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Background: Continuous changes in stroke treatment and care, as well as changes in stroke characteristics, may alter stroke outcome over time. The aim of this paper is to describe time trends for treatment and outcome data, and to discuss if any such changes could be attributed to quality changes in stroke care. Methods: Data from Riks-Stroke, the Swedish stroke register, were analyzed for the time period of 1995 through 2010. The total number of patients included was 320,181. The following parameters were included: use of computed tomography (CT), stroke unit care, thrombolysis, medication before and after the stroke, length of stay in hospital, and discharge destination. Three months after stroke, data regarding walking, toileting and dressing ability, as well social situation, were gathered. Survival status after 7, 27 and 90 days was registered. Results: In 1995, 53.9% of stroke patients were treated in stroke units. In 2010 this proportion had increased to 87.5%. Fewer patients were discharged to geriatric or rehabilitation departments in later years (23.6% in 2001 compared with 13.4% in 2010), but more were discharged directly home (44.2 vs. 52.4%) or home with home rehabilitation (0 vs. 10.7%). The need for home help service increased from 18.2% in 1995 to 22.1% in 2010. Regarding prevention, more patients were on warfarin, antihypertensives and statins both before and after the stroke. The functional outcome measures after 3 months did improve from 2001 to 2010. In 2001, 83.8% of patients were walking independently, while 85.6% were independent in 2010. For toileting, independence increased from 81.2 to 84.1%, and for dressing from 78.0 to 80.4%. Case fatality (CF) rates after 3 months increased from 18.7% (2001) to 20.0% (2010). This trend is driven by patients with severe strokes. Conclusions: Stroke outcomes may change over a relatively short time period. In some ways, the quality of care has improved. More stroke patients have CT, more patients are treated in stroke units and more have secondary prevention. Patients with milder strokes may have benefited more from these measures than patients with severe strokes. Increased CF rates for patients with severe stroke may be caused by shorter hospital stays, shorter in-hospital rehabilitation periods and lack of suitable care after discharge from hospital.

Background: Reported improvements in outcome in stroke patients treated in hospital are often attributed to advances in stroke care. However, secular trends in patient characteristics that are present already on admission to hospital may also contribute to improved outcome. Methods: Time trends for baseline data (289,854 stroke admittances) in Riks-Stroke, the Swedish national quality register for stroke care, were analyzed for the years 1995 through 2008. The following data were included: number of strokes for each year, age, sex, risk factors, stroke subtype, stroke severity, functional status and need of external home service before the stroke. Results: The number of annually reported strokes increased until 2005. The proportion of recurrent strokes decreased from 28.0 to 25.9%. The mean age at first-ever stroke increased in women, but not in men. The proportion of smokers dropped, and the proportion of patients who had treated hypertension increased. The stroke severity decreased in men. The prestroke functional status (walking, dressing, toileting) improved in both sexes over these years. More patients lived alone in 2008 than in 1995, and more had home help service. Conclusions: Many baseline parameters in Riks-Stroke have changed over the years. This has consequences for the interpretation of outcome data. Some changes may be due to inclusion bias, others due to alterations in general health, evolution of vascular risk factors or demographics.

Background: Recent studies suggest a relationship between atherosclerotic disease and osteoporosis. The aim of the study was to investigate whether bone mineral density (BMD) was prospectively related to stroke and death. Methods: BMD (g/cm2) was measured in 4,302 men and women (mean age 59 years, range 40–75) at baseline. The main outcome measures included validated strokes and death. Results: After a mean follow-up time of 5.6 years (range 0–15.8 years), 139 strokes were registered and 224 subjects had died. After adjustment for age, sex and body mass index, decreased femoral neck BMD and osteoporosis were found to be independent predictors of stroke (hazard ratio, HR, for each standard deviation decrease in BMD = 1.23, 95% CI = 1.01–1.49, and HR for osteoporosis = 1.92, 95% CI = 1.11–3.30). After adjustment for the same variables, the risk of death during follow-up was related to femoral neck BMD (HR = 1.41, 95% CI = 1.21–1.64) and osteoporosis at baseline (HR = 2.05, 95% CI = 1.28–3.29). Adjustment also for smoking, hypertension, hyperlipidemia and diabetes did not change any of these results. Conclusions: We found that decreased BMD as well as osteoporosis of the femoral neck are independently associated with stroke and death. Given the impact of osteoporosis and stroke on morbidity and mortality, this relationship is of high interest for further studies.

Background and Purpose— Riks-Stroke, the Swedish Stroke Register, was used to explore patient characteristics and stroke services as determinants of patient dissatisfaction with acute in-hospital care. Methods— All 79 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. During 2001 to 2007, 104 876 patients (87% of survivors) responded to a follow-up questionnaire 3 months after acute stroke; this included questions on satisfaction with various aspects of stroke care. Results— The majority (>90%) were satisfied with acute in-hospital stroke care. Dissatisfaction was closely associated with outcome at 3 months. Patient who were dependent regarding activities of daily living, felt depressed, or had poor self-perceived general health were more likely to be dissatisfied. Dissatisfaction with global acute stroke care was linked to dissatisfaction with other aspects of care, including rehabilitation and support by community services. Patients treated in stroke units were less often dissatisfied than patients in general wards, as were patients who had been treated in a small hospital (vs medium or large hospitals) and patient who had participated in discharge planning. In multivariate analyses, the strongest predictor of dissatisfaction with acute care was poor outcome (dependency regarding activities of daily living, depressed mood, poor self-perceived health). Conclusions— Dissatisfaction with in-hospital acute stroke care is part of a more extensive complex comprising poor functional outcome, depressive mood, poor self-perceived general health, and dissatisfaction not only with acute care but also with health care and social services at large. Several aspects of stroke care organization are associated with a lower risk of dissatisfaction.

To investigate whether subjects with daytime sleepiness who snore or report witnessed sleep apneas drive more than others.Questions on snoring, witnessed sleep apnea, excessive daytime sleepiness and driving distance per year were included in the Northern Sweden component of the WHO, MONICA study. Invited were 10756 subjects aged 25-79 years, randomly selected from the population register.There were 7905 (73%) subjects, 3858 men and 4047 women who responded to the questionnaire and attended a visit for a physical examination. Habitually snoring men with daytime sleepiness drove a mean of 22566 (95% CI 18550-26582)km a year, which was significantly more than non-snoring men without excessive daytime sleepiness who drove 17751 (95% CI 17076-18427)km a year, p=0.02, after adjustments for age, body mass index, smoking and physical activity. Men reporting witnessed sleep apnea and excessive daytime sleepiness also drove more than their counterparts in adjusted analysis, p=0.01. Women reporting daytime sleepiness and witnessed apnea tended to drive more, while snoring women with daytime sleepiness did not.Men suffering from excessive daytime sleepiness who snore habitually or report witnessed sleep apneas drive significantly more than others.

Background and Purpose— The purpose of this study was to compare definitions of metabolic syndrome with regard to their prediction of stroke and coronary heart disease incidence. Methods— The study comprises 4041 men and 3812 women of 6 Finnish and Swedish cohorts aged 25 to 74 years at baseline. Hazard ratio was estimated applying Cox regression analyses adjusting for cohort, cholesterol, and smoking and using age as a time scale. A paired homogeneity test was performed to compare the differences. Results— A total of 113 (47) ischemic and 43 (15) hemorrhagic stroke and 235 (50) coronary heart disease events were accumulated in men (women). Hazard ratios (95% CIs) for ischemic stroke in men were 1.59 (1.09 to 2.32), 1.52 (1.01 to 2.28), 1.16 (0.77 to 1.74), and 1.27 (0.87 to 1.86), respectively, for the World Health Organization, National Cholesterol Education Program, National Cholesterol Education Program revised, and the International Diabetes Federation definitions of metabolic syndrome, and in women 2.20 (1.15 to 4.19), 2.68 (1.47 to 4.87), 2.31 (1.27 to 4.20), and 1.91 (1.05 to 3.49), respectively. The corresponding hazard ratios (95% CIs) for coronary heart disease were 1.57 (1.21 to 2.04), 1.51 (1.15 to 1.99), 1.63 (1.25 to 2.13), and 1.46 (1.12 to 1.89) in men and 1.32 (0.69 to 2.51), 1.54 (0.85 to 2.79), 1.81 (1.02 to 3.21), and 2.47 (1.37 to 4.45) in women. None of the definitions of metabolic syndrome predicted hemorrhagic stroke. There was no difference between definitions of metabolic syndrome and between a full definition and its individual components. Conclusions— Metabolic syndrome as well as its individual components predicted the incidence of the ischemic stroke and the coronary heart disease equally well and should be treated equally as well.

Gender differences in the relationship of snoring and diabetes mellitus are mainly unknown. We aimed to analyze the relationship between snoring, witnessed sleep apnea and diabetes mellitus and to analyze possible gender related differences in an unselected population.Questions on snoring and witnessed sleep apneas were included in the Northern Sweden component of the WHO, MONICA study. Invited were 10,756 men and women aged 25-79 years, randomly selected from the population register.There were 7905 (73%) subjects, 4047 women and 3858 men who responded to the questionnaire and attended a visit for a physical examination. Habitual snoring was related to diabetes mellitus in women, with an adjusted odds ratio (OR)=1.58 (95% confidence interval (CI) 1.02-2.44, p=0.041) independent of smoking, age, body mass index and waist circumference. Witnessed sleep apnea was also independently related to diabetes mellitus in women, with an adjusted OR=3.29 (95% CI 1.20-8.32, p=0.012). Neither snoring, nor witnessed sleep apneas were associated with diabetes mellitus among men, except for witnessed sleep apnea in men aged 25-54 years old. They had an adjusted OR=3.84 (95% CI 1.36-10.9, p=0.011) for diabetes mellitus.Snoring and witnessed sleep apneas are related to diabetes mellitus in women. Witnessed sleep apnea is related to diabetes mellitus in men younger than 55 years old.

The renin-angiotensin system has a pathophysiological role in cardiovascular disease through a variety of processes. Polymorphisms in involved genes have been described and implicated in stroke. The aim of this study was to investigate two polymorphisms in two genes in the renin-angiotensin system and the risk of stroke.A nested case-control study using baseline data obtained from population-based surveys in northern Sweden was performed. There were 275 individuals without major concomitant disease who suffered a first ever stroke during follow-up and 549 controls matched for age, sex and domicile.Blood samples obtained at baseline were analyzed for potential risk factors including the A1166C polymorphism of the angiotensin II type I receptor (AT1R) gene and the functional insertion/deletion polymorphism of the angiotensin-converting enzyme gene.Individuals with the AA genotype of the AT1R gene were at increased risk of ischemic stroke (odds ratio = 1.60; P = 0.005) compared with those with the AC and CC genotypes. The D allele of the angiotensin-converting enzyme insertion/deletion polymorphism was associated with a higher risk of stroke (odds ratio = 1.58; P = 0.014).In this prospective study, there was an association between A1166C polymorphism in the angiotensin II receptor gene and ischemic stroke. We also replicated previous observations that the D allele of the angiotensin-converting enzyme insertion/deletion polymorphism was associated with increased risk of stroke. The observed elevated stroke risks conferred by these two polymorphisms are independent of each other and common risk factors such as blood pressure, diabetes, smoking and high cholesterol levels.

Background: When reporting stroke survival and prognostic factors with a possible effect on outcome, the starting point for the observation of a clinical cohort usually is the onset of stroke or the acute admission of a patient. Thus, acute and early mortality inflict prognosis on long-term outcome. In order to give a more robust analysis of long-term survival after the acute period we chose to start our observation with 3-month survivors. Methods: We used data from Riks-Stroke, the Swedish quality register for stroke care, together with survival information from the Swedish population register to explore the influence of disability level 3 months after stroke on long-term survival. The main analysis included 15,959 stroke patients, registered during 2001–2002, who had been independent in primary activities of daily living before stroke, had suffered an ischaemic or a haemorrhagic stroke and reported no previous stroke. Results: Impaired functional outcome after stroke was an independent predictor of poor survival. Patients with modified Rankin scale (mRS) grades 3, 4 and 5 had hazard ratios of 1.7, 2.5 and 3.8, respectively, as compared with patients with lower mRS grades. In addition to high mRS, male sex, high age, diabetes, smoking, hypertension therapy at stroke onset, atrial fibrillation and depressed mood were also recognized as significant predictors of poor survival using a multiple Cox regression model. Conclusion: The influence of disability on survival is stronger than that of several other well-known prognostic factors. This finding indicates that any intervention in the acute phase that may improve functional status at 3 months will also have favourable secondary effects on survival in the long term.

Objective: To establish whether subtypes of ischemic stroke aggregate within ischemic stroke–affected sibling pairs more than expected by chance alone. Methods: This retrospective family study was based on a pooled analysis of two cohorts of male and female adult sibling pairs with symptomatic ischemic stroke. One hospital-based cohort of 404 individuals (first proband seen August 30, 1999) was recruited from the United States and Canada, and another population-based cohort of 198 individuals (first proband seen April 17, 1997) was recruited from Umea, Sweden. Subtype diagnoses were based on Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Results: Agreement for subtype diagnoses within families was poor (mean ± asymptotic SE κ = 0.17 ± 0.04). Occurrence of one ischemic stroke subtype in a proband was not associated with a greater likelihood of that subtype being the qualifying stroke subtype in the sibling. Comparable levels of agreement were seen when restricting the analysis to same-sex sibling pairs (κ = 0.22 ± 0.05) to sibling pairs in which the proband’s stroke occurred before the age of 65 years (κ = 0.16 ± 0.05) or to pairs in which the proband’s stroke occurred at or after the age of 65 years (κ = 0.19 ± 0.05). Conclusions: The subtype of ischemic stroke in a proband was a poor determinant of the subtype of ischemic stroke in the respective sibling. This suggests that many genetic risk factors for ischemic stroke may not be specific for one subtype.

Background and Purpose— Taking advantage of low genetic variations in northern Sweden, we performed a genome-wide linkage scan to investigate the susceptibility loci for common forms of stroke. Methods— Fifty-six families, containing multiple cases of stroke and whose data had been previously used to replicate linkage to the phosphodiesterase 4D locus on chromosome 5q, were genotyped in a genome-wide scan. Fine mapping was performed, and subsequently 53 additional families from the same region were genotyped over the candidate regions. Results— Linkage calculations were performed by using 3 different disease models, from a very broad (all stroke cases defined by World Health Organization MONICA criteria) to a narrower (ischemic stroke only) stroke phenotype. With all models, nonparametric multipoint linkage analysis yielded allele-sharing log of the odds (LOD) scores >1.2 at 9 locations: 1p34, 5q13, 7q35, 9q22, 9q34, 13q32, 14q32, 18p11, and 20q13. The highest allele-sharing LOD scores were obtained on chromosomes 5q (previously reported), 1p (LOD=2.09), and 18p (LOD=2.14). Fine mapping resulted in increased allele-sharing LOD scores for chromosome 5q (previously reported) and 9q22 (LOD=1.56), but all others decreased. Combining these initial results with a subsequent analysis of 53 additional families, we obtained the highest allele-sharing LOD scores on chromosomes 5q, 13q, and 18p, although none reached the initial genome-wide allele-sharing LOD scores. Conclusions— Genetic analysis of stroke in families from northern Sweden did not identify any new major stroke loci. This indicates that multiple minor susceptibility loci in addition to the previously known locus on chromosome 5 could contribute to the disease.

For decades men in Sweden have smoked at far lower rates than those in comparable countries. Previous studies showed that snus use played a major role in low smoking rates among men in northern Sweden; daily smoking declined from 19% (95% CI 16—22%) in 1986 to 11% (CI 8.9—14%) in 1999. The prevalence of smoking among all men is now 9% (CI 7.0— 11%) and only 3% (CI 0.1—5.4%) among men age 25—34 years; the prevalence of exclusive snus use is 27% (CI 24—30%) and 34% (CI 27—42%) respectively. Combined smoking and snus use, an unstable and transient category, was under 5% in all surveys and was 2.2% (CI 1.4—3.4%) by 2004. For the first time snus use is also associated with a decrease in smoking prevalence among women. These patterns of tobacco use have implications for all smoking-dominated societies.

Methylmercury is eliminated from the human body as glutathione (GSH) conjugates. GSH production is mediated by glutamyl-cysteine ligase (GCL) and conjugation by glutathione S-transferases (GST). In this study, the authors tested whether polymorphisms in GCL and GST genes modify methylmercury retention. Erythrocyte mercury concentration (EryHg), plasma polyunsaturated fatty acids (PPUFA), and genotype for GCLC, GCLM, GSTA1, GSTM1, GSTP1, and GSTT1 were determined in 365 individuals. A general linear model was developed for analyzing whether genotype modified the regression of EryHg on PPUFA. The presence of one variant allele for either GCLC-129 or GSTP1-114 was associated with higher EryHg and steeper regression slope. No similar trends were shown for GCLM, GSTA1, GSTM1, or GSTT1. These findings indicate that GCLC polymorphisms that affect GSH production also affect methylmercury retention, and that GSTP1 may play a role in conjugating methylmercury with GSH.

Background and Purpose— Northern Sweden has one of the highest incidence rates of subarachnoid hemorrhage (SAH) among the populations covered by the WHO MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease) Project, approximately twice as high as in the other populations in Europe. In this study, trends in incidence, 28-day case fatality (CF), and mortality in SAH were followed over a 16-year period. Methods— Since 1985, all SAHs in northern Sweden among patients 25 to 74 years old have been validated using strict MONICA criteria. From 1985 through 2000, 392 men and 592 women had SAH. During 3 years, 1997 to 1999, SAH among those aged 75 and older were also included. Results— The total incidence among those 25 years and older was 13.3 per 100 000 in men and 24.4 per 100 000 in women. During the 16 years of observation, age standardized incidence in the group aged 25 to 74 years decreased significantly in men ( P for trend P for trend=0.64). The 28-day CF for all years was 36.5% in men, with no significant trend ( P =0.7). In women, average CF was 35%, with a significant decline ( P =0.003). The annual mortality decreased significantly in both sexes (by 3.87 [95% CI±2.75 percentage points] in men and 3.97 [95% CI±2.29] in women). Conclusions— The decline in SAH mortality has different explanations in men (declining incidence) and in women (declining CF).

Aims: To compare menopausal age and the use of oral contraceptives (OC) and hormonal replacement therapy (HRT) between the 32 populations of the WHO MONICA Project, representing 20 different countries. Methods: Using a uniform protocol, age at menopause and the use of OC and HRT was recorded in a random sample of 25–64 year-old women attending the final MONICA population cardiovascular risk factor survey between 1989 and 1997. A total of 39,120 women were included. Results: There were wide variations between the populations in the use of OC and HRT. The use of OC varied between 0 and 52% in pre-menopausal women aged 35–44 years, Central and East Europe and North America having the lowest and West Europe and Australasia the highest prevalence rates. Among post-menopausal women between 45 and 64 years, the prevalence of HRT use varied from 0 to 42%. In general, the use of HRT was high in Western and Northern Europe, North America and Australasia and low in Central, Eastern and Southern Europe and China. With the exception of Canada (45 years), the mean age at menopause differed only little (ranging from 48 to 50 years) between the populations. Conclusion: The use of OC and HRT varies markedly between populations, in general following a regional pattern. Whereas, the prevalence rates are mostly similar within a country, there are remarkable differences even between neighbouring countries, reflecting nation-specific medical practice and public attitudes that are not necessarily based on scientific evidence.

Levels of hypertension treatment and control have been noted to vary between Europe and North America, although direct comparisons with similar methods have not been undertaken. In this study, we sought to estimate the relative impact of hypertension treatment strategies in Germany, Sweden, England, Spain, Italy, Canada, and the United States by using sample surveys conducted in the 1990s. Hypertension was defined as a blood pressure of 160/95 mm Hg or 140/90 mm Hg, plus persons taking antihypertensive medication. “Controlled hypertension” was defined as a blood pressure less than threshold among persons taking antihypertensive medications. Among persons 35 to 64 years, 66% of hypertensives in the United States had their blood pressure controlled at 160/95 mm Hg, compared with 49% in Canada and 23% to 38% in Europe. Similar discrepancies were apparent at the 140/90 mm Hg threshold, at which 29% of hypertensives in the United States, 17% in Canada, and ≤10% in European countries had their blood pressure controlled. At the 140/90 mm Hg cutpoint, two thirds to three quarters of the hypertensives in Canada and Europe were untreated compared with slightly less than half in the United States. Although guidelines vary among countries, resulting in different case definitions, this does not account entirely for the varying success of different national control efforts. Low treatment and control rates in Europe, combined with a higher prevalence of hypertension, could contribute to a higher burden of cardiovascular disease risk attributable to elevated blood pressure compared with that in North America.

To explore nation-wide use of anticoagulation in stroke patients with atrial fibrillation, in routine clinical practice in Sweden.Cross-sectional cohort study.Patients included in Riks-Stroke, the Swedish national quality register for stroke care, during 2001.Hospitals with incomplete coverage were excluded, leaving 4538 stroke patients with atrial fibrillation amongst 18 276 stroke patients from 75 hospitals in six health care regions.Treatment with oral anticoagulants.At stroke onset, the proportion of patients with atrial fibrillation and first-ever stroke, receiving oral anticoagulants as primary prevention was 11.0% (range 8.4-13.5% between regions and 2.5-24.4% between hospitals). Younger age, male sex and diabetes at stroke onset independently predicted primary prevention with oral anticoagulants. The proportion of stroke patients with atrial fibrillation receiving oral anticoagulants as secondary prevention at discharge was 33.5% (range 29.9-40.6% between regions and 16.4-61.9% between hospitals). Independent predictors for secondary prevention were younger age, male sex and independent activities of daily life (ADL) function before the stroke, being discharged to home, being fully conscious on admission and health care region.There were variations between hospitals and regions that differences in age, sex, functional impairments and comorbidities could not fully explain. This indicates that evidence-based primary and secondary prevention of embolic stroke is insufficiently practised. Local factors seem to determine whether patients with atrial fibrillation gain access to optimal prevention of stroke or not.

Aims: The authors describe the occurrence of diabetes and obesity in the population of Northern Sweden and the role of diabetes in cardiovascular disease. Methods: Four surveys of the population aged 25 to 64 years were undertaken during a 14-year time span. Stroke events in subjects 35 - 74 years during 1985 - 92 and myocardial infarction in subjects 25 - 64 years 1989 - 93 were registered. Results: The prevalence of diagnosed diabetes was 3.1 and 2.0% in men and women, respectively, and 2.6 and 2.7% for previously undiagnosed diabetes. During the 13-year observation period, BMI increased 0.96 kg/m2 in men and 0.87 in women. The proportion of subjects with obesity (BMI≥30) increased from 10.3% to 14.6% in men and from 12.5% to 15.7% in women. Hip circumference increased substantially more than waist circumference, leading to a decreasing waits-to-hip ratio (WHR). The relative risk for stroke or myocardial infarction was four to six times higher in a person with diabetes than in those without diabetes. The 28-day case fatality for myocardial infarction, but not for stroke, was significantly higher in both men and women with diabetes. Population-attributable risk for diabetes and stroke was 18% in men and 22% in women and for myocardial infarction it was 11% in men and 17% in women. Conclusion: Obesity is becoming more common, although of a more distal than central distribution. The burden of diabetes in cardiovascular diseases in Northern Sweden is high.

Aim: To compare the levels of the main cardiovascular risk factors in communities of different sizes in northern Sweden. Methods: Blood pressure, cholesterol, smoking habits, the prevalence of diabetes mellitus, and body mass index for 6,167 men and women below age 65 were examined in the Northern Sweden MONICA surveys in 1986, 1990, 1994, and 1999. The size of the community where each individual lived and the levels of relevant confounders were also recorded. Results: The proportion of persons with a higher educational level decreased gradually with decreasing community size. Total serum cholesterol, systolic blood pressure, the prevalence of diabetes mellitus and the body mass index were significantly higher in the smallest communities (15,000 inhabitants) but there were fewer smokers among men in the smallest communities. The time trends indicated an overall decreasing serum cholesterol level and increasing body mass index for both sexes and a decreasing proportion of smokers among men during the years surveyed. Conclusions: There are differences in levels of cardiovascular risk factors between communities of different sizes in the Northern Sweden MONICA area, mainly to the disadvantage of the smallest communities.

Aims: To explore the stability of sense of coherence (SOC) over time in a normal population and to examine its relation to gender and psychosocial factors. Methods: The Northern Sweden MONICA Project population surveys were performed in 1994 and 1999. A cohort of 1,254 subjects participating in both surveys answered questions about experiences of disease, perceived health, marital status, psychosocial factors, and Antonovsky's SOC scale with 13 items. Results: The mean SOC score showed a decrease in the five-year follow-up and those with identified disease and the oldest age group (45 - 74 years) had the largest decrease of the SOC score. People with the lowest SOC scores in 1994 had the largest decrease during the period. Men and women shared a similar pattern regarding the decrease in SOC over time. The impact of individual social changes during the study period showed that both men and women who had experienced loss of perceived good health and high social support had the largest decrease. Furthermore, women seemed to be more affected by changes than men. Conclusions: We found that SOC was only stable for those with initially high levels of SOC. For other people, individual conditions and societal changes influenced their SOC. Further longitudinal studies in normal populations are needed to investigate the stability of SOC scores.

Background and Purpose— Mortality from stroke has been declining over recent decades in most countries, except in Eastern Europe. In this analysis, based on the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (WHO MONICA) Project, we explored to what extent these trends are due to changes in stroke event rate and to changes in case fatality. Methods— The WHO MONICA Project collected standardized data from 14 populations in 9 countries. All acute strokes occurring in men and women 35 to 64 years of age were included. Registration was carried out between 1982 and 1995, resulting in time spans from 7 to 13 years. Trends in event rates and case fatality were calculated as average annual percentage change. Results— Up to 6-fold differences were observed in stroke mortality. Mortality declined in 8 of 14 populations in men and in 10 of 14 populations in women. An increase in mortality was observed in Eastern Europe. In the populations with a declining trend, about two thirds of the change could be attributed to a decline in case fatality. In populations with increasing mortality, the rise was explained by an increase in case fatality. Conclusions— In most populations, changes in stroke mortality, whether declining or increasing, were principally attributable to changes in case fatality rather than changes in event rates. Whether this was due to changes in the management of stroke or changes in disease severity cannot be established on the basis of these results.

The World Health Organization/International Society of Hypertension (WHO/ISH) Hypertension Guidelines from 1999 propose a risk stratification scheme for estimating absolute risk for cardiovascular disease (CVD). Risk equations estimated by statistical methods are another way of predicting cardiovascular risk.We studied the differences between these two approaches when applied to the same set of individuals with high blood pressure.The two northernmost counties in Sweden (NSW) constitute one of the centres in the WHO MONICA (monitoring trends and determinants in cardiovascular disease) Project. Three population surveys have been carried out in 1986, 1990 and 1994, and were used to estimate a risk equation for predicting the 10-year risk of fatal/non-fatal stroke and myocardial infarction. Another MONICA sample from 1999, a total of 5997 subjects, was classified according to the recent WHO/ISH risk stratification scheme. A risk assessment was also performed, by using the risk equations from the NSW MONICA sample and Framingham risk equations.The agreement between the two methods was good when the values obtained from the risk equation were averaged for each risk group obtained from the risk classification by guidelines. However, if the predicted risk for each individual was considered, the agreement was poor for the medium and high-risk groups. Although the average risk for all individuals is the same, many subjects have a higher risk or a lower risk than predicted by guidelines.Risk classification by the 1999 WHO/ISH Hypertension Guidelines is not accurate and detailed enough for medium- and high-risk patients, which could be of clinical importance in the medium risk group.

OBJECTIVE—To report the age- and sex-specific prevalences of diabetes and impaired glucose regulation (IGR) according to the revised 1999 World Health Organization criteria for diabetes in Europe. RESEARCH DESIGN AND METHODS—A total of 13 studies from nine European countries with 7,680 men and 9,251 women aged 30–89 years were included in the data analysis. RESULTS—In most of the study populations, the age-specific prevalences of diabetes were 70 years of age). More than half of the diabetes was undiagnosed in subjects younger than 50 years of age. CONCLUSIONS—Most European populations have a moderate to low prevalence of diabetes and IGR. Diabetes and IGR will be underestimated in Europe, particularly in women and in elderly men, if diagnoses are based on fasting glucose determination alone.

Background and Purpose— In many countries, including Sweden, initiatives have been taken to reduce between-hospital differences in the quality of stroke services. We have explored to what extent hospital type (university, specialized nonuniversity, or community hospital) influences hospital performance. Methods— Riksstroke collects clinical data during hospital stay (national coverage 94%). Follow-up data at 3 months were collected using administrative registers and a questionnaire completed by surviving patients (response rate 88%). Structural data were collected from a questionnaire completed by hospital staff (response rate 100%). Multivariate analyses with adjustment for clustering were used to test differences between types of hospitals. Results— The proportion of patients admitted directly to a stroke unit was highest in community hospitals and lowest in university hospitals. Magnetic resonance, carotid imaging, and thrombectomy were more frequently performed in university hospitals, and the door-to-needle time for thrombolysis was shorter. Secondary prevention with antihypertensive drugs was used less often, and outpatient follow-up was less frequent in university hospitals. Fewer patients in community hospitals were dissatisfied with their rehabilitation. After adjusting for possible confounders, poor outcome (dead or activities of daily living dependency 3 months after stroke) was not significantly different between the 3 types of hospital. Conclusions— In a setting with national stroke guidelines, stroke units in all hospitals, and measurement of hospital performance and benchmarking, outcome (after case-mix adjustment) is similar in university, specialized nonuniversity, and community hospitals. There seems to be fewer barriers to organizing well-functioning stroke services in community hospitals compared with university hospitals.

SummaryThe aim of the present study was to examine if soluble thrombomodulin (sTM) and von Willebrand factor (VWF) could predict a first-ever ischemic or hemorrhagic stroke.This study was an incident case-referent study from within a population-based cohort in northern Sweden. Up to 1996 about 44,000 subjects had been screened and stroke cases were classified according to the WHO MONICA criteria. A first-ever stroke occurred in 108 cases. A total of 216 controls were selected from the same cohort.This prospective study found no association with sTM or VWF and the development of a first-ever ischemic stroke (n = 87) in the logistic regression model. For the hemorrhagic stroke cases (n = 18), the multivariate logistic regression model revealed a significant negative association with sTM. When dichotomized, the upper level (>17.3 µg/L) of sTM, as compared with the lower level (

Background and Purpose— Although the research linking cardiovascular disorders to geomagnetic activity is accumulating, robust evidence for the impact of geomagnetic activity on stroke occurrence is limited and controversial. Methods— We used a time-stratified case-crossover study design to analyze individual participant and daily geomagnetic activity (as measured by Ap Index) data from several large population-based stroke incidence studies (with information on 11 453 patients with stroke collected during 16 031 764 person-years of observation) in New Zealand, Australia, United Kingdom, France, and Sweden conducted between 1981 and 2004. Hazard ratios and corresponding 95% confidence intervals (CIs) were calculated. Results— Overall, geomagnetic storms (Ap Index 60+) were associated with 19% increase in the risk of stroke occurrence (95% CI, 11%–27%). The triggering effect of geomagnetic storms was most evident across the combined group of all strokes in those aged 50%: moderate geomagnetic storms (60–99 Ap Index) were associated with a 27% (95% CI, 8%–48%) increased risk of stroke occurrence, strong geomagnetic storms (100–149 Ap Index) with a 52% (95% CI, 19%–92%) increased risk, and severe/extreme geomagnetic storms (Ap Index 150+) with a 52% (95% CI, 19%–94%) increased risk (test for trend, P −16 ). Conclusions— Geomagnetic storms are associated with increased risk of stroke and should be considered along with other established risk factors. Our findings provide a framework to advance stroke prevention through future investigation of the contribution of geomagnetic factors to the risk of stroke occurrence and pathogenesis.

Background and Purpose —Anticardiolipin antibodies (aCL) have been proposed to be an independent risk factor for stroke. To test this hypothesis, a nested case-control study was performed to compare aCL with the other known risk factors for stroke. Methods —Within the framework of the World Health Organization Multinational Moni toring of Trends and Determinants in Ca rdiovascular Disease (MONICA) project and the Västerbotten Intervention Program (VIP) health survey, 44 725 men and women were enrolled and followed up from January 1, 1985, through August 31, 1996. Individuals free from cardiovascular events were followed up, and 123 developed stroke (on average, 34.1 months after blood sampling; 21 cerebral hemorrhage and 102 cerebral infarction); they were compared with 241 age- and sex-matched control subjects from the same population. ELISA was used for the analysis of IgG, IgM, and IgA aCL. Results —IgM-aCL were present in 11.4% of patients (14/123) who developed stroke and in 4.1% of individuals (10/241) who remained healthy ( P =0.013, OR 2.97, 95% CI 1.28 to 6.89). The OR for the levels of IgM-aCL was 1.34 ( P =0.01, 95% CI 1.07 to 1.68) without adjustment for other risk factors and 1.24 when adjusted for hypertension, diabetes mellitus, cigarette smoking, and use of smokeless tobacco ( P =0.077, 95% CI 0.98 to 1.56). There was no difference between patients and controls for the prevalence or level of IgG-aCL and IgA-aCL and also no difference between patients with cerebral hemorrhage and cerebral infarction for the prevalence of all 3 isotypes of aCL. Conclusions —We conclude that aCL are associated with future stroke but do not constitute an independent risk factor.

Background and Purpose —The risk of ischemic stroke is increased after a myocardial infarction. We quantified the stroke risk and evaluated ischemic stroke characteristics after an acute myocardial infarction. Methods —A case-control study including patients with first-ever stroke was undertaken. Cases (n=103) were recorded prospectively in the population-based Northern Sweden World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study. Two controls per case with a stroke but without a recent myocardial infarction were matched for age, sex, and year of stroke onset. Results —The sudden onset of neurological symptoms (76.7% versus 54.9%, P P P P P P =NS); lacunar infarcts, 4.8% versus 27.2% ( P P =0.051). During the first 28 days after myocardial infarction, the daily rate of stroke declined rapidly from ≈9 to 1 stroke per 10 000 myocardial infarction patients compared with an age-adjusted average daily stroke rate of 0.14 per 10 000 in the MONICA population. Conclusions —We conclude that the clinical characteristics of the stroke differ between patients with and without a recent myocardial infarction. The risk of a first-ever ischemic stroke is highest during the first few days after a myocardial infarction, but it then declines rapidly, and the absolute number of stroke events is low.

Background and Purpose— To enable self-reporting of functional outcome in quality registers, the corresponding questions have to be easy to interpret. In scientific research, the modified Rankin Scale (mRS) is a standard assessment method. Such methods, with an outsider observer, are not feasible to use in quality registers. For several aspects, eg, comparisons between outcome in clinical studies and observational studies, we determined to see whether the functional outcome, as assessed in a quality register, can be transformed into mRS grades. Methods— The agreement between self-reported functional outcome (including dependency, living situation, mobility, dressing and toileting) and mRS were analyzed using 555 stroke patients registered in Riks-Stroke, the Swedish quality register for acute stroke, during a 5-month period in 4 hospitals. The self-reported outcome and the mRS grades were concurrently assessed by a telephone interview performed by an experienced nurse 3 months after stroke. Results— A translation using 5 of the questions from Riks-Stroke classified 76% of the patients to the correct mRS grade. The correlation between Riks-Stroke and mRS was 0.821 and Cohen’s κ (weighted) was 0.853. Conclusion— The study shows that self-reported functional outcome can be transformed into mRS grades with a high precision, making the translation useful for future comparative purposes in stroke outcome studies.

Background: Routinely collected databases are kept for administrative purposes. We have refined the analyses of the Swedish National Patient Register and the Cause of Death Register and explored their validity to monitor stroke at the population level. Methods: First-ever strokes (incident cases) and all stroke events were measured by combining the two administrative registers and adding refinements. The administrative registers were validated against the Northern Sweden MONICA, a well-validated population-based epidemiological stroke register. Positive predictive values (PPVs) and sensitivity were calculated. Results: After refinements (restriction to first-ever strokes and additional minor delineations), the PPV of the two administrative registers combined was 94% and sensitivity 92% when compared with all MONICA stroke categories together. For stroke attacks (first and recurrent events together), the PPV in the administrative registers was 85% and sensitivity 91%. The PPV was higher in women than in men, whereas the sensitivity was similar. The PPV was lower but sensitivity higher in people below compared with those above 75 years of age. Both PPV and sensitivity were lower among fatal cases than among cases that survived 28 days. Conclusions: After refinement, Swedish national administrative registers may, with some caveats, be used as a low-resource-consuming alternative to crudely monitor stroke incidence rates at the national level. If further accuracy is strived for, high-quality conventional epidemiological registers are required.

Background In the 1970s, men in northern Sweden had among the highest prevalences of cardiovascular diseases (CVD) worldwide. An intervention program combining population- and individual-oriented activities was initiated in 1985. Concurrently, collection of information on medical risk factors, lifestyle and anthropometry started. Today, these data make up one of the largest databases in the world on diet intake in a population-based sample, both in terms of sample size and follow-up period. The study examines trends in food and nutrient intake, serum cholesterol and body mass index (BMI) from 1986 to 2010 in northern Sweden. Methods Cross-sectional information on self-reported food and nutrient intake and measured body weight, height, and serum cholesterol were compiled for over 140,000 observations. Trends and trend breaks over the 25-year period were evaluated for energy-providing nutrients, foods contributing to fat intake, serum cholesterol and BMI. Results Reported intake of fat exhibited two significant trend breaks in both sexes: a decrease between 1986 and 1992 and an increase from 2002 (women) or 2004 (men). A reverse trend was noted for carbohydrates, whereas protein intake remained unchanged during the 25-year period. Significant trend breaks in intake of foods contributing to total fat intake were seen. Reported intake of wine increased sharply for both sexes (more so for women) and export beer increased for men. BMI increased continuously for both sexes, whereas serum cholesterol levels decreased during 1986 - 2004, remained unchanged until 2007 and then began to rise. The increase in serum cholesterol coincided with the increase in fat intake, especially with intake of saturated fat and fats for spreading on bread and cooking. Conclusions Men and women in northern Sweden decreased their reported fat intake in the first 7 years (1986–1992) of an intervention program. After 2004 fat intake increased sharply for both genders, which coincided with introduction of a positive media support for low carbohydrate-high-fat (LCHF) diet. The decrease and following increase in cholesterol levels occurred simultaneously with the time trends in food selection, whereas a constant increase in BMI remained unaltered. These changes in risk factors may have important effects on primary and secondary prevention of cardiovascular disease (CVD).

SUMMARYA stratified and randomly-selected population sample was identified in 1990 in order to study the seroprevalence of nephropathia epidemica (haemorrhagic fever with renal syndrome) in Northern Sweden. Sera from 1538 subjects (750 men, 788 women), 25—64 years of age, were analysed for the presence of Puumala virus (PUV) specific-IgG by the indirect immunofluorescence antibody test. Specific IgG was detected in sera from 83 subjects (5·4%). Men and women had similar seroprevalence rates. The highest seroprevalences were found in subjects 55 years or older (8·0%) and among farmers and forestry workers (15·9%). The geographic distribution of seropositive individuals was uneven and there were significantly more seropositive persons in rural than in urban areas (P < 0·05).

Abnormalities in homocysteine metabolism have been suggested as risk factors for stroke. The aim of this prospective study was to examine whether total plasma homocysteine concentration (tHcy) and its main genetic determinant, methylene tetrahydrofolate reductase (MTHFR) polymorphisms, were associated with first ischemic or hemorrhagic stroke.This was a nested case-referent study of 321 ischemic and 60 hemorrhagic stroke cases, defined by WHO MONICA criteria and each matched with two event-free referents for sex, age, cohort, recruitment date and geographical area. All subjects were from the population-based Northern Sweden Health and Disease Study cohorts. Odds ratios were determined by conditional logistic regression.The mean follow-up time was 4.2 years. Both tHcy and MTHFR were independent predictors of hemorrhagic stroke in multivariate models including body mass index, hypertension and, for MTHFR, tHcy [OR for the highest vs. lowest tHcy quartile 8.13 (95% CI 1.83-36.1), p(trend)=0.002; OR for MTHFR 677TT vs. 677CC genotype 3.62 (95% CI 0.77-17.0), p(trend)=0.040]. Haplotype analyses confirmed that the MTHFR 677T-1298A haplotype was positively associated with hemorrhagic stroke [OR 1.81 (95% CI 1.09-3.00), p=0.022], whereas the MTHFR 677C-1298C haplotype was not significantly related to either hemorrhagic or ischemic stroke. Neither tHcy nor the MTHFR polymorphisms were significant predictors of ischemic stroke.Both elevated plasma homocysteine levels and the MTHFR 677T allele are indicators of increased risk of hemorrhagic stroke in the northern Swedish population.

Background and Purpose— High-dose heparin has been used extensively to treat patients with progressive ischemic stroke, but the scientific support is poor and the current stroke guidelines advise against its use. We studied how heparin treatment for progressive stroke has been discarded in Sweden. Methods— All 78 hospitals in Sweden that admit acute stroke patients participate in Riks-Stroke, the Swedish Stroke Register. During 2001 to 2008, information on the use of high-dose heparin was available for 155 344 patients with acute ischemic stroke. The determinants as to region, patient characteristics, and stroke service settings were analyzed. Results— Use of heparin for progressive stroke declined from 7.5% (2001) to 1.6% (2008) of all patients with ischemic stroke. The marked regional differences present in 2001 were reduced over time. The use of heparin declined at a similar rate in all types of hospital settings, in stroke units vs nonstroke units, and in neurological vs medical wards. Independent predictors of use of heparin included younger age, first-ever stroke, independence in activities of daily living before stroke, atrial fibrillation, no aspirin treatment, and lowered consciousness on admission. Conclusions— There is no immediate, stepwise effect of new scientific information and national guidelines on clinical practice. Rather, the phasing out of heparin has followed a linear course over several years, with less variation between hospitals. We speculate that open comparisons between hospitals in a national stroke register may have helped to reduce the variations in clinical practice.

Background and Purpose— Secondary prevention is recommended after stroke, but adherence to guidelines is unknown. We studied the prescription of antiplatelet drugs, angiotensin-converting enzyme inhibitors, statins, and anticoagulant drugs and their relation to risk of death. Methods— Patients with first-ever ischemic stroke in 2005 were registered in the Swedish Stroke Register. Odds ratios, hazard ratios, and 95% CIs were calculated using logistic and Cox proportional hazard regression models. Adjustments were performed for age, sex, cardiovascular risk factors, other drug therapies, and activities of daily living function. Results— In total, 14 529 patients with a mean age of 75.0 (±11.6) years were included. They were followed for 1.4 (±0.5) years: 52% had hypertension, 26% atrial fibrillation, 19% diabetes, and 15% were smokers. The odds ratio for prescription of antiplatelet was 2.20 (95% CI, 1.86 to 2.60) among the oldest patients (≥85 years of age) compared with the youngest (18 to 64 years of age). The corresponding odds ratio was 0.38 (0.32 to 0.45) for prescriptions of angiotensin-converting enzyme inhibitors, 0.09 (0.08 to 0.11) for statins, and 0.07 (0.05 to 0.09) for anticoagulant therapy. Prescription of statin and anticoagulant therapy was associated with reduced risk of death (hazard ratio, 0.78 [0.65 to 0.91] and hazard ratio, 0.58 [0.44 to 0.76], respectively) but not the prescription of antiplatelet drugs or angiotensin-converting enzyme inhibitors. Conclusions— The prescription of antiplatelet, angiotensin-converting enzyme inhibitors, statins, and anticoagulant therapy was strongly age related. Statin and anticoagulant therapy was associated with reduced risk of death and seemed to be underused among elderly patients. These findings should encourage physicians to follow today’s guidelines for stroke care.

Background and Purpose— We used Riks-Stroke, the Swedish Stroke Register, to explore how thrombolysis has been disseminated in Swedish hospitals since it was approved in 2003. Methods— All 78 hospitals in Sweden admitting patients with acute stroke participate in Riks-Stroke. Between 2003 and 2008, 72 033 adult patients were hospitalized for acute ischemic stroke. We analyzed thrombolysis use by region, patient characteristics, and stroke service settings. Results— Nationwide, the use of thrombolysis increased from 0.9% in 2003 to 6.6% in 2008. There were marked regional differences in the dissemination of thrombolysis, but these gaps narrowed over time. Nonuniversity hospitals reached treatment levels similar to university settings, although with a 2- to 3-year delay. Symptomatic intracranial hemorrhage remained at the 3% to 9% level without an apparent time trend during dissemination. Independent predictors of higher thrombolysis use included younger age, male sex, not living alone, and no history of stroke or diabetes. In 2008, patients admitted to a stroke unit were 5 times more likely to receive thrombolysis than those admitted to general wards. Conclusions— Nationwide implementation of thrombolysis has been slow but has accelerated mainly due to increased access outside university hospitals. The increased use has been achieved safely, but access has been unequal.

Background and Purpose— Natural immunoglobulin M antibodies specific for phosphorylcholine (anti-PC) have been implicated in atherosclerosis. We have shown previously that high levels of anti-PC predict a slower progression of atherosclerosis in humans and that low levels of anti-PC are associated with higher risk for cardiovascular disease. Here we determine the association between anti-PC and the incidence of stroke. Methods— Using a nested case control study design, we examined 227 incident cases (125 men and 102 women) of first-time stroke and 455 age- and sex-matched controls identified during a 13-year time period (1985 to 1999) within the population-based cohorts of the Västerbotten Intervention Project (VIP) and the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (WHO MONICA) project in Northern Sweden. Odds ratios of stroke with 95% CIs with adjustments for age, gender, smoking, serum cholesterol, diabetes, body mass index, and blood pressure were determined. Anti-PC levels were measured using ELISA. Results— A significant association between low levels of anti-PC at baseline and incident stroke was seen for the whole group of anti-PC levels below the 30th percentile (multivariately adjusted odds ratio, 1.62; CI, 1.11 to 2.35). Analyses of gender-specific associations indicated fairly strong associations for females, especially at the lowest 30th percentile (multivariately adjusted odds ratio, 2.65; CI, 1.41 to 4.95). No associations were noted for men. Conclusion— Low anti-PC is a novel independent risk marker for development of stroke. Measurements of anti-PC could be used to identify immunodeficient subjects at an increased risk for stroke. The possibility that such subjects might be targets for novel modes of treatment such as immunotherapies deserves further investigation.

The validity of routine stroke data (official mortality statistics and hospital discharge registries) and a population-based MONICA stroke registry was assessed in a population of 309,806 25- to 74-year-old people in Sweden. The 'true' number of strokes in the population was estimated by screening for non-stroke diagnoses in death certificates and hospital discharge records and by a period of intensified search for otherwise unrecognized non-hospitalized stroke cases. Applying strict stroke criteria, the proportion of false-positive diagnoses was 10% and false-negative 17% in official mortality statistics. Among patients discharged alive from hospital, there were 32% false-positive and 6% false-negative stroke diagnoses. In the MONICA registry, the proportion of false-negative cases was 6% in fatal cases and 4% in non-fatal cases. Diagnostic information for subtyping stroke improved over time in non-fatal cases but remained essentially unchanged in fatal cases. We conclude that official mortality statistics give a reasonably good estimate of fatal stroke cases in Sweden, whereas hospital discharge records reflect poorly the incidence of stroke in the population. The overall quality of the population-based MONICA registry is good, although 4% of all strokes are missed. The proportion of unspecified stroke is substantial and changes over time; this makes longitudinal studies of stroke subtype difficult.

The functional outcome of 42 patients with idiopathic adult hydrocephalus syndrome (IAHS) was followed over a 3-year period after shunting. Survival curves were compared with those of age-matched healthy elderly subjects and patients with first-ever ischemic stroke. Twenty-seven patients with IAHS were improved 3 months after the operation and 11 remained improved at the 3-year follow-up. The case fatality in patients with stroke and those with IAHS was similar (32% versus 28%), but the relative risk of death among IAHS patients compared to a general elderly population was 3.3.

The population of northern Sweden is characterized by reduced genetic diversity and a high incidence of stroke. We sought to reduce genetic variation further, using genealogic analysis in a set of nuclear families affected by stroke, and we subsequently performed a genome-wide scan to identify novel stroke susceptibility loci.Through genealogy, 7 nuclear families with a common ancestor, connected over 8 generations, were identified. A genome-wide scan using 449 microsatellite markers was performed with subsequent haplotype analyses.A maximum allele-sharing lod score of 4.81 on chromosome 9q31-q33 was detected. Haplotype analysis identified a common 2.2-megabase interval in the chromosomal region in 4 of the nuclear families, where an overrepresentation of intracerebral hemorrhage was observed.We have identified a novel susceptibility locus for stroke. Haplotype analysis suggests that a shared genetic factor is of particular importance for intracerebral hemorrhage.

Background Dairy products are high in saturated fat and are traditionally a risk factor for vascular diseases. The fatty acids 15:0 and 17:0 of plasma lipids are biomarkers of milk fat intake. The aim of the present study was to evaluate the risk of a first-ever stroke in relation to the plasma milk fat biomarkers. Methods A prospective case-control study was nested within two population based health surveys in Northern Sweden. Among 129 stroke cases and 257 matched controls, plasma samples for fatty acid analyses were available in 108 cases and 216 control subjects. Proportions of 15:0 and 17:0 of plasma lipids, weight, height, blood lipids, blood pressures, and lifestyle data were employed in conditional logistic regression modelling. Results The proportions of fatty acids 17:0 and 15:0+17:0 of total plasma phospholipids were significantly higher in female controls than cases, but not in men. 17:0 and 15:0+17:0 were significantly and inversely related to stroke in the whole study sample as well as in women. The standardised odds ratio (95% CI) in women to have a stroke was 0.41 (0.24–0.69) for 17:0 in plasma phospholipids. Adjustment for traditional cardiovascular risk factors, physical activity and diet had marginal effects on the odds ratios. A similar, but non-significant, trend was seen in men. Conclusion It is hypothesised that dairy or milk fat intake may be inversely related to the risk of a first event of stroke. The intriguing results of this study should be interpreted with caution. Follow up studies with greater power, and where intakes are monitored both by dietary recordings and fatty acid markers are needed.

Background: Treatment at stroke units is superior to treatment at other types of wards. The objective of the present study is to determine the effect size of stroke unit care in subgroups of patients with stroke. This information might be useful in a formal priority setting. Methods: All acute strokes reported to the Swedish Stroke Register from 2001 through 2005 were followed until January 2007. The subgroups were age (18-64, 65-74, 75-84, 85+ years and above), sex (male, female), stroke subtype (intracerebral haemorrhage, cerebral infarction and unspecified stroke) and level of consciousness (conscious, reduced, unconscious). Cox proportional hazards and logistic regression analyses were used to estimate the risk for death, institutional living or dependency. Results: 105 043 patients were registered at 86 hospitals. 79 689 patients (76%) were treated in stroke units and 25 354 patients (24%) in other types of wards. Stroke unit care was associated with better long-term survival in all subgroups. The best relative effect was seen among the following subgroups: age 18-64 years (hazard ratio (HR) for death 0.53; 0.49 to 0.58), intracerebral haemorrhage (HR 0.61; 0.58 to 0.65) and unconsciousness (HR 0.70; 0.66 to 0.75). Stroke unit care was also associated with reduced risk for death or institutional living after 3 months. Conclusions: Stroke unit care was associated with better long-term survival in all subgroups, but younger patients, patients with intracerebral haemorrhage and patients who were unconscious had the best relative effect and may be given the highest priority to this form of care.

Background and Purpose— Previous reports concerning sex-related differences in stroke management and outcome are inconsistent and are sometimes difficult to interpret. We used data from a national stroke register to further explore possible differences between men and women in baseline characteristics, stroke treatment, and outcome. Methods— This study included 24633 stroke events registered in Riks-Stroke, the Swedish national quality register for stroke care, during 2006. Information on background variables and treatment was collected during the hospital stay. After 3 months, the patients’ living situation and outcome were assessed. Results— Women were older than men when they had their stroke (mean age, 78.4 versus 73.6 years; P Conclusions— Reported sex differences in stroke care and outcome were mainly explained by the women’s higher age and lower level of consciousness on admission.

OBJECTIVE—We investigated stroke mortality in individuals in different categories of glycemia and compared hazard ratios (HRs) corresponding to a 1-SD increase in 2-h plasma glucose and fasting plasma glucose (FPG) criteria. RESEARCH DESIGN AND METHODS—We examined data from 2-h 75-g oral glucose tolerance tests taken from 13 European cohorts comprising 11,844 (55%) men and 9,862 (45%) women who were followed up for a median of 10.5 years. A multivariate adjusted Cox proportional hazards model was used to estimate HRs for stroke mortality. RESULTS—In men and women without a prior history of diabetes, multivariate adjusted HRs for stroke mortality corresponding to a 1-SD increase in FPG were 1.02 (95% CI 0.83–1.25) and 1.52 (1.22–1.88) and those in 2-h plasma glucose 1.21 (1.06–1.38) and 1.31 (1.06–1.61), respectively. Addition of 2-h plasma glucose to the model with FPG significantly improved prediction of stroke mortality in men (χ2 = 10.12; P = 0.001) but not in women (χ2 = 0.01; P = 0.94), whereas addition of FPG to 2-h plasma glucose improved stroke mortality in women (χ2 = 4.08; P = 0.04) but not in men (χ2 = 3.29; P = 0.07). CONCLUSIONS—Diabetes defined by either FPG or 2-h plasma glucose increases the risk of stroke mortality. In individuals without a history of diabetes, elevated 2-h postchallenge glucose is a better predictor than elevated fasting glucose in men, whereas the latter is better than the former in women.

Cardiovascular disease (CVD) and obesity have been coupled to short telomere length in peripheral blood. The biological background to this observation is not obvious from the literature. In this study we have analyzed a large set of known risk factors for CVD in relation to telomere length in blood cells on a merged cohort of 989 individuals recruited in the Malmo Diet and Cancer Cohort (MDCC) and the Northern Sweden MONICA project. We found a significant or borderline association between obesity parameters and telomere length in women after age and center adjustments (BMI: r = -0.106, P = 0.021, weight: r = -0.087, P = 0.060, waist circumference: r = -0.099, P = 0.032, hip circumference: r = -0.128, P = 0.005). In men, a positive borderline correlation to high-density lipoprotein (HDL) (r = 0.111, P = 0.053) and a negative correlation to 2-h post-oral glucose-tolerance test (OGTT) was observed (r = -0.202, P = 0.045). In neither group any association was found between telomere length and cholesterol, serum triglycerides, serum low-density lipoprotein, plasma insulin, blood pressure, pulse pressure, or smoking habits. Our data indicate that telomere length is associated with an "obesity-phenotype" but only in women.

Background and Purpose— Several studies indicate a declining case-fatality and mortality in stroke. Little is known about time trends in stroke for subjects with diabetes. The purpose of this study was to compare time trends in incidence, case-fatality and mortality for stroke patients with or without diabetes. Methods— This study was based on the Northern Sweden MONICA Project Stroke registry during 1985 to 2003. 15 382 patients, aged 35 to 74 years, were included in the study. 11 605 had a first-ever stroke and 3777 had a recurrent stroke. In both men and women previously diagnosed diabetes was found in 22.8%. Results— The incidence of stroke was 5 and 8 times higher in diabetic subjects than in nondiabetics, in men and women, respectively. Incidence of first-ever stroke decreased for nondiabetic men, probability value Conclusion— The incidence of stroke declined in both nondiabetic and diabetic subjects except for diabetic men and for nondiabetic women with first-ever stroke. Case-fatality in first-ever stroke declined for all but diabetic women. This led to a decreased mortality over the 19-year period for both groups. This is the first time that the decline in stroke incidence is reported in this MONICA population.

Telomeres are essential for maintaining chromosomal stability. Previous studies have indicated that individuals with shorter blood telomeres may be at higher risk of developing various types of cancer, such as in lung, bladder, and kidney. We have analyzed relative telomere length (RTL) of peripheral blood cells in relation to breast cancer incidence and prognosis. The study included 265 newly diagnosed breast cancer patients and 446 female controls. RTL was measured by real-time PCR, and our results show that the patient group displayed significantly longer telomeres compared with controls (P < 0.001). Age-adjusted odds ratios (OR) for breast cancer risk increased with increasing telomere length, with a maximal OR of 5.17 [95% confidence interval (95% CI), 3.09–8.64] for the quartile with the longest telomeres. Furthermore, RTL carried prognostic information for patients with advanced disease. Node positive (N+) patients with short telomeres (≤median) showed an increased survival compared with N+ patients with long telomeres (P = 0.001). For patients with ages 16 mm (median tumor diameter), short telomeres were associated with a significantly better outcome than longer telomeres (P = 0.006). Cox regression analysis showed that long RTL was a significant independent negative prognostic factor (hazards ratio, 2.92; 95% CI, 1.33–6.39; P = 0.007). Our results indicate that blood RTL may serve as a prognostic indicator in breast cancer patients with advanced disease. [Cancer Res 2008;68(10):3618–23]

Objective: Obesity, especially abdominal, is a risk factor for many diseases. This study explored trends in theprevalence of general and abdominal obesity, 1986–2004, in northern Sweden. Methods and Procedures: Cross-sectional population surveys were performed in 1986, 1990, 1994, 1999, and 2004;250 men and 250 women aged 25−34, 35−44, 45−54, and 55−64 years (from 1994, also 65−74 years) were randomlyselected; the overall participation rate was 77%. Anthropometric data were used. Results: Weight and BMI increased in all men, most significantly in men aged 25−64 years (P < 0.0005). Weightincreased in women aged 25−64 years (P < 0.005) and BMI in women aged 25−44 years (P < 0.005). Prevalence ofobesity (BMI≥ 30) increased significantly in men aged 25−44 and 55−74 years (P < 0.005; for men 65−74 years old,P< 0.05) and in women aged 25−44 years (P < 0.005). Waist circumference decreased significantly between 1986and 1990 in all women (P < 0.005) and in men aged 55−64 years (P < 0.05). After 1990 waist circumference increased, most markedly so in women; by 2004 circumference measurements for women, and for men aged 55−64 years, were equal to those of 1986, while for men aged 25−54 years they were higher. Prevalence of abdominal obesity has increased since 1990, most markedly so in women aged 45−64 years (P < 0.0005). Discussion: The rapid increase in both general and central obesity raises concern for the future; increasing abdominalobesity in women is particularly alarming.

This study analyzed the potential association between shift work and ischemic stroke.The analysis was carried out using a nested case-control study consisting of 138 shift workers and 469 day workers from the register of the Northern Sweden Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) study and the Västerbotten Intervention Programme. Logistic regression analysis was used to analyze the risk estimate for day workers in a comparison with shift workers and the risk of ischemic stroke.The crude odds ratio for shift workers' risk of experiencing an ischemic stroke was 1.0 (95% confidence interval 0.6-1.8) for both the men and the women. The risk estimates were consistent despite the introduction of several recognized risk factors for ischemic stroke in the logistic regression models.In the present study, none of the findings indicated a higher risk of shift workers undergoing an ischemic stroke than day workers.