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To examine the risk of post-polio syndrome (PPS) in immigrant groups using native Swedish-born individuals as referents. This is a retrospective study. The study population included all individuals aged 18 years and older registered in Sweden. PPS was defined as having at least one registered diagnosis in the Swedish National Patient Register. The incidence of post-polio in different immigrant groups, using Swedish-born individuals as referents, was assessed by Cox regression, with hazard ratios (HRs) and 99% 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 total 5300 post-polio cases were registered, 2413 males and 2887 females. Fully adjusted HRs (99% CI) in immigrants versus Swedish-born were 1.77 in men (1.52–2.07) and 1.39 (1.19–1.62) in women. Statistically significant excess risks of post-polio were found in the following subgroups: men and women from Africa, HRs (with 99% CI) 7.40 (5.17–10.59) and 8.39 (5.44–12.95), respectively, and Asia, HRs 6.32 (5.11–7.81) and 4.36 (3.38–5.62) respectively, and in men from Latin America, HR 3.66 (2.17–6.18). It is of importance to be aware of risks of PPS in immigrants settled in Western countries, and that it is more common in immigrants from regions of the world where polio is still prevalent. Patients with PPS need treatment and proper follow-up until polio has been eradicated through global vaccination programs.

Background Elevated levels of cardiac troponin T has been observed in patients seeking care at the emergency department (ED) presenting with chest pain but without myocardial infarction (MI). The clinical importance of this observation remains, however, still unclear. Our main aim was to study the role of cardiac troponin T in patients admitted to the emergency department with acute dyspnea, a group of patients with a high cardiovascular comorbidity, but no primary acute MI. Population and methods Patients from the age of 18 seeking care at the ED for dyspnea, without an acute cardiac syndrome, and with a recorded assessment of high-sensitivity cardiac troponin T (hs-cTnT), were included (n = 1001). Patients were categorized into 3 groups by hs-cTnT level, i.e. 100 µg/l. Cox regression with Hazard Ratios (HRs) and 95% Confidence Intervals (CI) for 3-months mortality was performed, with adjustment for sex, age, respiratory frequency, saturation, CHF, renal disease, and BMI. Results Fully adjusted HRs (95% CI) for 3-month mortality, with hs-cTnT 100 a HR of 10.523 (4.465–24.803). Conclusion Elevated hs-cTnT seems to be a relevant marker of poor prognosis in patients with acute dyspnea without MI and warrants further validation and clinical testing.

Aim The use of direct-to-consumer (DTC) telemedicine consultations in primary healthcare has increased rapidly, in Sweden and internationally. Such consultations may be a low-cost alternative to face-to-face visits, but there is limited evidence on their effects on overall healthcare consumption. The aim of this study was to assess the short- and intermediate-term impact of DTC telemedicine consultations on subsequent primary healthcare consumption, by comparing DTC telemedicine users to matched controls in a Swedish setting. Methods We constructed a database with individual-level data on healthcare consumption, for all residents of Region Stockholm in 2018, by linking national and regional registries. The study population included all individuals who had ≥ 1 physician consultation (telemedicine or face-to-face) during the first half of 2018. DTC telemedicine users were matched 1:2 to controls who were non-users of DTC telemedicine but who had a traditional face-to-face consultation during the study period. The matching criteria were diagnosis and demographic and socioeconomic variables. An interrupted time series analysis was performed to compare the healthcare consumption of DTC telemedicine users to that of the control group. Results DTC telemedicine users increased their healthcare consumption more than controls. The effect seemed to be mostly short term (within a month), but was also present at the intermediate term (2–6 months after the initial consultation). The results were robust across age and disease groups. Conclusion The results indicate that DTC telemedicine consultations increase the total number of physician consultations in primary healthcare. From a policy perspective, it is therefore important to further investigate for which diagnoses and treatments DTC telemedicine is suitable so that its use can be encouraged when it is most cost-efficient and limited when it is not. Given the fundamentally different models for reimbursement, there are reasons to review and possibly harmonise the incentive structures for DTC telemedicine and traditional primary healthcare.

Objective We aimed to study open-angle glaucoma in association with somatic comorbidities in the total population of adults in Region Stockholm. Methods The study population included all living persons aged 19 years and above who resided in Stockholm County, Sweden, on 1 January 2017 (N = 1 703 675). Subjects with specified diseases were identified with data from all registered consultations and hospital stays during 2008–2019. As outcome, the risk of being associated with a diagnosis of open-angle glaucoma was identified during 2012–2018. Analyses were performed by gender, controlling for age and socio-economic status. Age-adjusted odds ratios (ORs) with 95% confidence intervals (95% CI) for women and men with open-angle glaucoma, using individuals without this as referents, were calculated. Socio-economic status was assessed based on the neighbourhood the subjects lived in. Results In total, 16,299 cases of open-angle glaucoma were identified during 2012–2018, 9204 women and 7095 men. Higher fully adjusted OR (95% CI) for risk of being associated with open-angle glaucoma was for women and men with diabetes 1.138 (1.074–1.207) and 1.216 (1.148–1.289), cancer 1.175 (1.120–1.233) and 1.106 (1.048–1.166), hypertension 1.372 (1.306–1.440) and 1.243 (1.179–1.311); and for women with thyroid diseases 1.086 (1.030–1.146), chronic lung diseases 1.153 (1.093–1.216), and inflammatory arthropathies 1.132 (1.006–1.275). Higher glaucoma incidence was observed in individuals residing in high socio-economic status neighbourhoods. Conclusion The risk of glaucoma is increased in some somatic diseases, especially in individuals with diabetes, hypertension and cancer; and in higher socio-economic neighbourhoods as compared to lower socio-economic neighbourhoods.

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.

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.

Summary In this national study of osteoporotic fractures in second-generation immigrants in Sweden, we found a similar risk of osteoporotic fractures in general compared to Swedish natives, which suggests that environmental factors are important for the high risk of osteoporotic fractures in Nordic countries. Introduction Second generation immigrants may have a similar environment as individuals with two native-born parents. These individuals may be of interest to study concerning whether environmental or hereditary factors could be mostly associated to the risk of osteoporotic fractures. The aim of this study was to analyse the risk of osteoporotic fractures in second-generation immigrants compared to Swedish natives. Methods This was a nationwide study of individuals aged 50 years of age and older (N = 1,377,035; 691,750 men and 685,285 women). 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 95% confidence intervals (CI)) of incident osteoporotic fractures in second generation immigrants compared to Swedish natives. The Cox regression models were adjusted for age, comorbidities and for sociodemographic status. Results A total of 114,505 osteoporotic fractures were registered, 109,622 (8.4%) were among individuals with Swedish-born parents and 4883 (7.5%) among those with foreign-born parents, with distal forearm fractures dominating in general (44.9%). Fully adjusted HRs (95% CI) were for all immigrants 0.95 (95% CI, 0.91–0.99), for men 0.96 (95% CI, 0.89–1.04) and for women 0.95 (95% CI, 0.90–1.00). Conclusions We observed a similar risk of osteoporotic fractures among second-generation immigrants as in Swedish natives, which suggests that environmental factors are important for osteoporotic fractures. Supplementary Information The online version contains supplementary material available at 10.1007/s00198-020-05776-4.

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.

Venous thromboembolism (VTE) is an important cause of morbidity and mortality in Western countries. The incidence rate of VTE is estimated at 1–2 cases per 1000 annually. This study was a population-based cohort study of previously treatment naïve patients with a first occurrence of venous thromboembolism (VTE), using data from the administrative health data register of the Stockholm Region 2011–2018. Data on anticoagulant treatment was taken from the Swedish Prescribed Drug Register. We also analyzed all VTE events between 2011 and 2018. Altogether 14,849 naïve incident VTE cases were identified. In 2011 the majority of patients with a first episode of VTE were prescribed warfarin versus non-vitamin K antagonist oral anticoagulants (NOACs), 1144 versus 5. In contrast in 2018, the majority of patients were treated with NOACs, 1049 versus 59 treated with warfarin. Treatment with low molecular weight heparin only decreased from 814 to 683 patients. The frequency of all VTE events in the population increased over time from 1.88/1000 to 1.93/1000 (p = 0.072), and PE diagnoses increased from 0.69/1000 to 0.76/1000 (p = 0.003). In conclusion, during 2011–2018 there has been a shift of prescription of warfarin to a clear predominance of NOACs in the treatment of VTE in the Stockholm Region, in line with current recommendations. In the clinical situation, treatment has been simplified as monitoring of warfarin has decreased substantially. PE events increased during the time period in the population even if the increase was rather modest, while all VTE events did not increase significantly. Electronic supplementary material The online version of this article (10.1007/s11239-019-01966-y) contains supplementary material, which is available to authorized users.

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 In recent years, telemedicine consultations have evolved as a new form of providing primary healthcare. Telemedicine options can provide benefits to patients in terms of access, reduced travel time and no risk of disease spreading. However, concerns have been raised that access is not equally distributed in the population, which could lead to increased inequality in health. The aim of this paper is to explore the determinants for use of direct-to-consumer (DTC) telemedicine consultations in a setting where telemedicine is included in the publicly funded healthcare system. Methods To investigate factors associated with the use of DTC telemedicine, a database was constructed by linking national and regional registries covering the entire population of Stockholm, Sweden (N = 2.3 million). Logistic regressions were applied to explore the determinants for utilization in 2018. As comparators, face-to-face physician consultations in primary healthcare were included in the study, as well as digi-physical physician consultations, i.e., telemedicine consultations offered by traditional primary healthcare providers also offering face-to-face visits, and telephone consultations by nurses. Results The determinants for use of DTC telemedicine differed substantially from face-to-face visits but also to some extent from the other telemedicine options. For the DTC telemedicine consultations, the factors associated with higher probability of utilization were younger age, higher educational attainment, higher income and being born in Sweden. In contrast, the main determinants for use of face-to-face visits were higher age, lower educational background and being born outside of Sweden. Conclusion The use of DTC telemedicine is determined by factors that are generally not associated with greater healthcare need and the distribution raises some concerns about the equity implications. Policy makers aiming to increase the level of telemedicine consultations in healthcare should consider measures to promote access for elderly and individuals born outside of Sweden to ensure that all groups have access to healthcare services according to their needs.

Risk of dementia is increased in patients with atrial fibrillation (AF). We aimed to study associations between relevant comorbidities and prevalent as well as incident dementia in AF patients. Study population included all adults (n = 12,283) ≥ 45 years diagnosed with AF at 75 primary care centers in Sweden 2001–2007. Logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (95% CI) for associations between comorbidities and prevalent dementia. In a subsample (n = 12,096), (excluding patients with dementia diagnosed before AF onset), Cox regression was used to estimate hazard ratios (HR) with 95% CIs for association between comorbidities, and incident dementia, after adjustment for age, socioeconomic factors and anticoagulant treatment. Totally 937 patients (7.6%), 388 men (5.8%) and 549 women (9.7%), were diagnosed with dementia. After adjustments, prevalent dementia was more common in (ORs, 95% CI) men with congestive heart failure (CHF), stroke, and depression; in women with CHF and depression, and among women > 75 years with stroke, but less common in women with hypertension. During a 5.6-year follow-up (standard deviation 2.5), 750 patients (6.2%; 322 men, 4.9%, and 428 women, 7.8%) were diagnosed with incident dementia. An increased risk of incident dementia was found among men with diabetes and depression; a decreased risk among men and women with CHF, and among women with hypertension, myocardial infarction cerebrovascular diseases. The findings regarding incident dementia need to be interpreted with great caution, as they may have been subject to survival bias. Electronic supplementary material The online version of this article (10.1007/s11357-018-0029-8) contains supplementary material, which is available to authorized users.

To explore if health related quality of life(HRQoL) increased after traditional yoga(TY), mindfulness based cognitive therapy(MBCT), or cognitive behavioral therapy(CBT), in patients on sick leave because of burnout. Randomized controlled trial, blinded, in ninety-four primary health care patients, block randomized to TY, MBCT or CBT (active control) between September 2007 and November 2009. Patients were living in the Stockholm metropolitan area, Sweden, were aged 18–65 years and were on 50%–100% sick leave. A group treatment for 20 weeks, three hours per week, with homework four hours per week. HRQoL was measured by the SWED-QUAL questionnaire, comprising 67 items grouped into 13 subscales, each with a separate index, and scores from 0 (worse) to 100 (best). SWED-QUAL covers aspects of physical and emotional well-being, cognitive function, sleep, general health and social and sexual functioning. Statistics: Wilcoxon’s rank sum and Wilcoxon’s sign rank tests, Bonett-Price for medians and confidence intervals, and Cohen’s D. Twenty-six patients in the TY (21 women), and 27 patients in both the MBCT (24 women) and in the CBT (25 women), were analyzed. Ten subscales in TY and seven subscales in MBCT and CBT showed improvements, p

To explore the health-related quality of life (HRQoL), the cause of being ill, and the pharmacological treatment in patients on sick leave because of Burnout. The HRQoL among these patients was also compared with that of individuals who were working full time. HRQoL was measured using the SWED-QUAL questionnaire, comprising 67 items grouped into 13 subscales, scored from 0 (worst) to 100 (best) points, and covering aspects of physical and emotional well-being, cognitive function, sleep, general health, social, and sexual functioning. The Burnout group (n = 94), mean age 43 years, were on 50 % sick leave or more. The comparison group consisted of healthy persons (n = 88) of similar age and educational level who were working full time. The Burnout group had markedly low scores in general. The cause of illness was mainly work-related. Psychotropic medication was prescribed for 55 %. Significantly lower scores were found in the Burnout group than in the comparison group in all subscales, p

This study evaluated the benefits of and possible contraindications to warfarin treatment in patients with atrial fibrillation (AF) prior to the introduction of new oral anticoagulants using health registry data from inpatient care, specialist ambulatory care, and primary care.This is a cohort study including all patients in the region of Stockholm, Sweden (2.1 million inhabitants) with a diagnosis of non-valvular AF (n = 41 810) recorded during 2005-2009. The risks of suffering ischemic stroke, bleeding, or death with warfarin, aspirin, or no antithrombotic treatment during 2010 were related to CHA2DS2VASc scores, age, and complicating co-morbidities.One-year risks for ischemic stroke were 1.0-1.2 % with aspirin, 0-0.3 % with warfarin, and 0.1-0.2 % without treatment at CHA2DS2VASc scores 0-1. Among the aspirin-treated patients with CHA2DS2VASc scores ≥2, half had possible contraindications and high risks for ischemic stroke (5.2 %), bleeding (5.0 %), and death (19.3 %). The other half of the patients with no identified contraindications had a high risk for ischemic stroke (4.0 %) but a low bleeding risk (1.8 %) and a moderate mortality rate (8.4 %).The present observations confirm earlier findings of undertreatment with warfarin and half of the high-risk patients treated with aspirin were obvious candidates for anticoagulant treatment. However, the other half of the patients had complicating co-morbidities, high bleeding risk, and poor prognosis. This and possible overtreatment of low-risk patients should be taken into account when considering more aggressive use of anticoagulant treatment.

Although antihypertensive drugs are known to reduce mortality in individuals with hypertension, the effects of different cardiovascular pharmacotherapies on mortality among patients with hypertension and atrial fibrillation (AF) have been less thoroughly explored. To study mortality rates in men and women separately with hypertension and AF prescribed different cardiovascular pharmacotherapies. A cohort of men (n=2809) and women (n=2793) aged45 years diagnosed with hypertension and AF were selected using patient records. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using Cox regression, with all-cause mortality as the outcome. Analysis was performed on the whole population and after stratification by age and sex. Independent factors were prescribed pharmacotherapies. Adjustments were made for a propensity score comprising age, comorbidities, education and marital status. The higher the number of antihypertensive drugs prescribed, the lower the mortality rate (P-value for trend 0.005). Individuals prescribed 4-5 antihypertensive drugs had a lower risk of mortality than those prescribed 0-1 drugs (HR: 0.62; 95% CI: 0.45-0.86). The HRs for the following drug classes were: loop diuretics 1.39 (95% CI: 1.08-1.78), non-selective β-blockers 0.68 (95% CI: 0.53-0.88), angiotensin receptor blockers 0.75 (95% CI: 0.56-0.99) and statins 0.68 (95% CI: 0.53-0.88). AF patients with hypertension prescribed statins, non-selective β-blockers and angiotensin receptor blockers had low relative mortality risks, suggesting that these prescribed pharmacotherapies were beneficial. This needs to be further explored in other clinical settings.

Risk factors for stroke are well known in atrial fibrillation (AF) patients, while less is known on the effect of these factors on total mortality. Our aim was to study the impact of cardiovascular drug classes on mortality in AF patients treated in primary care. The study population was chosen based on patient data from 75 primary care centres in Sweden compiled in a database. Individuals diagnosed with AF who were older than 45 years were enrolled (n = 12,302, of whom 6,660 were men). Cox regression analysis with mortality (years to death) as outcome was conducted in the men and women separately, as well in the age categories < 80 and a parts per thousand yen80 years, with cardiovascular drugs as independent factors, and age, cardiovascular diagnoses and educational level as covariates. Lower mortality was shown for anticoagulant treatment among men, both younger (< 80 years) [adjusted hazard ratio (HR) 0.43, 95 % confidence interval (CI) 0.31-0.61] and older (a parts per thousand yen80 years) (adjusted HR 0.47, 95 % CI 0.32-0.69), and among younger women (adjusted HR 0.46, 95 % CI 0.29-0.74), and for antiplatelet treatment in older men (adjusted HR 0.51, 95 % CI 0.35-0.74). Treatment with thiazides was associated with lower mortality among younger men (adjusted HR 0.68, 95 % CI 0.48-0.96), older men (adjusted HR 0.67, 95 % CI 0.46-0.98) and older women (adjusted HR 0.70, 95 % CI 0.52-0.94). Statins were associated with lower mortality among younger patients, in both men (adjusted HR 0.47, 95 % CI 0.32-0.68) and women (adjusted HR 0.54, 95 % CI 0.35-0.82). The differences in age and gender patterns need further exploration.

We identified patients with newly diagnosed rheumatoid arthritis (RA) in the ages 18-65 years who needed psychosocial interventions. A total of 123 patients (90 women) were asked to participate, but 19 declined and 4 dropped out early in the study, leaving a total of 100 patients (75 women) in the sample. Questionnaires used were the Epidemiological Investigation on Rheumatoid Arthritis study questionnaire, the Hospital Anxiety and Depression Scale, the Sense of Coherence (SOC) scale, and the General Coping Questionnaire. Interviews showed that 46% of the included 100 patients had psychosocial problems (PSP). One third of them had problems directly related to RA. The rest had problems with their life situation in general, without or reinforced by RA. Compared to patients without psychosocial problems, PSP patients lived in more strained social situations, especially regarding personal finances and social support. More of the PSP patients were anxious, showed lower SOC scores, and also used more emotion-based coping strategies (resignation, protest, isolation and intrusion) and less problem-oriented (minimization). They also had higher scores on depression and more frequently expected that RA would negatively affect their future. PSP patients also experienced a more negative impact of the disease, a finding not confirmed by the sickness activity score judged by the rheumatologist. Thus, early in the course of RA, screening instruments should be used to identify PSP patients. Psychosocial treatment and support by medical social workers skilled in RA care should be offered.

The objective of this study was to describe cardiovascular risk profiles of 60-year-olds with uncontrolled diagnosed hypertension (>or=140/90 mm Hg) in comparison with individuals with controlled diagnosed hypertension. To study how medical, lifestyle and socioeconomic factors are associated with uncontrolled diagnosed hypertension in men and women separately, a population-based, cross-sectional study of 4228 60-year-olds in Sweden, of whom 503 men and 445 women had previously diagnosed hypertension, was conducted. Physical examination including measuring blood pressure was carried out, and a medical/lifestyle/socioeconomic questionnaire was completed. Only 22% of the men and 33% of the women with diagnosed hypertension had a blood pressure below 140/90 mm Hg. Both men and women had multiple cardiovascular risk factors in addition to hypertension. Antihypertensive monotherapy was more common in men and women with controlled hypertension. None of the participants without pharmacological treatment had a controlled blood pressure. Four factors were independently associated with uncontrolled hypertension in men: waist circumference above 97 cm (odds ratio (OR)=1.85, confidence interval (CI)=1.17-2.92), coronary heart disease (CHD) (OR=0.28, CI=0.17-0.46), no health care for financial reasons (OR=2.71, CI=1.09-6.78) and daily intake of fruit (OR=0.59, CI=0.37-0.93). In women, three factors remained independently associated: waist circumference above 78 cm (OR=1.93, CI=1.09-3.43), CHD (OR=0.36, CI=0.18-0.72) and living in an apartment (OR=0.55, CI=0.35-0.85). More efforts are warranted to reduce blood pressure and to modulate associated risk factors to be able to reduce the high morbidity and mortality observed in individuals with hypertension.

To study total mortality in different categories of BMI values, with adjustments for important covariates in a population-based 26-year mortality follow-up. Special interest will be given to gender differences and low BMI values. From a stratified sample in 1969 of 32 185 individuals aged 18–64 years from Stockholm County, 2422 underwent a health examination, with complete data obtained for 1020 subjects. BMI was classified as underweight (

Objective Assess changes in quality of life and in sense of coherence (SOC), after an intervention involving a self-development course using mind–body medicine (MBM) activities. Design A questionnaire study using a health-related quality of life (HRQOL) instrument, the SWEDQUAL, with 13 subscales and scores ranging from 0 to 100, combined with the SOC-13 scale, healthcare utilisation, medication and sick listing data. Setting A training centre for MBM. Eligible course attendants (study group, SG, n = 83) assessed their HRQOL before and 6 months after a 1-week course. A control group (CG) of individuals who had previously attended the course (n = 69), matched for age, sex and length of course time to the SG, also made assessments. Main outcome Changes in HRQOL and SOC in SG and CG. Results Of the 13 HRQOL subscales, eight showed clinically significant improvement in the SG (>9%, p

Prevention of cardiovascular diseases by paleolithic or hunterer-gatherer diets has been discussed during recent years. Our aim was to assess the effect of a paleolithic diet in a pilot study on healthy volunteers during 3 weeks. The intention was to include 20 subjects, of whom 14 fulfilled the study. Complete dietary assessment was available for six subjects. Mean weight decreased by 2.3 kg (P

A cross-sectional survey of quality of life of people attending a self-development course involving psychophysiological mind-body medicine (MBM) activities.A questionnaire study using a health-related quality of life (HRQoL) instrument, the SWED-QUAL, with 13 subscales scored 0-100, and questions about utilisation of alternative and standard health care, medication and sick leave.A training centre for MBM, established 15 years ago.One hundred and seven eligible course attendants (response rate 88%, age 20-70 years) during the year 2000 assessed their HRQoL just before entering the course. Attendance was self-initiated, without referral. The results on HRQoL were compared with those of control subjects from the general Swedish population.Six of the thirteen HRQoL subscales were strongly and significantly reduced (p0.0001) in the study group: Negative affectivity, Role limitation due to emotional health, Positive affectivity, Cognitive functioning, Family functioning and Marital functioning. Long-term sick leave (6 months) was three times as frequent in the study group as in the general population. Use of psychotropic medication was slightly increased compared to the general population, at least among the younger male participants. The education level was high, health care utilisation was average and body functioning was good.This group of well-educated men and women gave their emotional health an unexpectedly low rating, on a par with that given by people with chronic diseases.

Objective. To describe, and compare between 1995 and 2001, the distribution of prescribed drugs in diabetic men and women. Methods. Two cross-sectional surveys of medical records of diabetic patients with type-2 diabetes were carried out in two primary health care centres in Stockholm County; age 35–64 years; 59 men and 43 women in 1995, and 80 men and 80 women in 2001. Prescriptions of pharmaceutical preparations, metabolic outcome, cardiovascular risk factors and diabetes-related co-morbidity were noted. Correlation of significant outcomes was performed using logistic regression. Results. The pattern of antidiabetic therapy changed between 1995 and 2001 (P=0.001), with fewer subjects treated with insulin (15% vs 3%), and more subjects with tablets and insulin combined (13% vs 23%). Prescription rate of sulphonylureas decreased (54% vs 41%; P=0.035), and rate of metformin increased (34% vs 48%; P=0.035). The use of lipid-lowering agents rose from 14% to 37% (P

Objective: Assessing the quality of anticoagulant (AC) treatment in primary health care with regard to safety. Design: Surveys of patients on AC treatment during 1999. Setting: Community health centres (CHCs) in the north-eastern region of Stockholm County. Subjects: Nine hundred and fifty-seven patients, from 16 CHCs. Main outcome measures: Rate of bleeding and thrombo-embolic events during AC treatment and rate of values within the recommended treatment interval. The reporting of prothrombin-time (PT) results changed during the year from PT values to international normalised ratio (INR). Results: A total of 48 bleeding events in 44 patients were noted, i.e. 6.8 per 100 patient-years. Of these, ten were major bleedings, 1.4 per 100 patient-years, including three fatal bleedings, 0.4 per 100 patient-years. Six thrombo-embolic events were noted during treatment, i.e. 0.8 per 100 patient-years. Bleeding events were more common at INR values greater than 2.80 than at values of 2.80, [relative risk (RR) 3.30, 95% confidence interval 1.90–5.71]. Of all the noted PT values, 65% were within the recommended intervals (the most common being PT 15–25%) and of all noted INR values 60% (the most common being INR 2.1–3.0). No differences in the rate of bleeding or the number of thrombo-embolic events between the periods of PT and INR results were found. Conclusions: The rate of complications was low and AC treatment in primary health care seems to be as safe as in hospital clinics.

This study was an assessment of sexual functioning by making cross-sectional surveys of patients aged 45–84 years with chronic disorders; 397 had diabetes, 248 had glaucoma and 1914 had chronic, stable, angina pectoris; 1669 came from a standard population sample (SPS). Sexual functioning was assessed on one scale from the Swedish health-related quality of life survey (SWED-QUAL), adapted from the medical outcomes study (MOS). Both sexual functioning in general and specific sexual items were studied. Values were adjusted for non-respondents and standardised to the Swedish population. Response rates in the samples were 54–64% among men and 22–41% among women, decreasing with age for women. General sexual functioning decreased with age and was most apparent in patients with diabetes and angina pectoris, while glaucoma patients reported better results than the SPS. Loss of male erectile function was as common in diabetes (30%) as in angina pectoris (29%) and significantly higher than in the SPS (20%) (p

To assess change over time in health-related quality of life (HRQoL) in diabetic patients in primary health care and differences to general Swedish population samples, 341 diabetic subjects in 1992 and 413 in 1995, aged 20-84 years, were chosen from three community health centres (CHCs) in the Metropolitan Stockholm area and compared to controls matched by age and sex in randomly selected samples of 2,366 subjects in 1991 and 2,500 in 1995 from the general population. HRQoL was assessed by the Swedish Health-Related Quality of Life Survey (SWED-QUAL), adapted from the Medical Outcomes Study, which measures aspects of physical, mental, social and general health in 13 scales. Information on diabetic and general medical data were extracted from the medical records at the CHCs. HRQoL was lower in diabetic subjects compared with the general population in both 1992 and 1995 in all scales except family functioning and marital functioning. The level of HRQoL did not change significantly between the diabetic samples, but decreased in the population samples, making the difference compared to diabetic patients smaller in five of the scales. The most significant predicting factors for the SWED-QUAL results in diabetic patients in 1995 were the vascular and non-vascular co-morbidity.

Objective: To describe and compare the distribution of prescribed drugs in diabetic patients between 1992 and 1995. Methods: Two cross-sectional surveys of a random selection of medical records of diabetic patients, from three community health centres (CHCs) in the Stockholm metropolitan area, were carried out. The age of the subjects ranged from 20 to 84 years. The number of prescriptions of pharmaceutical preparations given to the diabetic patients was noted, as well as classification of the diabetes, the metabolic outcome, and concomitant hypertension. Results: Between 1992 and 1995, the use of oral antidiabetics increased significantly from 43 to 57% of the patients and the rate of treatment with diet only decreased from 30 to 20%. Combination treatment with oral drugs and insulin rose significantly from 1 to 8% of the patients. However, the greatest increase observed between 1992 and 1995 concerns cardiovascular drugs. The prescription rate of ACE inhibitors increased from 5 to 21%, of loop diuretics from 19 to 28%, of ASA from 9 to 21%, and of lipid-lowering agents from 1 to 7%. There was also a considerable variation between the three CHCs. Despite the more aggressive diabetic treatment strategies, the metabolic state was unchanged and unsatisfactory for 40–50% of the patients. Conclusions: There have been major changes towards more active pharmacological treatment regarding antidiabetic, cardiovascular, and lipid-lowering agents.

Background: There is limited knowledge on the prevalence of disease in total populations. Such studies have historically been difficult to conduct but the development of health data registers has facilitated large-scale studies on recorded diagnoses in entire regions. The aim of this study was to analyze the prevalence of diagnosis of six common diseases in the Swedish capital region. Methods: The study population included all living persons who resided in Stockholm County, Sweden, on December 31 st 2011 (N = 2 093 717). Information on all consultations between 2007 and 2011 was obtained from primary health care, specialist outpatient care and inpatient care. Prevalence was defined as the proportion of individuals with a recorded diagnosis of diabetes, depression, anxiety disorders, hypertension, asthma and chronic obstructive pulmonary disease during the five year period, respectively. Analyses were done by age and gender. Results: Hypertension had the highest five-year prevalence (12.2%), followed by depression (6.6%), diabetes mellitus (6.2%), asthma (5.9%), anxiety disorders/phobia (4.8%), and COPD (1.8%). Diabetes was more common in men (5.3% of women and 7.1% of men) while depression (8.7% in women and 4.4% in men) and anxiety (6.3% in women and 3.4% in men) were considerably more common in women. Smaller gender differences were also found for hypertension (13.0% in women and 11.4% in men), asthma (6.4% in women and 5.4% in men) and COPD (2.1% in women and 1.6% in men). Diabetes, hypertension and COPD increased markedly with age, whereas anxiety, depression and asthma were fairly constant in individuals above 18 years. During one year of observation, more than half of all patients had only been diagnosed in primary health care, with hypertension being the diagnosis with the largest proportion of patients only identified in primary health care (70.6%). Conclusion: The prevalence of common diseases in the population can be estimated by combining data gathered during consecutive years from primary care, specialist outpatient care and inpatient care. However, accuracy of disease prevalence is highly dependent on the quality of the data. The high prevalence of the six diagnoses analysed in this study calls for preventive action to minimize suffering and costs to society.

Background Hypertension is common among persons with type 2 diabetes. The aim of this study was to analyze the association between ethnicity and hypertension prevalence after adjusting for age, sex, Hba1c, total cholesterol, elevated triglycerides and hypertriglyceridemic waist. The study population consisted of 354 primary health care patients diagnosed with type 2 diabetes (173 Assyrians/Syrians and 181 Swedes) residing in Södertälje, Sweden. Unconditional logistic regression was used to analyze the data. Results Hypertension prevalence was higher among Swedes than Assyrians/Syrians, (77% versus 58%; p = 0.001). In the unadjusted logistic regression model, the odds ratio for hypertension in Swedes was twice as high than that in Assyrians/Syrians (OR = 2.44; 95% CI =1.54-3.86). In the age- and sex-adjusted model, odds ratio of hypertension was 2.25 (95% CI 1.41-3.60). After adjustments for total cholesterol was made, the odds ratio of hypertension decreased slightly to 1.73. When elevated triglycerides and hypertriglyceridemic waist were separately introduced, the odds ratio of hypertension was no longer significant between the ethnic groups (1.60 and 1.43 for triglycerides and hypertriglyceridemic waist respectively). In addition, advanced age – 60–69 years old (OR = 1.80, CI 95% 1.00-3.20) and ≥ 70 years old (OR = 2.88, CI 95% 1.40-5.93), elevated total cholesterol (OR = 1.48, CI 95% 1.12-1.95) and presents of hypertriglyceridemic waist (those with high WC and high TG) were significant confounding factors for the increased risk of hypertension independent of ethnicity. Conclusions The crude differences in prevalence of hypertension between the Swedes and Assyrians/Syrians in our study population with type 2 diabetes were no longer significant when adjusting for high triglycerides levels or the presence of hypertriglyceridemic waist.