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Purpose: The aim was to study mortality due to cardiovascular disease as well as total mortality, among female industrial workers, and the association to occupational noise and shift work., Methods: Women from cohorts of soft tissue paper mills (N = 3013) and pulp and paper mills (N = 1483) were merged into one cohort. Job exposure matrices were developed and used for classification of shift work and noise exposure. Every year was classified as shift work excluding nights or shift work including nights. Noise was classified into seven 5 dB(A) bins from < 75 to ≥ 100 dB(A). Mortality from cardiovascular diseases and total mortality during 1956-2013 was calculated as a standardized mortality ratio (SMR) with 95% confidence interval (CI) using the female general population as a reference., Results: Fatal myocardial infarctions (N = 144) were increased in the total cohort, SMR 1.20 (95% CI 1.01-1.41) but not total mortality. The SMR for myocardial infarction for women exposed to noise ≥ 90 dB(A) for > 10 years was 1.41 (95% CI 1.02-1.89) and for those exposed to night shifts > 10 years, 1.33 (95% CI 0.91-1.89). Shift workers without nights ≤ 65 years, with noise exposure ≥ 90 dB(A), had SMR 2.41 (95% CI 1.20-4.31) from myocardial infarction. There was no increased mortality from cerebrovascular disease., Conclusions: Female paper mill workers had an increased mortality from acute myocardial infarction, especially before retirement age, when exposed to noise ≥ 90 dB(A) and with long-time employment. Exposure to shift work and noise usually occurred concurrently.

Background: Malignant diseases but also cardiovascular and respiratory disorders and diabetes mellitus have been associated with work in pulp and paper production. The present cohort focuses on cardiovascular mortality in relation to various exposures in this industry., Methods: The cohort, followed-up for mortality, includes 7,107 workers, 6,350 men and 757 women, from three major old mills in the middle of Sweden., Results: Instead of a healthy-worker effect, a slightly increased risk for death in diseases of the circulatory system was found for male workers. Notably, work with sulfate digestion, steam and power generation and maintenance was associated with significantly increased risks. Cerebrovascular diseases showed non-significantly increased risks for maintenance and paper and paperboard production and manufacture., Conclusions: The differences in risk among various parts of the production are striking although it is hard to pinpoint any specific exposures. Dust and small particles along with sulfur compounds might be suspected., ((c) 2007 Wiley-Liss, Inc.)

Background: Since 1901, at least 15 scholars who contributed to cardiovascular research have received a Nobel prize in physiology or medicine., Methods: Using the Nobel nomination database (nobelprize.org), which contains 5950 nominations in the accessible period from 1901 to 1953 in physiology or medicine, we listed all international nominees who contributed to cardiovascular research. We subsequently collected nomination letters and jury reports of the prime candidates from the archive of the Nobel Committee in Sweden to identify shortlisted candidates., Results: The five most frequently nominated researchers with cardiovascular connections from 1901 to 1953 were, in descending order, the surgeon René Leriche (1879-1955) (FR) with a total of 79 nominations, the physiologist and 1924 Nobel laureate Willem Einthoven (1860-1927) (NL) (31 nominations), the surgeon Alfred Blalock (1899-1964) (US) (29 nominations), the pharmacologist and 1936 Nobel laureate Otto Loewi (1873-1961) (DE, AT, US) (27 nominations) and the paediatric cardiologist Helen Taussig (1898-1986) (US) (24 nominations). The research of these scholars merely hints at the width of topics brought up by nominators ranging from the physiological and pathological basics to the diagnosis and (surgical) interventions of diseases such as heart malformation or hypertension., Conclusion: We argue that an analysis of Nobel Prize nominations can reconstruct important scientific trends within cardiovascular research during the first half of the twentieth century., (© 2021. The Author(s).)

Objectives: The aim of the study was to examine the associations between heavy physical workload among middle-aged and older workers and disability pension due to any diagnosis, as well as musculoskeletal, psychiatric, cardiovascular or respiratory diagnoses. The population-based design made it possible to examine dose-response and potential gender differences in the associations., Methods: About 1.8 million men and women aged 44-63 years and registered as living in Sweden in 2005 were followed regarding disability pension during 2006-2016, until ages 55-65 years. Mean values of physical workload and job control, estimated through gender-specific job-exposure matrices (JEMs), were assigned to individuals through their occupational titles in 2005. Exposure values were ranked separately for women and men and divided into quintiles. Associations were analyzed with Cox proportional-hazards regression., Results: The analyses showed robust, dose-response associations between physical workload and disability pension with a musculoskeletal diagnosis in both genders: the adjusted hazard ratio and 95% confidence interval for those with the heaviest exposure was 2.58 (2.37-2.81) in women and 3.34 (2.83-3.94) in men. Dose-response associations were also seen in relation to disability pension with a cardiovascular or a respiratory diagnosis, though the hazard ratios were smaller. Physical workload was not associated with disability pension with a psychiatric diagnosis after adjustment for job control., Conclusion: This study of the entire Swedish population of middle-aged and older workers suggests that higher degrees of physical workload may increase the risk of disability pension overall, and specifically with musculoskeletal, cardiovascular or respiratory diagnosis, in both women and men., (© 2021. The Author(s).)

Background: The aging patient with adult congenital heart disease (ACHD) faces the risk of developing atherosclerotic disease. Patients with coarctation of the aorta (CoA) are especially vulnerable because of an inherent high risk of developing hypertension. However, data on the prevalence of other cardiovascular risk factors are scarce. Therefore, this study aimed to describe the prevalence of traditional cardiovascular risk factors (diabetes, hypertension, hyperlipidemia, smoking, obesity, and sedentary lifestyle) in adult patients with CoA., Methods: Patients with CoA who were registered at the ACHD clinic in Gothenburg were asked to participate in a comprehensive cardiovascular risk assessment. This assessment included a glucose tolerance test, cholesterol profile, ambulatory blood pressure measurements, and a lifestyle questionnaire., Results: A total of 72 patients participated. The median age was 43.5 years and 58.3% were men. Sixty-six (91.7%) patients had ≥one cardiovascular risk factor and 40.3% had ≥three risk factors. Three (4.2%) patients were newly diagnosed with diabetes or impaired glucose tolerance. More than half of the patients had hyperlipidemia (n = 42, 58.3%) and 35 patients (48.6%) were overweight or obese. Only three (4.2%) patients smoked regularly. Of the 60 patients who underwent 24-hour ambulatory blood pressure measurement, 33 (55.0%) were hypertensive. Of the 30 patients with known hypertension only 9 (30.0%) had well-controlled blood pressure on ambulatory blood pressure measurement., Conclusions: Cardiovascular risk factors among patients with CoA are prevalent. This may indicate a need for more aggressive screening strategies of traditional risk factors to minimize the risk of these patients also developing atherosclerotic disease., (© 2019 Wiley Periodicals, Inc.)

Background: Lead exposure is associated with cardiovascular disease. Atherosclerosis has been hypothesized to be one of the underlying mechanisms behind this association., Aim: To investigate whether lead exposure is associated with an increased risk of atherosclerosis in the carotid arteries in a large Swedish population-based cohort., Methods: We performed a cross-sectional study using data from the population-based Swedish CardioPulmonary bioImage Study (SCAPIS), including 5622 middle-aged men and women, enrolled 2013-2018. Blood lead (B-Pb), measured by inductively coupled plasma mass spectrometry, was used as exposure biomarker. The presence of atherosclerotic plaque in the carotid arteries (yes/no), total plaque area (mm 2 ) and the presence of large plaques (>25 mm 2 ) were determined by ultrasonography. Associations between B-Pb and the different outcomes were analysed using Poisson and linear regression models, adjusted for potential confounders., Results: Atherosclerotic plaque was present in 57% of the individuals, for whom the median total plaque area was 16 mm 2 (range: 0.2-222). The median B-Pb concentration was 14 μg/L (range: 0.75-203). After adjusting for potential confounders, individuals in the fourth quartile of B-Pb (Q4) had a prevalence ratio (PR) for plaque of 1.08 (95% CI: 1.01, 1.16) when compared with the first quartile (Q1). A 10 μg/L increase in B-Pb concentrations was associated with an increase of 0.92 mm 2 (95% CI: 0.14, 1.71) in total plaque area. The PR for large plaque was 1.09 (95% CI: 0.84, 1.42 for Q4 vs Q1)., Conclusions: This study shows an association between B-Pb and atherosclerosis in the carotid arteries providing some support for the hypothesis that atherosclerosis is one of the mechanisms underlying the association between lead exposure and cardiovascular disease., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Although adverse pregnancy outcomes are associated with an increased risk of cardiovascular disease, studies on timing and subtypes of heart failure after a hypertensive pregnancy are lacking., Objectives: The goal of this study was to assess the association between pregnancy-induced hypertensive disorder and risk of heart failure, according to ischemic and nonischemic subtypes, and the impact of disease characteristics and the timing of heart failure risks., Methods: This was a population-based matched cohort study, comprising all primiparous women without a history of cardiovascular disease included in the Swedish Medical Birth Register between 1988 and 2019. Women with pregnancy-induced hypertensive disorder were matched with women with normotensive pregnancies. Through linkage with health care registers, all women were followed up for incident heart failure, classified as ischemic or nonischemic., Results: In total, 79,334 women with pregnancy-induced hypertensive disorder were matched with 396,531 women with normotensive pregnancies. During a median follow-up of 13 years, rates of all heart failure subtypes were more common among women with pregnancy-induced hypertensive disorder. Compared with women with normotensive pregnancies, adjusted HRs (aHRs) with 95% CIs were as follows: heart failure overall, aHR: 1.70 (95% CI: 1.51-1.91); ischemic heart failure, aHR: 2.28 (95% CI: 1.74-2.98); and nonischemic heart failure, aHR: 1.60 (95% CI: 1.40-1.83). Disease characteristics indicating severe hypertensive disorder were associated with higher heart failure rates, and rates were highest within the first years after the hypertensive pregnancy but remained significantly increased thereafter., Conclusions: Pregnancy-induced hypertensive disorder is associated with an increased short-term and long-term risk of incident ischemic and nonischemic heart failure. Disease characteristics indicating more severe forms of pregnancy-induced hypertensive disorder amplify the heart failure risks., Competing Interests: Funding Support and Author Disclosures This study was supported by Region Stockholm; the Swedish Research Council for Health, Working Life and Welfare; and the Swedish Heart and Lung Foundation. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

This paper addresses how the educational gradient in the mortality rate is influenced by the educational difference in hospitalisation for Cardiovascular diseases. We account for possible selective hospitalisation, by using 'Timing-of-events'- model and for selection into education, by using an inverse propensity weighting method. Based on the estimated model we simulate the educational gains of improving education and decompose these educational gains into an indirect effect, running through changes in the hospitalisation process, and a direct effect due to other factors. We use Swedish Military Conscription Data (1951-1960), for males only, linked to administrative Swedish registers. Our empirical results show that the implied educational gains in the survival probability till age 63 are 2% to 5.5%-point, with the largest effect for the low educated. These gains are mainly due educational difference in hospitalisation for the high educated (1.3%-point) and mainly due to other factors (4.9%-point) for the low educated. However, for the (significant) educational gain in implied months lost due premature mortality before age 63 (2 to 9 months) we do not find a significant impact of the educational difference in hospitalisation., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: There is a lack of comprehensive cost information for cardiovascular events since 2013.Objective: A systematic review on the contemporary cost of cardiovascular events was therefore undertaken.Methods: Methods complied with those recommended by the Cochrane Collaboration and the Centre for Reviews and Dissemination. Studies were unrestricted by language, were from 2013 to 23 December 2017, and included cost-of-illness data in adults with the following cardiovascular conditions: myocardial infarction (MI), stroke, transient ischaemic attack (TIA), heart failure (HF), unstable angina (UA), coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), or peripheral artery disease (PAD). Seven electronic databases were searched, namely Embase (Ovid), MEDLINE (Ovid), MEDLINE In-Process Citations and Daily Update (Ovid), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) database, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed. The included studies reported data from a variety of years (sometimes prior to 2013), so costs were inflated and converted to $US, year 2018 values, for standardization.Results: After de-duplication, 29,945 titles and abstracts and then 403 full papers were screened; 82 studies (88 papers) were extracted. Year 1 average cost ranges were as follows: MI ($11,970 in Sweden to $61,864 in the USA), stroke ($10,162 in Spain to $46,162 in the USA), TIA ($6049 in Sweden to $25,306 in the USA), HF ($4456 in China to $49,427 in the USA), UA ($11,237 in Sweden to $31,860 in the USA), PCI ($17,923 in Italy to $45,533 in the USA), CABG ($17,972 in the UK to $76,279 in the USA). One Swedish study reported PAD costs in a format convertible to $US, 2018 values, with a mean annual cost of $15,565.Conclusions: There was considerable unexplained variation in contemporary costs for all major cardiovascular events. One emerging theme was that average costs in the USA were considerably higher than anywhere else. [ABSTRACT FROM AUTHOR]

(1) Background: Cardiometabolic diseases are the most common cause of death worldwide. As part of a collaborative European study, this paper aims to explore the implementation of primary care selective-prevention services in five European countries. We assessed the implementation process of the selective-prevention services, participants' cardiometabolic profile and risk and participants' evaluation of the services, in terms of feasibility and impact in promoting a healthy lifestyle. (2) Methods: Eligible participants were primary care patients, 40-65 years of age, without any diagnosis of cardiometabolic disease. Two hundred patients were invited to participate per country. The extent to which participants adopted and completed the implementation of selective-prevention services was recorded. Patient demographics, lifestyle-related cardiometabolic risk factors and opinions on the implementation's feasibility were also collected. (3) Results: Acceptance rates varied from 19.5% (n = 39/200) in Sweden to 100% (n = 200/200) in the Czech Republic. Risk assessment completion rates ranged from 65.4% (n = 70/107) in Greece to 100% (n = 39/39) in Sweden. On a ten-point scale, the median (25-75% quartile) of participant-reported implementation feasibility ranged from 7.4 (6.9-7.8) in Greece to 9.2 (8.2-9.9) in Sweden. Willingness to change lifestyle exceeded 80% in all countries. (4) Conclusions: A substantial variation in the implementation of selective-prevention receptiveness and patient risk profile was observed among countries. Our findings suggest that the design and implementation of behavior change cardiometabolic programmes in each country should be informed by the local context and provide some background evidence towards this direction, which can be even more relevant during the current pandemic period.

Urbanization and increasing road traffic cause exposure to both noise and air pollution. While the levels of air pollutants such as nitrogen oxides (NO x ) have decreased in Sweden during the past decades, exposure to traffic noise has increased. The association with cardiovascular morbidity is less well established for noise than for air pollution, and most studies have only studied one of the two highly spatially correlated exposures. The Swedish Primary Prevention Study cohort consists of men aged 47 to 55 when first examined in 1970-1973. The cohort members were linked to the Swedish patient registry through their personal identity number and followed until first cardiovascular event 1970-2011. The address history during the entire study period was used to assign annual modelled residential exposure to road traffic noise and NO x . The Cox proportional hazards model with age on the time axis and time-varying exposures were used in the analysis. The results for 6304 men showed a non-significant increased risk of cardiovascular disease for long-term road traffic noise at the home address, after adjusting for air pollution. The hazard ratios were 1.08 (95% CI 0.90-1.28) for cardiovascular mortality, 1.14 (95% CI 0.96-1.36) for ischemic heart disease incidence and 1.07 (95% CI 0.85-1.36) for stroke incidence, for noise above 60 dB, compared to below 50 dB. This study found some support for cardiovascular health effects of long-term exposure to road traffic noise above 60 dB, after having accounted for exposure to air pollution., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine all-cause and cause-specific mortality in adult-onset and elderly-onset IBD and to describe time trends in mortality over the past 50 years., Design: Swedish nationwide register-based cohort study 1964-2014, comparing mortality in 82 718 incident IBD cases (inpatient and non-primary outpatient care) with 10 times as many matched general population reference individuals (n=801 180) using multivariable Cox regression to estimate HRs. Among patients with IBD, the number of participants with elderly-onset (≥60 years) IBD was 17 873., Results: During 984 330 person-years of follow-up, 15 698/82 718 (19%) of all patients with IBD died (15.9/1000 person-years) compared with 121 095/801 180 (15.1%) of reference individuals, corresponding to an HR of 1.5 for IBD (95% CI=1.5 to 1.5 (HR=1.5; 95% CI=1.5 to 1.5 in elderly-onset IBD)) or one extra death each year per 263 patients. Mortality was increased specifically for UC (HR=1.4; 95% CI=1.4 to 1.5), Crohn's disease (HR=1.6; 95% CI=1.6 to 1.7) and IBD-unclasssified (HR=1.6; 95% CI=1.5 to 1.8). IBD was linked to increased rates of multiple causes of death, including cardiovascular disease (HR=1.3; 1.3 to 1.3), malignancy (HR=1.4; 1.4 to 1.5) and digestive disease (HR=5.2; 95% CI=4.9 to 5.5). Relative mortality during the first 5 years of follow-up decreased significantly over time. Incident cases of 2002-2014 had 2.3 years shorter mean estimated life span than matched comparators., Conclusions: Adult-onset and elderly-onset patients with UC, Crohn's disease and IBD-unclassified were all at increased risk of death. The increased mortality remained also after the introduction of biological therapies but has decreased over time., Competing Interests: Competing interests: OO has been principal investigator (PI) on projects at Karolinska Institutet partly financed by investigator-initiated grants from Janssen, Ferring, Takeda and Pfizer. None of those studies have any relation to the present study. Karolinska Institutet has received fees for lectures and participation on advisory boards from Janssen, Ferring, Takeda and Pfizer regarding topics not related to the present study. JA reports grants from AbbVie, Bristol-Myers Squibb, Lilly, Merck, Pfizer, Roche, Samsung Bioepis and UCB, mainly in the context of a national safety monitoring programme for immunomodulators in rheumatology (ARTIS). JFL coordinates a study unrelated to the present study on behalf of the Swedish IBD Quality Register (SWIBREG). That study has received funding from Janssen. KES has been PI for research projects partly financed by unrestricted grants from Janssen pharmaceutical to Karolinska Institutet. MN has been PI for research projects unrelated to the current paper and partly financed by investigator-initiated grants from Pfizer and Astra Zeneca to Karolinska Institutet, and has received fees for participation in advisory boards (related to rheumatology). Other authors disclosed no conflicts of interest., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: Genetic loci associated with CHD show different relationships with intima-media thickness in the common carotid artery (IMT-CCA) and in the bulb (IMT-bulb). We evaluated if IMT-CCA and IMT-bulb differ also with respect to circulating protein profiles and risk of incident atherosclerotic disease., Methods: In three Swedish cohorts (MDC, IMPROVE, PIVUS, total n > 7000), IMT-CCA and IMT-bulb were assessed by ultrasound at baseline, and 86 cardiovascular-related proteins were analyzed. In the PIVUS study only, IMT-CCA and IMT-bulb were investigated in relation to incident atherosclerotic disease over 10 years of follow-up., Results: In a meta-analysis of the analysis performed separately in the cohorts, three proteins, matrix metalloproteinase-12 (MMP-12), hepatocyte growth factor (HGF) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), were associated with IMT-CCA when adjusted for traditional cardiovascular risk factors. Five proteins were associated with IMT-bulb (MMP-12, growth/differentiation factor 15 (GDF-15), osteoprotegerin, growth hormone and renin). Following adjustment for cardiovascular risk factors, IMT-bulb was significantly more closely related to incident stroke or myocardial infarction (total number of cases, 111) than IMT-CCA in the PIVUS study (HR 1.51 for 1 SD, 95%CI 1.21-1.87, p < 0.001 vs HR 1.17, 95%CI 0.93-1.47, p = 0.16). MMP-12 levels were related to this combined end-point (HR 1.30, 95%CI 1.08-1.56, p = 0.0061)., Conclusions: Elevated levels of MMP-12 were associated with both IMT-CCA and IMT-bulb, but other proteins were significantly related to IMT in only one of these locations. The finding that IMT-bulb was more closely related to incident atherosclerotic disease than IMT-CCA emphasizes a difference between these measurements of IMT., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020. Published by Elsevier B.V.)

Background: Chronic low-grade inflammation and associated insulin resistance and metabolic abnormalities have been proposed as 'common soil' for diabetes mellitus (DM) and cardiovascular disease (CVD). This paper aimed to investigate the inflammatory profiles of DM and CVD and to distinguish their shared and specific markers., Methods: Based on the Malmö Diet and Cancer cohort, total and differential leukocyte counts were measured in 25,969 participants without previous DM or CVD and were studied in relation to incident DM (mean follow-up 17.4 ± 5.58 years) and incident CVD (i.e., coronary events, including fatal and nonfatal myocardial infarction, or stroke); mean follow-up 17.7 ± 5.46 years, using multivariable Cox regression models. Furthermore, plasma concentrations of another seven inflammatory markers were examined in relation to incident DM and incident CVD in a sub-cohort of 4658 participants. The associations of each inflammatory marker with incident DM versus incident CVD were compared using the Lunn-McNeil competing risks approach. In sensitivity analyses, those who developed both DM and CVD during follow-up were excluded., Results: After adjustment for conventional risk factors, total and differential leukocyte counts, orosomucoid, and C-reactive protein were associated with an increased risk of both DM and CVD. Neutrophil to lymphocyte ratio, ceruloplasmin, alpha1-antitrypsin and soluble urokinase plasminogen activator receptor predicted increased risk of CVD but not DM, while haptoglobin and complement C3 showed the opposite pattern. In competing risks analyses, lymphocyte count and complement C3 had stronger associations with risk of DM than with risk of CVD (p for equal associations = 0.020 and 0.006). The reverse was true for neutrophil to lymphocyte ratio (p for equal associations = 0.025). Results were consistent in sensitivity analyses., Conclusions: The results indicated substantial similarities in the inflammatory profiles associated with DM and CVD. However, there are also significant differences. These findings may help discriminate between individuals at elevated risk of DM and those at elevated risk of CVD, which is a prerequisite for targeted therapies.

Objective:The aim of the study was to describe and explore patient agency through resistance in decision-making about cardiovascular preventive drugs in primary care. Design:Six general practitioners from the southeast of Sweden audiorecorded 80 consultations. From these, 28 consultations with proposals from GPs for cardiovascular preventive drug treatments were chosen for theme-oriented discourse analysis. Results:The study shows how patients participate in decision-making about cardiovascular preventive drug treatments through resistance in response to treatment proposals. Passive modes of resistance were withheld responses and minimal unmarked acknowledgements. Active modes were to ask questions, contest the address of an inclusive we, present an identity as a non-drugtaker, disclose non-adherence to drug treatments, and to present counterproposals. The active forms were also found in anticipation to treatment proposals from the GPs. Patients and GPs sometimes displayed mutual renouncement of responsibility for decision-making. The decision-making process appeared to expand both beyond a particular phase in the consultations and beyond the single consultation. Conclusions:The recognition of active and passive resistance from patients as one way of exerting agency may prove valuable when working for patient participation in clinical practice, education and research about patient–doctor communication about cardiovascular preventive medication. We propose particular attentiveness to patient agency through anticipatory resistance, patients’ disclosures of non-adherence and presentations of themselves as non-drugtakers. The expansion of the decision-making process beyond single encounters points to the importance of continuity of care.KEY POINTSGuidelines recommend shared decision-making about cardiovascular preventive treatment. We need an understanding of how this is accomplished in actual consultations.This paper describes how patient agency in decision-making is displayed through different forms of resistance to treatment proposals.•The decision-making process expands beyond particular phases in consultations and beyond single encounters, implying the importance of continuity of care.•Attentiveness to patient participation through resistance in treatment negotiations is warranted in clinical practice, research and education about prescribing communication. [ABSTRACT FROM PUBLISHER]

Many studies, including self‐controlled case series (SCCS) studies, are being undertaken to quantify the risks of complications following infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), the virus that causes coronavirus disease 2019 (COVID‐19). One such SCCS study, based on all COVID‐19 cases arising in Sweden over an 8‐month period, has shown that SARS‐CoV‐2 infection increases the risks of AMI and ischemic stroke. Some features of SARS‐CoV‐2 infection and COVID‐19, present in this study and likely in others, complicate the analysis and may introduce bias. In the present paper we describe these features, and explore the biases they may generate. Motivated by data‐based simulations, we propose methods to reduce or remove these biases. [ABSTRACT FROM AUTHOR]

Aims: Self-rated health comprehensively accounts for many health domains. Using self-ratings and a knowledge of associations with health domains might help personnel in the health care sector to understand reports of ill health. The aim of this paper was to investigate associations between age-comparative self-rated health and disease, risk factors, emotions and psychosocial factors in a general population. Methods: We based our study on population-based cross-sectional surveys performed in 1999, 2004 and 2009 in northern Sweden. Participants were 25–74 years of age and 5314 of the 7500 people invited completed the survey. Comparative self-rated health was measured on a three-grade ordinal scale by the question ‘How would you assess your general health condition compared to persons of your own age?’ with the alternatives ‘better’, ‘worse’ or ‘similar’. The independent variables were sex, age, blood pressure, cholesterol, body mass index, self-reported myocardial infarction, stroke, diabetes, physical activity, smoking, risk of unemployment, satisfaction with economic situation, anxiety and depressive emotions, education and Karasek scale of working conditions. Odds ratios using ordinal regression were calculated. Results: Age, sex, stroke, myocardial infarction, diabetes, body mass index, physical activity, economic satisfaction, anxiety and depressive emotions were associated with comparative self-rated health. The risk of unemployment, a tense work situation and educational level were also associated with comparative self-rated health, although they were considerably weaker when adjusted for the the other variables. Anxiety, depressive emotions, low economic satisfaction and a tense work situation were common in the population. Conclusions:Emotions and economic satisfaction were associated with comparative self-rated health as well as some medical variables. Utilization of the knowledge of these associations in health care should be further investigated. [ABSTRACT FROM AUTHOR]

A large amount of evidence, including neurohumoral, inflammatory, and metabolic physiological adaptations, emphasize the importance of the individual lifestyle as a public health concern. The related burden of chronic diseases in the European Union, which could be minimized by appropriate lifestyles, requires consistent transfer of evidence-based prevention guidelines. Due to the epidemiologic importance of cardiovascular diseases and innovative health-promoting strategies in Sweden, a comparative analysis between German and Swedish practices preventing cardiovascular events in high-risk populations is presented in this paper. This qualitative analysis demonstrates that lifestyle-related risk and protective factors based on smoking, physical activity, nutrition, and psychosocial determinants are of growing importance in cardiac death prevention. Especially in Sweden, behavioral prevention is joined by condition prevention. In Germany, intersectoral rehabilitation concepts improve patient adherence to behavioral recommendations but interdisciplinary communication between different health experts needs to be improved. The health-promoting hospital composes a health professional's interface, which is based on the understanding that behavioral risk factors are not only highly interrelated, but also require sophisticated healthcare delivery to optimize health management effectiveness.

The rising trend in the prevalence of obesity, which is a major risk factor for a number of diseases notably diabetes and cardiovascular diseases, has become a major public health concern in many countries during the past decades. This development has also led to an increased cost burden on the public health care delivery system that has been documented in many studies. The standard approach taken for estimating the cost burden attributed to a risk factor is the so-called PAR (Population Attributed Risk) approach; an approach that is based on cross-sectional data. In this paper, the methods and findings of two studies that have documented the cost burden attributed to overweight and obesity on the public health care delivery system in Sweden are contrasted: one using the PAR approach and one using a statistical modeling approach based on longitudinal hospital care data for 15 years for 33 000 individuals. The main motivation for this paper is that the study using the PAR approach is only available in the Swedish language. The PAR approach estimated a cost burden of 3 600 million SEK (390 million Euro), equavalent to 1.9% of national health care expenditure, out of which 1 800 million SEK (190 million Euro) were spent on hospital care. The statistical modeling approach estimated the corresponding cost burden for hospital care at 2 100 million SEK (230 million Euro). The statistical modeling approach presents no estimates of the total cost burden attributed to overweight and obesity.

The purpose of this paper is to determine if differences in health outcomes of two cardiovascular disease prevention programs can be attributed to the inclusion of population based efforts in one of the programs. Propensity score matching has been used to eliminate possible selection bias. The results indicate that the intervention including population-based measures was not more effective than the intervention directed toward the individual.

The purpose of this paper is, first, to describe the organization, sampling procedures, availability of samples/database, ethical considerations, and quality control program of the Northern Sweden Health and Disease Study Cohort. Secondly, some examples are given of studies on cardiovascular disease and diabetes with a focus on the biomarker programme. The cohort has been positioned as a national and international resource for scientific research.

Objectives: This paper evaluates the 10-year outcomes of a Northern Sweden community intervention program for the prevention of cardiovascular disease (CVD), with special reference to the social patterning of risk development., Methods: Using a quasi-experimental design, trends in risk factors and predicted mortality in an intervention area (Norsjö municipality) are compared with those in a reference area (Northern Sweden region) by repeated independent cross-sectional surveys., Results: There were significant differences in changes in total cholesterol level and systolic blood pressure between the intervention and reference populations. The predicted coronary heart disease mortality (based on the North Karelia risk equation). after adjustment for age and education, was reduced by 36% in the intervention area and by 1% in the reference area., Conclusions: We conclude that a long-term community-based CVD prevention program which combines population and individual strategies can substantially promote a health shift in CVD risk in a high risk rural population. When evaluated for different social strata, we found no signs of an increasing health gap between socially privileged and less privileged groups. Socially less-privileged groups benefited the most from the present prevention program.

Objectives: This paper aims to develop and describe a method for combining. comparing, and maximizing the statistical power of two longitudinal studies of risk factors for cardiovascular disease that did not have identical data collection methodologies., Methods: Subjects from a 1986 cross-sectional study (n = 180) were pair-matched with subjects of corresponding gender and age (+5 years) from a 1990 cross-sectional study. The methodology is described and results are calculated for various measures of cardiovascular risk or risk factors (e.g. cholesterol. Finnish Risk Score)., Results: Box's test of equality and symmetry of covariance matrices gave chi-square values of 223.8 and 710.0 for two cardiovascular risk factors (cholesterol and cardiac risk score, respectively); these values were highly significant (p=0.0001) For the North Karelia Risk Score, repeated measures ANOVA revealed a borderline significant interaction for treatment by time (p=0.054) and a significant interaction for treatment by time by country (p=0.035). These probabilities compared favorably with a randomized blocks model., Conclusions: Creation of a synthetic longitudinal control group resulted in a statistically valid ANOVA model that increased the statistical power of the study.

Objectives: When epidemiologic data on cardiovascular disease (CVD) mortality rates in different Swedish regions were published in the early 1980s, there was great concern about the high CVD incidence in the northernmost counties of Sweden, namely Västerbotten and Norrbotten. This paper describe the development of a Northern Sweden community intervention programme for the prevention of CVD., Methods: As there were no Swedish prototypes, the programme was designed by drawing on experiences from other community interventions. One unique emphasis of the Norsjö intervention programme was to combine a population strategy with efforts to contact each person individually when they became 30, 40, 50, and 60 years of age (the primary care approach). Using the primary care system as part of the community intervention, systematic risk factor screening and counselling by family medicine providers were carried out at the same time as the community intervention programme invoked other efforts to raise public awareness., Results: During the first 10 years of the programme >90% of those invited participated in the individual health screening and counselling. A new food labelling system was introduced in the grocery stores, which after a few years became the official Swedish food labelling system. Sales statistics regarding dairy products showed a significant turnover of low fat products. According to public opinion, the health screening and counselling were reported to be the most influential factors supporting lifestyle changes., Conclusions: It was possible in Norsjö to create a local health promotion collaboration between healthcare providers, grocery stores, schools, municipal authorities, and the public in order to develop a Swedish model for community intervention. The different programme components were well received by the public.

Objectives: There is a need among healthcare providers to acquire more knowledge about small-scale and low budget community intervention programmes. This paper compares risk factor outcomes in Swedish and US intervention programmes for the prevention of cardiovascular disease (CVD). The aim was to explore how different intervention programme profiles affect outcome., Methods: Using a quasi-experimental design, trends in risk factors and estimated CVD risk in two intervention areas (Norsjö. Sweden and Otsego-Schoharie County, New York state) are compared with those in reference areas (Northern Sweden region and Herkimer County, New York state) using serial cross-sectional studies and panel studies., Results: The programmes were able to achieve significant changes in CVD risk factors that the local communities recognized as major concerns: changing eating habits in the Swedish population and reducing smoking in the US population. For the Swedish cross-sectional follow-up study cholesterol reduction was 12%, compared to 5% in the reference population (p for trend differences <0.000). The significantly higher estimated CVD risk (as assessed by risk scores) at baseline in the intervention population was below that of the Swedish reference population after 5 years of intervention. The Swedish panel study provided the same results. In the US, both the serial cross-sectional and panel studies showed a > 10% decline in smoking prevalence in the intervention population, while it increased slightly in the reference population. When pooling the serial cross-sectional studies the estimated risk reduction (using the Framingham risk equation) was significantly greater in the intervention populations compared to the reference populations., Conclusions: The overall pattern of risk reduction is consistent and suggests that the two different models of rural county intervention can contribute to significant risk reduction. The Swedish programme had its greatest effect on reduction of serum cholesterol levels whereas the US programme had its greatest effect on smoking prevention and cessation. These outcomes are consistent with programmatic emphases. Socially less privileged groups in these rural areas benefited as much or more from the interventions as those with greater social resources.

Aims: Cardiovascular disease (CVD) is the dominant diagnosis in in-patient care in Sweden and the third most common cause for long-term sick leave and disability pension. Women are higher consumers of health care than men and have higher frequencies of sickness absenteeism. The aim of this paper was to evaluate whether a five-year long rehabilitation programme for women with CVD affected the use of hospital care and sickness absenteeism. Methods: 130 women below 65 years of age with CVD were randomized to either intervention (n = 69, mean age 52.4 years) with an intensive lifestyle programme (e.g. physical exercise, smoking cessation, dietary advice), including stress management or to standard care (n = 61, mean age 54.3 years). All patients went through baseline medical examinations, including self-administered questionnaires. This procedure was repeated yearly during the rehabilitation period. The frequency of cardiac-related healthcare use was followed via official registers. Results: Emergency visits and number of in-patient days decreased significantly in the intervention group from year one to year five (p<0.05) but remained unchanged in the control group. Scheduled doctor visits decreased significantly in both groups. There were no significant differences between groups regarding proportion of women on sick leave after one, three and five years. Conclusions: This extensive intervention programme reduced visits at emergency wards and numbers of in-patient days, which in the long run may have beneficial effects on public finances and the patient’s quality of life. The study confirmed previous findings from interventions showing difficulties in influencing sick-leave rates. [ABSTRACT FROM AUTHOR]

Objectives: Job demands and control at work and their combination, job strain, have been studied in relation to risk of disability pension (DP) previously. In the present study, based on registry data, we aimed to deepen the knowledge by analyzing major disease groups among the DPs, dose–response shape of the associations, and potential confounding effects of physical workload. Methods: Approximately 1.8 million workers aged 44 or older and living in Sweden in 2005 were followed up for 16 years, up to a maximum of 65 years of age. We linked mean values of job demands and job control, estimated in a job-exposure matrice (JEM) by gender, to individuals through their occupational titles in 2005. These values were categorized by rank order, and, for the construction of job-strain quadrants, we used a median cut-off. Associations with DP were estimated in Cox proportional-hazards models. Results: In models accounting for covariates including physical workload, low levels of job control were associated with higher risk of DP among both men and women. This association was most clear for DP with a psychiatric diagnosis, although a dose–response shape was found only among the men. High levels of job demands were associated with decreased risk of DP across diagnoses among men, but the same association varied from weak to non-existing among women. The high- and passive job-strain quadrants both showed increased risk of DP with a psychiatric diagnosis. Conclusion: The results suggest that, at the occupational level, low job control, but not high job demands, contributes to an increased incidence of DP, particularly regarding DP with a psychiatric diagnosis. [ABSTRACT FROM AUTHOR]

Objective: Pre‐eclampsia and gestational diabetes mellitus (GDM) are two common pregnancy complications that affect birth outcomes and are associated with a long‐term risk of cardiovascular disease (CVD). The aims of this study were to investigate if the pre‐eclampsia association with CVD is independent of GDM and modified by body mass index (BMI) or GDM. Design: Case–control study. Setting: Sweden. Population: Cases were women with a first CVD event between 1991 and 2008 and a previous pregnancy who were matched with controls without CVD (1:5) by year of birth, age and region of birth. Methods: Conditional logistic regression was used to evaluate the associations of GDM, pre‐eclampsia and maternal BMI with CVD adjusted for potential confounders and effect modifications with interaction tests. Main outcome measures: CVD. Results: There were 2639 cases and 13 310 controls with complete data. Pre‐eclampsia and GDM were independent risk factors for CVD (adjusted odds ratio [aOR] 2.59, 95% CI 2.12–3.17 and aOR 1.47, 95% CI 1.04–2.09, respectively). After stratifying by maternal BMI, the adjusted association of pre‐eclampsia with CVD did not differ notably between BMI groups: normal weight (aOR 2.65, 95% CI 1.90–3.69), overweight (aOR 2.67, 95% CI 1.52–4.68) and obesity (aOR 3.03, 95% CI 0.74–12.4). Similar findings were seen when stratifying on GDM/non‐GDM. Conclusions: Pre‐eclampsia and GDM are independent risk factors for later CVD and having both during pregnancy is a major risk factor for later CVD. The association between pre‐eclampsia and CVD is not modified by BMI. Effective CVD preventive programs for high‐risk women are urgently needed in order to improve women's long‐term health. [ABSTRACT FROM AUTHOR]

Epidemiological studies have demonstrated an excess mortality caused by cancer and cardiovascular diseases among the workers employed at a smeltery in Northern Sweden. The aim of this paper is to elucidate the attitudes of the smelter workers to their working environment and to their health and to examine how these attitudes have changed over time. Moreover, in the analysis, we have sought explanations in the norm systems surrounding the workers and the changes in these. Interviews were carried out with 40 employees and previous employees at the smeltery. The interviewees were strategically chosen to reflect the development process of these norms within the company from its inception in the 1920s and onwards. We have attempted to describe the differences in behavioural patterns and norm expectations which characterize different periods in the history of the smeltery using four ideal type categories; the heroic man, the working-class man, the independent man and the anomic man. The workers' reactions to the norm systems have shifted gradually from conformity to indifference. The degree of individuality during these decades could be shown as a u-shaped curve.

Background: The administration of anticancer drugs in females with comorbidity increases the risk for cancer therapy-related cardiovascular toxicity (CTR-CVT), which in turn contributes to cardiovascular disease (CVD). Furthermore, a pathophysiological connection between cancer and cardiovascular disease may exist. Objective: To assess the long-term risks and predictors of CTR-CVT, including clinical hypertension (HT), coronary artery disease (CAD), heart failure (HF), atrial fibrillation (AF), as well as all-cause mortality in women diagnosed with early breast cancer (BC) and eligible for adjuvant chemotherapy in Sweden. Methods: Data were extracted from Swedish registers and medical records on 433 women, 18-60 years of age, diagnosed 1998-2002 with lymph nodepositive BC, and considered for adjuvant chemotherapy. CTR-CVT was defined as HT, CAD, HF, or AF after the diagnosis of BC. Follow-up was from the date of BC diagnosis until November 30, 2021, or death. Prevalence of CTR-CVT and allcause mortality were calculated. Hazard ratios (HR) were determined for factors associated with CTR-CVT. Results: The median age was 50 (interquartile range (IQR) 32) years. 910 CTRCVT events were diagnosed in 311 women with a median of 19.3 (IQR 15,3) years follow-up. The proportions of CTR-CVT events were: HT 281 (64%); CAD 198 (46%); HF 206 (47%); and AF 225 (51%). The cumulative incidence of CTR-CVT was 71.8%, and 50% of all 433 patients developed CTR-CVT within 11.7 years of BC diagnosis (standard deviation (SD) 0.57, 95% confidence interval (CI) 10.6-12.9). Age was a risk factor for CTR-CVT. Anthracycline increased the risk for HF (p=0,001; HR 2,0; 95%CI 1,4-2,8), CAD (p= 0,002; HR 1,7; 95% CI 1,2-2,4), and AF (p=0,013; HR 1,5; 95% CI 1,0-2,0). At the end of the 24-year study period, 227 of the 433 women were alive, and the total cumulative mortality was 47,6%. Conclusion: The prevalence of CTR-CVT and all-cause mortality is high after BC diagnosis and treatment, particularly in older patients and those receiving anthracyclines. These findings and the onset of CTR-CVT support cardiooncology guidelines recommending initial risk stratification and cardiovascular monitoring during treatment, followed by long-term annual screening for cardiovascular risk factors and CTR-CVT among BC survivors. [ABSTRACT FROM AUTHOR]

Immigrants from the Middle East to Sweden have a twice as high prevalence of type 2 diabetes (T2D) and obesity as native-born Swedes. Both obesity and T2D have been linked to increased incidence of cancer, cardiovascular disease (CVD) and all-cause mortality (ACM); however, data on differences between ethnicities are scarce. In a population-based cohort we aimed to study the impact of Middle Eastern and European ethnicity on ACM, cancer- and CVD related mortality, incidence of cancer and CVD in an eight-year follow-up study. Methods: People born in Iraq or Sweden, who were 30–75 years of age, were invited from 2010 to 2012 to participate in the population based MEDIM study including a health exam, fasting blood sampling, assessment of insulin secretion and action (through oral glucose tolerance test) and questionnaires assessing history of CVD, cancer and T2D. Register data were retrieved from baseline until the 31st of December 2018 from the Swedish National Patient Register and Cause of Death register regarding CVD diagnosis, cancer diagnosis and cause of death. Information regarding diabetes diagnosis was retrieved from the National Diabetes Register. Individuals with a history of cancer or CVD at baseline were excluded. Cox regression analysis was assessed to study the adjusted hazard ratios (HR) for the relationships between ethnicity and ACM, cancer events, CVD events, death from cancer, and death from CVD, with adjustments for age, sex, anthropometrical measures, T2D and lifestyle. A total of 1398 Iraqi- and 757 Swedish-born residents participated in the study. ACM was considerably lower in Iraqi- compared to Swedish-born individuals HR 0.32 (95% CI 0.13–0.79) (p < 0.05). Furthermore, cancer related morbidity and mortality HR 0.39 (0.22–0.69) (p < 0.01) as well as CVD related morbidity and mortality HR 0.56 (0.33–0.95) (p < 0.05) were lower in the Iraqi-born group compared to the Swedish-born group for. The differences in mortality and cancer rates across ethnicities are not fully explained by anthropometric, environmental or metabolic measures but lie elsewhere. Further studies are needed to increase the understanding of contributing mechanisms. [ABSTRACT FROM AUTHOR]

The article offers information on the symposium on diabetes, inflammation and cardiovascular disease held at Goteborg, Sweden on September 7-8, 2006. Five papers presented during the event are published within the issue. The papers discussed the current challenges that the world is facing on Type 2 diabetes and its complication. The epidemic rate is increasing mainly due to the changing lifestyle such as low physical activity.

Objective In terms of prevention, it is important to determine effects on cardiovascular disease (CVD) when some workplace psychosocial resources are high while others are low. The aim of the study was to assess the prospective relationship between clustering of workplace psychosocial resources and risk of CVD among employees. Methods We pooled data from three cohort studies of 135 669 employees (65% women, age 18-65 years and free of CVD) from Denmark, Finland and Sweden. Baseline horizontal resources (culture of collaboration and support from colleagues) and vertical resources (leadership quality and procedural justice) were measured using standard questionnaire items. Incident CVD, including coronary heart and cerebrovascular disease, was ascertained using linked electronic health records. We used latent class analysis to assess clustering (latent classes) of workplace psychosocial resources. Cox proportional hazard models were used to examine the association between these clusters and risk of CVD, adjusting for demographic and employment-related factors and pre-existing physical and mental disorders. Results We identified five clusters of workplace psychosocial resources from low on both vertical and horizontal resources (13%) to generally high resources (28%). High horizontal resources were combined with either intermediate [hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.74-0.95] or high (HR 0.88, 95% CI 0.78-1.00) vertical resources were associated with lower risks of CVD compared to those with generally low resources. The association was most prominent for cerebrovascular disease (eg, general high resources: HR 0.80, 95% CI 0.67-0.96). Conclusions Individuals with high levels of workplace psychosocial resources across horizontal and vertical dimensions have a lower risk of CVD, particularly cerebrovascular disease. [ABSTRACT FROM AUTHOR]

Objective: Ambient particle matter is a risk factor for cardiovascular disease (CVD). However, little is known about associations between particles in occupational settings and risk of CVD. We investigated associations between occupational dust exposure and biomarkers of CVD, and potential recovery effects after vacation. Methods: Personal dust exposure measurements (respirable silica, respirable dust < 4 µm, and particles of 0.1–10 µm (PM 0.1–10) were conducted once, and biological sampling were performed twice on non-smoking, male construction workers in Stockholm county, Sweden; during work and immediately after summer vacation. Linear regressions with adjustments for confounders and covariates were performed evaluating associations between occupational dust exposure and biomarkers. Paired t tests were performed evaluating changes before and after vacation. Results: Sixty-five workers participated. Homocysteine concentrations were significantly higher with increasing concentrations (mg/m3) of respirable silica, respirable dust, and PM 0.1–10, and pulse rate with higher levels of respirable dust and dust of PM 0.1–10. Homocysteine levels were also positively correlated to number of years of dust exposure, as were low-density lipoprotein (LDL) levels. A clear recovery effect was present for LDL after vacation, but not for homocysteine. Conclusions: Occupational dust exposure was associated with some CVD risk markers, even at mean exposure concentrations below the Swedish occupational exposure limits for respirable silica and respirable dust, respectively. Vacation resulted in recovery for some risk markers. However, the change of the homocysteine and LDL levels suggest a long-term effect. Reduction of occupational exposure to dust may decrease the risk of CVD among exposed workers. [ABSTRACT FROM AUTHOR]

Aims: There are few cohorts of type 1 diabetes that follow individuals over more than half a century in terms of health outcomes. The aim of this study was to examine associations between type 1 diabetes, diagnosed before age 18, and long‐term morbidity and mortality, and to investigate whether cognitive ability plays a role in long‐term morbidity and mortality risk. Methods: In a Swedish cohort, 120 men with type 1 diabetes and 469 without type 1 diabetes were followed between 18 and 77 years of age as regards morbidity and mortality outcomes, and impact of cognitive ability at military conscription for the outcomes. In Cox regression analyses and Kaplan‐Meier analyses with log‐rank tests, associations between diabetes and cognitive ability respectively, and outcomes (mortality, cardiovascular morbidity and diabetes complications) were investigated. Results: Men with type 1 diabetes suffered from dramatically higher mortality (HR 4.62, 95% CI: 3.56–5.60), cardiovascular mortality (HR 5.60, 95% CI: 3.27–9.57), and cardiovascular events (HR 3.97, 95% CI: 2.79–5.64) compared to men without diabetes. Higher cognitive ability at military conscription was associated with lower mortality in men without diabetes, but was not associated with any outcome in men with diabetes. Conclusions: In this historical cohort study with 60 years of follow‐up time and a less effective treatment of diabetes than today, mortality rates and cardiovascular outcomes were high for men with type 1 diabetes. Morbidity or mortality did not differ between those that had low to normal or high cognitive ability among men with type 1 diabetes. [ABSTRACT FROM AUTHOR]

Objectives: The study aimed to collect and compare practising characteristics for dental hygienists (DHs) in New Zealand (NZ) and Sweden. Methods: Dental hygienists from NZ and Sweden were invited to participate in an anonymous online survey focussing on their working practices. An email, with a link to the online survey and a participant information sheet, was sent to DHs registered with their professional association in their respective country. Frequency analyses and cross‐tabulations were conducted using chi‐square and Fisher's exact tests to investigate possible statistical associations to allow for comparisons between the countries. Results: DH is a female‐dominated workforce with equal distribution of gender in both countries. The majority of DHs in NZ worked in private practice while Swedish DHs mostly worked in the public sector. NZ participants were younger and with a more recent qualification than their Swedish counterparts. The highest degree of education was a PhD for DHs working in Sweden, compared with a master's degree for NZ participants. The majority of participants from both countries treated patients 65 years of age or older, with the most common medical conditions being cardiovascular disease and diabetes mellitus. The most common dental condition observed/treated was periodontal disease. Over 60% agreed to have an understanding of information technology (IT). The most used technical equipment was digital radiology, followed by other diagnostic tools. Conclusion: Findings confirm previous international data on demographical uptake for the DH workforce in NZ and Sweden. A coherence was seen in patient characteristics, DHs' attitudes towards information technology and use of technical equipment. [ABSTRACT FROM AUTHOR]

Background the aim of this study was to examine the cross-sectional and longitudinal associations of different multimorbidity patterns with physical frailty in older adults. Methods we used data from the Swedish National study on Aging and Care in Kungsholmen to generate a physical frailty measure, and clusters of participants with similar multimorbidity patterns were identified through fuzzy c-means cluster analyses. The cross-sectional association (n  = 2,534) between multimorbidity clusters and physical frailty was measured through logistic regression analyses. Six- (n  = 2,122) and 12-year (n  = 2,140) longitudinal associations were determined through multinomial logistic regression analyses. Results six multimorbidity patterns were identified at baseline: psychiatric diseases; cardiovascular diseases, anaemia and dementia; sensory impairments and cancer; metabolic and sleep disorders; musculoskeletal, respiratory and gastrointestinal diseases; and an unspecific pattern lacking any overrepresented diseases. Cross-sectionally, each pattern was associated with physical frailty compared with the unspecific pattern. Over 6 years, the psychiatric diseases (relative risk ratio [RRR]: 3.04; 95% confidence intervals [CI]: 1.59–5.79); cardiovascular diseases, anaemia and dementia (RRR 2.25; 95% CI: 1.13–4.49) and metabolic and sleep disorders (RRR 1.99; 95% CI: 1.25–3.16) patterns were associated with incident physical frailty. The cardiovascular diseases, anaemia and dementia (RRR: 4.81; 95% CI: 1.59–14.60); psychiatric diseases (RRR 2.62; 95% CI: 1.45–4.72) and sensory impairments and cancer (RRR 1.87; 95% CI: 1.05–3.35) patterns were more associated with physical frailty, compared with the unspecific pattern, over 12 years. Conclusions we found that older adults with multimorbidity characterised by cardiovascular and neuropsychiatric disease patterns are most susceptible to developing physical frailty. [ABSTRACT FROM AUTHOR]

Objective: To identify occupations where employees with type 2 diabetes have a high risk of cardiovascular disease (CVD) and mortality, and their prevalence of CVD risk factors. This study can contribute in the creation of targeted interventions at the workplace. Research design and methods: This nationwide registry-based study included all employees with type 2 diabetes born in Sweden in 1937–1979 (n = 180,620) and followed up in 2002–2015. We calculated age-standardized incidence (per 100,000 person-years) of all-cause and CVD mortality, ischemic heart disease (IHD) and stroke across the 30 most common occupations. Information on prognostic factors was retrieved from the National Diabetes Register. Results: In males with type 2 diabetes, mortality rates were highest in manufacturing workers (1782) and machine operators (1329), and lowest in specialist managers (633). The risk of death at age 61–70 years was 21.8% in manufacturing workers and 8.5% in managers. In females with type 2 diabetes, mortality rates were highest in manufacturing workers (1150) and cleaners (876), and lowest in writers and artists (458); the risk of death at age 61–70 years was 12.4% in manufacturing workers and 4.3% in writers and artists. The same occupations also had relatively high incidences of CVD mortality, IHD and stroke. Occupational groups with poor prognosis had high prevalence of CVD risk factors including poor glycemic control, smoking and obesity. Conclusions: Manufacturing workers, machine operators and cleaners with type 2 diabetes have two to three times higher mortality rates than managers, writers and artists with type 2 diabetes. Major health gains would be made if targeted workplace interventions could reduce CVD risk factors in these occupations. [ABSTRACT FROM AUTHOR]

The associations of multiple pollutants and cardiovascular disease (CVD) morbidity, and the spatial variations of these associations have not been nationally studied in Sweden. The main aim of this study was, thus, to spatially analyze the associations between ambient air pollution (black carbon, carbon monoxide, particulate matter (both <10 µm and <2.5 µm in diameter) and Sulfur oxides considered) and CVD admissions while controlling for neighborhood deprivation across Sweden from 2005 to 2010. Annual emission estimates across Sweden along with admission records for coronary heart disease, ischemic stroke, atherosclerotic and aortic disease were obtained and aggregated at Small Areas for Market Statistics level. Global associations were analyzed using global Poisson regression and spatially autoregressive Poisson regression models. Spatial non‐stationarity of the associations was analyzed using Geographically Weighted Poisson Regression. Generally, weak but significant associations were observed between most of the air pollutants and CVD admissions. These associations were non‐homogeneous, with more variability in the southern parts of Sweden. Our study demonstrates significant spatially varying associations between ambient air pollution and CVD admissions across Sweden and provides an empirical basis for developing healthcare policies and intervention strategies with more emphasis on local impacts of ambient air pollution on CVD outcomes in Sweden. Plain Language Summary: There are significant place‐specific associations between air pollutants and cardiovascular disease (CVD) admissions across Sweden. The southern parts of Sweden show more spatial variability of these place‐specific associations than other parts. More epidemiologic emphasis should be placed on local impacts of air pollution on CVD outcomes in Sweden. Key Points: There are significant place‐specific associations between air pollutants and cardiovascular disease (CVD) admissions across SwedenThe southern parts of Sweden show more spatial variability of these place‐specific associations than other partsMore epidemiologic emphasis should be placed on local impacts of air pollution on CVD outcomes in Sweden [ABSTRACT FROM AUTHOR]

Background: The chronic inflammation in patients with rheumatoid arthritis (RA) increases the risk for cardiovascular diseases (CVD). The contribution of diet as a risk factor for CVD among these patients is however not fully understood. The aim of this study is to investigate if a proposed anti-inflammatory diet improves cardiovascular profile in weight stable patients with RA.Methods: Patients (n = 50) with RA were included in a cross-over trial. They were randomized to either a diet rich in whole grain, fatty fish, nuts, vegetables and fruit and supplemented with probiotics, or a control diet resembling average nutritional intake in Sweden, for ten weeks. After a 4-month washout they switched diet. Participants received food bags and dietary guidelines. Primary outcome was triglyceride (TG) concentration. Secondary outcomes were total-, high density lipoprotein- (HDL) and low density lipoprotein- (LDL) cholesterol, Apolipoprotein-B100 and -A1, lipoprotein composition, plasma phospholipid fatty acids and blood pressure.Results: Forty-seven patients completed at least one period and they remained weight stable. There was a significant between-dietary treatment effect in TG and HDL-cholesterol concentration in favor of intervention (p = 0.007 and p = 0.049, respectively). Likewise, Apolipoprotein-B100/A1 ratio shifted toward a less atherogenic profile in favor of the intervention (p = 0.007). Plasma fatty acids increased in polyunsaturated- and decreased in monounsaturated- and saturated fatty acids between diet periods in favor of the intervention period.Conclusion: Blood lipid profile improved indicating cardioprotective effects from an anti-inflammatory dietary intervention in patients with RA.Trial Registration: This trial is registered at ClinicalTrials.gov as NCT02941055 . [ABSTRACT FROM AUTHOR]

Background: Hypertension, together with obesity, is a leading cause of mortality and disability. Whilst metabolic surgery offers remission of several metabolic comorbidities, the effect for patients with hypertension remains controversial. The objective of the present study was to evaluate the effect of metabolic surgery on cardiovascular events and mortality on patients with morbid obesity (body mass index [BMI] ≥ 35 kg/m2) and hypertension.Methods and Findings: We conducted a matched cohort study of 11,863 patients with morbid obesity and pharmacologically treated hypertension operated on with metabolic surgery and a matched non-operated-on control group of 26,199 subjects with hypertension (matched by age, sex, and area of residence) of varied matching ratios from 1:1 to 1:9, using data from the Scandinavian Obesity Surgery Register (SOReg), the Swedish National Patient Registers (NPR) for in-hospital and outpatient care, the Swedish Prescribed Drug Register, and Statistics Sweden. The main outcome was major adverse cardiovascular event (MACE), defined as first occurrence of acute coronary syndrome (ACS) event, cerebrovascular event, fatal cardiovascular event, or unattended sudden cardiac death. The mean age in the study group was 52.1 ± 7.46 years, with 65.8% being women (n = 7,810), and mean BMI was 41.9 ± 5.43 kg/m2. MACEs occurred in 379 operated-on patients (3.2%) and 1,125 subjects in the control group (4.5%). After adjustment for duration of hypertension, comorbidities, and education, a reduction in risk was seen in the metabolic surgery group (adjusted hazard ratio [HR] 0.73, 95% confidence intervals [CIs] 0.64-0.84, P < 0.001). The surgery group had lower risk for ACS events (adjusted HR 0.52, 95% CI 0.41-0.66, P < 0.001) and a tendency towards lower risk for cerebrovascular events (adjusted HR 0.81, 95% CI 0.63-1.01, P = 0.060) compared with controls. The main limitations with the study were the lack of information on BMI and history of smoking in the control group and the nonrandomised study design.Conclusion: Metabolic surgery on patients with morbid obesity and pharmacologically treated hypertension was associated with lower risk for MACEs and all-cause mortality compared with age- and sex-matched controls with hypertension from the general population. [ABSTRACT FROM AUTHOR]

Background: In individuals below 65 years of age, primary prevention programs have not been successful in reducing the risk of cardiovascular disease (CVD) and death. However, no large study to our knowledge has previously evaluated the effects of prevention programs in individuals aged 65 years or older. The present cohort study evaluated the risk of CVD in a primary prevention program for community-dwelling 70-year-olds.Method and Findings: In 2012-2017, we included 3,613 community-dwelling 70-year-olds living in Umeå, in the north of Sweden, in a health survey and multidimensional prevention program (the Healthy Ageing Initiative [HAI]). Classic risk factors for CVD were evaluated, such as blood pressure, lipid levels, obesity, and physical inactivity. In the current analysis, each HAI participant was propensity-score-matched to 4 controls (n = 14,452) from the general Swedish population using national databases. The matching variables included age, sex, diagnoses, medication use, and socioeconomic factors. The primary outcome was the composite of myocardial infarction, angina pectoris, and stroke. The 18,065 participants and controls were followed for a mean of 2.5 (range 0-6) years. The primary outcome occurred in 128 (3.5%) HAI participants and 636 (4.4%) controls (hazard ratio [HR] 0.80, 95% CI 0.66-0.97, p = 0.026). In HAI participants, high baseline levels of blood pressure and lipids were associated with subsequent initiation of antihypertensive and lipid-lowering therapy, respectively, as well as with decreases in blood pressure and lipids during follow-up. In an intention-to-treat approach, the risk of the primary outcome was lower when comparing all 70-year-olds in Umeå, regardless of participation in HAI, to 70-year-olds in the rest of Sweden for the first 6 years of the HAI project (HR 0.87, 95% CI 0.77-0.97, p = 0.014). In contrast, the risk was similar in the 6-year period before the project started (HR 1.04, 95% CI 0.93-1.17, p = 0.03 for interaction). Limitations of the study include the observational design and that changes in blood pressure and lipid levels likely were influenced by regression towards the mean.Conclusions: In this study, a primary prevention program was associated with a lower risk of CVD in community-dwelling 70-year-olds. With the limitation of this being an observational study, the associations may partly be explained by improved control of classic risk factors for CVD with the program. [ABSTRACT FROM AUTHOR]

Aims: Research is scarce regarding studies on income and educational inequality trends in cardiovascular disease in Sweden. The aim of this study was to assess trends in educational and income inequalities in first hospitalizations due to cardiovascular disease (CVD) from 1993 to 2010 among middle-aged women and men in Northern Sweden. Methods : The study comprised repeated cross-sectional register data from year 1993–2010 of all individuals aged 38–62 years enrolled in the Västerbotten Intervention Programme (VIP). Data included highest educational level, total earned income and first-time hospitalization for CVD from national registers. The relative and slope indices of inequality (RII and SII, respectively) were used to estimate educational and income inequalities in CVD for six subsamples for women and men, and interaction analyses were used to estimate trends across time periods. Results : Educational RII and SII were stable in women, while they decreased in men. Income inequalities in CVD developed differently compared with educational inequalities, with RII and SII for both men and women increasing during the study period, the most marked for RII in women rising from 1.52 in the 1990s to 2.62 in the late 2000s. Conclusions: The trend of widening income inequalities over 18 years in the middle-aged in Northern Sweden, in the face of stable or even decreasing educational inequalities, is worrisome from a public health perspective, especially as Swedish authorities monitor socioeconomical inequalities exclusively by education. The results show that certain social inequalities in CVD rise and persist even within a traditionally egalitarian welfare regime. [ABSTRACT FROM AUTHOR]

Background: To assess the risk of incident cardiovascular disease in patients with primary Sjögren's syndrome, overall and stratified by Ro/SSA and La/SSB autoantibody status.Methods: A cohort of patients with primary Sjögren's syndrome in Sweden (n = 960) and matched controls from the general population (n = 9035) were included, and data extracted from the National Patient Register to identify events of myocardial infarction, cerebral infarction and venous thromboembolism. Hazard ratios were estimated using cox proportional hazard regressions.Results: During a median follow-up of 9.5 years, the overall hazard ratio (HR) was 1.6 (95% CI 1.2-2.1) for myocardial infarction, 1.2 (95% CI 0.9-1.7) for cerebral infarction and 2.1 (95% CI 1.6-2.9) for venous thromboembolism. Patients positive for both Ro/SSA and La/SSB autoantibodies had a substantially higher risk of cerebral infarction (HR 1.7, 95% CI 1.0-2.9) and venous thromboembolism (HR 3.1, 95% CI 1.9-4.8) than the general population. These risks were not significantly increased in Ro/SSA- and La/SSB-negative patients. Among autoantibody-positive patients, the highest HR of cerebral infarction was seen after ≥10 years disease duration (HR 2.8, 95% CI 1.4-5.4), while the HR for venous thromboembolism was highest 0-5 years after disease diagnosis (HR 4.7, 95% CI 2.3-9.3) and remained high throughout disease duration.Conclusions: Primary Sjögren's syndrome is associated with a markedly increased risk of cardiovascular disease and the presence of Ro/SSA and La/SSB autoantibodies identify the subgroup of patients carrying the highest risk. These findings suggest that monitoring and prevention of cardiovascular disease in this patient group should be considered. [ABSTRACT FROM AUTHOR]

Aims and objectives: To evaluate a walk‐in centre at a healthcare centre in an immigrant‐dense area where a high proportion of the patients have limited language ability in Swedish, from the perspective of healthcare personnel. Background: Increased global migration results in higher vulnerability in migrants, with the risk of increased morbidity and mortality. Migrants' health often deteriorates, which can be attributed to an increased level of stress and adaptation to a new lifestyle. Therefore, immigrants are at higher risk of being affected by, for example, cardiovascular diseases and diabetes. This requires access to good health care. Design: A qualitative exploratory study was conducted, using semi‐structured interviews. Content analysis was used in the analysis process. Methods: Semi‐structured interviews were held with 15 purposively sampled doctors and nurses, working at a healthcare centre in Sweden. Data were collected during autumn 2017. The study was performed in accordance with COREQ. Results: Working at the walk‐in centre involved caring for everything from basic to advanced health problems and meant a high pace that required stress‐resistant personnel. The walk‐in centre was described as both promoting and threatening patient safety. The personnel had several ideas on how to develop the walk‐in centre. Conclusions: A walk‐in centre can be seen as a necessity related to issues of ensuring patient safety and delivering care for everyone in an immigrant‐dense area. However, it cannot be the only form of care offered, as it seems not be adapted to certain groups, such as people with disabilities and the elderly. Relevance to clinical practice: The findings emphasise that a walk‐in centre is a way to increase accessibility for the entire population and offer equal care for all, even if it involves challenges that need to be addressed. [ABSTRACT FROM AUTHOR]

Objective: Hypertension is a major cause of cardiovascular disease. Nevertheless, blood pressure (BP) is often inadequately treated. We studied visit patterns at primary health care centres (PHCCs) and their relation to individual BP control. Design and setting: Cross-sectional register-based study on all patients with hypertension who visited 188 PHCCs in a Swedish region. Patients: A total of 88,945 patients with uncomplicated hypertension age 40-79. Main outcome measures: Odds ratio (OR) for the individual patient to achieve the BP target of ≤140/90 mmHg. Results: Overall, 63% of patients had BP ≤ 140/90 mmHg (48% BP < 140/90). The PHCC that the patient was enrolled at and, as part of that, more nurse visits at PHCC level was associated with BP control, adjusted OR 1,10 (95% CI 1.01 to 1.21). Patients visiting PHCCs with the highest proportion of visits with nurses had an even higher chance of achieving the BP target, OR 1.19 (95% CI 1.07 to 1.32). Conclusions: In a Swedish population of patients with hypertension, about half do not achieve recommended treatment goals. Organisation of PHCC and team care are known as factors influencing BP control. Our results suggests that a larger focus on PHCC organisation including nurse based care could improve hypertension care. [ABSTRACT FROM AUTHOR]

Cardiovascular diseases are the most common comorbidities in COPD, due to common risk factors such as smoking. The prevalence of current smokers in Sweden has decreased over four decades to around 10%. The aim of the present study was to investigate the prevalence, distribution and associations of cardiovascular comorbidities in COPD by disease severity in two large areas of Sweden, both with low-smoking prevalence. Data from clinical examinations in 2009-2012, including spirometry and structured interview, from two large-scale population studies, the West Sweden Asthma Study (WSAS) and the OLIN Studies in Northern Sweden, were pooled. COPD was defined using post-bronchodilator spirometry according to the fixed ratio FEV1/FVC <0.70 and the lower limit of normal (LLN5th percentile) of the ratio of FEV1/FVC. Of the 1839 subjects included, 8.7% and 5.7% had COPD according to the fixed ratio and the LLN criterion. Medication for heart disease or hypertension among those with moderate-to-severe COPD was more common than among those without COPD (fixed ratio definition of COPD: 51% vs. 23%, p < 0.001; LLN definition: 42% vs. 24%, p = 0.002). After adjusting for known risk factors for COPD, including smoking, age, socio-economic status, and occupational exposure for gas, dust and fumes, only heart failure remained significantly, and independently, associated with COPD, irrespective of the definitions of COPD. Though a major decrease in smoking prevalence, the pattern of cardiovascular comorbidities in COPD still remains similar with previously performed studies in Sweden and in other Westernized countries as well. [ABSTRACT FROM AUTHOR]

Background: Machine learning algorithms hold potential for improved prediction of all-cause mortality in cardiovascular patients, yet have not previously been developed with high-quality population data. This study compared four popular machine learning algorithms trained on unselected, nation-wide population data from Sweden to solve the binary classification problem of predicting survival versus non-survival 2 years after first myocardial infarction (MI).Methods: This prospective national registry study for prognostic accuracy validation of predictive models used data from 51,943 complete first MI cases as registered during 6 years (2006-2011) in the national quality register SWEDEHEART/RIKS-HIA (90% coverage of all MIs in Sweden) with follow-up in the Cause of Death register (> 99% coverage). Primary outcome was AUROC (C-statistic) performance of each model on the untouched test set (40% of cases) after model development on the training set (60% of cases) with the full (39) predictor set. Model AUROCs were bootstrapped and compared, correcting the P-values for multiple comparisons with the Bonferroni method. Secondary outcomes were derived when varying sample size (1-100% of total) and predictor sets (39, 10, and 5) for each model. Analyses were repeated on 79,869 completed cases after multivariable imputation of predictors.Results: A Support Vector Machine with a radial basis kernel developed on 39 predictors had the highest complete cases performance on the test set (AUROC = 0.845, PPV = 0.280, NPV = 0.966) outperforming Boosted C5.0 (0.845 vs. 0.841, P = 0.028) but not significantly higher than Logistic Regression or Random Forest. Models converged to the point of algorithm indifference with increased sample size and predictors. Using the top five predictors also produced good classifiers. Imputed analyses had slightly higher performance.Conclusions: Improved mortality prediction at hospital discharge after first MI is important for identifying high-risk individuals eligible for intensified treatment and care. All models performed accurately and similarly and because of the superior national coverage, the best model can potentially be used to better differentiate new patients, allowing for improved targeting of limited resources. Future research should focus on further model development and investigate possibilities for implementation. [ABSTRACT FROM AUTHOR]

Aim: To illustrate how the fundamental epidemiological measures, incidence rate and prevalence proportion, can be estimated based on Swedish population registers using acute myocardial infarction (MI) as an example, together with a discussion about the analytical decisions. Methods: All individuals in Sweden aged 60–89 (born 1904–1954) during the study period 1994–2014 were identified through the Total Population Register. Cases of MI were defined and identified from information on hospital admissions and causes of death. Incidence rates of all, first, and recurrent MI were calculated together with prevalence proportions. Results: The incidence rate of all, first, and recurrent MI declined over the study period. While the incidence rates of first MI are lower for women than men, the incidence rates of recurrent MI are considerably higher but similar for men and women. The prevalence calculated with duration of disease set at 28 days also declined. This was despite improved survival from MI and increased life expectancy over the same period meaning that the decline in incidence was large enough to compensate for increased survival. Conclusions: Calculating incidence and prevalence of diseases using population registers requires detailed and well-reasoned definitions. The definitions will affect both the study population and the number of disease events and it is essential that the cases and the study population are defined in a coherent way. Different measures of disease occurrence contribute with different aspects of the disease panorama and a joint interpretation contributes to a thorough understanding of the disease development in a population. [ABSTRACT FROM AUTHOR]

Survival data analysis becomes complex when the proportional hazards assumption is violated at population level or when crude hazard rates are no longer estimators of marginal ones. We develop a Bayesian survival analysis method to deal with these situations, on the basis of assuming that the complexities are induced by latent cohort or disease heterogeneity that is not captured by covariates and that proportional hazards hold at the level of individuals. This leads to a description from which risk-specific marginal hazard rates and survival functions are fully accessible, 'decontaminated' of the effects of informative censoring, and which includes Cox, random effects and latent class models as special cases. Simulated data confirm that our approach can map a cohort's substructure and remove heterogeneity-induced informative censoring effects. Application to data from the Uppsala Longitudinal Study of Adult Men cohort leads to plausible alternative explanations for previous counter-intuitive inferences on prostate cancer. The importance of managing cardiovascular disease as a comorbidity in women diagnosed with breast cancer is suggested on application to data from the Swedish Apolipoprotein Mortality Risk Study. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]