Validation of the Health Assessment Tool (HAT) based on four aging cohorts from the Swedish National study on Aging and Care.

BACKGROUND: As global aging accelerates, routinely assessing the functional status and morbidity burden of older patients becomes paramount. The aim of this study is to assess the validity of the comprehensive clinical and functional Health Assessment Tool (HAT) based on four cohorts of older adults (60 + years) from the Swedish National study on Aging and Care (SNAC) spanning urban, suburban, and rural areas. METHODS: The HAT integrates five health indicators (gait speed, global cognition, number of chronic diseases, and basic and instrumental activities of daily living), providing an individual-level score between 0 and 10. The tool was constructed using nominal response models, first separately for each cohort and then in a harmonized dataset. Outcomes included all-cause mortality over a maximum follow-up of 16 years and unplanned hospital admissions over a maximum of 3 years of follow-up. The predictive capacity was assessed through the area under the curve (AUC) using logistic regressions. For time to death, Cox regressions were performed, and Harrell's C-indices were reported. Results from the four cohorts were pooled using individual participant data meta-analysis and compared with those from the harmonized dataset. RESULTS: The HAT demonstrated high predictive capacity across all cohorts as well as in the harmonized dataset. In the harmonized dataset, the AUC was 0.84 (95% CI 0.81-0.87) for 1-year mortality, 0.81 (95% CI 0.80-0.83) for 3-year mortality, 0.80 (95% CI 0.79-0.82) for 5-year mortality, 0.69 (95% CI 0.67-0.70) for 1-year unplanned admissions, and 0.69 (95% CI 0.68-0.70) for 3-year unplanned admissions. The Harrell's C for time-to-death throughout 16 years of follow-up was 0.75 (95% CI 0.74-0.75). CONCLUSIONS: The HAT is a highly predictive, clinically intuitive, and externally valid instrument with potential for better addressing older adults' health needs and optimizing risk stratification at the population level.

The influence of meteorological factors on COVID-19 spread in Italy during the first and second wave.

The relation between meteorological factors and COVID-19 spread remains uncertain, particularly with regard to the role of temperature, relative humidity and solar ultraviolet (UV) radiation. To assess this relation, we investigated disease spread within Italy during 2020. The pandemic had a large and early impact in Italy, and during 2020 the effects of vaccination and viral variants had not yet complicated the dynamics. We used non-linear, spline-based Poisson regression of modeled temperature, UV and relative humidity, adjusting for mobility patterns and additional confounders, to estimate daily rates of COVID-19 new cases, hospital and intensive care unit admissions, and deaths during the two waves of the pandemic in Italy during 2020. We found little association between relative humidity and COVID-19 endpoints in both waves, whereas UV radiation above 40 kJ/m2 showed a weak inverse association with hospital and ICU admissions in the first wave, and a stronger relation with all COVID-19 endpoints in the second wave. Temperature above 283 K (10 °C/50 °F) showed a strong non-linear negative relation with COVID-19 endpoints, with inconsistent relations below this cutpoint in the two waves. Given the biological plausibility of a relation between temperature and COVID-19, these data add support to the proposition that temperature above 283 K, and possibly high levels of solar UV radiation, reduced COVID-19 spread.

Socio-demographic differences in polypharmacy and potentially inappropriate drug use among older people with different care needs and in care settings in Stockholm, Sweden.

AIMS: Polypharmacy and potentially inappropriate medications (PIM) are risk factors for negative health outcomes among older people. This study aimed to investigate socio-demographic differences in polypharmacy and PIM use among older people with different care needs in a standard versus an integrated care setting. METHODS: Population-based register data on residents aged ⩾65 years in Stockholm County based on socio-demographic background and social care use in 2014 was linked to prescription drug use in 2015. A logistic regression analysis was used to estimate socio-demographic differences in polypharmacy and PIM, adjusting for education, age group, sex, country of birth, living alone, morbidity and dementia by care setting based on area and by care need (i.e. independent, home help or institutionalised). RESULTS: The prevalence of polypharmacy and PIM was greater among home-help users (60.4% and 11.5% respectively) and institutional residents (74.4% and 11.9%, respectively). However, there were greater socio-demographic differences among the independent, with those with lower education, older age and females having higher odds of polypharmacy and PIM. Morbidity was a driver of polypharmacy (odds ratio (OR)=1.19, confidence interval (CI) 1.16-1.22) among home-help users. Dementia diagnosis was associated with reduced odds of polypharmacy and PIM among those in institutions (OR=0.78, CI 0.71-0.87 and OR 0.52, CI 0.45-0.59, respectively) and of PIM among home-help users (OR=0.53, 95% CI 0.42-0.67). CONCLUSIONS: Polypharmacy and PIM were associated with care needs, most prevalent among home-help users and institutional residents, but socio-demographic differences were most prominent among those living independently, suggesting that municipal care might reduce differences between socio-demographic groups. Care setting had little effect on inappropriate drug use, indicating that national guidelines are followed.

Does misclassification of former tobacco smokers explain the 'smoker's paradox' in the risk of COVID-19? Insights from the Stockholm Public Health Cohort.

BACKGROUND: The association between tobacco smoking and the risk of COVID-19 and its adverse outcomes is controversial, as studies reported contrasting findings. Bias due to misclassification of the exposure in the analyses of current versus non-current smoking could be a possible explanation because former smokers may have higher background risks of the disease due to co-morbidity. The aim of the study was to investigate the extent of this potential bias by separating non-, former, and current smokers when assessing the risk or prognosis of diseases. METHODS: We analysed data from 43,400 participants in the Stockholm Public Health Cohort, Sweden, with information on smoking obtained prior to the pandemic. We estimated the risk of COVID-19, hospital admissions and death for (a) former and current smokers relative to non-smokers, (b) current smokers relative to non-current smokers, that is, including former smokers; adjusting for potential confounders (aRR). RESULTS: The aRR of a COVID-19 diagnosis was elevated for former smokers compared with non-smokers (1.07; 95% confidence interval (CI) =1.00-1.15); including hospital admission with any COVID-19 diagnosis (aRR= 1.23; 95% CI = 1.03-1.48); or with COVID-19 as the main diagnosis (aRR=1.23, 95% CI= 1.01-1.49); and death within 30 days with COVID-19 as the main or a contributory cause (aRR=1.40; 95% CI=1.00-1.95). Current smoking was negatively associated with risk of COVID-19 (aRR=0.79; 95% CI=0.68-0.91). CONCLUSIONS: Separating non-smokers from former smokers when assessing the disease risk or prognosis is essential to avoid bias. However, the negative association between current smoking and the risk of COVID-19 could not be entirely explained by misclassification.

Knowledge of the abortion law and key legal issues of sexual and reproductive health and rights among recently arrived migrants in Sweden: a cross-sectional survey.

BACKGROUND: Sexual and reproductive health and rights (SRHR), including access and information on the laws and policies related to abortion, varies considerably between countries. Migrants may have limited knowledge of SRHR and related resources in their new country. This study investigates migrants' knowledge of the right to safe and legal abortion and other associated factors including the recent law on sexual consent, the legal age for sexual consent and age to marry in Sweden. METHODS: We conducted a cross-sectional study from 2018 to 2019 among recent migrants attending high schools or Swedish language schools. Descriptive statistics were computed on the knowledge of the Swedish abortion law and other legal aspects. Univariable and multivariable logistic regression analyses were conducted to assess if migrants' socio-demographic characteristics were associated with knowledge (i.e. correct/incorrect) of the Swedish abortion law and other key SRHR-related legal issues. RESULTS: Of the total 6,263 participants, 3,557 (57%) responded about whether it is legal to have an induced abortion in Sweden, and of these, 2,632 (74%) answered incorrectly. While more than half (61%) of the respondents knew the sexual consent law, nearly half (48%) did not know that sexual consent is also required for married couples. About 90% correctly responded that it is illegal to have sex with a minor (under the age of 15) and were aware of the legal age (18 years) to marry in Sweden. Incorrect knowledge of the Swedish abortion law was associated with being religious (adjusted odds ratio (AOR), 2.12; 95% confidence interval (CI), 1.42-3.15), not having previous sexual health education (AOR, 1.68; 95% CI, 1.38-2.05), coming from a country with predominantly restrictive abortion laws (AOR, 1.46; 95% CI, 1.16-1.84), low level of education (AOR, 1.29; 95% CI, 1.04-1.61) and having a temporary residence permit (AOR, 1.27; 95% CI, 1.02-1.57). CONCLUSION: We found a substantial lack of knowledge among migrants of reproductive age in Sweden regarding important laws and policies of SRHR, particularly the right to abortion. SRHR-related programmes and comprehensive sexual health education for recently arrived migrants could include components to increase knowledge of legal and safe abortions and other laws concerning SRHR.

Blood Pressure Effects of Sodium Reduction: Dose-Response Meta-Analysis of Experimental Studies.

BACKGROUND: The relationship between dietary sodium intake and blood pressure (BP) has been tested in clinical trials and nonexperimental human studies, indicating a direct association. The exact shape of the dose-response relationship has been difficult to assess in clinical trials because of the lack of random-effects dose-response statistical models that can include 2-arm comparisons. METHODS: After performing a comprehensive literature search for experimental studies that investigated the BP effects of changes in dietary sodium intake, we conducted a dose-response meta-analysis using the new 1-stage cubic spline mixed-effects model. We included trials with at least 4 weeks of follow-up; 24-hour urinary sodium excretion measurements; sodium manipulation through dietary change or supplementation, or both; and measurements of systolic and diastolic BP at the beginning and end of treatment. RESULTS: We identified 85 eligible trials with sodium intake ranging from 0.4 to 7.6 g/d and follow-up from 4 weeks to 36 months. The trials were conducted in participants with hypertension (n=65), without hypertension (n=11), or a combination (n=9). Overall, the pooled data were compatible with an approximately linear relationship between achieved sodium intake and mean systolic as well as diastolic BP, with no indication of a flattening of the curve at either the lowest or highest levels of sodium exposure. Results were similar for participants with or without hypertension, but the former group showed a steeper decrease in BP after sodium reduction. Intervention duration (≥12 weeks versus 4 to 11 weeks), type of study design (parallel or crossover), use of antihypertensive medication, and participants' sex had little influence on the BP effects of sodium reduction. Additional analyses based on the BP effect of difference in sodium exposure between study arms at the end of the trial confirmed the results on the basis of achieved sodium intake. CONCLUSIONS: In this dose-response analysis of sodium reduction in clinical trials, we identified an approximately linear relationship between sodium intake and reduction in both systolic and diastolic BP across the entire range of dietary sodium exposure. Although this occurred independently of baseline BP, the effect of sodium reduction on level of BP was more pronounced in participants with a higher BP level.

Social factors and chronic pain: the modifying effect of sex in the Stockholm Public Health Cohort Study.

OBJECTIVES: To assess the relationship between social factors (socio-economic status, household load and job strain) and chronic pain occurrence, and the role of gender in this relationship. METHODS: We used data corresponding to 8 years of follow-up of the Stockholm Public Health Cohort Study (2006-2014) to compute Adjusted Incidence Rate Ratios (IRRs) and additive interaction measures of chronic pain episodes, social factors, and sex in 16 687 subjects. RESULTS: For men, increased rates of chronic pain occurrence were observed for skilled workers (IRR = 1.27, 95% CI: 0.99, 1.61) and lower non-manual employees (IRR = 1.37, 95% CI: 1.05, 1.78), compared with unskilled workers; subjects with high household load (IRR = 1.39; 95% CI: 1.03, 1.88), compared with those with a null score; and subjects with active jobs (IRR = 1.27, 95% CI: 1.06, 1.51), compared with those with low-strain jobs. For women, we observed decreased rates of chronic pain occurrence in lower (IRR = 0.82, 95% CI: 0.68, 0.99), intermediate (IRR = 0.74, 95% CI: 0.63, 0.88) and higher non-manual employees (IRR = 0.65, 95% CI: 0.54, 0.79), compared with unskilled workers. Compared with subjects with a null score, women with low household load showed a lower rate of chronic pain occurrence (IRR = 0.85; 95% CI: 0.72, 1.00). Compared with subjects with low-strain jobs, those with passive jobs (IRR = 1.21; 95% CI: 1.02, 1.44) and high-strain jobs (IRR = 1.46; 95% CI: 1.02, 2.09) showed higher rates of chronic pain occurrence. CONCLUSION: In general, our analysis yielded different, if not opposite, results when data were stratified by sex. Sex may then represent an effect modifier of the relationship between social factors and chronic pain.

Sexual risk-taking behaviors among young migrant population in Sweden.

BACKGROUND: Migration is a complex process of high uncertainty with adjustments to new contexts and experiences influencing individuals' health. This study aims to assess the prevalence of self-reported sexual risk-taking behaviors among migrant youth population in Sweden, fulfilling the research gap in that field. METHODS: A pre-tested, web-based self-administered cross-sectional survey was used to collect data among 1563 migrant youth (15-25 years old) in Sweden. The survey was conducted in high schools and Swedish language schools for foreigners between December 2018 and November 2019. Pearson chi-square and t-tests were used to compare whether sociodemographic characteristics and migration status varied between those engaging in sexual risk behaviors or not. Multivariate logistic regression was used to determine the adjusted odds ratio of the key outcome variable and independent variables. RESULTS: There is a profound heterogeneity in migrant youth characteristics related to engagement in different sexual risk-taking behaviors. Those engaging in condomless sex were older, coming from the Americas and Europe, living longer in Sweden and came to live with their family. Belonging to the Islamic religion was a protective factor. Sex under the influence of drugs was related to those from Europe, and Middle East and North Africa (MENA) and coming to Sweden to work/study, where age was a protective factor. Living longer in Sweden, coming for work/study or to live with family had higher odds to engage in sex in exchange for gifts/money. CONCLUSION: The results highlight the needed reconsideration of the broader system response that can influence migrant youth health outcomes and public health implications. The approach should consider and relate to sexual risk-taking behavior's long-term consequences. Migrant youth background needs and knowledge should guide this response.

Surgery Improves Survival After Neoadjuvant Therapy for Borderline and Locally Advanced Pancreatic Cancer: A Single Institution Experience.

OBJECTIVE: Neoadjuvant therapy (NAT) has become part of the multimodality treatment for borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC). SUMMARY BACKGROUND DATA: It is currently uncertain which are the preferable NAT regimens, who benefits from surgery, and whether more aggressive surgical strategy is motivated. METHODS: A retrospective cohort analysis was performed for all patients with BRPC/LAPC discussed and planned for NAT at multidisciplinary conference at Karolinska University Hospital from 2010 to 2017. RESULTS: Of 233 patients eligible, 168 (72%) received NAT and were reevaluated for possibility of resection. A total of 156 (67%) patients (mean 64 yrs, 53% male) had pancreatic adenocarcinoma, comprising the study group for survival analysis. LAPC was diagnosed in 132 patients (85%), BRPC in 22 (14%), and resectable tumor in 2 (1.3%). Fifty patients (40.3%) received full-dose NAT. Only 54 (34.6%) had FOLFIRINOX. The overall survival among resected patients was similar for BRPC and LAPC (median survival 15.0 vs 14.5 mo, P = 0.4; and 31.9 vs 21.8 mo, P = 0.7, respectively). Resected patients had better survival than nonresected, irrespective of the type or whether full-dose NAT was given (median survival 22.4 vs 12.7 mo; 1-, 3-, and 5-yr survival: 86.4%, 38.9%, 26.9% vs 52.2%, 1.5%, 0%, respectively (P < 0001). For all preoperative values of Ca 19-9, surgical resection had positive impact on survival. CONCLUSIONS: All patients with BRPC/LAPC who do not progress during NAT should be considered for surgical resection, irrespective of the type or dose of NAT given. Higher levels of Ca 19-9 should not be considered an absolute contraindication for resection.

Social factors and pain worsening: a retrospective cohort study.

BACKGROUND: Pain, specifically chronic pain, is a major public health issue worldwide with considerable health-related consequences and large economic impact. The relation between socioeconomic status and pain occurrence is well established. However, little is known on the relation between socioeconomic factors and worsening of pain, including progression from non-chronic pain to chronic pain. METHODS: To assess the relation between socioeconomic status and pain worsening, we used the Stockholm Public Health Cohort Study from 2006 to 2014 and analysed data of 9721 participants who completed follow-up. The adjusted incidence rate ratios (IRRs) of moderate and severe pain worsening episodes were computed, using a pain amplification model, which encompasses spreading, somatisation, and psychological distress components. Multiple imputation analysis was performed subsequently to adjust for cohort attrition. RESULTS: Compared with non-skilled workers, self-employed subjects (IRR=1.18; 95% confidence interval [CI], 1.01-1.39) and non-manual employees were at higher risk of moderate worsening (lower non-manual employees: IRR=1.21; 95% CI, 1.03-1.41; intermediate non-manual employees: IRR=1.26; 95% CI, 1.10-1.44; higher non-manual employees: IRR=1.25; 95% CI, 1.08-1.45). This risk increase was limited to worsening starting at stage 0 (non-chronic pain). No association was found between socioeconomic status and severe pain worsening. CONCLUSION: Our results support a moderate association between intermediate and high socioeconomic status, and moderate pain worsening. This association could be explained by the heterogeneous composition of the socioeconomic variable used in this cohort, and by changes in exposure and other time-varying covariables' status during follow-up.

SARS-CoV-2 infection incidence during the first and second COVID-19 waves in Italy.

We assessed the relation between COVID-19 waves in Italy, which was severely affected during the pandemic. We evaluated the hypothesis that a larger impact from the first wave (February-May 2020) predicts a smaller peak during the second wave (September-October 2020), in the absence of local changes in public health interventions and area-specific differences in time trends of environmental parameters. Based on publicly available data on province-specific SARS-CoV-2 infections and both crude and multivariable cubic spline regression models, we found that for provinces with the lowest incidence rates in the first wave, the incidence in the second wave increased roughly in proportion with the incidence in the first wave until an incidence of about 500-600 cases/100,000 in the first wave. Above that value, provinces with higher incidences in the first wave experienced lower incidences in the second wave. It appears that a comparatively high cumulative incidence of infection, even if far below theoretical thresholds required for herd immunity, may provide noticeable protection during the second wave. We speculate that, if real, the mechanism for this pattern could be depletion of most susceptible individuals and of superspreaders in the first wave. A population learning effect regarding cautious behavior could have also contributed. Since no area-specific variation of the national policy against the SARS-CoV-2 outbreak was allowed until early November 2020, neither individual behaviors nor established or purported environmental risk factors of COVID-19, such as air pollution and meteorological factors, are likely to have confounded the inverse trends we observed in infection incidence over time.

The association between first and second wave COVID-19 mortality in Italy.

BACKGROUND: The relation between the magnitude of successive waves of the COVID-19 outbreak within the same communities could be useful in predicting the scope of new outbreaks. METHODS: We investigated the extent to which COVID-19 mortality in Italy during the second wave was related to first wave mortality within the same provinces. We compared data on province-specific COVID-19 2020 mortality in two time periods, corresponding to the first wave (February 24-June 30, 2020) and to the second wave (September 1-December 31, 2020), using cubic spline regression. RESULTS: For provinces with the lowest crude mortality rate in the first wave (February-June), i.e. < 22 cases/100,000/month, mortality in the second wave (September-December) was positively associated with mortality during the first wave. In provinces with mortality greater than 22/100,000/month during the first wave, higher mortality in the first wave was associated with a lower second wave mortality. Results were similar when the analysis was censored at October 2020, before the implementation of region-specific measures against the outbreak. Neither vaccination nor variant spread had any role during the study period. CONCLUSIONS: These findings indicate that provinces with the most severe initial COVID-19 outbreaks, as assessed through mortality data, faced milder second waves.

Main Duct Dilatation Is the Best Predictor of High-grade Dysplasia or Invasion in Intraductal Papillary Mucinous Neoplasms of the Pancreas.

OBJECTIVE: The purpose of this study is to determine preoperative factors that are predictive of malignancy in patients undergoing pancreatic resection for intraductal papillary mucinous neoplasms (IPMN). SUMMARY BACKGROUND DATA: IPMN of the pancreas may be precursor lesions to pancreatic cancer (PC) and represent a target for early diagnosis or prevention. While there has been much effort to define preoperative risk factors for malignant pathology, guidelines are ever-changing and controversy remains surrounding which patients would benefit most from resection. METHODS: We performed a retrospective analysis of 901 consecutive patients obtained from two tertiary referral centers who underwent pancreatic resection for histologically proven IPMN between 2004 and 2017. Collected data included patient demographic characteristics, preoperative symptoms, radiological findings, and laboratory data. RESULTS: Main pancreatic duct (MPD) dilatation was the only variable that was significantly associated with increased probability of malignancy (defined high-dysplasia or invasion) on both univariate and multivariate analysis. Even middle-range MPD dilatation from 5 mm to 9.9 mm (n = 286) was associated with increased odds of HG-IPMN (OR = 2.74; 95% CI = 1.80-4.16) and invasion (OR = 4.42; 95% CI = 2.55-7.66). MPD dilatation >10 mm (n = 150) had even greater odds of HG-IPMN (OR = 6.57; 95% CI = 3.94-10.98) and invasion (OR = 15.07; 95% CI = 8.21-27.65). A cutoff of 5 to 7 mm MPD diameter was determined to be the best predictor to discriminate between malignant and benign lesions. CONCLUSIONS: In agreement with current IPMN management guidelines, we found MPD dilatation, even low levels from 5 mm to 9.9 mm, to be the single best predictor of HG-IPMN or invasion, highlighting the critical role that MPD plays in the selection of surgical candidates.

Effects of acute fructose loading on levels of serum uric acid-a pilot study.

BACKGROUND: Fructose intake may lead to hyperuricaemia, which is associated with increased risk and progression of kidney disease. We aimed to explore the acute effects of fructose loading from different sources, with and without a pizza, on levels of serum uric acid in patients with chronic kidney disease (CKD), type 2 diabetes (T2D) without CKD, and in healthy subjects (HS). METHODS: The study included six HS, and three CKD stage 4-5 and seven T2D patients. Drinks consumed were blueberry drink (17.5 g fructose), Coca-Cola (18 g fructose) and fructose drink (35 g fructose). The drinks were also combined with pizza, in total six interventions. Serum samples were collected fasting and 30, 60, 90 and 120 minutes after intake and also 240 minutes after drink + pizza, and analysed for fructose, uric acid and triglycerides. Postprandial responses were explored using repeated-measure ANOVA. RESULTS: Baseline serum uric acid levels were increased in CKD (P = 0.037). There were significant differences in serum fructose and serum uric levels over time between drinks and drinks + pizza for all groups (P < 0.001 and P < 0.05, respectively). The highest peak in serum fructose followed the fructose drink interventions and the lowest the blueberry drink. The fructose drink interventions gave the highest responses in serum uric acid and the lowest responses followed the blueberry drink. Triglycerides increased following pizza interventions (P < 0.001). CONCLUSIONS: Intake of fructose increases serum uric acid. The fructose intake via a blueberry drink induced lowest increase and thus may be protective.

Socio-demographic differences in the frequent use of emergency department care by older persons: a population-based study in Stockholm County.

BACKGROUND: In Sweden, the number of older people using emergency department (ED) care is rising. Among older persons an ED visit is a stressful event, which potentially could have been prevented or treated at other levels of care. Frequent ED use (> 4 visits a year) by older persons might reflect issues in the organisation of health care system to address their needs. We aimed to explore socio-demographic differences among older people seeking ED care in terms age and gender, and to investigate the association between income and frequent ED use. METHODS: A population-based study analysing the utilisation of ED care by (N = 356,375) individuals aged 65+ years. We linked register data on socio-demographic characteristics from 2013 to health care utilisation data in 2014. Multivariable logistic regression was used to estimate the income differences in the frequent use of ED care, adjusting for living situation, country of birth, residential area, age in years, multi-morbidity and the use of other health care services. RESULTS: Those 65+ years accounted for (27%) of all ED visits in Stockholm County in 2014. In the study population (2.5%) were identified as frequent ED users, who were predominantly in the lower income groups, living alone or in an institution, had more multi-morbidity, and utilised more of other health care services. The lowest income groups had a three-fold greater odds of being a frequent ED user than those in the highest income group. In the adjusted models, the odds were reduced by 12-44% for those in the lowest income groups. However, age and gender differences were observed with men 65-79 years (OR 1.75 CI: 1.51-2.03) and women 80+ years (OR 1.50, CI 1.19-1.87) in the lowest income groups having a higher odds of frequent ED use. CONCLUSION: This study observed that ED visits by older persons are driven by a need of care, and those that frequently visit hospital-based EDs are a socially disadvantaged group, which suggests that the organisation of care for older people should be reviewed in order to better meet their needs in other levels of care.

Associations With and Prognostic and Discriminatory Role of N-Terminal Pro-B-Type Natriuretic Peptide in Heart Failure With Preserved Versus Mid-range Versus Reduced Ejection Fraction.

BACKGROUND: The aim of this study was to characterize N-terminal pro-B-type natriuretic peptide (NT-proBNP) in terms of determinants of levels and of its prognostic and discriminatory role in heart failure with mid-range (HFmrEF) versus preserved (HFpEF) and reduced (HFrEF) ejection fraction. METHODS AND RESULTS: In 9847 outpatients with HFpEF (n = 1811; 18%), HFmrEF (n = 2122; 22%) and HFrEF (n = 5914; 60%) enrolled in the Swedish Heart Failure Registry, median NT-proBNP levels were 1428, 1540, and 2288 pg/mL, respectively. Many determinants of NT-proBNP differed by ejection fraction, with atrial fibrillation (AF) more important in HFmrEF and HFpEF, diabetes and hypertension in HFmrEF, and age and body mass index in HFrEF and HFmrEF, whereas renal function, New York Heart Association functional class, heart rate, and anemia were similar. Hazard ratios for death and death/HF hospitalization for NT-proBNP above the median ranged from 1.48 to 2.00 and were greatest for HFmrEF and HFpEF. Areas under the receiver operating characteristic curve for death and death/HF hospitalization were greater in HFmrEF than in HFpEF and HFrEF and were reduced by AF in HFpEF and HFmrEF but not in HFrEF. CONCLUSIONS: In HFpEF and especially HFmrEF, NT-proBNP was more prognostic and discriminatory, but also more affected by confounders such as AF. These data support the use of NT-proBNP for eligibility, enrichment, and surrogate end points in HFpEF and HFmrEF trials, and suggest that cutoff levels for eligibility should be carefully tailored to comorbidity.

Red and processed meat consumption and risk of bladder cancer: a dose-response meta-analysis of epidemiological studies.

BACKGROUND/OBJECTIVES: Several epidemiological studies have analyzed the associations between red and processed meat and bladder cancer risk but the shape and strength of the associations are still unclear. Therefore, we conducted a dose-response meta-analysis to quantify the potential association between red and processed meat and bladder cancer risk. METHODS: Relevant studies were identified by searching the PubMed database through January 2016 and reviewing the reference lists of the retrieved articles. Results were combined using random-effects models. RESULTS: Five cohort studies with 3262 cases and 1,038,787 participants and 8 cases-control studies with 7009 cases and 27,240 participants met the inclusion criteria. Red meat was linearly associated with bladder cancer risk in case-control studies, with a pooled RR of 1.51 (95% confidence interval (CI) 1.13, 2.02) for every 100 g increase per day, while no association was observed among cohort studies (P heterogeneity across study design = 0.02). Based on both case-control and cohort studies, the pooled relative risk (RR) for every 50 g increase of processed meat per day was 1.20 (95% CI 1.06, 1.37) (P heterogeneity across study design = 0.22). CONCLUSIONS: This meta-analysis suggests that processed meat may be positively associated with bladder cancer risk. A positive association between red meat and risk of bladder cancer was observed only in case-control studies, while no association was observe in prospective studies.

Overall diet quality and risk of recurrence and progression of non-gallstone-related acute pancreatitis: a prospective cohort study.

PURPOSE: An incident episode of acute pancreatitis is often followed by recurrent attacks and/or progression to chronic pancreatitis, especially if the etiology is non-gallstone-related. We examined whether overall diet quality influences the natural history of non-gallstone-related acute pancreatitis. METHODS: Three hundred and eighty-six individuals (born 1914-1952) were included in a prospective study, all of whom had an incident diagnosis of non-gallstone-related acute pancreatitis in the Swedish National Patient Register between 1998 and 2013. Participants were already enrolled in two population-based cohorts and had completed a food frequency questionnaire in 1997. Overall diet quality was calculated using a recommended food score (RFS), which was based on 25 food items. Post-diagnosis follow-up was conducted throughout 2014 for recurrence of acute pancreatitis and/or progression to chronic pancreatic disease (including cancer). Hazard ratios were estimated using Cox models. RESULTS: During 1859 person-years of follow-up, 23.3% of the study population (n = 90) developed recurrent or progressive pancreatic disease. An inverse association was observed between the RFS and risk of recurrent and progressive pancreatic disease after adjustment for age and sex (hazard ratio for each 2-unit increase 0.90, 95% confidence interval 0.81-1.01) (P overall association = 0.06). However, the association became weaker and was not statistically significant after adjustment for other potential confounders, including alcohol drinking and cigarette smoking (P overall association = 0.27). CONCLUSIONS: In this prospective study of individuals with non-gallstone-related acute pancreatitis, there was no clear association between overall diet quality and risk of recurrent and progressive pancreatic disease.

Alcohol consumption and gastric cancer risk-A pooled analysis within the StoP project consortium.

An association between heavy alcohol drinking and gastric cancer risk has been recently reported, but the issue is still open to discussion and quantification. We investigated the role of alcohol drinking on gastric cancer risk in the "Stomach cancer Pooling (StoP) Project," a consortium of epidemiological studies. A total of 9,669 cases and 25,336 controls from 20 studies from Europe, Asia and North America were included. We estimated summary odds-ratios (ORs) and the corresponding 95% confidence intervals (CIs) by pooling study-specific ORs using random-effects meta-regression models. Compared with abstainers, drinkers of up to 4 drinks/day of alcohol had no increase in gastric cancer risk, while the ORs were 1.26 (95% CI, 1.08-1.48) for heavy (>4 to 6 drinks/day) and 1.48 (95% CI 1.29-1.70) for very heavy (>6 drinks/day) drinkers. The risk for drinkers of >4 drinks/day was higher in never smokers (OR 1.87, 95% CI 1.35-2.58) as compared with current smokers (OR 1.14, 95% CI 0.93-1.40). Somewhat stronger associations emerged with heavy drinking in cardia (OR 1.61, 95% CI 1.11-2.34) than in non-cardia (OR 1.28, 95% CI 1.13-1.45) gastric cancers, and in intestinal-type (OR 1.54, 95% CI 1.20-1.97) than in diffuse-type (OR 1.29, 95% CI 1.05-1.58) cancers. The association was similar in strata of H. pylori infected (OR = 1.52, 95% CI 1.16-2.00) and noninfected subjects (OR = 1.69, 95% CI 0.95-3.01). Our collaborative pooled-analysis provides definite, more precise quantitative evidence than previously available of an association between heavy alcohol drinking and gastric cancer risk.