Use of antidepressants and association with elective termination of pregnancy: population based case-control study.

OBJECTIVE: To assess whether the use of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, mirtazapine, venlafaxine or other antidepressants is associated with late elective termination of pregnancy. DESIGN: Case-control study using data from national registers. SETTING: Denmark, Finland, and Norway during the period 1996-2007. POPULATION: A total of 14,902 women were included as cases and 148,929 women were included as controls. METHODS: Cases were women with elective termination of pregnancy at 12-23 weeks of gestation. Controls continued their pregnancy and were matched with cases on key factors. MAIN OUTCOME MEASURES: Association between antidepressant use during pregnancy and elective termination of pregnancy at 12-23 weeks of gestation for fetal anomalies, or for maternal ill health or socio-economic disadvantage. RESULTS: At least one prescription of antidepressants was filled by 3.7% of the cases and 2.2% of the controls. Use of any type of antidepressant was associated with elective termination of pregnancy for maternal ill health or socio-economic disadvantage (odds ratio, OR 2.3; 95% confidence interval, 95% CI 2.0-2.5). Elective termination of pregnancy for fetal anomalies was associated with the use of mirtazapine (OR 2.2, 95% CI 1.1-4.5). There was no association between the use of any of the other antidepressants and elective termination of pregnancy for fetal anomalies. CONCLUSION: The use of any type of antidepressants was associated with elective termination of pregnancy at 12-23 weeks for maternal ill health or socio-economic disadvantage, but not with terminations for fetal anomalies. Further studies need to confirm the findings concerning mirtazapine and termination of pregnancy for fetal anomalies.

Increased risk of severe maternal morbidity (near-miss) among immigrant women in Sweden: a population register-based study.

OBJECTIVE: To determine if immigrant women from low-, middle- and high-income countries have an increased risk of severe maternal morbidity (near-miss) when they deliver in Sweden. DESIGN: Population register-based study. SETTING: Nationwide study including all singleton deliveries (≥28 weeks of gestation) between 1998 and 2007. POPULATION: Women with a near-miss event; all women with a singleton delivery ≥28 weeks of gestation during the same period acted as reference group. METHODS: Near-miss was defined by a combined clinical and management approach with use of International Classification of Diseases, 10th revision codes for severe maternal morbidity. A woman's country of origin was designated as low-, middle- or high-income according to the World Bank Classification of 2009. Unconditional logistic regression models were used in the analysis. MAIN OUTCOME MEASURES: Maternal near-miss frequencies per 1000 deliveries and odds ratios with 95% confidence intervals. RESULTS: There were 914 474 deliveries during the study period and 2655 near-misses (2.9 per 1000 deliveries). In comparison to Swedish-born women, those from low-income countries had an increased risk of near-miss (odds ratio 2.3, 95% confidence interval 1.9-2.8) that was significant in all morbidity groups except for cardiovascular diseases and sepsis. Women from middle- and high-income countries showed no increased risk of near-miss. CONCLUSIONS: Women from low-income countries have an increased risk of maternal near-miss morbidity compared with women born in Sweden. Although the rate is low it should alert healthcare providers.

Invasive procedures for fetal karyotyping: no cause of subsequent gestational hypertension or pre-eclampsia.

The aim was to estimate the risk of maternal hypertensive complications following first- or second-trimester invasive diagnostic procedures, i.e. chorionic villus sampling (CVS) and amniocentesis (AC). Odds ratios (ORs) for gestational hypertension, mild pre-eclampsia or severe pre-eclampsia were calculated for women who underwent CVS (n = 1,984) or AC (n = 21,748) compared with non-exposed women (n = 47,854). No increase in the development of gestational hypertension, mild pre-eclampsia or severe pre-eclampsia was observed. The results do not support an association between invasive procedures for fetal karyotyping and subsequent gestational hypertension or pre-eclampsia.

Gestational diabetes and offspring body disproportion.

AIM: It has been demonstrated that females born large for gestational age (LGA) in weight but not length are at increased risk of being obese at childbearing age. We addressed the question whether women with gestational diabetes mellitus (GDM) are at increased risk of giving birth to such infants. METHODS: Birth characteristics of 884,267 infants of non-diabetic mothers and 7817 of mothers with GDM were analysed. LGA was defined as birth weight or birth length >2 standard deviation scores for gestational age. Multiple logistic regression analysis was performed. RESULTS: The odds ratio (OR) for a woman with GDM to give birth to an LGA infant that was heavy alone was four times increased (OR: 3.71, 95% CI: 3.41-4.04). Furthermore, in the population of mothers giving birth to LGA infants, the proportion heavy alone was 68% in the group of women with GDM compared with 64.4% in the group of non-diabetic women. The risks were independent of gender of the foetus. CONCLUSION: Women with GDM have an almost four times higher risk of delivering an LGA infant that is heavy alone. The noted disproportion between weight and length in infants of such mothers may have an impact on the risk of later obesity.

Insulin glargine use and short-term incidence of malignancies-a population-based follow-up study in Sweden.

AIMS/HYPOTHESIS: In the light of a report suggesting that insulin glargine may increase cancer occurrence, the EASD asked us to perform this study. METHODS: We followed 114,841 individuals who had a prescription dispensed for insulin between 1 July and 31 December 2005. From 1 January 2006 to 31 December 2007, we noted the occurrence of malignancies. Seven different nationwide registers were used to obtain information on insulin exposure, outcome and possible confounders; these were linked using the unique personal identity number assigned to every Swedish resident. RESULTS: After adjustment for age and, when appropriate, sex, users of insulin glargine alone (no other types of insulin), compared with users of types of insulin other than insulin glargine, had an RR of 1.99 (95% CI 1.31-3.03) for breast cancer, 0.93 (95% CI 0.61-1.40) for gastrointestinal cancer, 1.27 (95% CI 0.89-1.82) for prostate cancer and 1.07 (95% CI 0.91-1.27) for any type of malignancy. Adjustment for age, smoking, BMI, age at onset of diabetes, age at birth of first child, cardiovascular disease and oestrogen use gave an RR for breast cancer of 1.97 (95% CI 1.29-3.00). The 95% CIs crossed 1.0 for the RR calculated in all analyses of users of insulin glargine in combination with other types of insulin. CONCLUSIONS/INTERPRETATION: In Sweden, during 2006 and 2007, women using insulin glargine alone (no other types of insulin) had an increased incidence rate of breast cancer as compared with women using types of insulin other than insulin glargine. This result may be due to a random fluctuation; the possibilities for examining validity are limited, and no statistically significant results were obtained for any other individual cancer site or for the outcome 'all malignancies'. No definitive conclusions regarding a possible causal relationship between insulin glargine use and the occurrence of malignancies can be drawn from the results of this study.

Prenatal ultrasound exposure and children's school performance at age 15-16: follow-up of a randomized controlled trial.

OBJECTIVE: To evaluate the association between prenatal ultrasound exposure and school performance at 15-16 years of age. METHODS: The study population consisted of children born to women who participated in a randomized controlled trial on the second-trimester ultrasound examination in Sweden from 1985 to 1987. Information about the children's grades when graduating from primary school and information on socioeconomic factors was obtained from Swedish nationwide registers. Comparisons were made using linear and logistic regression analyses according to randomization to ultrasound, ultrasound exposure in the second trimester and ultrasound exposure at any time during pregnancy. Boys and girls were analyzed separately. RESULTS: Of the 4756 singleton children from the randomized trial, we identified 4458 (94%) in the National School Register. There were no statistically significant differences in school performance for boys or girls according to randomization or exposure to ultrasound in the second trimester. Compared to those who were unexposed, boys exposed to ultrasound at least once at any time during fetal life had a tendency towards lower mean school grades in general (-4.39 points; 95% CI, -9.59 to 0.81 (max possible, 320) points) and in physical education (-0.45 points; 95% CI, -0.91 to 0.01 (max possible, 20) points), but the differences did not reach significance. CONCLUSION: In general, routine ultrasound examination in the second trimester had no effect on overall school performance in teenagers.

Higher education and more physical activity limit the development of obesity in a Swedish rural population. The Skaraborg Project.

OBJECTIVE: To investigate the prevalence and the secular trends of obesity in a rural Swedish community with emphasis on the association with socioeconomic status and lifestyle. DESIGN: The Skaraborg Project cross-sectional population surveys were conducted in Vara, a rural community in the southwest of Sweden, every fifth year between 1977 and 2002. SUBJECTS: A total of 3365 residents (1634 men and 1731 women) aged 30-60 years. MEASUREMENTS: Obesity was defined as body mass index> or =30 kg m(-2). Information on ethnicity, marital status, socioeconomic status and lifestyle was collected by a questionnaire. RESULTS: In 1977-1982, the average prevalence of obesity was 14% in both men and women, and in 2002, the prevalence of obesity was 19% in men and 21% in women. The age-adjusted odds ratio (OR) of obesity in 2002 was 1.48 (1.00, 2.20) in men and 1.41 (0.97, 2.05) in women. Without the simultaneous increase in the level of education and leisure-time physical activity (LTPA), the risk of developing obesity could have been considerably higher; in men OR=3.08 (1.88, 5.03) and in women OR=2.72 (1.66, 4.44). In multivariate models, higher levels of education and LTPA were associated with protective effects on obesity in both men (OR=0.60 (0.43, 0.83) and OR=0.50 (0.45, 0.79)) and women (OR=0.73 (0.54, 0.98) and OR=0.57 (0.42, 0.78)), respectively. CONCLUSIONS: This study revealed an upward secular trend in the prevalence of obesity in a rural community in Sweden. Increasing levels of education and LTPA limit this ongoing development of obesity. Public health strategies for the prevention of obesity should consider the special condition in rural environments.

The association of maternal chronic hypertension with perinatal death in male and female offspring: a record linkage study of 866,188 women.

OBJECTIVE: The purpose of this study was to determine whether there is a difference, by gender, in perinatal mortality in chronically hypertensive women compared with normotensive women. DESIGN: Population-based prospective cohort study. SETTING: Sweden. POPULATION: A total of 866,188 women with singleton pregnancies registered in the Swedish Medical Birth Registry 1992-2004, of which 4749 were diagnosed with chronic hypertension. METHODS: Multivariate logistic regression analysis was performed. In a first step, we adjusted for maternal characteristics and in a second step for mild and severe pre-eclampsia, gestational diabetes, placental abruption and small for gestational age. An effect modification by gender was included in the model. MAIN OUTCOME MEASURES: Odds ratios (OR) for intrauterine death, neonatal death and post-neonatal death with respect to gender of offspring. RESULTS: The unadjusted OR of intrauterine death was 4.12 (95% CI: 2.84-5.96) and 1.29 (95% CI: 0.67-2.48) for male and female offspring, respectively, and of neonatal death, it was 3.45 (95% CI: 2.13-5.59) and 2.17 (95% CI: 1.08-4.35) for male and female offspring, respectively. After multivariate analysis, the OR of intrauterine death was 3.07 (95% CI: 2.12-4.46) and neonatal death was 2.99 (95% CI: 1.84-4.85) for male offspring. For female offspring, the OR of intrauterine death was 0.98 (95% CI: 0.51-1.89) and neonatal death was 1.88 (95% CI: 0.93-3.79). CONCLUSION: Mothers with chronic hypertension have an increased risk of perinatal mortality of their male offspring.

Evidence of a relationship between childhood-onset type I diabetes and low groundwater concentration of zinc.

OBJECTIVE: Zinc deficiency has shown to increase the risk for diabetes in diabetes-prone experimental animals. Low concentrations of zinc have also been shown in serum of recent onset cases with IDDM. The present study examines the hypothesis that exposure to a low concentration of zinc in drinking water could increase the risk for future onset of IDDM. RESEARCH DESIGN AND METHODS: Using the Swedish childhood diabetes registry and data on residence 3 years before the onset of disease, a case-control study was designed comparing cases and control subjects with estimates of groundwater contents of zinc obtained in biogeochemical samples from areas of residence. RESULTS: A high groundwater concentration of zinc was associated with a significant decrease in risk (odds ration [OR] = 0.8; 95% CI = 0.7-0.9). The same OR was obtained when the model included information of other metals that might act as possible confounders (chromium, vanadium, cobalt selenium, cadmium, lead, and mercury). In small rural areas, in which drinking water is taken from local wells and thus is closely associated with the groundwater content within the area, an even stronger association between zinc and diabetes (OR = 0.6; 95% CI = 0.4-0.9) was found. CONCLUSIONS: It is concluded that this study for the first time provides evidence that a low groundwater content of zinc, which may reflect long-term exposure through drinking water, is associated with later development of childhood onset diabetes.

A high birth weight is associated with increased risk of type 2 diabetes and obesity.

BACKGROUND: The association between low birth weight and adult disease is well known. Less is known on long-term effects of high birth weight. OBJECTIVE: This study aims to investigate whether a high birth weight increases risk for adult metabolic disease. METHODS: Swedish term single births, 1973-1982 (n = 759,999), were studied to age 27.5-37.5 years using Swedish national registers. Hazard ratios (HRs) were calculated in relation to birth weight for type 2 diabetes, obesity, hypertension and dyslipidaemia. RESULTS: Men with birth weights between 2 and 3 standard deviation score (SDS) had a 1.9-fold increased risk (HR 1.91, 95% confidence interval [CI] 1.25-2.90) of type 2 diabetes, whereas those with birth weights above 3 SDS had a 5.4-fold increased risk (HR 5.44, 95% CI 2.70-10.96) compared to men with birth weights between -2 and 2 SDS. The corresponding HRs for women were 0.60 (95% CI 0.40-0.91) and 1.71 (95% CI 0.85-3.43) for birth weights 2-3 SDS and >3 SDS, respectively. Men with birth weights between 2 and 3 SDS had a 1.5-fold increased risk (HR 1.47, 95% CI 1.22-1.77) of obesity. The corresponding risk for women was 1.3-fold increased (HR 1.32, 95% CI 1.19-1.46). For men and women with birth weights above 3 SDS, the risks of adult obesity were higher, HR 2.46 (95% CI 1.63-3.71) and HR 1.85 (95% CI 1.44-2.37), respectively. CONCLUSIONS: A high birth weight, particularly very high, increases the risk of type 2 diabetes in male young adults. The risk of obesity increases with increasing birth weight in both genders.

Health service areas for the United States.

The objectives of this report are to document methods used to identify health service areas for the United States and to describe and evaluate these areas. A health service area is defined as one or more counties that are relatively self-contained with respect to the provision of routine hospital care. Service areas that include more than one county are characterized by travel between the counties for routine hospital care.

Lack of serum cholesterol-lowering effect of skimmed milk and butter milk under controlled conditions.

The effects of skimmed milk and butter milk on the plasma concentration of cholesterol, triglyceride and high density lipoprotein cholesterol were studied in voluntary male prisoners under carefully controlled conditions. No significant differences were observed in the serum lipid or lipoprotein levels between the groups ingesting the control diet and the diets containing 2.71 of skimmed milk or 2.01 of butter milk per day for 3 weeks.

Routine ultrasound screening in pregnancy and the children's subsequent neurologic development.

OBJECTIVE: To test the null hypothesis of no association between ultrasound exposure in early fetal life and impaired neurologic development in childhood. METHODS: Study of children age 8-9 years whose mothers participated in a randomized controlled trial of ultrasound screening during pregnancy in Sweden during 1985-1987. Of 4637 eligible singletons, 3265 (70%) were studied through a questionnaire to their mothers. Assessment of neurologic development was based on parents' report of their child's speech and motor development. Behavioral disorders were assessed by a ten-item parent scale. Analyses were performed according to both assignment and ultrasound exposure. With a sample size of 1600 children in each group, a two-sided alpha of .05 and beta of .10, a risk ratio of less than 1.4 for the studied variables could not be detected. RESULTS: Delayed speech development was reported by 2.9% in the screening group compared with 2.4% in the nonscreening group (odds ratio [OR] 1.21; 95% confidence interval [CI] 0.79, 1.88). Similar prevalences were found when analysis was according to ultrasound exposure (OR 1.19, 95% CI 0.78, 1.83). Delayed motor development was reported by 7.6% in the screening group compared with 7.2% in the nonscreening group (OR 1.05; 95% CI 0.81, 1.37). Corresponding figures for ultrasound-exposed and -unexposed were 7.7% and 7.2%, respectively (OR 1.08; 95% CI 0.83, 1.40). There also were no significant differences in behavioral disorders between screened and unscreened children or between exposed and unexposed children, respectively, according to parents' ratings. CONCLUSION: No significant difference in impaired neurologic development between ultrasound-exposed and -unexposed children was found in this study.

A food fair to promote dietary change in the Stockholm cancer prevention programme.

Involving organizations is crucial when developing community intervention strategies aimed at dietary change. This case study describes the use of a food fair as a change agent. The aim of the food fair was to obtain commitment and build up a network in the community comprised of professionals in the fields of food production, food distribution and information. The fair was organized in 1989 and intended to disseminate knowledge and information about healthy foods and encourage food industries, test kitchens and also publishing companies to develop and present products in accordance with the dietary objectives of the Stockholm Cancer Prevention Programme (ie a simultaneous reduction of fat and an increase in fibre intake). The food fair consisted of exhibitions and conferences/seminars. Policy makers, journalists, people in the educational and health professions and those working with food were invited to participate. Nearly 60 companies and organizations made presentations at the exhibition and 1,000 professionals attended the conferences and seminars. In all, 6,400 people visited the fair. Seventy-eight trade journals and newspapers and three radio stations reported on the fair. The food fair was so well received that a second fair was arranged in 1991.

A tobacco quit and win model in the Stockholm cancer prevention programme.

The main objective of the Stockholm Cancer Prevention Programme (SCPP) is to reduce cancer incidence and mortality among the 1.6 million inhabitants in Stockholm county by reducing risk factors particularly related to lifestyle. The objective of the SCPP's tobacco action programme is to reduce the number of adult daily users of tobacco (including oral snuff) to 20% by the year 2000. In 1988, a nationwide Quit and Win contest was conceived as part of this long-term programme. The contest recruited nearly 13,000 participants or 0.6% of the daily tobacco users in Sweden over the age of 16 years. More than 60% of the participants were recruited from Stockholm county. This corresponds to 1.9% of the daily tobacco users in Stockholm county compared with 0.3% in the rest of Sweden. The pharmacies and the public health services organizations were the principal distributors of contest entry forms. Sixty-two percent of the men and 59% of the women were tobacco free one month after the contest, and after 6 months the corresponding figures were 30 and 25%, respectively.

The sociodemographic pattern of tobacco cessation in the 1980s: results from a panel study of living condition surveys in Sweden.

STUDY OBJECTIVES: To analyse the factors that determined whether or not people were successful in quitting tobacco during the 1980s in Sweden. DESIGN: A logistic regression model was used for the analyses and included: education, marital status, socioeconomic group, social network, physical activities, cigarette consumption, and years spent smoking as independent variables. Men and women were analysed separately for smoking. A specific univariate analysis was also performed for men who used snuff. SETTING: Sweden. PARTICIPANTS: A panel of 5104 randomised people aged 16-84 years was interviewed in 1980-81 and followed up in 1988-89 in the survey of living conditions undertaken by Statistics Sweden. The participation rate was 86%. The panel included 1546 men and women who were daily smokers. There were 418 daily users of snuff among the men, and 129 men both smoked and used snuff. MAIN RESULTS: Together 26% of women and 23% of men had quit smoking. Five percent in both groups were new smokers. Among men, 26% had quit using snuff and 5% had begun smoking. New snuff users among men were 5%. In the multivariate analysis, unmarried men kept smoking at significantly higher rates (OR 2.1; 95% CI 1.2,3.6), as did those men who smoked 11-20 cigarettes/day (OR 2.2; 95% CI 1.5, 3.4), or more than 20 cigarettes/day (OR 2.8; 95% CI 1.4,5.7). Among women, smoking 11-20 cigarettes/day was also a significant factor (OR 3.3; 95% CI 2.1,5.0). Men and women aged 25-44 were significantly more likely to continue smoking (OR = 2.1; 95% CI 1.1,3.7, and 2.2; 95% CI 1.2,4.4) as were those who had smoked for 20 years or more (OR 4.7; 95% CI 2.0,10.8 and OR 2.5; 95% CI 1.1,5.5, respectively). For women, low education (up to grade 9) was also a significant factor (OR = 2.5; 95% CI 1.2,5.1). Among men who had quit using snuff we did not find any values of significance. CONCLUSIONS: One in four smokers had quit during the 1980s and a few started smoking (5%). Some men quit smoking and started using snuff instead. For both sexes, the daily consumption of cigarettes, years spent smoking, and age were the most important determinants of successful quitting. In men, being married/ cohabiting was an important factor as was higher education in women.

Tarsal tunnel syndrome in runners.

Tarsal tunnel syndrome has only recently been noted to be a cause of foot and ankle pain in runners. The tarsal tunnel is located just posterior to the medial malleolus and may compress the posterior tibial nerve as it passes through it, producing numbness and paraesthesia in the foot. While the aetiology of this condition is frequently multifactorial, abnormal foot and ankle mechanics and excessive training tend to be the most commonly cited aetiological factors. Successful treatment of tarsal tunnel syndrome requires an accurate diagnosis by differentiating it from plantar fasciitis and Achilles tendinitis and then making proper biomechanical and training changes in the runner. Conservative treatment is generally successful, but occasionally surgical treatment is required to decompress the nerve.

A cartographic study of hospital utilization in the county of Uppsala.

In this study the question whether increased resources in community based primary care lead to decreased utilization of in-patient care has been analysed. Two alternative types of analysis were compared: a municipality-based analysis and a cartographic analysis based on non-administrative reference areas. The study material consisted of person-based data from Uppsala County in Sweden. The cartographic analyses revealed important characteristics of the utilization pattern, which would not have been possible to ascertain using traditional methods such as analyses based on administrative areas. Thus, the cartographic analysis gave some support to the hypothesis that increased resources to primary care will reduce the utilization of in-patient care.

Psychotropic drug use in a Swedish community--the importance of demographic and socioeconomic factors.

In this study the importance of demographic and socioeconomic factors for the use of psychotropic drugs in the general population of a Swedish community was studied using data from a research registry on prescriptions. The study showed that age, gender, marital status, socioeconomic status and distance to the health center had independent and significant effects on the use of psychotropic drugs. Age was of very great importance; the proportion of users was more than ten times greater among individuals aged 75-84 years than among those aged 18-34 years. Furthermore it was approximately twice as common with those drugs among women as compared to men. Differences with regard to marital and socioeconomic status were also present but these were generally small except in certain groups such as men aged 35-44 who were not employed, divorced men aged 45-54 and 55-64 years and single women aged 35-44 years.

Psychotropic drug use in a Swedish community--patterns of individual use during 2 years.

Psychotropic drug use in a Swedish community with a general population of about 20,000 was studied using data from a research registry on prescriptions. Patterns of individual psychotropic drug use during 2 years, 1980 and 1981, were analyzed. Use during the second year was studied in relation to use during the first year, and individuals with continued and new use were identified. About two thirds of those who obtained psychotropics during the first year continued using such drugs during the following year. Among those with no use during the first year, 6% obtained psychotropic drugs during the second year. Both continued and new use increased with age. Psychotropic drug use was nearly twice as common among women as compared to men among new users, whereas practically no sex difference was observed in continued use among previous users of psychotropics. Despite the finding that male psychotropic drug users were almost as likely as females to continue using these drugs, the overall proportion of continuous users in the population remained considerably higher among women as compared to men. The results from this study suggest that the greater use of psychotropics among women can be explained by a greater extent of occasional use as well as continuous use among women as compared to men.