Association between snus use and lipid status in Swedish men.

Snus is a common tobacco product in Sweden, but the cardiovascular risk profile for snus users is less known than for cigarette smokers. We examined the association of snus use with lipid status, particularly in comparison to non-tobacco use and cigarette smoking, using data from 5930 men in the Northern Sweden MONICA study. Tobacco use was self-reported in 1986 to 2014 (24.4% used snus) and blood samples were collected at the same time. Harmonized analyses on non-high-density lipoprotein (non-HDL) cholesterol, HDL cholesterol, and triglycerides were conducted in 2016 to 2018. Three hundred eighty-one snus users had also been examined more than once, allowing us to study the effect of discontinued use (achieved by 21.0%). In multivariable linear regression models, snus use was associated with higher HDL cholesterol and triglyceride concentrations compared to non-tobacco use (p values ≤ 0.04), and it was associated with higher HDL cholesterol concentrations and lower triglyceride concentrations compared to cigarette smoking (p values ≤ 0.02). Snus use was not associated with non-HDL cholesterol concentrations, irrespective of the comparison group (p values ≥ 0.07). There was no indication that higher intensity of snus use led to a worse lipid profile, given that high-consumers had higher HDL cholesterol concentrations than low-consumers (p value = 0.02), or that discontinuation of snus use led to a better lipid profile, given that continued users had lower triglyceride concentrations than discontinued users (p value = 0.03). Further studies are needed to confirm or refute our findings.

Influence of geographical latitude on vitamin D status: cross-sectional results from the BiomarCaRE consortium.

Even though sunlight is viewed as the most important determinant of 25-hydroxyvitamin D (25(OH)D) status, several European studies have observed higher 25(OH)D concentrations among north-Europeans than south-Europeans. We studied the association between geographical latitude (derived from ecological data) and 25(OH)D status in six European countries using harmonised immunoassay data from 81 084 participants in the Biomarkers for Cardiovascular Risk Assessment in Europe (BiomarCaRE) project (male sex 48·9 %; median age 50·8 years; examination period 1984-2014). Quantile regression models, adjusted for age, sex, decade and calendar week of sampling and time from sampling to analysis, were used for between-country comparisons. Up until the median percentile, the ordering of countries by 25(OH)D status (from highest to lowest) was as follows: Sweden (at 65·6-63·8°N), Germany (at 48·4°N), Finland (at 65·0-60·2°N), Italy (at 45·6-41·5°N), Scotland (at 58·2-55·1°N) and Spain (at 41·5°N). From the 75th percentile and upwards, Finland had higher values than Germany. As an example, using the Swedish cohort as a comparator, the median 25(OH)D concentration was 3·03, 3·28, 5·41, 6·54 and 9·28 ng/ml lower in the German, Finnish, Italian, Scottish and Spanish cohort, respectively (P-value < 0·001 for all comparisons). The ordering of countries was highly consistent in subgroup analyses by sex, age, and decade and season of sampling. In conclusion, we confirmed the previous observation of a north-to-south gradient of 25(OH)D status in Europe, with higher percentile values among north-Europeans than south-Europeans.

Comparison of dietary trends between two counties with and without a cardiovascular prevention programme: a population-based cross-sectional study in northern Sweden.

OBJECTIVE: To compare temporal trends, over a 20-year period, in dietary habits between a county (Västerbotten) with a CVD prevention programme and a county (Norrbotten) without such a programme. DESIGN: Cross-sectional data from the Northern Sweden MONICA study (survey period 1994, 1999, 2004, 2009 and 2014). Dietary habits were assessed by a semi-quantitative FFQ. SETTING: Counties of Norrbotten and Västerbotten, Northern Sweden. PARTICIPANTS: Five thousand four hundred Swedish adults (mean age 56·9 years; 51·2 % women) from Västerbotten (47 %) and Norrbotten (53 %). RESULTS: No differences in temporal trend for estimated percentage of energy intake from total carbohydrates, total fat, total protein and alcohol were observed between the counties (Pfor interaction ≥ 0·33). There were no between-county difference in temporal trends for overall diet quality (assessed by the Healthy Diet Score; Pfor interaction = 0·36). Nor were there any between-county differences for the intake of whole grain products, fruits, vegetables, fish, sweetened beverages or fried potatoes (Pfor interaction ≥ 0·09). Consumption of meat (Pfor interaction = 0·05) increased to a greater extent in Norrbotten from 2009 and onwards, mainly in men (sex-specific analyses, Pfor interaction = 0·04). Men in Västerbotten decreased their intake of sweets to a greater extent than men in Norrbotten (Pfor interaction < 0·01). CONCLUSIONS: Over a 20-year period in northern Sweden, only small differences in dietary habits were observed in favour of a county with a CVD prevention programme compared with a county without such a programme.

Time trends of vitamin D concentrations in northern Sweden between 1986 and 2014: a population-based cross-sectional study.

PURPOSE: Vitamin D, produced through cutaneous photosynthesis or ingested via foods or supplements, has generated considerable research interest due to its potential health effects. However, epidemiological data on the time trends of vitamin D status are sparse, especially from northern Europe. We examined the time trend of vitamin D concentrations in northern Sweden between 1986 and 2014. METHODS: We used data on 11,129 men and women (aged 25-74 years) from seven population-based surveys (the Northern Sweden MONICA study), recruited between 1986 and 2014. Serum vitamin D (25-hydroxyvitamin D) status was measured using a one-step immunoassay (Abbott Architect). Multivariable linear regression models, adjusted for age, sex, and a number of other variables, were used to estimate the time trend of vitamin D concentrations. RESULTS: The mean value of vitamin D in the entire study population was 19.9 ng/mL [standard deviation (SD) 7.9], with lower values in men (19.4 ng/mL; SD 7.5) than in women (20.5 ng/mL; SD 8.2). Using the survey in 1986 as reference category, the multivariable-adjusted mean difference [95% confidence interval (CI)] in ng/mL was 2.7 (2.2, 3.3) in 1990, 3.2 (2.7, 3.7) in 1994, 1.6 (1.0, 2.1) in 1999, - 2.0 (- 2.5, - 1.4) in 2004, 1.0 (0.4, 1.5) in 2009, and 3.1 (2.5, 3.6) in 2014. CONCLUSION: In this large cross-sectional study, we observed no clear upward or downward trend of vitamin D concentrations in northern Sweden between 1986 and 2014.

Postmenopausal hormone therapy and risk of stroke: A pooled analysis of data from population-based cohort studies.

BACKGROUND: Recent research indicates a favourable influence of postmenopausal hormone therapy (HT) if initiated early, but not late, on subclinical atherosclerosis. However, the clinical relevance of timing of HT initiation for hard end points such as stroke remains to be determined. Further, no previous research has considered the timing of initiation of HT in relation to haemorrhagic stroke risk. The importance of the route of administration, type, active ingredient, and duration of HT for stroke risk is also unclear. We aimed to assess the association between HT and risk of stroke, considering the timing of initiation, route of administration, type, active ingredient, and duration of HT. METHODS AND FINDINGS: Data on HT use reported by the participants in 5 population-based Swedish cohort studies, with baseline investigations performed during the period 1987-2002, were combined in this observational study. In total, 88,914 postmenopausal women who reported data on HT use and had no previous cardiovascular disease diagnosis were included. Incident events of stroke (ischaemic, haemorrhagic, or unspecified) and haemorrhagic stroke were identified from national population registers. Laplace regression was employed to assess crude and multivariable-adjusted associations between HT and stroke risk by estimating percentile differences (PDs) with 95% confidence intervals (CIs). The fifth and first PDs were calculated for stroke and haemorrhagic stroke, respectively. Crude models were adjusted for age at baseline only. The final adjusted models included age at baseline, level of education, smoking status, body mass index, level of physical activity, and age at menopause onset. Additional variables evaluated for potential confounding were type of menopause, parity, use of oral contraceptives, alcohol consumption, hypertension, dyslipidaemia, diabetes, family history of cardiovascular disease, and cohort. During a median follow-up of 14.3 years, 6,371 first-time stroke events were recorded; of these, 1,080 were haemorrhagic. Following multivariable adjustment, early initiation (<5 years since menopause onset) of HT was associated with a longer stroke-free period than never use (fifth PD, 1.00 years; 95% CI 0.42 to 1.57), but there was no significant extension to the time period free of haemorrhagic stroke (first PD, 1.52 years; 95% CI -0.32 to 3.37). When considering timing as a continuous variable, the stroke-free and the haemorrhagic stroke-free periods were maximal if HT was initiated approximately 0-5 years from the onset of menopause. If single conjugated equine oestrogen HT was used, late initiation of HT was associated with a shorter stroke-free (fifth PD, -4.41 years; 95% CI -7.14 to -1.68) and haemorrhagic stroke-free (first PD, -9.51 years; 95% CI -12.77 to -6.24) period than never use. Combined HT when initiated late was significantly associated with a shorter haemorrhagic stroke-free period (first PD, -1.97 years; 95% CI -3.81 to -0.13), but not with a shorter stroke-free period (fifth PD, -1.21 years; 95% CI -3.11 to 0.68) than never use. Given the observational nature of this study, the possibility of uncontrolled confounding cannot be excluded. Further, immortal time bias, also related to the observational design, cannot be ruled out. CONCLUSIONS: When initiated early in relation to menopause onset, HT was not associated with increased risk of incident stroke, regardless of the route of administration, type of HT, active ingredient, and duration. Generally, these findings held also for haemorrhagic stroke. Our results suggest that the initiation of HT 0-5 years after menopause onset, as compared to never use, is associated with a decreased risk of stroke and haemorrhagic stroke. Late initiation was associated with elevated risks of stroke and haemorrhagic stroke when conjugated equine oestrogen was used as single therapy. Late initiation of combined HT was associated with haemorrhagic stroke risk.

Fatigue in the general population- associations to age, sex, socioeconomic status, physical activity, sitting time and self-rated health: the northern Sweden MONICA study 2014.

BACKGROUND: Fatigue is widespread in the population and a common complaint in primary care. Little is known about prevalence of fatigue in the population and its predictors. We aimed to describe the pattern of fatigue in the general population and to explore the associations with age, sex, socioeconomic status, self-reported physical activity, sitting time and self-rated health. METHODS: One thousand, five hundred and fifty-seven out of 2500 invited subjects in the Northern Sweden MONICA Study 2014, aged 25-74 years, filled out the Multidimensional Fatigue Inventory (MFI-20), consisting of four subscales: General fatigue (GF), Physical fatigue (PF), Reduced activity (RA) and Mental fatigue (MF). Questions regarding age, sex, socioeconomic status, physical activity, sitting time and self-rated health were also included. RESULTS: Higher age correlated significantly with lower fatigue scores for the GF and MF subscales. Women had higher fatigue scores than men on all subscales (p < 0.05). Among men, higher socioeconomic status was related to lower fatigue for the GF, PF and RA subscales (age adjusted p < 0.05). Among women, higher socioeconomic status was related to lower fatigue for the PF and MF subscales (age adjusted p < 0.05). Higher physical activity was connected to lower levels of fatigue for all subscales (age and sex adjusted p < 0.001) except for MF. Longer time spent sitting was also related to more fatigue on all subscales (age and sex adjusted p < 0.005) except for MF. Better self-rated health was strongly associated with lower fatigue for all subscales (age and sex adjusted p < 0.001). CONCLUSION: Older, highly educated, physically active men, with little sedentary behavior are generally the least fatigued. Self-rated health is strongly related to fatigue. Interventions increasing physical exercise and reducing sedentary behavior may be important to help patients with fatigue and should be investigated in prospective studies.

Greater decreases in cholesterol levels among individuals with high cardiovascular risk than among the general population: the northern Sweden MONICA study 1994 to 2014.

AIM: Decreasing cholesterol levels in Western populations is the main reason for decreasing mortality due to coronary heart disease. Our aim was to analyze trends in cholesterol levels in the population during a period of 20 years in relation to previous cardiovascular disease (CVD), other cardiovascular risk factors, and socioeconomic status. METHODS AND RESULTS: A total of 4546 women and 4349 men aged 25-74 years participated in five population-based surveys in the Northern Sweden MONICA Study between 1994 and 2014 (participation rate 76.8-62.5%). Total cholesterol levels decreased from 6.2 mmol/L (95% confidence interval, CI, 6.1-6.2) in 1994 to 5.5 mmol/L (CI 5.4-5.5) in 2014. The decrease was more pronounced in elderly vs. younger participants (1.0 vs. 0.5 mmol/L). In 2014, participants with previous CVD, diabetes, or hypertension had lower cholesterol levels than the general population, whereas their levels were higher or similar to the general population in 1994. The use of lipid-lowering drugs increased markedly and was used by 14.3% in 2014. Previously described differences in cholesterol levels between participants with obesity and normal weight, and between those with and without university education, diminished, or vanished over time. CONCLUSION: Cholesterol levels decreased by 0.7 mmol/L over 20 years with no sign of abating. The improvement occurred in all age and gender groups but more prominently among those at high risk of ischaemic heart disease.

Association of CD247 (CD3ζ) gene polymorphisms with T1D and AITD in the population of northern Sweden.

BACKGROUND: T1D and AITD are autoimmune disorders commonly occurring in the same family and even in the same individual. The genetic contribution to these disorders is complex making uncovering of susceptibility genes very challenging. The general aim of this study was to identify loci and genes contributing to T1D/AITD susceptibility. Our strategy was to perform linkage and association studies in the relatively genetically homogenous population of northern Sweden. We performed a GWLS to find genomic regions linked to T1D/AITD in families from northern Sweden and we performed an association study in the families to test for association between T1D/AITD and variants in previously published candidate genes as well as a novel candidate gene, CD247. METHODS: DNA prepared from 459 individuals was used to perform a linkage and an association study. The ABI PRISM Linkage Mapping Set v2.5MD10 was employed for an initial 10-cM GWLS, and additional markers were added for fine mapping. Merlin was used for linkage calculations. For the association analysis, a GoldenGate Custom Panel from Illumina containing 79 SNPs of interest was used and FBAT was used for association calculations. RESULTS: Our study revealed linkage to two previously identified chromosomal regions, 4q25 and 6p22, as well as to a novel chromosomal region, 1q23. The association study replicated association to PTPN22, HLA-DRB1, INS, IFIH1, CTLA4 and C12orf30. Evidence in favor of association was also found for SNPs in the novel susceptibility gene CD247. CONCLUSIONS: Several risk loci for T1D/AITD identified in published association studies were replicated in a family material, of modest size, from northern Sweden. This provides evidence that these loci confer disease susceptibility in this population and emphasizes that small to intermediate sized family studies in this population can be used in a cost-effective manner for the search of genes involved in complex diseases. The linkage study revealed a chromosomal region in which a novel T1D/AITD susceptibility gene, CD247, is located. The association study showed association between T1D/AITD and several variants in this gene. These results suggests that common susceptibility genes act in concert with variants of CD247 to generate genetic risk for T1D/AITD in this population.

Symptoms and delay times during myocardial infarction in 694 patients with and without diabetes; an explorative cross-sectional study.

BACKGROUND: In myocardial infarction (MI) a short pre-hospital delay, prompt diagnosis and timely reperfusion treatment can improve the prognosis. Despite the importance of timely care seeking, many patients with MI symptoms delay seeking medical care. Previous research is inconclusive about differences in symptom presentation and pre-hospital delay between patients with and without diabetes during MI. The aim of this study was to describe symptoms and patient delay during MI in patients with and without diabetes. METHODS: Swedish cross-sectional multicentre survey study enrolling MI patients in 5 centres within 24 h from admittance. RESULTS: Chest pain was common in patients both with and without diabetes and did not differ after adjustment for age and sex. Patients with diabetes had higher risk for shoulder pain/discomfort, shortness of breath, and tiredness, but lower risk for cold sweat. The three most common symptoms reported by patients with diabetes were chest pain, pain in arms/hands and tiredness. In patients without diabetes the most common symptoms were chest pain, cold sweat and pain in arms/hands. Median patient delay time was 2 h, 24 min for patients with diabetes and 1 h, 15 min for patients without diabetes (p = 0.024). CONCLUSION: Chest pain was common both in patients with and without diabetes. There were more similarities than differences in MI symptoms between patients with and without diabetes but patients with diabetes had considerably longer delay. This knowledge is important not only for health care personnel meeting patients with suspected MI, but also for the education of people with diabetes.

Increased risk of acute myocardial infarction and stroke during hemorrhagic fever with renal syndrome: a self-controlled case series study.

BACKGROUND: We recently observed that cardiovascular causes of death are common in patients with hemorrhagic fever with renal syndrome (HFRS), which is caused by hantaviruses. However, it is not known whether HFRS is a risk factor for the acute cardiovascular events of acute myocardial infarction (AMI) and stroke. METHODS AND RESULTS: Personal identification numbers from the Swedish HFRS patient database (1997-2012; n=6643) were cross-linked with the National Patient Register from 1987 to 2011. Using the self-controlled case series method, we calculated the incidence rate ratio of AMI/stroke in the 21 days after HFRS against 2 different control periods either excluding (analysis 1) or including (analysis 2) fatal AMI/stroke events. The incidence rate ratios for analyses 1 and 2 for all AMI events were 5.53 (95% confidence interval [CI], 2.6-11.8) and 6.02 (95% CI, 2.95-12.3) and for first AMI events were 3.53 (95% CI, 1.25-9.96) and 4.64 (95% CI, 1.83-11.77). The incidence rate ratios for analyses 1 and 2 for all stroke events were 12.93 (95% CI, 5.62-29.74) and 15.16 (95% CI, 7.21-31.87) and for first stroke events were 14.54 (95% CI, 5.87-36.04) and 17.09 (95% CI, 7.49-38.96). The majority of stroke events occurred in the first week after HFRS. Seasonal effects were not observed, and apart from 1 study, neither sex nor age interacted with the associations observed in this study. CONCLUSIONS: There is a significantly increased risk for AMI and stroke in the immediate time period after HFRS. Therefore, HFRS patients should be carefully monitored during the acute phase of disease to ensure early recognition of symptoms of impending AMI or stroke.

Increase in the Prevalence of Atrophic Gastritis Among Adults Age 35 to 44 Years Old in Northern Sweden Between 1990 and 2009.

BACKGROUND & AIMS: Atrophic corpus gastritis (ACG) is believed to be an early precursor of gastric adenocarcinoma. We aimed to investigate trends of ACG in Northern Sweden, from 1990 through 2009, and to identify possible risk factors. METHODS: We randomly selected serum samples collected from 5284 participants in 1990, 1994, 1999, 2004, and 2009, as part of the population-based, cross-sectional Northern Sweden Multinational Monitoring of Trends and Determinants in Cardiovascular Disease study (ages, 35-64 y). Information was collected on sociodemographic, anthropometric, lifestyle, and medical factors using questionnaires. Serum samples were analyzed for levels of pepsinogen I to identify participants with functional ACG; data from participants with ACG were compared with those from frequency-matched individuals without ACG (controls). Blood samples were analyzed for antibodies against Helicobacter pylori and Cag pathogenicity island protein A. Associations were estimated with unconditional logistic regression models. RESULTS: Overall, 305 subjects tested positive for functional ACG, based on their level of pepsinogen I. The prevalence of ACG in participants age 55 to 64 years old decreased from 124 per 1000 to 49 per 1000 individuals between 1990 and 2009. However, the prevalence of ACG increased from 22 per 1000 to 64 per 1000 individuals among participants age 35 to 44 years old during this time period. Cag pathogenicity island protein A seropositivity was associated with risk for ACG (odds ratio, 2.29; 95% confidence interval, 1.69-3.12). Other risk factors included diabetes, low level of education, and high body mass index. The association between body mass index and ACG was confined to individuals age 35 to 44 years old; in this group, overweight and obesity were associated with a 2.8-fold and a 4.7-fold increased risk of ACG, respectively. CONCLUSIONS: Among residents of Northern Sweden, the prevalence of ACG increased from 1990 through 2009, specifically among adults age 35 to 44 years old. The stabilizing seroprevalence of H pylori and the increasing prevalence of overweight and obesity might contribute to this unexpected trend. Studies are needed to determine whether these changes have affected the incidence of gastric cancer.

Long term trends in control of hypertension in the Northern Sweden MONICA study 1986-2009.

BACKGROUND: A large proportion of treated hypertensive subjects do not achieve target blood pressure (BP) levels. We investigated trends in treatment and BP levels in the population, and among treated hypertensive subjects in northern Sweden. METHODS: The six Northern Sweden MONICA population surveys 1986 to 2009, included 6342 subjects aged 45 to 74 years of age, participation rate 79.3%. Factors associated with lack of BP control are presented for 1106 participants in 2009. BP control was defined as a systolic BP <140 and a diastolic BP <90 mm Hg among treated hypertensive patients. RESULTS: Between 1986 and 2009, the proportion of the population that received antihypertensive treatment increased. The proportion of the whole population having BP <140/90 mm Hg increased for all (p < 0.001 for each subgroup), except for men 45-55 years old. In 2009, 62.4% of the population had BP <140/90 mm Hg, 67.2% in women and 58.1% in men (p = 0.002). In the group of treated hypertensive patients, the proportion having BP control increased (p < 0.001) with no difference between sex or age groups. In 2009 52.1% of treated hypertensives had BP control. In 2009, adequate BP control among treated hypertensive patients was 63.9% for those with BMI <25, but only 48.8% for those with BMI > 25 (p = 0.015). Abdominal obesity was associated with less BP control (48.1%) than without abdominal obesity (66.2%, p = 0.007). Women who were physically inactive had better BP control than those who were active (p = 0.03). Men treated with two or more antihypertensive drugs were 50% more likely to reach target BP than men with monotherapy (60.4% vs. 40.0 %, p = 0.035). Rural or urban living, level of education, diabetes mellitus or having a high cardiovascular risk were not associated with better BP control. CONCLUSION: Antihypertensive treatment and BP control have increased in northern Sweden since 1986, although in 2009 still barely half of the treated patients achieved adequate BP levels. Intensified treatment and weight reduction may help to further improve BP control.

The Process of Care-seeking for Myocardial Infarction Among Patients With Diabetes.

BACKGROUND: People with diabetes have a higher risk for myocardial infarction (MI) than do people without diabetes. It is extremely important that patients with MI seek medical care as soon as possible after symptom onset because the shorter the time from symptom onset to treatment, the better the prognosis. OBJECTIVE: The aim of this study was to explore how people with diabetes experience the onset of MI and how they decide to seek care. METHODS: We interviewed 15 patients with diabetes, 7 men and 8 women, seeking care for MI. They were interviewed 1 to 5 days after their admission to hospital. Five of the participants had had a previous MI; 5 were being treated with insulin; 5, with a combination of insulin and oral antidiabetic agents; and 5, with oral agents only. Data were analyzed according to grounded theory. RESULTS: The core category that emerged, "becoming ready to act," incorporated the related categories of perceiving symptoms, becoming aware of illness, feeling endangered, and acting on illness experience. Our results suggest that responses in each of the categories affect the care-seeking process and could be barriers or facilitators in timely care-seeking. Many participants did not see themselves as susceptible to MI and MI was not expressed as a complication of diabetes. CONCLUSIONS: Patients with diabetes engaged in a complex care-seeking process, including several delaying barriers, when they experienced symptoms of an MI. Education for patients with diabetes should include discussions about their increased risk of MI, the range of individual variation in symptoms and onset of MI, and the best course of action when possible symptoms of MI occur.

Cardiovascular risk factors differ between rural and urban Sweden: the 2009 Northern Sweden MONICA cohort.

BACKGROUND: Rural communities have a higher burden of cardiovascular risk factors than urban communities. In Sweden, socioeconomic transition and urbanization have led to decreased populations in rural areas and changing characteristics of the remaining inhabitants. We investigated the risk factors in urban and rural populations in Northern Sweden. METHODS: The 2009 Northern Sweden MONICA Study invited a random sample of 2,500 people, 25 to 74 years and 69.2% participated. Community size was classified as rural = <1,000 inhabitants, town = 1,000-15,000, or urban/city = >15,000. We adjusted our analysis for age, gender and education. RESULTS: The rural population was older and the proportion of men was higher than in the urban areas. Having only primary education was more common in rural areas than in urban areas (26.2% vs. 12.3%). Waist and hip circumference, body mass index (BMI), and total cholesterol levels were higher in rural areas than in urban areas, even after adjusting for differences in age and gender. The largest differences between rural and urban dwellers were seen in waist circumference of women (4.8 cm), BMI of women (1.8 units) and cholesterol of men (0.37 mmol/l). Blood pressure was higher in rural areas, but not after adjusting for age and gender.Participants in rural areas were more often treated for hypertension and hyperlipidaemia, hospitalized for myocardial infarction and diagnosed with diabetes. However, after adjusting for age and gender, there were no differences. The odds ratio for being physically active comparing rural areas to urban areas was 0.73 (95% CI 0.53; 1.01). Smoking, snuff use and the prevalence of pathological glucose tolerance did not differ between community sizes. Middle-sized communities often had values in between those found in rural and urban communities, but overall they were more similar to the rural population. Further adjustment for education did not change the results for any variable. CONCLUSIONS: In 2009 the rural population in northern Sweden was older, with less education, higher BMI, more sedentary lifestyle, and had higher cholesterol levels than the urban population. The rural population should be considered targets for focused preventive interventions, but with due consideration of the socioeconomic and cultural context.

Differences in cardiovascular risk factors and socioeconomic status do not explain the increased risk of death after a first stroke in diabetic patients: results from the Swedish Stroke Register.

AIMS/HYPOTHESIS: This study compared survival rates and causes of death after stroke in diabetic and non-diabetic patients in Sweden. We hypothesised that differences in cardiovascular risk factors, acute stroke management or socioeconomic status (SES) could explain the higher risk of death after stroke in diabetic patients. METHODS: The study included 155,806 first-ever stroke patients from the Swedish Stroke Register between 2001 and 2009. Individual patient information on SES was retrieved from Statistics Sweden. Survival was followed until 2010 (532,140 person-years) with a median follow-up time of 35 months. Multiple Cox regression was used to analyse survival adjusting for differences in background characteristics, in-hospital treatment, SES and year of stroke. Causes of death were analysed using cause-specific proportional hazard models. RESULTS: The risk of death after stroke increased in diabetic patients (HR 1.28, 95% CI 1.25, 1.31), and this risk was greater in younger patients and in women. Differences in background characteristics, cardiovascular risk factors, in-hospital treatment and SES did not explain the increased risk of death after stroke (HR 1.35, 95% CI 1.32, 1.37) after adjustments. Diabetic patients had an increased probability of dying from cerebrovascular disease and even higher probabilities of dying from other circulatory causes and all other causes except cancer. CONCLUSIONS/INTERPRETATION: Differences in cardiovascular risk factors, acute stroke management and SES do not explain the lower survival after stroke in diabetic compared with non-diabetic patients. Diabetic patients are at higher risk of dying from cardiovascular causes and all other causes of death, other than cancer.

Longer pre-hospital delay in first myocardial infarction among patients with diabetes: an analysis of 4266 patients in the northern Sweden MONICA Study.

BACKGROUND: Reperfusion therapy reduces both morbidity and mortality in myocardial infarction, but the effectiveness depends on how fast the patient receives treatment. Despite the time-dependent effectiveness of reperfusion therapy, many patients with myocardial infarction have delays in seeking medical care. The aim of this study was to describe pre-hospital delay in a first myocardial infarction among men and women with and without diabetes and to describe the association between pre-hospital delay time and diabetes, sex, age, symptoms and size of residential area as a proxy for distance to hospital. METHODS: This population based study was based on data from 4266 people aged 25-74 years, with a first myocardial infarction registered in the Northern Sweden MONICA myocardial infarction registry between 2000 and 2008. RESULTS: The proportion of patients with delay times ≥ 2 h was 64% for patients with diabetes and 58% for patients without diabetes. There was no difference in delay time ≥ 2 h between men and women with diabetes. Diabetes, older age and living in a town or rural areas were factors associated with pre-hospital delay times ≥ 2 h. Atypical symptoms were not a predictor for pre-hospital delay times ≥ 2 h, OR 0.59 (0.47; 0.75). CONCLUSIONS: A higher proportion of patients with diabetes have longer pre-hospital delay in myocardial infarction than patients without diabetes. There are no differences in pre-hospital delay between men and women with diabetes. The largest risk difference for pre-hospital delay ≥ 2 h is between women with and without diabetes. Diabetes, older age and living in a town or rural area are predictors for pre-hospital delay ≥ 2 h.

Plasma folate, but not homocysteine, is associated with Apolipoprotein A1 levels in a non-fortified population.

BACKGROUND: Elevated total plasma homocysteine (tHcy) in humans is associated with cardiovascular disease but prevention trials have failed to confirm causality. Reported reasons for this association have been that homocysteine and its major genetic determinant methylenetetrahydrofolate reductase (MTHFR) may have an effect on HDL and Apolipoprotein (Apo) A1 levels. We wanted to study if tHcy and its major determinants were correlated with Apo A1 levels in a large population without folate fortification. METHODS: This study was a prospective incident nested case-referent study within the Northern Sweden Health and Disease Study Cohort (NSHDSC), including 545 cases with first myocardial infarction and 1054 matched referents, median age at inclusion was 59 years. Univariate and multiple regression analyzes was used to study the associations between apolipoproteins Apo A1 and B, tHcy, folate and vitamin B12 in plasma as well as MTHFR polymorphisms 677C>T and 1298A>C. RESULTS: Apo A1 and Apo B were strongly associated with the risk of a first myocardial infarction. tHcy was not associated with Apo A1 levels. Instead, folate had an independent positive association with Apo A1 levels in univariate and multiple regression models. The associations were seen in all men and women, among referents but not among cases. MTHFR polymorphisms had no clear effect on Apo A1 levels. CONCLUSIONS: Analyzing over 1500 subjects we found an independent positive association between plasma folate (major dietary determinant of tHcy) and Apo A1 levels among those who later did not develop a first myocardial infarction. No association was seen between tHcy and Apo A1.

The low prevalence of smoking in the Northern Sweden MONICA study, 2009.

AIMS: The purpose of this study was to describe tobacco use in the 2009 Northern Sweden cohort of the World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) study. METHODS: Subjects (N = 1698) were randomly selected from population registers, stratified for age (25-74 years old) and gender, in the two northernmost Swedish counties of Norrbotten and Västerbotten. Responses from tobacco-related questions were used to develop three mutually exclusive categories of snus use: past, current, or never use; and three comparable categories of smoking that were consistent with previous studies. RESULTS: Among men, the prevalence of smoking (9%) and dual use (2%) remain unchanged from 2004, although the prevalence of snus use declined from 27% in 2004 to 24% in 2009. Among women, the prevalence of all forms of tobacco use declined between 2004 and 2009; smoking dropped from 16% to 11%, dual use from 2% to less than 1%, and snus use from 9% to 8%. Although overall prevalence of tobacco use was similar for younger versus older men and younger versus older women, there were notable differences in specific snus and smoking rates. CONCLUSIONS: This study confirms that use of snus was a significant factor in the low prevalence of smoking, especially among younger men and women in Northern Sweden. Furthermore, it documents that tobacco harm reduction is entirely compatible with a population-level decline in overall tobacco use.

Older women's prehospital experiences of their first myocardial infarction.

BACKGROUND: Few qualitative studies have been conducted on older women's experiences of myocardial infarction (MI) and, in particular, the time before they seek medical care. OBJECTIVE: The aim of this study was to explore older women's prehospital experiences of their first MI. METHODS: Qualitative content analysis was performed on data from individual interviews with 20 women, aged 65 to 80 years (mean, 73.0 years). The participants were interviewed 3 days after admission to a hospital for a confirmed first MI. RESULTS: The women perceived their symptoms as a strange and unfamiliar development from indistinct physical sensations to persistent and overwhelming chest pain. Throughout the prehospital phase, they used different strategies such as downplaying and neglecting the symptoms. The symptoms were seen as intrusions in their daily lives, against which the participants defended themselves to remain in control and to maintain social responsibilities. As their symptoms evolved into constant chest pain, the women began to realize the seriousness of their symptoms. When the pain became unbearable, the women took the decision to seek medical care. CONCLUSION: Understanding the complex experiences of older women in the prehospital phase is essential to reducing their patient decision times. The findings of this study should be incorporated into the education of professionals involved in the care of cardiac patients, including those who answer informational and emergency telephone lines.

Incidence of hyperthyroidism in patients with bipolar or schizoaffective disorder with or without lithium: 21-year follow-up from the LiSIE retrospective cohort study.

Background: Lithium-associated hyperthyroidism is much rarer than lithium-associated hypothyroidism. Yet, it may be of substantial clinical significance for affected individuals. For instance, lithium-associated hyperthyroidism could destabilise mood, mimic manic episodes and impact physical health. Only few studies have explored incidence rates of lithium-associated hyperthyroidism. Even fewer studies have compared incidence rates according to lithium exposure history. Objectives: To determine the impact of lithium treatment on the incidence rate of hyperthyroidism in patients with bipolar or schizoaffective disorder and assess its aetiology. Design: This study is part of the LiSIE (Lithium - Study into Effects and Side Effects) retrospective cohort study. Methods: Between 1997 and 2017, patients in the Swedish region of Norrbotten with a diagnosis of bipolar or schizoaffective disorder were screened for all episodes of overt hyperthyroidism in form of thyrotoxicosis or thyroiditis. Incidence rates of episodes of hyperthyroidism per 1000 person-years (PY) were compared in relation to lithium exposure; concurrent, previous, or no exposure ever (lithium-naïve patients). Results: In 1562 patients, we identified 16 episodes of hyperthyroidism corresponding to an incidence rate of 0.88 episodes per 1000 PY. Ninety-four percent of episodes had occurred in women. Patients who had concurrently been exposed to lithium, had an incidence rate of 1.35 episodes per 1000 PY. Patients who had previously been exposed to lithium had an incidence rate of 0.79 per 1000 PY. Patients who had never been exposed to lithium had an incidence rate of 0.47 per 1000 PY. There were no significant differences in the risk ratios for patients with concurrent or previous exposure compared with lithium-naïve patients, neither for hyperthyroidism overall, thyrotoxicosis, or thyroiditis. Conclusion: Lithium-associated hyperthyroidism seems uncommon. The risk of hyperthyroidism does not seem significantly higher in patients with current or previous lithium exposure than in lithium-naïve patients.