as regular exercise. Exercise can probably be tailored to reduce the risk of cardiovascular disease and extent of bone loss. To ensure adherence, it is important to increase slowly the frequency, duration and intensity of exercise, and to find activities that suit the individual. More research is needed to find ideal modes and doses of exercise, and to increase long-term adherence. Dietary and exercise modification seem to be strong promoters of healthy ageing.

Low level of antimicrobial resistance in Escherichia coli among Swedish nursing home residents.

BACKGROUND: Screening for bacterial colonization and antimicrobial resistance (AMR) among a defined population could aid in the identification of at-risk populations and provide targets for antibiotic stewardship and infection control programmes. METHODS: Two hundred and sixty-eight participants at 11 Swedish nursing homes underwent serial screening for colonization with Escherichia coli between March 2008 and September 2010. Seventy-two of the 268 participants (27%) were male. The median age was 85 y. Samples were collected from urine, the rectal mucosa, the groin, and active skin lesions. RESULTS: Two hundred and nine of 268 participants (78%) were colonized with E. coli at any body site/fluid. The specific colonization rates were 81% (rectum), 48% (urine), 30% (groin), 59% (unknown), and 13% (skin lesion). An antibiotic-resistant E. coli isolate was identified in 18% of all participants regardless of colonization status; all together, 87 resistant isolates were detected. Only 1 participant carried isolates with resistance to third-generation cephalosporins (cefotaxime and ceftazidime). CONCLUSIONS: The presence of resistance was generally low, and the greater part of the resistant cases was connected with 3 common antibiotics: ampicillin, trimethoprim/sulfamethoxazole, and ciprofloxacin. In spite of generally increasing resistance against third-generation cephalosporins in E. coli in Sweden, this study does not implicate residence at a Swedish nursing home as a risk factor for the acquisition of expressed cephalosporin resistance.

Colonization with Staphylococcus aureus in Swedish nursing homes: a cross-sectional study.

BACKGROUND: Screening for bacterial colonization among risk populations could provide better estimates of the volume of the bacteria-related disease reservoir and the level of antimicrobial resistance, than do conventional laboratory reports. METHODS: Two hundred and one participants at 10 Swedish nursing homes were screened for colonization with Staphylococcus aureus between January and October 2009. Of the 201 participants, 61 (30%) were male. The median age was 86 y. All participants were systematically sampled from the nasal mucosa, the pharyngeal mucosa, the groin, and active skin lesions, if any. RESULTS: Ninety-nine of 199 participants (50%) were colonized with S. aureus. The colonization rate was 34% for the nose, 35% for throat, 10% for groin, and 54% for active skin lesions. An antibiotic-resistant S. aureus isolate was identified in 8.5% of all participants regardless of colonization status. A total of 24 resistant isolates were detected, and 21 of these were resistant to fluoroquinolones. There was no case of colonization with methicillin-resistant S. aureus (MRSA). CONCLUSIONS: The presence of resistant isolates was generally low, and the greater part of the resistance was fluoroquinolone-related. To achieve reasonable precision, screening programmes of this kind must include samples from both the nose and throat, and, although low, the prevalence of antimicrobial resistance in Swedish nursing homes still calls for reflection on how to use the fluoroquinolones wisely.