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To study incident narcolepsy in first- and second-generation immigrant groups using Swedish-born individuals and native Swedes as referents.The study population included all individuals registered and alive in Sweden at baseline. Narcolepsy was defined as having at least one registered diagnosis of narcolepsy in the Swedish National Patient Register. The incidence of narcolepsy in different immigrant groups was assessed by Cox regression, with hazard ratios (HRs) and 95% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, co-morbidities, and neighbourhood socioeconomic status.In the first-generation study, 1225 narcolepsy cases were found; 465 males and 760 females, and in the second-generation study, 1710 cases, 702 males and 1008 females. Fully adjusted HRs (95% CI) in the first-generation study was for males 0.83 (0.61-1.13) and females 0.83 (0.64-1.07), and in the second-generation study for males 0.76 (0.60-0.95) and females 0.91 (95% CI 0.76-1.09). Statistically significant excess risks of narcolepsy were found in first-generation males from North America, and second-generation males with parents from North America, and second-generation females with parents from Latin America.There were only significant differences in incident narcolepsy between native Swedes and second-generation male immigrants. The observed differences can partly be explained by differences in Pandemrix® vaccinations and are probably not attributable to genetic differences between immigrants and natives.

Purpose To analyse risk of vision impairment (VI) and blindness in adult foreign-born individuals and Swedish-born individuals. Methods A nationwide study of individuals 18 years of age and older (N = 6,042,891; 2,902,918 men and 3,139,973 women) in Sweden. VI (in general) and blindness was defined as at least one registered diagnosis in the National Patient Register between January 1, 1998 and December 31, 2015. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident VI in foreign-born compared to Swedish-born individuals. The Cox regression models were stratified by sex and adjusted for age, co-morbidities, and for sociodemographic status. Results A total of 14,597 cases (6433 men and 8164 women) of VI were registered, with an age-standardized incidence per 100,000 person-years of 10.37 in men and 11.03 in women. VI (in general) was more common in immigrants, fully adjusted HRs (95% CI) were for immigrant men 1.38 (95% CI, 1.29–1.48) and women 1.24 (95% CI, 1.16–1.32), with significantly higher HRs among men and women from Eastern Europe, Africa, Latin America and Asia. Higher risks of blindness were also seen for immigrant men, HR 1.75 (95% CI 1.36–2.25), as well as for the other degrees of VI among immigrant men, HR 1.36 (95% CI 1.26–1.47), and immigrant women, HR 1.26 (95% CI 1.18–1.35). Conclusions We observed a generally higher risk of VI among foreign-born men and women, especially from some regions.

Purpose Prostate cancer is the second most common cancer in men and a leading cause of cancer mortality worldwide. Men with drug use disorders (DUD) may potentially be at high risk for prostate cancer mortality because of delayed diagnosis and/or undertreatment. In this study, we aimed to investigate prostate cancer incidence, mortality, and stage at time of diagnosis among men with DUD compared to the general male population in Sweden. Methods We performed a follow-up study based on Swedish national register data for the period January 1997–December 2016. The study was based on 1,361,532 men aged 50–75 years at inclusion, of whom 9,259 were registered with DUD. Cox regression analysis was used to compute adjusted hazard ratios (HRs) for incident and fatal prostate cancer, and cancer stage at time of diagnosis, associated with DUD. Results DUD was associated with a slightly increased risk of incident prostate cancer (HR: 1.07, 95% confidence interval [CI] 1.00–1.14, p = 0.048) and substantially higher risk of fatal prostate cancer (HR: 1.59, 95% CI 1.40–1.82, p Conclusions Men with DUD have an increased risk of fatal prostate cancer, possibly related to undertreatment in this patient population. Our findings should raise attention among medical staff and decision-makers towards a disadvantaged group of men in need of easily accessible prostate cancer evaluation and treatment.

Objective: To study the relationship between sociodemographic factors and pyelonephritis. Methods: A nationwide open cohort study consisting of 2,052,873 women (76.2% Swedish-born) aged 15-50 years was conducted (1997-2018). The outcome was the first event of acute uncomplicated pyelonephritis diagnosed in primary healthcare settings in relation to the sociodemographic factors. Cox regression models were used in the analyses. Results: The study identified 40,724 cases. In the fully adjusted model, women from non-Western countries had a higher risk of pyelonephritis compared to Swedish-born women. Women from Latin America/the Caribbean had the highest risk (Hazard ratio = 1.60; 95% CI 1.49-1.72), followed by Eastern Europe (HR = 1.26; 95% CI 1.21-1.32) and the Middle East/North Africa (HR = 1.25; 95% CI 1.19-1.30). Low education, low income, urban living, and young age were also associated with higher risks of pyelonephritis. Conclusion: This study presents novel risk factors associated with pyelonephritis. Women from non-Western countries and with low socioeconomic status might disproportionately suffer from this serious infection. This might be due to biological predispositions and the fact that immigrant women do not acquire the same level of health or might receive less healthcare compared to native women, even in the presence of universal healthcare. (Less)

Purpose We aimed to analyze the risk of cardiomyopathies (CMPs) among first-generation and second-generation immigrants. Methods All individuals aged 18 years of age and older, n = 6,123,661 in the first-generation study, and n = 4,587,764 in the second-generation study were analyzed. CMP was defined as at least one registered diagnosis in the National Patient Register between January 1, 1998 and December 31, 2018. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 99% confidence intervals (CI)) of incident CMP with adjustments made for age, cancer, other comorbidities, and sociodemographic factors. Results In the first-generation study, a total of 33,321 CMP cases were registered, 20,780 men and 12,541 women, where the fully adjusted models showed HRs (99% CI) for all foreign-born men of 0.92 (0.86–0.98) and for women of 0.90 (0.83–0.98). For dilated CMP, the risk was higher for men from Nordic countries, more specifically men from Finland, and lower for men and women from Asia. For hypertrophic CMP, the risk was higher for men from Africa and Asia. For other types of CMPs, the risk was lower in men and women from Asia. In the second-generation study, a total of 26,559 cases were registered (17,620 men and 8939 women), with no significant differences overall or among specific groups, when Swedish-born with foreign-born parents were compared to Swedish-born with Swedish-born parents. Conclusions We observed a generally lower risk of CMPs among foreign-born individuals, but with a higher risk especially for hypertrophic CMPs for men from Africa and Asia, and a higher risk of dilated CMP for men from Nordic countries.

Background There is a lack of studies of amyotrophic lateral sclerosis (ALS) in immigrants. Objective The objective is to study the association between country of birth and incident ALS in first-generation immigrants versus Swedish-born individuals, and in second-generation immigrants versus native Swedes. Methods Study populations included all adults aged 18 years and older in Sweden, in the first-generation study 6,128,698 individuals (2,975,141 men, 3,153,557 women) with 5,344 ALS cases (3017 men, 2327 women), and in the second-generation study 4,588,845 individuals (2,346,855 men and 2,241,990 women) with 3,420 cases (2027 men and 1393 women). ALS was defined as having at least one registered diagnosis of ALS in the National Patient Register 1998–2017. The incidence of ALS in different first-generation immigrant groups versus Swedish-born individuals was assessed by Cox regression, expressed as hazard ratios (HRs) with 95% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, and neighbourhood socioeconomic status. Results After adjusting for potential confounders, the HRs were lower in foreign-born men, 0.71 (95% CI 0.63–0.81), and women, 0.80 (95% CI 0.70–0.92). The ALS risk was lower among men and women from most Western countries (Europe outside Nordic countries, and North America), and from other regions of the world (Africa, Asia, and Latin America). Among men and women with foreign-born parents, the risk of ALS did not differ significantly from native Swedes. Significance In general, the risk of ALS was lower in first-generation men and women but did not differ in second-generation individuals.

Objectives. The aim of this study was to analyse the risk of valvular heart diseases among foreign-born individuals in Sweden. Design. This was a nationwide study of individuals aged 18 years of age and older (N = 6,118,649; 2,970,055 men and 3,148,594 women). Valvular heart diseases were defined as at least one registered diagnosis in the National Patient Register between 1 January 1998 and 31 December 2012. Cox regression analysis was used to estimate hazard ratios (HR) with 99% confidence intervals (CI) of incident valvular heart diseases in foreign-born individuals compared to Swedish natives. The Cox regression models were adjusted for age, co-morbidities, and sociodemographic factors. Sub-categories were chronic rheumatic valvular heart diseases and non-rheumatic valvular heart diseases. Results. There were 64,979 male cases and 59,075 female cases. Fully adjusted HRs (99% CI) were among immigrant men 0.86 (0.82–0.89) and immigrant women 0.96 (0.92–1.00). For chronic rheumatic valvular disease among immigrant men and women, the HRs were 1.62 (1.37–1.92) and 1.75 (1.52–2.00), respectively, and, for non-rheumatic valvular disease among immigrant men 0.83 (0.80–0.87) and immigrant women 0.92 (0.88–0.96). Increased risks for chronic rheumatic valvular disease were found among men from Southern, Eastern and Central Europe, Africa and Asia and among women from Western, Eastern and Central Europe and Africa, Latin America and Asia. Conclusions. We observed lower risks in general of valvular heart disease, but higher risks of chronic rheumatic valvular heart disease in immigrants, which is important in the clinical situation.

Aim: We aimed to estimate the risk of hearing impairment in children and adolescents with foreign-born parents, compared to natives. Methods: A nationwide study of 1,923,590 (51.4% boys) individuals aged 0–17 years of age in Sweden. Hearing impairment was defined as at least one registered diagnosis in the National Patient Register between 1 January 1998 and 31 December 2015. We used Cox regression analysis to estimate relative risk (hazard ratios with 99% confidence intervals) of incident hearing impairment in children with foreign-born parents compared to Swedish-born natives. Cox regression models were stratified by sex and adjusted for age, co-morbidities and socioeconomic status. Results: A total of 20,514 cases (53.7% boys) with extended sensorineural hearing impairment were registered, also including noise-induced hearing impairment and that from other causes, and 6172 cases (50.0% boys) with conductive hearing impairment. The risk of extended sensorineural hearing impairment was higher in boys with parents from Asia, especially from Iraq, fully adjusted HR (99% CI) 1.30 (1.17–1.4), and lower in boys with parents from Nordic countries, South Europe, and North America. Conclusion: The risk of extended sensorineural hearing impairment was higher in boys with parents from Asia, in particular Iraq. (Less)

Aims Certain autoimmune diseases (ADs), such as Crohn’s disease and celiac diseases, have been linked to acute cardiovascular disorders. We examined whether there is an association between 43 different ADs and risk of subsequent hospitalization and mortality of cardiomyopathy in a nationwide follow-up study in Sweden. Methods and results All individuals in Sweden hospitalized with a main diagnosis of an AD (n = 955 410) without previous or coexisting cardiomyopathy, between 1 January 1987 and 31 December 2018, were followed for hospitalization or mortality of cardiomyopathy. The reference population was the total population of Sweden. Standardized incidence ratios (SIRs) for cardiomyopathy were calculated. Overall risk of cardiomyopathy during the first year after hospitalization for an AD was 3.63 [99% confidence interval (CI) 3.29–4.00]. A total of 21 of the 43 ADs studied were associated with an increased risk of cardiomyopathy during the first year after hospitalization. The overall risk of cardiomyopathy decreased over time, from 1.18 (99% CI 1.12–1.25) after 1+ year to 1.07 (99% CI 0.96–1.19) after 5+ years. Females generally had higher SIRs than males. The ADs for which the SIRs of cardiomyopathy were highest after 1 year of hospitalization included Crohn’s disease (1.92), rheumatoid arthritis (1.57), sarcoidosis (1.48), and psoriasis (1.31). Conclusion Most ADs are associated with an increased risk of cardiomyopathy, particularly in the first year after hospital admission. Our findings show that many hospitalized ADs are tightly linked to cardiomyopathy but the mechanisms need to be further evaluated.

Background/Aim Cervical cancer incidence and mortality has decreased after introduction of national screening in Sweden, but women with drug use disorders (DUD) are less likely to participate in screening programs. We aimed to investigate cervical cancer incidence and mortality among women with DUD compared to the general female population in Sweden. Methods We conducted a cohort study based on Swedish national register data for the period January 1997–December 2015. Data was collected for 3,838,248 women aged 15–75 years of whom 50,858 had DUD. Adjusted hazard ratios (HRs) for incident and fatal cervical cancer were calculated for women with and without DUD using Cox regression analysis. Results DUD was significantly associated with incident cervical cancer (HR = 1.39, 95% confidence interval [CI] 1.39–1.61), but not fatal cervical cancer (HR = 1.25, 95% CI: 0.91–1.71), after adjusting for age, educational attainment, social welfare, region of residence, marital status and HIV infection. Conclusion Women with DUD were thus identified as a risk group for incident cervical cancer, which calls for attention from clinicians and policy makers. It is possible that non-attendance in cancer screening and other healthcare seeking barriers may affect the risk of incident cervical cancer among women with DUD but more research on this topic is needed.

Background There is a lack of studies of Huntington’s disease (HD) in immigrants. Objective To study the association between country of birth and incident HD in first-generation immigrants versus Swedish-born individuals and in second-generation immigrants versus Swedish-born individuals with Swedish-born parents. Methods Study populations included all adults aged 18 years and older in Sweden, i.e., in the first-generation study 6,042,891 individuals with 1034 HD cases and in the second-generation study 4,860,469 individuals with 1001 cases. HD was defined as having at least one registered diagnosis of HD in the National Patient Register. The incidence of HD in different first-generation immigrant groups versus Swedish-born individuals was assessed by Cox regression, expressed as hazard ratios (HRs) and 95% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, and neighborhood socioeconomic status. Results Mean age-standardized incidence rates per 100,000 person-years were for all Swedish-born 0.82 and for all foreign born 0.53 and for all men 0.73 and for all women 0.81, with the highest incidence rates for the group 80–84 years of age. After adjusting for potential confounders, the HRs were lower in women in the first- and second-generation, i.e., 0.49 (95% CI 0.36–0.67) and 0.63 (95% 0.45–0.87), respectively, and also among women from Finland or with parents from Finland. Significance In general, the risk of HD was lower in first-generation and second-generation immigrant women but not among male immigrants.

Background Aortic stenosis (AS) is the most common valvular heart disease in developed countries, confers high mortality in advanced cases, but can effectively be reversed using endovascular or open-heart surgery. We evaluated the association between AS and neighborhood socioeconomic status (NSES). Methods We used Swedish population-based nationwide registers and an echocardiography screening cohort during the study period 1997–2014. NSES was determined by an established neighborhood deprivation index composed of education, income, unemployment, and receipt of social welfare. Multilevel adjusted logistic regression models determined the association between NSES and incident AS (according to ICD-10 diagnostic codes). Results The study population of men and women (n=6,641,905) was divided into individuals living in high (n = 1,608,815 [24%]), moderate (n = 3,857,367 [58%]) and low (n = 1,175,723 [18%]) SES neighborhoods. There were 63,227 AS cases in total. Low NSES (versus high) was associated with a slightly increased risk of AS (OR 1.06 [95% CI 1.03–1.08]) in the nationwide study population. In the echocardiography screening cohort (n = 1586), the association between low NSES and AS was markedly stronger (OR: 2.73 [1.05–7.12]). There were more previously undiagnosed AS cases in low compared to high SES neighborhoods (3.1% versus 1.0%). Conclusions In this nationwide Swedish register study, low NSES was associated with a slightly increased risk of incident AS. However, the association was markedly stronger in the echocardiography screening cohort, which revealed an almost three-fold increase of AS among individuals living in low SES neighborhoods, possibly indicating an underdiagnosis of AS among these individuals.

Summary In this national study of osteoporotic fractures in foreign-born individuals, we found a lower risk of osteoporotic fractures in general among foreign-born individuals compared with Swedish-born, especially in immigrants from southern Europe. A higher risk was found among some groups, i.e. men and women from Bosnia and Iraq and men from Lebanon. Introduction The aim of this study was to analyse risk of osteoporotic fractures in foreign-born individuals compared with Swedish-born individuals. Methods This was a nationwide study of individuals 50 years of age and older (N = 2,775,736). Osteoporotic fractures were defined as at least one registered diagnosis of fractures in the hip, humerus, forearm or vertebrae, in the National Patient Register between January 1, 1998, and December 31, 2012. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 99% confidence intervals (CI)) of incident osteoporotic fractures in foreign-born compared with Swedish-born individuals. The Cox regression models were stratified by sex and adjusted for age, comorbidities and sociodemographic status. Results A total of 362,899 osteoporotic fractures were registered (96,847 among men and 266,052 among women), with hip fractures dominating (54.0% among men, 42.6% among women). Fully adjusted HRs (99% CI) were for all immigrant men 0.75 (99% CI, 0.73–0.78) and women 0.83 (99% CI, 0.81–0.84), with significantly lower HRs among most groups but with higher HRs in certain countries. For the specific fractures, higher HRs were found for lower forearm fractures for men from Asia and for vertebral fractures among women from Asia. Conclusions We observed a generally lower risk of osteoporotic fractures among first-generation immigrants, with few exceptions. Electronic supplementary material The online version of this article (10.1007/s00198-020-05597-5) contains supplementary material, which is available to authorized users.

Congestive heart failure (CHF) is the most important cause of death in patients with atrial fibrillation (AF). We aimed to study the association between cardiovascular drugs in AF patients and incident CHF. The study population included all adults (n = 120 756) aged ≥45 years diagnosed with AF in Sweden diagnosed for the period 1998‐2006. Outcome was incident congestive heart failure (follow‐up 2007‐2015) in AF patients. Associations between treatment with cardiovascular pharmacotherapies and CHF were evaluated using Cox regression to estimate hazard ratios (HRs) with 95% CIs, after adjustment for age, sociodemographic variables, and comorbidities. During a mean 5.3 years (SD 3.0) of follow‐up, there were 28 257 (23.4%) incident cases of CHF. Treatment with beta‐1‐selective and non‐selective beta‐blockers and statins was associated with lower risks of incident CHF in men, HR, (95% CI); 0.90, (0.87‐0.94); 0.90, (0.84‐0.97), and 0.94, (0.90‐0.99), respectively. Only beta‐1‐selective beta‐blockers were protective in women 0.94 (0.91‐0.98). Treatment with loop diuretics, potassium‐saving agents, ACE inhibitors, and angiotensin receptor blockers was associated with a higher risk of CHF. For men, treatment with heart‐active calcium channel blockers also led to a higher risk of CHF. In conclusion, we found that beta‐blockers, in particular, but also statins were associated with lower risk of incident CHF in patients with AF.

Aim: To compare incidence of urolithiasis in second-generation immigrant children aged 0-17 years to children of Swedish-born parents. Methods: A nationwide study of individuals residing in Sweden. Urolithiasis was defined as having at least one registered diagnosis of urolithiasis in the Swedish National Patient Register between January 1, 1998 and December 31, 2015. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident urolithiasis compared to individuals with Swedish-born parents. The models were stratified by sex and adjusted for age, co-morbidities and sociodemographic status of parents. Results: Totally, 1653 incident cases of urolithiasis were registered, 658 boys and 995 girls, with a mean annual incidence per 100 000 person-years for children with Swedish-born parents of 4.0 (95% CI 3.7-4.3) in boys and 6.7 (95% CI 6.2-7.2) in girls, and for children with foreign-born parents of 5.3 (95% CI 5.1-5.4) in boys and 7.2 (95% CI 6.9-7.4) in girls. The fully adjusted HRs of urolithiasis in second-generation immigrants were non-significant, in boys (1.20, 95% CI 0.99-1.46) and girls (0.95, 95% CI 0.80-1.12). Conclusion: The risk of urolithiasis in second-generation immigrants was not significantly different from that of children with Swedish-born parents. (Less)

Background Our aim was to study the potential effect of neighborhood deprivation on incident heart failure (HF) in patients with diabetes mellitus (DM). Methods The study population included adults (n = 434,542) aged 30 years or older with DM followed from 2005 to 2015 in Sweden for incident HF. The association between neighborhood deprivation and the outcome was explored using Cox regression analysis, with hazard ratios (HRs) and 95% confidence intervals (95% CIs). All models were conducted in both men and women and adjusted for age, educational level, family income, employment status, region of residence, immigrant status, marital status, mobility, and comorbidities. DM patients living in neighborhoods with high or moderate levels of deprivation were compared with those living in neighborhoods with low deprivation scores (reference group). Results There was an association between level of neighborhood deprivation and HF in DM patients. The HRs were 1.27, 95% CI 1.21–1.33, for men and 1.30, 95% CI 1.23–1.37, for women) among DM patients living in high deprivation neighborhoods compared with those from low deprivation neighborhoods. After adjustments for potential confounders, the higher HRs of HF remained significant: 1.11, 95% CI 1.06–1.16, in men and 1.15, 95% CI 1.09–1.21, in women living in high deprivation neighborhoods. Conclusions Increased incidence rates of HF among DM patients living in deprived neighborhoods raise important clinical and public health concerns. These findings could serve as an aid to policy-makers when allocating resources in primary health-care settings as well as to clinicians who encounter patients in deprived neighborhoods.

Objectives To analyze the risk of hearing impairment in adult first-generation immigrants, i.e., foreign-born individuals as compared to Swedish-born individuals. Study design A register-based study follow-up study. Methods A nationwide study of individuals 25 years of age and older (N = 5 464 245; 2 627 364 men and 2 836 881 women) in Sweden. Hearing impairment was defined as at least one registered diagnosis in the National Patient Register between January 1st, 1998 and December 31st, 2015. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident hearing impairment in foreign-born compared to Swedish-born individuals. Cox regression models were stratified by sex and adjusted for age, comorbidities, and socioeconomic status. Results A total of 244 171 cases (124 349 men and 119 822 women) of hearing impairment were registered. Hearing impairment risk expressed as fully adjusted HRs (99% CI) was somewhat lower among immigrant men 0.95 (0.92–97) but not among immigrant women 0.97 (0.95–1.00), with significantly higher fully adjusted HRs among men and women from Asia, and Eastern Europe, and women from Africa. Conclusions We observed a somewhat lower risk of hearing impairment among foreign-born men, but there was a higher risk among men and women from some regions.

In this nationwide cohort of one million fertile women, BMI, height, and parity only had minor but statistically significant effects on the risk of uncomplicated cystitis. The results indicate that underweight women and certain sociodemographic groups might have higher risks, which could have underlying explanations that need further studying.

Past research on the social determinants of colorectal cancer (CRC) has shown that lower socioeconomic status (SES) is associated with a higher risk of CRC. Similar to SES at the individual level, the neighbourhood social environment may partly affect the development of CRC. Although one important aspect of the neighbourhood social environment is social capital, no large-scale follow-up study has examined its potential effect on CRC. We examined whether neighbourhood "linking social capital," which is established through social relationships and may enable individuals to gain health-promotional resources, is associated with the incidence of and mortality related to CRC, after adjusting for individual- and familial-level factors. This longitudinal study, conducted in Sweden, comprised over 2 million men and over 2 million women aged 25 years or older. The follow-up period started on January 1, 2002 and continued until first incidence of CRC, death due to CRC, death from any other cause, emigration, or the end of the study period on December 31, 2015. We identified over 20,000 CRC cases during the follow-up period. We used multilevel logistic regression models to calculate odds ratios (ORs) with 95% confidence intervals. After adjustment for potential confounding factors, higher ORs of CRC were observed in individuals who lived in neighbourhoods with low, relative to high social capital. Our results suggest that neighbourhood linking social capital has independent effects on CRC. Future studies could explore how simple interventions that can build linking social capital can enhance people's health.

Background Patients with atrial fibrillation (AF) have an increased dementia risk dementia. We aimed to study the effect of antihypertensive drugs on dementia in AF patients. Methods Included patients were ≥45 years diagnosed with AF in Swedish National Patient Register (n = 160,251; 89,723 men and 70,528 women) and alive on January 1, 2007. We excluded patients with dementia before onset of AF. Cox regression was used (hazard ratios, HRs, and 99% confidence interval, CI) with adjustments for sex, age, socioeconomic factors and co-morbidities, using incident dementia diagnosis until December 31, 2015 as outcome. Cardiovascular pharmacotherapies were obtained from the Swedish Prescribed Drug Register. Results Incident dementia occurred in 9532 patients (5.9%), 4669 men (5.2%) and 4863 women (6.9%). ARBs were associated with lower risk for all patients (HR 0.87, 99% CI 0.78–0.98), especially in the ages 65–84 years of age (HR 0.87, 99% CI 0.76–0.99). Loop-diuretics were associated with higher risk for all dementia among patients 65–84 years of age (HR 1.16, 99% CI 1.00–1.35), and in the sub-group of other causes of dementia than Alzheimer Disease (AD) and vascular dementia (VaD) (HR 1.14, 99% CI 1.00–1.30), but with a lower risk in the sub-group of AD and VaD (HR 0.81, 99% CI 0.68–0.95). Conclusion ARBs were associated with a decreased incidence of dementia, and loop diuretics with a higher risk in general but lower risk in the AD and VaD sub-group. ARBs could have specific advantages in prevention of dementia, but the results need confirmation in further studies.

Background The aim of this nationwide follow-up study was to examine whether neighborhood linking social capital is associated with lung cancer, including incident and mortality cases, after adjustment for individual- and familial-level factors. Methods This follow-up study comprised 2,123,707 men and 2,046,174 women aged 25 years or older in Sweden. The follow-up period started on January 1, 2002 and proceeded until first incident of lung cancer, mortality of lung cancer, death from any other cause, emigration or the end of the study period on December 31, 2010. Multilevel logistic regression models (individual-level factors at the first level and neighborhood-level factors at the second level) were used to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs). Results We identified 16,561 lung cancer cases (8422 men and 8139 women) during the follow-up period. Higher ORs of lung cancer, including incident and mortality cases, were observed in individuals who lived in neighborhoods with low social capital (men: OR = 1.37, 95% CI = 1.27–1.47; women: OR = 1.32, 95% CI = 1.23–1.42) than in those living in neighborhoods with high social capital, after adjustment for potential confounding factors. Conclusion The results of this large national cohort study suggest that neighborhood linking social capital has important independent effects on lung cancer, including incident and mortality cases. These findings indicate that decision-makers must consider the effect of neighborhood-level factors as well as individual- and familial-level factors.

Objective Levothyroxine treatment is common among older adults as is atrial fibrillation (AF), yet less is known about its potential effects on the development of dementia. Methods The study population included all adults with diagnosed AF (n = 156,104) aged ≥ 45 years in Sweden without an earlier recorded diagnosis of dementia. Individuals with a dispensed prescription of levothyroxine on two or more occasions between July 1 2005 and December 31 2006 in Sweden were considered exposed (n = 12,978; 8.3%), and were compared to all other patients with AF without this treatment. Cox regression with hazard ratios (HRs) and 95% confidence interval (95% CI), with outcome defined as dementia of all causes between January 1, 2007 and December 31, 2015, was used in the analysis. Adjustments were made for socio-demographic factors (age, immigration status, marital status, educational level, neighborhood socioeconomic status), co-morbidity (cardiovascular disease, obesity, diabetes, COPD, depression, anxiety and alcohol related diagnoses), and cardiovascular medications. Results During follow-up, a total of 9054 patients with AF were diagnosed with dementia (5.8%). We found no significant association of levothyroxine treatment and incident dementia, fully adjusted HR 1.03 (95% CI 0.96–1.11), neither among men and women, nor in different age-groups or subgroups of dementia. Conclusion We found no significant association of levothyroxine treatment and incident dementia among patients with AF, which contrasts some earlier findings. Electronic supplementary material The online version of this article (10.1007/s40520-019-01217-3) contains supplementary material, which is available to authorized users.

Background Preterm birth (gestational age Methods A national cohort study was conducted of all 4 186 615 singleton live births in Sweden during 1973–2014, who were followed for SDB ascertained from nationwide inpatient and outpatient diagnoses through 2015 (maximum age 43 years). Cox regression was used to examine gestational age at birth in relation to SDB while adjusting for other perinatal and maternal factors, and co-sibling analyses assessed for potential confounding by unmeasured shared familial factors. Results There were 171 100 (4.1%) persons diagnosed with SDB in 86.0 million person-years of follow-up. Preterm birth was associated with increased risk of SDB from childhood into mid-adulthood, relative to full-term birth (39–41 weeks) [adjusted hazard ratio (aHR), ages 0–43 years: 1.43; 95% confidence interval (CI), 1.40, 1.46; P Conclusions Preterm-born children and adults need long-term follow-up for anticipatory screening and potential treatment of SDB.

Objective: To study the association between country of birth and incident urolithiasis in immigrant groups in Sweden, using individuals born in Sweden (or with Swedish-born parents in the second-generation study) as referents. Methods: This nationwide follow-up study included first- and second-generation immigrants residing in Sweden between 1 January 1998 and 31 December 2012. Urolithiasis was defined as having at least one registered diagnosis of urolithiasis in the National Patient Register. Cox regression analysis was used to estimate the risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident urolithiasis. The models were stratified by sex and adjusted for age, sociodemographic status and co-morbidity. Results: Compared to referents, slightly higher incidence rates and HRs of urolithiasis (HR; 95% CI) were observed among first-generation men (1.06; 1.04–1.09) and women (1.12; 1.08–1.16) but not among second-generation immigrants (persons born in Sweden with foreign-born parents). Among first-generation immigrants, higher HRs were noted among men and women from Central and Eastern Europe, Russia, Latin America, Africa and Asia. Lower HRs were seen among men and women from the Nordic countries, most Western European countries and North America. Among second-generation immigrants, higher HRs were noted among men and women from Denmark, Germany and Hungary, in men from Austria, and in women from the Netherlands and Poland. Lower HRs were seen in second generation immigrants from Latin America, Africa and Asia (men and women). Conclusions: We observed substantial differences in incidence of urolithiasis between certain immigrant groups and the Swedish-born population, of importance in the clinical situation.

Background: Our aim was to study the association between the country of birth and incident end-stage kidney disease (ESKD) in several immigrant groups in Sweden, using individuals born in Sweden or with Swedish-born parents as referents. Methods: A cohort study of first- and second-generation immigrants residing in Sweden between January 1, 1998 and December 31, 2012 was performed. Outcomes were defined as having at least one registered diagnosis of ESKD in the National Patient Register. The incidence of ESKD in different immigrant groups was used in the Cox regression models to estimate hazard ratios (HRs) and 95% CIs. All models were stratified by sex and adjusted for age, geographical residence, educational level, marital status, and neighbourhood socioeconomic status. Results: Compared to their referents, higher incidence rates and HRs of ESKD (HR; 95% CI) were observed in general among foreign-born men (1.10; 1.04–1.16) and women (1.12; 1.04–1.21) but not among second-generation immigrants (persons born in Sweden with foreign-born parents). A particularly high ­incidence was noted among men and women from ­East-European countries, as well as from non-European regions. A lower incidence of ESKD was noted among men from Finland. Conclusions: We observed substantial differences in incidence of ESKD between immigrant groups and the Swedish-born population, which may be clinically relevant when monitoring preventive measures in patient subgroups with a higher risk of deteriorating kidney disease, and suggest higher attention to hypertension and diabetes control in immigrants. Mechanisms attributable to the migration process or ethnic differences may lead to an increased risk of ESKD.

Background Few longitudinal studies investigate predictors of substance use incidence among immigrants. The current study describes substance use disorders in immigrants to Sweden, focusing on drinking culture in the country of origin and socioeconomic status (SES), and how these intersect with generational status to influence risk. Methods Using pseudonymized Swedish population registry data, we track onset of alcohol use disorder and drug use disorder in a longitudinal study of 815,778 first-generation immigrants and 674,757 second-generation immigrants from 64 countries over a 6-year period. Cox regression analysis estimated risks of alcohol and drug use disorders in second-generation immigrants compared to first-generation, and moderation analyses assessed interactions of generational status with country-of-origin per capita alcohol consumption and SES. Results Immigrants and second-generation immigrants originating from countries with high levels of alcohol consumption had higher risks for alcohol and drug use disorders. Immigrants with high SES had lower risks for alcohol and drug use disorders. The interaction between generational status and country-of-origin alcohol consumption was significant for drug use disorder (not for alcohol use disorder), with drug use disorder risk for second-generation immigrants being highest for those from countries with the lowest level of country-of-origin per capita alcohol consumption. The interaction between generational status and SES was significant for alcohol use disorder, with low-SES second-generation immigrants showing markedly higher risk than first-generation immigrants with comparable SES. Conclusions Among immigrants in Sweden, second-generation immigrants are at increased risk of developing alcohol and drug use disorders, particularly if they have lower SES. Policy and community attention to these high-risk subgroups in immigrant communities is warranted.

Background The number and rank order of siblings could be of importance for risk of cardiovascular disease and mortality. Previous studies have used only fatal events for risk prediction. We, therefore, aimed to use also non-fatal coronary and cardiovascular events in fully adjusted models. Methods From the Multiple-Generation Register in Sweden, data were used from 1.36 million men and 1.32 million women (born 1932–1960), aged 30–58 years at baseline and with follow-up from 1990 to 2015. Mean age at follow-up was 67 years (range 55–83 years). Fatal and non-fatal events were retrieved from national registers. Results Compared with men with no siblings, those with 1–2 siblings had a lower, and those with four or more siblings had a higher adjusted risk of cardiovascular events. Again, compared with men with no siblings, those with more than one sibling had a lower total mortality risk, and those with three or more siblings had an increased risk of coronary events. Correspondingly, compared with women with no siblings those women with three siblings or more had an increased risk of cardiovascular events, and those with two siblings or more had an increased risk of coronary events. Women with one sibling or more were at lower total mortality risk, following full adjustment. Conclusion Being first born is associated with a favourable effect on non-fatal cardiovascular and coronary events for both men and women. The underlying biological mechanisms for this should be studied in a sociocultural context.

There is a growing interest in the contextual effect of neighborhood linking social capital on different health outcomes, including cancer.To examine associations between neighborhood linking social capital and incidence and mortality of prostate cancer.This cohort study was based on national registers. Between 2002 and 2015, we included 1,196,563 men aged 50 years and above in the analyses. Multilevel logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CI) for the association between exposure and outcome, adjusting for potential confounding factors.The total incidence of prostate cancer and mortality in patients with prostate cancer were 8.22 (per 100) and 1.80 (per 100), respectively, during the follow-up period. Individuals living in neighborhoods with low (OR 0.90; 95% CI 0.88-0.93) and intermediate (OR 0.94; 95% CI 0.92-0.96) linking social capital were less likely to be diagnosed with prostate cancer than those living in neighborhoods with high linking social capital. Opposite effects were observed for mortality; prostate cancer patients living in neighborhoods with low (OR 1.15; 95% CI 1.08-1.23) and intermediate (OR 1.09; 95% CI 1.03-1.14) linking social capital were more likely to die from prostate cancer than those in neighborhoods with high linking social capital.Lower neighborhood linking social capital was associated with lower incidence but higher mortality in patients with prostate cancer. These findings suggest that men living in neighborhoods with low linking social capital may need additional surveillance for prostate cancer.

Purpose Breast cancer is one of the most common cancer forms in women and it is often detected by screening. However, women with drug use disorders (DUD) are less likely to be reached by screening programs. In this study, we aimed to investigate breast cancer incidence, mortality and stage at time of diagnosis among women with DUD compared to the general female population in Sweden. Methods We performed a follow-up study based on Swedish national register data for the period January 1997–December 2015. The study was based on 3,838,248 women aged 15–75 years, of whom 50,858 were registered with DUD. Adjusted hazard ratios (HRs) for incident and fatal breast cancer, and cancer stage at time of diagnosis, were calculated for women with and without DUD using Cox regression analysis. Results DUD was associated with incident breast cancer (HR 1.08, 95% confidence interval [CI] 1.02–1.14, p = 0.0069), fatal breast cancer (HR 1.60, 95% CI 1.42–1.82, p p Conclusions Women with DUD were identified as a risk group for incident, fatal and metastasized breast cancer, which calls for attention from clinicians and policy makers. Cancer screening attendance and other healthcare seeking barriers are likely to affect the risk increase among women who use drugs; however, more research is needed on the underlying mechanisms.

Background: There is a lack of studies of Parkinson's disease (PD) in immigrants. Objective: To study the association between country of birth and incident PD in immigrants in Sweden versus Swedish-born individuals. Methods: Study population included all adults aged 50 years and older in Sweden (n=2775736). PD was defined as having at least one registered diagnosis of PD in the National Patient Register. The incidence of PD in different first-generation immigrant groups versus Swedish-born individuals was assessed by Cox regression, expressed as hazard ratios (HRs) and 95% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, neighbourhood socioeconomic status and co-morbidity. Results: Totally 35833 individuals had an incident diagnosis of PD (20401 men and 15432 women). Incidence rates per 100,000 person-years were for all Swedish-born 95.9 and for all foreign-born 60.1; for all men 112.3 and for all women 73.4, with a male to female ratio of 1.53, with the highest incidence rates for the group 80-84 years of age. After adjusting for potential confounders, the overall relative risk of PD was lower in immigrant men (HR 0.78; 95% CI 0.74-0.82) and women (HR 0.92; 95% CI 0.87-0.98). Among immigrant subgroups, a higher risk of PD was found among women from Finland (HR 1.13; 95% CI 1.05-1.23). Conclusion: In general, the risk of PD was lower in first-generation immigrant men and women compared to Swedish-born. The only group with a higher risk of PD was women from Finland. (Less)

Background It remains unclear whether heritable factors can contribute to risk stratification for ischemic stroke in patients with atrial fibrillation (AF). We examined whether having a sibling with ischemic stroke was associated with increased risk of ischemic stroke and mortality in patients with AF . Methods and Results In this nationwide study of the Swedish population, patients with AF and their siblings were identified from the Swedish patient registers and the Swedish MGR (Multi‐Generation Register). Ischemic stroke events were retrieved from the Swedish patient registers and CDR (Cause of Death Register). Risk of ischemic stroke was compared between patients with AF with and without a sibling affected by ischemic stroke, AF , or both ischemic stroke and AF . The total study population comprised 113 988 subjects (mean age, 60±12 years) diagnosed with AF between 1989 and 2012. In total, 11 709 of them were diagnosed with a first ischemic stroke and 20 097 died during a mean follow‐up time of 5.5 years for ischemic stroke and 5.9 years for mortality. After adjustment for covariates having a sibling with ischemic stroke, or both ischemic stroke and AF , was associated with increased risk of ischemic stroke (hazard ratio, 1.31; 95% CI, 1.23–1.40 or hazard ratio, 1.36; 95% CI , 1.24–1.49, respectively). Furthermore, ischemic stroke in a sibling was associated with all‐cause mortality (hazard ratio, 1.09; 95% CI , 1.05–1.14). In contrast, the risk of stroke was only marginally increased for patients with AF with a spouse affected by ischemic stroke. Conclusions Having a sibling affected by ischemic stroke confers an increased risk of ischemic stroke and death independently of traditional risk factors in patients with AF.

Autoimmune hepatitis (AH) and primary biliary cirrhosis (PBC) are autoimmune diseases (AIDs) targeting cellular components of the liver. Being rare diseases, limited data are available about familial risks among these AIDs (concordant) or between them and other AIDs (discordant). We aimed to carry out an unbiased study on these AIDs based on medically diagnosed patients. We collected data on patients diagnosed in Swedish hospitals with AH, PBC and other AIDs and calculated familial standardized incidence ratios (SIRs) for concordant and discordant familial relative risks. The number of AH patients was 6,269, of whom 43.0% were male; patient numbers for PBC were 4,269, with 17.8% males. AH accounted for 0.8% and 0.6% of all hospitalized AIDs in Sweden. For AH only the familial risk between siblings was significant (3.83). For PBC the risks for offspring of parents (9.05) and siblings (10.88) were high, but only risk for females was significant. Spousal risks were very high, 5.91 and 6.07 for AH. Risk for AH was 2.21 in families of PBC, and it was 2.47 for PBC in families of AH patients. Among other AIDs, 14 showed a significant association with AH, compared to 16 AIDs with PBC. The surprising finding in this nation-wide family study on medically diagnosed patients was the high risk for AH (6.0) between spouses, which exceed the risk between siblings, suggesting the existence of strong environmental risk factors. AH and PBC were associated with multiple other AIDs. The results call attention to environmental factors in AID etiology which should also be in focus in taking anamnestic data from patients.

Introduction: The hospitalization rate of paroxysmal supraventricular tachycardia (PSVT) in a nationwide study is not established. We determined age- and sex-specific hospitalization rates and time trends for hospitalized PSVT in the Swedish population between 1987 and 2010. Methods: This nationwide study is based on the Swedish Hospital Discharge Register. The patients with first PSVT diagnoses between January 1987 and December 2010 were identified. Results: A total of 42,765 individuals with PSVT were diagnosed (mean age 60 years; 44% males). The overall age- and sex-adjusted hospitalization rate was 20 per 100,000 person-years. The hospitalization rate increased with advancing age with highest hospitalization rates in individuals aged 80–84 years (67.12 per 100,000 person-years) and did not change significantly over time. A total of 20,011 (46.8%) patients had “lone” PSVT without any comorbidities. Lone PSVT patients were younger than PSVT patients with comorbidities (mean age 54 vs. 67 years, p = .0002). Conclusions: This study showed a slight preponderance for females and stable hospitalization rate of PSVT over time; the hospitalization rate increased with age. A high proportion of PSVT patients had no comorbidities. They were affected at a younger age than patients with comorbidities, which suggests an inherent predisposition.Key messagesThis study represents the first extensive and nationwide hospitalization study of PSVT. Hospitalization is highest in old age but a bimodal pattern was observed with a small peak in the first years of life. Patients with lone PSVT are younger than those with comorbidities; which suggests an inherent predisposition. This study represents the first extensive and nationwide hospitalization study of PSVT. Hospitalization is highest in old age but a bimodal pattern was observed with a small peak in the first years of life. Patients with lone PSVT are younger than those with comorbidities; which suggests an inherent predisposition.

Family history of depression is an important risk factor for depression. The aim of this study was to examine whether the effect of family history of depression is confounded by individual and familial socioeconomic factors (i.e., country of origin, educational attainment, family income and mobility) and neighborhood environmental factors (i.e., neighborhood deprivation and neighborhood social capital). The study population comprised 188,907 individuals aged 20–44 years from a nationwide sample of primary care centers in Sweden. Among these individuals, 22,014 with a first event of depression (6,486 men and 15,528 women) were identified during the 7-year follow-up period. Family history of depression was defined as depression in at least one parent. Cross-classified multilevel logistic regression models were used to calculate odds ratios with 95% credible intervals. Increased familial odds were observed after adjustment for individual and familial socioeconomic factors and neighborhood environmental factors for both men and women. Our results suggest that family history of depression is an independent risk factor for depression. Offspring of parents with depression are important targets for disease prevention, regardless of individual and familial socioeconomic factors and neighborhood environmental factors.

Objective: To assess detailed familial risks for medically diagnosed urolithiasis (UL, urinary tract stone disease) based on nationwide hospital and population records. Patients/Subjects and Methods: Subjects were identified from the Swedish Multigeneration Register in which there were 211 718 patients with UL. Standardised incidence ratios (SIRs) were calculated by comparison to individuals without a family history of UL. Results: The highest familial SIRs were invariably found for the same (concordant) type of UL: 2.18 for kidney, 2.20 for ureter, and 1.93 for bladder. SIRs increased from 1.84, when one parent was affected, to 3.54 when both parents were affected, which was a multiplicative interaction. The SIR was 1.79 when one sibling was affected but it increased to 24.91 when two siblings were affected. Such excessive risks (5.2% of familial cases) are probably explained by high-penetrant genes. A low SIR of 1.29 between spouses suggested a minor contribution by shared environmental factors on the familial risk. Conclusions: The results point to underlying genetic causes for the observed familial clustering and establish the genetic landscape of UL. Family histories should be taken in UL diagnostics and prevention could follow guidelines recommended for recurrent UL. (Less)

OBJECTIVE:An increased risk of being diagnosed with coronary heart disease or atrial fibrillation has been shown among different immigrant groups. However, less is known on the risk of being diagnosed with congestive heart failure (CHF).DESIGN:We studied CHF in immigrants including all adults ≥45 years in Sweden (n = 3,274,119) from 1998 to 2012. CHF was defined as at the first event registered in the National Patient Register. Risk of incident CHF in immigrant groups compared to the Swedish-born population was assessed by Cox regression, stratified by sex, adjusting for age, socio-demographic status, and co-morbidities.RESULTS:During a mean follow-up of 14 years in total, a total of 302,340 (9.2%) events of CHF were registered. We found the following: higher incidence in men from Bosnia, Iraq, Lebanon, Russia and Africa; among women from Bosnia, Iraq, Lebanon, Turkey, Central Europe and Finland; lower incidence in men from Iceland, Latin America, Southern Europe, Norway and Western Europe; and among women from Iceland, Southern Europe, Norway, Denmark and Western Europe.CONCLUSION:It is important to be aware of the increased incidence of CHF in some immigrant groups, especially from countries and areas where the immigrants have been refugees, in order to enable for a timely diagnosis, treatment of and prevention of CHF and its debilitating complications.

Objective We aimed to study the association between neighborhood socioeconomic status at the age of 40 years and risk of ischemic stroke before the age of 50 years. Methods All individuals in Sweden were included if their 40th birthday occurred between 1998 and 2010. National registers were used to categorize neighborhood socioeconomic status into high, middle, and low and to retrieve information on incident ischemic strokes. Hazard ratios and their 95% confidence intervals were estimated. Results A total of 1,153,451 adults (women 48.9%) were followed for a mean of 5.5 years (SD 3.5 years), during which 1777 (0.30%) strokes among men and 1374 (0.24%) strokes among women were recorded. After adjustment for sex, marital status, education level, immigrant status, region of residence, and neighborhood services, there was a lower risk of stroke in residents from high-socioeconomic status neighborhoods (hazard ratio 0.87, 95% confidence interval 0.78–0.96), and an increased risk of stroke in adults from low-socioeconomic status neighborhoods (hazard ratio 1.16, 95% confidence interval 1.06–1.27), compared to their counterparts living in middle-socioeconomic status neighborhoods. After further adjustment for hospital diagnoses of hypertension, diabetes, heart failure, and atrial fibrillation prior to the age of 40, the higher risk in neighborhoods with low socioeconomic status was attenuated, but remained significant (hazard ratio 1.12, 95% confidence interval 1.02–1.23). Conclusions In a nationwide study of individuals between 40 and 50 years, we found that the risk of ischemic stroke differed depending on neighborhood socioeconomic status, which calls for increased efforts to prevent cardiovascular diseases in low socioeconomic status neighborhoods.

Objectives: The aim of this 6-year follow-up study was to examine whether neighbourhood accessibility to fast-food outlets was associated with diagnosed childhood obesity, after adjustment for neighbourhood- and individual-level socio-demographic factors. Methods: This 6-year follow-up study comprised 484,677 boys and 459,810 girls aged 0-14 years in Sweden. The follow-up period ran from January 1, 2005, until hospitalisation/out-patient treatment for obesity, death, emigration or the end of the study period on December 31, 2010. Multilevel logistic regression models (individual-level factors at the first level and neighbourhood-level factors at the second level) were used to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs). Results: We identified 6,968 obesity cases (3,878 boys and 3,090 girls) during the follow-up period. Higher odds of childhood obesity for those living in neighbourhoods with accessibility to fast-food outlets was observed (OR = 1.14, 95% CI = 1.07-1.22) that remained significant after adjustments (OR = 1.06, 95% CI = 1.00-1.13). Conclusions: This prospective nationwide study showed that the neighbourhood accessibility to fast-food outlets was independently associated with increased odds of diagnosed childhood obesity. This finding implicates that residential environments should be considered when developing health promotion programmes.

Objectives: Risk of multiple sclerosis (MS) is low among first-generation immigrants in Sweden. We aimed to study incident MS in first- and second-generation immigrant groups. Materials & Methods: We included adults aged 18 years and older in Sweden in first-generation (n = 6 042 891) and second-generation (n = 4 860 469) sub-studies. MS was defined via two diagnoses in the Swedish National Patient Register. MS risk was estimated by Cox regression, with hazard ratios (HRs) and 95% confidence intervals (CI), in different immigrant groups, using Swedish-born as referents in first-generation sub-study, and individuals with Swedish-born parents in the second-generation. Full models were adjusted for age, geographic residence in Sweden, educational level, marital status, neighborhood socioeconomic status, and co-morbidity. Results: MS was diagnosed among 10 746 individuals in the first-generation sub-study, (men 3055 and women 7691), and 11 737 in the second-generation sub-study (men 3549 and women 8188) in the period 1998-2015. The annual incidence rate was higher in Swedish-born compared to foreign-born, 11.5 vs 6.3 per 100 000 person-years (age-standardized to the European standard population). Fully adjusted HRs were lower in first-generation immigrant men (HR 0.72, 0.64-0.82) and women (HR 0.67, 0.62-0.73), and in second-generation immigrant men (HR 0.88, 0.79-0.97) and women (HR 0.79; 0.73-0.84). Among first-generation immigrants, lower HRs were found in most groups. Significance: The MS risk was lower in first- and second-generation immigrants compared to Swedish-born or individuals with Swedish-born parents. (Less)

Objectives Association between socio-demographic factors and dementia risk is studied in general but not for atrial fibrillation (AF) patients. Methods We studied AF patients ≥ 45 years in Sweden 1998–2012 (n = 537,513) using the Total Population Register for socio-demographic factors, the Swedish Cause of Death Register, and the National Patient Register (NPR) for incident dementia. Cox regression with hazard ratios (HR) and 95% confidence intervals (CI) was used for the association between exposure and outcome, adjusting for age and comorbidities. Results Totally 30,332 patients (5.6%) were diagnosed with dementia during the follow-up (mean 5.4 years). Of these, 14,097 were men (4.9%) and 16,235 were women (6.5%). Lower educational levels (reference: highest level) were associated with increased dementia, HRs (95% CI) for basic school for men 1.23 (1.18–1.29) and women 1.36 (1.30–1.42), and middle-level school for men 1.17 (1.11–1.22) and women 1.28 (1.22–1.34). Divorced men and women (reference: married) showed increased risk of dementia, HR 1.07 (1.01–1.13) and 1.12 (1.06–1.18), respectively, while widowed men showed lower risk, HR 0.84 (0.80–0.88). High deprivation neighborhood socio-economic status (NSES; reference: medium level) was associated with increased dementia in men, HR 1.11 (1.05–1.17), and low deprivation neighborhood socio-economic status (NSES) with increased dementia in men and women, HR 1.12 (1.06–1.18) and 1.18 (1.12–1.24), respectively. Conclusions Some results were expected, i.e. association between lower educational level and dementia. The higher risk of dementia in low deprivation NSES-areas could be due to a higher awareness about dementia, and subsequent earlier diagnosis and treatment of dementia.

Background: No study to date, as far as we know, has analyzed the potential effect of neighborhood-level deprivation on autoimmune disorders (ADs), when adjusted for individual-level characteristics. Methods: A total of 5.4 million individuals from 8363 neighborhoods, comprising the whole Swedish population (ages 25&ndash, 74 years), were followed for the period 1 January 2000, until admission due to diagnosis of ADs during the period of the study, or the conclusion of the study (31 December 2010). We used a neighborhood deprivation index, constructed from variables such as low education, low income, unemployment, and social welfare assistance, to assess the level of neighborhood deprivation. Multilevel logistic regression was used in the analysis with individual level characteristics at the first level and level of neighborhood deprivation at the second level. Results: A significant association between level of neighborhood deprivation and ADs was found. The crude odds were 1.32 (95% confidence interval 1.27&ndash, 1.36) for those residing in the high-deprived neighborhoods compared to those living in low-deprivation neighborhoods. In the full model, where individual level characteristics were taken into account, the odds of ADs were 1.18 (1.14&ndash, 1.22) in the most deprived neighborhoods. Certain Ads&mdash, angiitis hypersensitive (5.14), ankylosing spondylitis (1.66), celiac disease (1.65), Crohn&rsquo, s disease (1.21), diabetes mellitus type 1 (1.45), Graves&rsquo, s disease (1.13), Hashimoto thyroiditis (1.51), psoriasis (1.15), rheumatoid arthritis (1.15), sarcoidosis (1.20), and systemic sclerosis (1.27)&mdash, remained significantly associated with high level of neighborhood deprivation after adjustment for the individual-level variables. Conclusion: This study is the largest to date analyzing the potential influence of neighborhood deprivation on ADs. Our results indicate that neighborhood deprivation may affect risk of ADs, independent of individual level sociodemographic characteristics. For health care policies, both individual and neighborhood level approaches seem to be of importance.

OBJECTIVE: To study association between country of birth and incident epilepsy in second-generation immigrants in Sweden.METHODS: Study population included all children (n=4,023,149) aged up to 18 years of age in Sweden. Epilepsy was defined as at least one registered diagnosis of epilepsy in the National Patient Register. The incidence of epilepsy, using individuals with Swedish-born parents as referents, was assessed by Cox regression, expressed in hazard ratios (HRs) and 95% confidence intervals (95% CI). All models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, neighbourhood socioeconomic status and comorbid conditions, also using data from the Total Population Register.RESULTS: A total of 26,310 individuals had a registered epilepsy event, i.e. 6.5/1000 (6.6/1000 among boys and 6.3/1000 among girls). After adjustment, the risk of epilepsy was lower than in children of Swedish-born parents. Among girls, the significant HR was 0.85 (95% CI, 0.81-0.88) but in boys only when adjusting also for co-morbidity (HR = 0.96, 0.92-0.99). Among specific immigrant groups, a higher incidence of epilepsy was observed among boys with parents from Turkey and Africa, but not when adjusting for co-morbidity, and a lower risk in many other groups (boys with parents from Latvia, girls with parents from Finland, Iceland, Southern Europe, countries from the former Yugoslavia, and Asia).SIGNIFICANCE: Risk of epilepsy was lower in second-generation immigrant children compared to children with Swedish-born parents, however, with substantial differences between different immigrant groups. This article is protected by copyright. All rights reserved.

Background The risk of dementia is increased in patients with atrial fibrillation (AF). Objective To study relevant co-morbidities and incident dementia (vascular dementia, Alzheimers disease, other dementia and all dementia) in AF patients. Methods All adults (n = 537,513) ≥45 years diagnosed with AF in hospitals in Sweden 1998–2012 were included. Cox regression was used to estimate hazard ratios (HR) with 95% CIs for association between co-morbidities, and incident dementia, after adjustment for age, residence place in Sweden, and socio-economic factors. Results Totally 30,332 patients (5.6%) were diagnosed with dementia during the follow-up, with 14,097 men (4.9%) and 16,235 women (6.5%). After adjustments (HRs; 95% CI), hypertension was associated with lower risk of incident dementia (all types) in men (0.79; 0.76–0.82) and women (0.77; 0.74–0.79). Higher risk of dementia was seen in patients with stroke, diabetes, depression and anxiety. Lower risks of dementia were also seen in AF patients with concomitant coronary heart disease and congestive heart failure. Conclusions The findings regarding incident dementia need to be interpreted with great caution, owing to possible “survival bias” or reversed causation. However, the lower associated risks of dementia associated with hypertension could possibly be explained by protective effects of certain antihypertensive drugs.

Background Bariatric surgery is considered to be the most effective method of weight loss today. The aim of the present Swedish study, which was performed in a country that has universal health care, was to investigate if there is an association between socioeconomic factors and bariatric surgery by taking body mass index (BMI) into account. Methods In this prospective cohort study, BMI data were collected for the period 1985–2010 from the Military Service Conscription Register (for men) and from the Medical Birth Register in the first trimester (for women). The follow-up period started in 2005 and continued until 2012. Age-standardized cumulative incidence rates (CR) of bariatric surgery were compared between different BMI groups by considering individual variables. We analyzed the association between the individual variables and bariatric surgery using Cox proportional hazard models. Results In the study population of 814,703 women and 787,027 men, a total of 7433 women and 1961 men underwent bariatric surgery. In women, the hazard ratios (HRs) for bariatric surgery were higher for low and middle income and educational levels, compared to high income and educational levels. In men, the highest HR for bariatric surgery was found among those with a high income. The HRs when comparing the different socioeconomic groups in those with BMI > 40 kg/m2 showed no significant results, except for middle education in women. Conclusion Differences in bariatric surgery between socioeconomic groups were found, favoring those with a low socioeconomic status. However, very few socioeconomic differences were found amongst those who had a BMI > 40 kg/m2. This indicates that the Swedish healthcare system seems to have achieved equal access to health care for bariatric surgery. Electronic supplementary material The online version of this article (10.1186/s12889-019-6585-8) contains supplementary material, which is available to authorized users.

Background Varicose veins (VVs) cluster in families, but the familial risk of VVs has not been determined among adoptees. The aim was to estimate whether the familial transmission of VVs is related to disease in biological and/or adoptive parents. Study Design The Swedish Multi-Generation Register and the Swedish Patient Register were used to follow all Swedish-born adoptees (born 1932 through 2004) that could be linked to both their biological and their adoptive parents (n = 80,214; 50% females). The risk of VVs was estimated in adoptees with at least 1 biological parent with VVs, but no adoptive parent with VVs (n = 187) compared with adoptees without a biological or adoptive parent with VVs (n = 1,758). The risk of VVs was also determined in adoptees with at least 1 adoptive parent, but no biological parent with VVs (n = 87), and in adoptees with both biological and adoptive parents affected (n = 21). Results Adoptees from an affected biological parent, but no adoptive parent, were more likely to have VVs than adoptees from an unaffected biological or adoptive parent (standard incidence ratio [SIR] = 2.21; 95% CI, 1.91–2.55). The familial SIR for adoptees with both an affected biological parent and an adoptive parent was 4.58 (95% CI, 2.83–7.01). Adoptees with an affected adoptive parent but no biological parent were not at increased risk of VVs (SIR = 1.15; 95% CI, 0.92–1.42). Conclusions These novel findings suggest that genetic factors make a strong contribution to the familial transmission of VVs from parents to offspring, although familial environmental factors might contribute.

Characteristics of the built environment, including access to unhealthy food outlets, are hypothesized to contribute to type 2 diabetes mellitus (T2D). Swedish nationwide registry data on 4,718,583 adults aged 35–80 years living in 9,353 neighborhoods, each with at least 1 food outlet, were geocoded and linked to commercial registers (e.g., restaurants and grocery stores). Multilevel logistic regression was used to examine the prospective relationship between characteristics of the food environment and T2D from 2005 to 2010. Relative access to health-harming food outlets was associated with greater likelihood of both prevalent and incident T2D in a curvilinear manner, with the highest risk being observed for environments in which one-third of outlets were health-harming. Relative to individuals whose food environment did not change, those who moved into areas with more health-harming food outlets had higher odds of developing T2D (odds ratio = 3.67, 95% confidence interval: 2.14, 6.30). Among those who did not move, living in an area that gained relative access to health-harming food outlets was also associated with higher odds of T2D (odds ratio = 1.72, 95% confidence interval: 1.27, 2.33). These results suggest that local food environment, including changes that result in greater access to unhealthy food outlets, is associated with T2D.

The incidences of both type 1 diabetes (T1D) and T2D are increasing worldwide. T2D is associated with many cancers. However, no data are available on cancer of unknown primary (CUP), a relatively common, fatal cancer for which tobacco smoking is the only known risk factor. At diagnosis, CUP metastases are found in various organs, which has implications for prognosis. We carried out a nationwide study on the association of CUP with T1D and T2D. 32 600 T1D patients and 178 000 T2D patients were identified from the national healthcare registers and these were linked to the Swedish Cancer Registry. Standardized incidence ratios (SIRs) were calculated for CUP from 1997 through 2010 using anyone without diabetes as a reference. The SIR of CUP in 421 diabetic patients was 1.71, highest for CUP with liver (2.17) and respiratory system (1.95) metastases. The SIR was 2.91 for T1D, but with a small number of patients, 1.38 for T2D with insulin treatment, and 1.78 for the main group of T2D. CUP with liver and respiratory system metastases increased for each diabetic type; however, for T2D, CUP with gastrointestinal and bone metastases also increased. The results provide the first demonstration that CUP is one of the cancers associated with diabetes, with definite evidence on T2D. CUP has a poor prognosis, which may be even worse when diabetes is the underlying comorbidity. A mechanistic question for future work is to determine whether diabetes promotes primaries that escape detection or their metastatic spread.

Familial risks of glomerulonephritis (acute, chronic and unspecified glomerulonephritis) have not been studied. This study aims to determine the familial risks of glomerulonephritis.Individuals born from1932 onwards diagnosed with glomerulonephritis (acute [n = 7011], chronic [n = 10,242] and unspecified glomerulonephritis [n = 5762]) were included. The familial risk (Standardized incidence ratio = SIR) was calculated for individuals whose parents/full-siblings were diagnosed with glomerulonephritis compared to those whose parents/full-siblings were not. The procedure was repeated for spouses. Familial concordant risk (same disease in proband and exposed relative) and discordant risk (different disease in proband and exposed relative) of glomerulonephritis were determined.Familial concordant risks (parents/full-sibling history) were: SIR = 3.57 (95% confidence interval, 2.77-4.53) for acute glomerulonephritis, SIR = 3.84 (3.37-4.36) for chronic glomerulonephritis and SIR = 3.75 (2.85-4.83) for unspecified glomerulonephritis. High familial risks were observed if two or more relatives were affected; the SIR was 209.83 (150.51-284.87) in individuals with at least one affected parent as well as one full-sibling. The spouse risk was only moderately increased (SIR = 1.53, 1.33-1.75).Family history of glomerulonephritis is a strong predictor for glomerulonephritis, and is a potentially useful tool in clinical risk assessment. Our data emphasize the contribution of familial factors to the glomerulonephritis burden in the community. Key Messages The familial risks (full-sibling/parent history) of glomerulonephritis (acute, chronic and unspecified glomerulonephritis) have not been determined previously. The familial risks of glomerulonephritis were increased among individuals with family history of acute, chronic or unspecified glomerulonephritis. The familial risks of glomerulonephritis were slightly increased among spouses indicating a modest non-genetic contribution. Very high familial risks were observed in multiplex families, i.e. with one or more affected first-degree relatives.