Neighbourhood socioeconomic status and pain among older adults-A cross-sectional study.

BACKGROUND: Pain is associated with falls, disability and a poor quality of life among older adults. It is highly prevalent in many societies, and studies have shown that pain could be preventable or managed more effectively at the population level. However, few studies have investigated who is at higher risk of pain in the general population, which is important for development of effective interventions. The purpose of this study was to investigate, by using nationally representative samples in Sweden, whether neighbourhood socioeconomic status (SES) is associated with pain among older adults after considering other important risk factors. METHODS: The study used the Statistics on Income and Living Conditions (EU-SILC), which is a nationwide annual survey of the living conditions of residents in Sweden. We used the data of individuals who were over 65 years of age between 2008 and 2013. Multivariable logistic regression was conducted to investigate the association between neighbourhood SES and severe pain. RESULTS: Those who resided in low SES neighbourhoods had a 30% higher odds of having severe pain than those who resided in high SES neighbourhoods after controlling for individual risk factors, such as the sex, age, individual SES, smoking, exercise habits and body mass index. Exercise was protective against severe pain. CONCLUSION: Given the high prevalence of pain across populations, interventions targeting geographic areas (such as those in the current study) in combination with individual risk factors could be effective to reduce the burden of pain at the population level. SIGNIFICANCE: Those who reside in neighbourhoods with low SES may have higher risks of pain due to a lack of health-promoting resources as well as psychological stress. Further studies identifying the specific mechanisms behind the association between neighbourhood SES and pain would be useful in order to develop effective interventions.

Impact of feed, light and access to manipulable material on tail biting in pigs with intact tails.

BACKGROUND: Tail biting (TB) is a welfare issue with economic consequences due to infections and ill-thrift. This study aimed to reduce tail injuries in a high-performing non-tail-docking pig herd. RESULTS: During eleven years preceding the trial, the annual incidence of tail injuries registered at slaughter in pigs from the herd increased from 3% (equivalent to the national mean) to 10%. It was positively correlated to a high weight gain and negatively correlated to daylight length. The overall incidence of tail injuries during the four years preceding the trial was 9.2% with significant differences between four identically structured buildings for fatteners (I < II < III < IV). The feed was enriched with amino acids, minerals and fibres. The buildings used different illumination strategies, I: standard fluorescent tubes with an invisible flickering light of 30-40% for 14 h daily, II: non-flickering led light for 14 h daily, III (control) and IV: standard fluorescent tubes for 2 h daily. IV had free access to manipulable material (hay-silage), while I-III was offered 100-200 g daily. During the adaptation period (6 months), the incidence of tail injuries decreased significantly in all buildings to a mean of 5.4%. The largest decrease (from 11.4 to 4.3%) was obtained in IV. During the trial period (12 months), the mean incidence of tail injuries decreased in all groups to a mean of 3.0%. There were no differences in treatment incidences of individual pigs due to TB between groups, but the use of enriched pellets due to TB in pens was lowest in II. The low incidence of tail injuries was retained during the post-trial period (6 months) when all buildings used artificial illumination for two hours per day. CONCLUSIONS: The incidence of TB in fast growing non-tail-docked pigs in the herd was successfully reduced by supplementing the feed with amino acids, minerals, vitamins and fibres. Additional manipulable material accelerated that process and non-flickering illumination may have had an impact in preventing TB. The results obtained do not support the need for tail-docking of pigs, provided that the needs of the pigs in terms of feed ingredients, stocking density and access to manipulable materials are fulfilled.

A longitudinal study of the association between attending cultural events and coronary heart disease.

BACKGROUND: The experiences of art and music are an essential part of human life and this study aimed to examine the longitudinal association between cultural participation and coronary heart disease. METHODS: This was a longitudinal study on a randomly selected representative adult cohort (n = 3296) of the Swedish population. The study period was over 36 years (1982-2017) with three separate eight-year interval measurements of cultural exposure (for example, visiting theatres and museums) starting in 1982/83. The outcome was coronary heart disease during the study period. Marginal structural Cox models with inverse probability weighting were used to account for time-varying weights of the exposure and potential confounders during the follow-up. The associations were also examined through a time-varying Cox proportional hazard regression model. RESULTS: Cultural participation shows a graded association, the higher the exposure the lower the risk of coronary heart disease; the hazard ratio was 0.66 (95% confidence interval, 0.50 to 0.86) for coronary heart disease in participants with the highest level of cultural exposure compared with the lowest level. CONCLUSION: Although causality cannot be determined due to the remaining risk of residual confounding and bias, the use of marginal structural Cox models with inverse probability weighting strengthens the evidence for a potentially causal association with cardiovascular health, which warrants further studies.

This study examined whether people taking part in cultural activities, such as going to museums or theatres, were less likely to get coronary heart disease. The study included 3296 adults in Sweden over a period of 36 years. Information on cultural participation was collected by questionnaires on three occasions, eight-years apart. National healthcare data was used to identify cases of coronary heart disease. The main finding was that people who took part in more cultural activities were less likely to have coronary heart disease. This study suggests that taking part in cultural activities may be an important way to keep your heart healthy.

Long term association of hip fractures by questions of physical health in a cohort of men and women.

We do not know if fracture predicting factors are constant throughout life, if they can be assessed earlier in life, and for how long. The aim was to study the association between questions about health status and mobility and fragility fractures in a cohort during a 35-year follow-up. A cohort of 16,536 men and women in two age groups, 26-45 and 46-65 years old, who answered five questions of their physical health status in postal surveys in 1969-1970. We obtained data on hip fractures from 1970 to the end of 2016. We found most significant results when restricting the follow-up to age 60-85 years, 35 for the younger age group and 20 years for the older. Men of both age groups considered "at risk" according to their answers had a 2.69 (CI 1.85-3.90)- 3.30 (CI 1.51-7.23) increased risk of having a hip fracture during a follow-up. Women in the younger age group had a 2.69 (CI 1.85-3.90) increased risk, but there was no elevated risk for women in the older age group. This study shows that questions/index of physical health status may be associated with hip fractures that occur many years later in life, and that there is a time span when the predictive value of the questions can be used, before other, age-related, factors dominate. Our interpretation of the results is that we are studying the most vulnerable, who have hip fractures relatively early in life, and that hip fractures are so common among older women that the questions in the survey lose their predictive value.

Association between attending cultural events and all-cause mortality: a longitudinal study with three measurements (1982-2017).

OBJECTIVES: To examine the association between cultural attendance and all-cause mortality. DESIGN: A longitudinal cohort study over 36 years (1982-2017) with three 8-year interval measurements of exposure (1982/1983, 1990/1991 and 1998/1999) to cultural attendance and a follow-up period to 31 December 2017. SETTING: Sweden. PARTICIPANTS: The study included 3311 randomly selected individuals from the Swedish population with complete data for all three measurements. PRIMARY OUTCOME MEASUREMENTS: All-cause mortality during the study period in relation to level of cultural attendance. Cox regression models with time-varying covariates were used to estimate HRs adjusted for potential confounders. RESULTS: The HRs of cultural attendance in the lowest and middle levels compared with the highest level (reference; HR=1) were 1.63 (95% CI 1.34 to 2.00) and 1.25 (95% CI 1.03 to 1.51), respectively. CONCLUSION: Attending cultural events has a suggested gradient, the lesser cultural exposure the higher all-cause mortality during the follow-up.

Examining the causal effect of type 2 diabetes on ischemic heart disease - A longitudinal study with four measurements (1980-2017).

OBJECTIVE: This longitudinal study examines a possible causal effect between type 2 diabetes and ischemic heart disease (IHD) by using measurements on four occasions from the Swedish Statistics on Income and Living Conditions (SILC) together with nationwide healthcare registers. METHODS: This was a longitudinal study based on a random sample of men and women (n = 2014) from the Swedish population with four measurements in the SILC every eight years. Baseline was 1980/81 and the participants were followed for up to 37 years. The mean age and age range at baseline were 36.5 and 20-59 years, respectively. The study used Marginal Structural Modeling (MSM-Cox) to account for time-varying exposures by implementing inverse probability weighting (IPTW). MSM-Cox with IPTW was compared with Cox proportional hazard modelling. RESULTS: The hazard ratio (HR) for IHD (369 cases) with 95% confidence interval (CI) in participants with type 2 diabetes (11.1%) compared to participants without type 2 diabetes (88.9%) was significantly higher (1.99; CI = 1.15 - 3.44) when using MSM-Cox with IPTW after adjustments for clinical and sociodemographic risk factors. When applying Cox proportional hazard models adjusted for the same variables, the HR was lower and non-significant at 1.34 (CI = 0.94 - 1.98). CONCLUSIONS: This longitudinal study with four measurements assessed a possible causal association between type 2 diabetes and IHD by applying MSM-Cox with IPTW. Although causality cannot be determined due to the remaining risk of residual bias, the results may help to elucidate a potential causal relationship between type 2 diabetes and IHD. Further causal studies on possible underlying mechanisms are, however, needed.

Trajectories of body mass index and risk for coronary heart disease: A 38-year follow-up study.

OBJECTIVE: Obesity is a well-known risk factor for coronary heart disease (CHD), but there is little evidence on the effect of long-term trajectories of body mass index (BMI) over the life course. By using repeated assessments, the aim was to study the risk of CHD in adults during 38 years in different trajectories of BMI. METHODS: A sample of 2129 men and women, aged 20-59 years at baseline, took part in four repeated interviews between 1980 and 2005. Data on BMI, medical history, lifestyle and socioeconomy were collected. Based on the World Health Organization categories of BMI, life course trajectories of stable normal weight, stable overweight, stable obesity, increasing BMI and fluctuating BMI were created. The individuals were followed through national registers for first hospitalization of CHD (389 events) until the end of 2017, and Hazard Ratios (HRs) were calculated, adjusted for age, sex, socioeconomic factors, lifestyle factors and metabolic comorbidities. RESULTS: Stable normal weight in all assessments was the reference group. Those who had an increase in BMI from normal weight in the first assessment to overweight or obesity in later assessments had no increased risk of CHD, HR 1.04 (95% CI: 0.70-1.53). The HR for individuals with fluctuating BMI was 1.25 (0.97-1.61), for stable overweight 1.43 (1.03-1.98), for stable obesity 1.50 (0.92-2.55), and for stable overweight or obesity 1.45 (1.07-1.97), after full adjustments. CONCLUSION: Having a stable overweight or obesity throughout adult life was associated with increased CHD risk but changing from normal weight at baseline to overweight or obesity was not associated with increased CHD risk. Prevention of obesity early in life may be particularly important to reduce CHD risk.

Elucidating causal effects of type 2 diabetes on ischemic heart disease from observational data on middle-aged Swedish women: a triangular analytical approach.

The association between type 2 diabetes (T2D) and ischemic heart disease (IHD) is well established but the potential causal association needs further studying. In an attempt to elucidate the causal effect of T2D on IHD, we used three different analytical approaches in two different datasets. A well-defined cohort of 6047 women aged 50-59 years were included at baseline (1995 to 2000) and followed until 2015 for IHD. The median follow-up was 16.3 years. We used a Marginal Structural Cox model (MSM Cox) to account for time-varying exposure (time at onset of T2D) and for ten confounders (using inverse probability weighting, IPW). We also compared the MSM-Cox models with traditional Cox regression modelling in the cohort. Finally, we analyzed information on individuals from Swedish population-based registers with national coverage in a comprehensive co-relative design and extrapolated the results to MZ twins. The Hazard Ratio (HR) for IHD in relation to T2D at baseline and T2D occurring during the follow-up in the MSM Cox model weighted by IPW (based on the ten included confounders) was 1.43 (95% confidence interval [CI] 1.07-1.92). The corresponding HR from the traditional Cox regression model was of similar effect size. The average extrapolated MZ twin estimate from our co-relative model was 1.61 (95% CI 1.48-1.86). Our findings, based on a triangular approach, support the existence of a causal association between T2D and IHD and that preventive long-term measures in order to avoid or postpone IHD should include monitoring and treatment of both the T2D itself as well as other cardiovascular risk factors.

Total cholesterol/HDL-C ratio versus non-HDL-C as predictors for ischemic heart disease: a 17-year follow-up study of women in southern Sweden.

BACKGROUND: A distorted blood lipid profile is an important risk factor for ischemic heart disease (IHD) but the predictive ability of the different lipid measures has rarely been studied. Our aim was to examine and compare, in a large sample of women, the predictive ability of total cholesterol/HDL cholesterol ratio (TC/HDL-C) and non-HDL-C in relation to IHD, adjusted for age, exercise, smoking, waist-hip ratio, blood pressure, and diabetes mellitus. METHODS: Between 1995 and 2000, a total of 6537 women aged 50-59 years from the Women's Health in Lund area (WHILA) study in southern Sweden were included and underwent a baseline examination. The women were followed through national registers for incidence of IHD during a mean follow-up of 17 years. The prediction accuracy was estimated through Harrell's C and Akaike Information Criterion (AIC). RESULTS: Increasing TC/HDL-C as well as non-HDL-C showed strong associations with IHD, with the highest risk in the 5th quintile, where the HR was 2.30 (95% CI: 1.70-3.11) for TC/HDL-C and 1.67 (95% CI: 1.25-2.24) for non-HDL-C, after adjustments. Comparisons using Harrell's C and AIC indicated that TC/HDL-C has a slightly higher predictive ability than that of non-HDL-C (Harrell's C 0.62 and 0.59 respectively, p = 0.003 for difference, age-adjusted model; AIC for TC/HDL-C < AIC for non-HDL-C). CONCLUSIONS: TC/HDL-C ratio and non-HDL-C are both clinical predictors for IHD in middle-aged women. The results indicate that the predictive ability of TC/HDL-C was higher than that of non-HDL-C; however, non-HDL-C was linearly related to IHD (p = 0.58) and may be easier to calculate and interpret in clinical practice, for early identification of future IHD in women.

Patient outcomes following GPs' educations about COPD: a cluster randomized controlled trial.

This study aimed to compare patient outcomes following case method learning and traditional lectures as methods for continuing medical education (CME) about chronic obstructive pulmonary disease (COPD) for general practitioners (GPs) in Sweden. In a pragmatic cluster randomized controlled trial, COPD patients (n = 425; case method group n = 209, traditional lectures group n = 216) from 24 primary health care centers replied to questionnaires prior to and 18 months after a 2 × 2-h CME was given to GPs (n = 255). We measured changes in the scores of the Clinical COPD Questionnaire (CCQ), symptoms, needs for disease information, exacerbations, smoking, and use of pulmonary rehabilitation. The changes over time were similar for both CME methods. Patients who had used pulmonary rehabilitation increased from 13.2 to 17.8% (P = 0.04), and prevalence of smoking decreased from 28.9 to 25.1% (P = 0.003). In conclusion, neither of the used CME methods was superior than the other regarding patient outcomes. CME's primary value may lay in improving GPs' adherence to guidelines, which should lead to long-term positive changes in patient health.

The ratio of total cholesterol to high density lipoprotein cholesterol and myocardial infarction in Women's health in the Lund area (WHILA): a 17-year follow-up cohort study.

BACKGROUND: Identifying variables predictive of acute myocardial infarction (AMI) in women is important. The use of the ratio of total cholesterol-to-high density lipoprotein cholesterol (TC/HDL-C) is often overlooked. The aim was to study TC/HDL-C in relation to later AMI, in a large sample of women, adjusted for age, educational status, smoking, waist-hip ratio, blood pressure, and neighbourhood socioeconomic status. The hypothesis was that increasing TC/HDL-C is associated with an increased risk of later AMI. METHODS: From December 1995 to February 2000, 6147 women aged 50-59 years from the Womens' Health in Lund area (WHILA) study in southern Sweden underwent a physical examination, laboratory tests and filled in a questionnaire. The women were followed through national registers for incidence of AMI during a mean follow up of 17 years. RESULTS: An increasing TC/HDL-C showed a strong relationship with AMI, with the lowest hazard ratio (HR = 1) in women with a ratio of ≤3.5. The HR for AMI was 1.14 (95% CI: 0.73-1.78) for those with a ratio between 3.5 and 4.0; in those with a ratio between 4.0 and 5.0 the HR for AMI was 1.46 (95% CI: 1.00-2.13) and in those with a ratio > 5.0 the HR was 1.89 (95% CI 1.26-2.82), after adjusting for potential confounding factors. CONCLUSIONS: TC/HDL-C ratio is a powerful predictor of AMI in middle-aged women. The results indicate that this variable should be used in clinical practice and is important for early identification of individuals at risk of AMI.

Duodenal eosinophilia is associated with functional dyspepsia and new onset gastro-oesophageal reflux disease.

BACKGROUND: It is unexplained why functional dyspepsia and gastro-oesophageal reflux disease (GERD) overlap more often than expected by chance. Post-prandial distress syndrome has been linked to impaired gastric fundic accommodation which may induce increased transient lower oesophageal sphincter relaxations and consequent GERD. Duodenal eosinophilia has been linked to functional dyspepsia and post-prandial distress syndrome. AIM: To identify if there is an association between duodenal eosinophilia in functional dyspepsia and symptoms of GERD and whether post-prandial distress syndrome or epigastric pain syndrome are associated with new onset GERD. METHODS: Participants (n = 1000) were randomly selected from the national Swedish population register and surveyed by questionnaires and oesophagogastroduodenoscopy in 1999-2001. All eligible subjects (n = 887) were invited to a follow-up study in 2010 (response rate 79%). In a case-control study of 213 subjects (functional dyspepsia vs healthy controls), histology from the duodenum was evaluated at baseline and the possible association of eosinophilia to new onset GERD symptoms was analysed. RESULTS: Functional dyspepsia (OR 7.6; 95% CI 2.93-19.4, P < 0.001) and post-prandial distress syndrome at baseline (OR 9.0, 95% CI 3.36-24.0, P < 0.001) were associated with an increased risk of GERD at follow-up. Eosinophilia in the second part of duodenum only was independently associated with an increased risk of GERD amongst those with functional dyspepsia (OR 4.2; 95% CI 1.2-4.77, P = 0.024) and post-prandial distress syndrome at baseline (OR 6.0; 95% CI 1.50-23.6, P = 0.011), respectively. CONCLUSIONS: Duodenal eosinophilia is associated with increased risk of GERD at 10-year follow-up in those with functional dyspepsia and post-prandial distress syndrome at baseline. Duodenal eosinophilia may explain the link between GERD and functional dyspepsia, suggesting subsets of functional dyspepsia and GERD may be part of the same disease spectrum.

Effectiveness of traditional lectures and case methods in Swedish general practitioners' continuing medical education about COPD: a cluster randomised controlled trial.

OBJECTIVES: To study the effects of continuing medical education (CME) about chronic obstructive pulmonary disease (COPD) for general practitioners (GPs) by comparing two commonly used CME methods with each other and no CME (reference group). DESIGN: A pragmatic cluster randomised controlled trial with primary healthcare centres (PHCCs) as units of randomisation. SETTING, PARTICIPANTS AND INTERVENTIONS: 24 PHCCs in Stockholm County, Sweden, were randomised into two CME intervention arms: case method learning (CM) (n=12) and traditional lectures (TL) (n=12). A reference group without CME (n=11) was recruited separately. GPs (n=255) participated in the study arm to which their PHCC was allocated: CM, n=87; TL, n=93; and reference, n=75. Two 2-hour CME seminars were given in a period of 3 months. PRIMARY OUTCOME MEASURES: Changes in scores between baseline and 12 months on a 13-item questionnaire about evidence-based COPD management (0-2 points/question, maximum total score 26 points). RESULTS: 133 (52%) GPs completed the questionnaire both at baseline and 12 months. Both CM and TL resulted in small yet significantly higher total scores at 12 months than at baseline (CM, 10.34 vs 11.44; TL, 10.21 vs 10.91; p<0.05); there were few significant differences between these CME methods. At both baseline and 12 months, all three groups' scores were generally high on questions about smoking cessation support and low on those that measured spirometry interpretation skills, interprofessional care and management of multimorbidity. CONCLUSIONS: Neither short CM nor short TL CME sessions substantially improve GPs' skills in managing COPD. It is justified to challenge the use of these common CME methods as a strategy for improving GPs' level of knowledge about management of COPD and other complex chronic diseases characterised by multimorbidity. TRIAL REGISTRATION NUMBER: NCT02213809; Results.

Women's Health in the Lund Area (WHILA) study. Health problems and acute myocardial infarction in women - A 17-year follow-up study.

OBJECTIVES: The literature has highlighted the importance of identifying symptoms predictive of acute myocardial infarction (AMI) in women, in addition to traditional cardiovascular risk factors. The objective was to study subjective health problems, in relation to later AMI, in a large sample of women, adjusted for age, educational status, smoking, waist/hip ratio, blood pressure, total cholesterol/HDL ratio, diabetes and neighbourhood socioeconomic status. STUDY DESIGN: From December 1995 to February 2000 a cohort of 6711 women aged 50-59 years in southern Sweden underwent a physical examination and answered a questionnaire that had 18 items on health problems such as stress symptoms, tiredness and pain. MAIN OUTCOME MEASURES: Incidence of AMI during a mean follow-up of 17 years, drawn from national registers. RESULTS: The number of health problems showed a J-shaped relationship with AMI, with the lowest hazard ratio (HR) in women with a median of 4 health problems. The HR for AMI in women with 0 health problems was 1.58 (95% CI: 0.95-2.63) and in those with 13 problems HR 1.65 (95% CI 1.16-2.36), after adjusting for potential confounding factors. CONCLUSIONS: The presence of several health problems, including pain and stress symptoms, is associated with an increased risk of later AMI in middle-aged women. Awareness among clinicians of predictive risk factors for AMI is important for the early identification of individuals at higher risk.

Postnatal ER visits within 30 days-Pattern, risk factors and implications for care.

AIMS AND OBJECTIVES: To (i) reveal care-seeking patterns of emergency room visits within 30 days following childbirth (i.e., identify risk factors that trigger contact with emergency room, visit rate and diagnoses) and (ii) suggest clinical implications for postnatal follow-up. DESIGN: The study had a longitudinal design; it used anonymised data from a county council database on all women in Stockholm County, Sweden, who gave birth in 2013. METHODS: Descriptive and inferential data analysis methods were used. Cox regression was applied to these variables: age when giving birth, diagnostic codes at birth, care encounters and types (e.g., visits or hospital admissions), day of discharge and care organisation and type. The data covered the period from childbirth through a 30-day period following discharge from hospital. RESULTS: The database contained 28,963 births and 59,202 healthcare or medical care encounters. Of these encounters, 50.3% (n = 29,774) were planned visits to hospital postnatal care units within 7 days following discharge and 1.2% (n = 681) were admissions to hospitals. Of all women who gave birth, 12.2% (n = 3,533) visited the emergency room at least once. The number of visits peaked at day 6 following discharge. These factors significantly increased risk for emergency room visits: caesarean, assisted birth and sphincter injury. CONCLUSIONS: Emergency room visits occurred most commonly immediately following discharge when there were no routine check-ups. Greater risk of emergency room visits - following caesareans, assisted childbirths or sphincter injuries - indicated that early support for women with childbirth complications should be improved upon discharge from hospital. Other multiple risk factors for emergency room visits might exist. RELEVANCE TO CLINICAL PRACTICE: Many emergency room visits could be prevented through early, more qualified, appropriate follow-up via maternity care systems and effective midwifery interventions. These initiatives could enhance care continuity and facilitate postpartum recovery.

Early palliative home care: Evaluation of an interprofessional educational intervention for district nurses and general practitioners about nutritional care.

BACKGROUND: Teamwork is important in early palliative home care, and interprofessional education is required to achieve teamwork. It is thus crucial to ensure that interprofessional education works well for the members of all participating professions because levels of knowledge and educational needs may vary. AIM: To evaluate, by profession, the effectiveness of an interprofessional educational intervention for district nurses and general practitioners on three areas of nutritional care for patients in a palliative phase. DESIGN: A quasi-experimental study that used a computer-based, study-specific questionnaire to evaluate the effectiveness of the intervention. The continuing education in primary health care (ConPrim®) model was used to create the intervention. ConPrim includes a web-based program, a practical exercise and a case seminar, all with interprofessional training. SETTING: Primary health care centers in Stockholm County, Sweden. Intervention group (n = 87; 48 district nurses, 39 general practitioners); control group (n = 53; 36 district nurses, 17 general practitioners). RESULTS: The total intervention effect was significant in all three areas, p = 0.000-0.004. The intervention effects were similar and significant for both professions in areas 1 and 2. In area 3, the intervention effects were significant for general practitioners but not for district nurses. CONCLUSIONS: The intervention seems promising, as it may create better prerequisites for teamwork and caring for patients living at home. However, it needs to be optimized to better increase district nurses' level of knowledge (area 3).

Longitudinal trends in self-reported anxiety. Effects of age and birth cohort during 25 years.

BACKGROUND: Anxiety has been suggested to increase among young individuals, but previous studies on longitudinal trends are inconclusive. The aim of this study was to analyze longitudinally, the changes over time of prevalence of self-reported anxiety in the Swedish population between 1980/1981 and 2004/2005, in different birth cohorts and age groups. METHODS: A random sample of non-institutionalized persons aged 16-71 years was interviewed every eighth year. Self-reported anxiety was assessed using the question" Do you suffer from nervousness, uneasiness, or anxiety?" (no; yes, mild; yes, severe). Mixed models with random intercepts were used to estimate changes in rates of anxiety (mild or severe) within different age groups and birth cohorts and in males and females separately. In addition to three time-related variables - year of interview, age at the time of the interview, and year of birth -the following explanatory variables were included: education, urbanization, marital status, smoking, leisure time physical activity and body mass index. RESULTS: Overall prevalence of self-reported anxiety increased from 8.0 to 12.4% in males and from 17.8% to 23.6% in females, during the 25-year follow-up period. The increasing trend was found in all age groups except in the oldest age groups, and the highest increase was found in young adults 16-23 years, with more than a three-fold increase in females, and a 2.5-fold increase in males, after adjustments for covariates. CONCLUSIONS: Between 1980/81 and 2004/05, there was an increasing prevalence of self-reported anxiety in all age groups except in the oldest, which indicates increased suffering for a large part of the population, and probably an increased burden on the health care system. Clinical efforts should focus particularly on young females (16-23 years), where the increase was particularly large; almost one third experienced anxiety at the end of the 25-year follow-up.

Association between antithrombotic treatment and hemorrhagic stroke in patients with atrial fibrillation-a cohort study in primary care.

OBJECTIVE: The objective of this study was to study the association between antithrombotic treatment and risk of hemorrhagic stroke (HS) in patients with atrial fibrillation (AF) treated in primary health care. METHODS: Study population included all adults (n = 12,215) 45 years and older diagnosed with AF at 75 primary care centers in Sweden 2001-2007. Outcome was defined as a first hospital episode with a discharge episode of HS after the AF diagnosis. Association between HS and persistent treatment with antithrombotic agents (warfarin, acetylsalicylic acid (ASA), clopidogrel) was explored using Cox regression analysis, with hazard ratios (HRs) and 95 % CIs. Adjustment was made for age, socioeconomic status, and co-morbid cardiovascular conditions. RESULTS: During a mean of 5.8 years (SD 2.4) of follow-up, 162 patients (1.3 %; 67 women and 95 men) with HS were recorded. The adjusted risk associated with persistent warfarin treatment compared to no antithrombotic treatment consistently showed no increased HS risk, HR for women 0.53 (95 % CI 0.23-1.27) and for men 0.55 (95 % CI 0.29-1.04); corresponding HRs for ASA were, for women, 0.45 (95 % CI 0.14-1.44) and, for men, 0.56 (95 % CI 0.24-1.29). CONCLUSIONS: In this clinical setting, we found no evidence pointing to an increased risk of HS with antithrombotic treatment.

Warfarin treatment and risk of myocardial infarction - A cohort study of patients with atrial fibrillation treated in primary health care.

OBJECTIVE: To study the risk of myocardial infarction (MI) in patients with atrial fibrillation (AF) treated in primary health care with warfarin or acetylsalicylic acid (ASA, aspirin). METHODS: The study population included subjects (n=12,283) 45years or older diagnosed with AF who were treated in 75 primary care centres in Sweden between 2001 and 2007. MI was defined as a hospital stay for MI during 2001 through 2010 registered in the Swedish Patient Register. Associations between warfarin or ASA treatment and incident MI were explored using Cox regression analysis, by estimating hazard ratios (HRs) and 95% confidence intervals (95% CIs). Adjustment was made for age, socio-economic factors and cardio-vascular co-morbidity. RESULTS: Persistent treatment ("per protocol" treatment) with warfarin alone was present among 32.4% of women and 37.4% of men, and with ASA alone among 30.0% of women and 28.1% of men. The fully adjusted HRs for MI, compared to those with no antithrombotic treatment, with warfarin treatment for women were 0.26 (95% CI 0.16-0.41) and for men 0.28 (95% CI 0.20-0.39); and the corresponding HRs for those treated with ASA were for women 0.57 (95% CI 0.37-0.87), and for men 0.44 95% CI (0.31-0.63). The fully adjusted HR for MI when comparing patients with warfarin treatment to those with ASA treatment was for women 0.46 (95% CI 0.27-0.80), and for men 0.58 (95% CI 0.38-0.89). CONCLUSIONS: Warfarin seems to prevent MI among AF patients in a primary healthcare setting, which emphasizes the importance of persistent anticoagulant treatment in those patients.