Obesity, survival, and hospital costs-findings from a screening project in Sweden

OBJECTIVE

Our aims were to estimate 1) the costs of hospital treatment and 2) the value of lost production due to early death associated with overweight and obese patients, and then to extrapolate the findings to national costs.

METHODS

We use regression models to analyze survival, expected number of days in hospital treatment for patients with different body mass index (BMI), and costs with data obtained from screening of 33,196 middle-aged subjects living in Malmö, Sweden, and collected during a 15-year follow-up period. We subsequently scale up costs to national aggregate level using the BMI prevalence data from the screening project to the national population.

RESULTS

The total excess hospital (somatic, psychiatric) care cost (Swedish krona or SEK) for the national health-care budget, excess as compared to normal weight patients for obese (BMI > 30) and overweight (25 < or = BMI < 30) was estimated to SEK2155 million per annum (269 million dollars, assuming 1 dollar = SEK8), or about 2.3% of total hospital care costs in Sweden. The corresponding indirect costs due to early death were estimated to SEK2935 million (367 million dollars). For males at age 55, the potential hospital costs saving, excluding costs of the intervention that could be gained by an intervention that successfully and safely could alter the weight of an obese individual to become normal weight, was estimated on average to SEK4434 (554 dollars) per annum.

CONCLUSION

Hospital treatment costs are found to be higher for obese and overweight patients than for normal weight patients indicating potential cost savings especially on indirect costs by effective, safe and low cost weight-loss intervention.

A longitudinal study of growth in children with acute lymphoblastic leukemia

Growth in terms of both height and weight was studied in a longitudinal sample consisting of ten children who all experienced the onset of acute leukemia between 18 months and 7 years of age. In spite of the lack of deviation in body size at birth, these children had somewhat higher values for attained size than the reference group one year before diagnosis. The information from this study showing a decrease in growth rate before the start of treatment, could suggest that the disease causes the growth failure. Growth rate for height increased with time from the first year of treatment, which could be correlated to a positive effect of medical treatment of the disease. These results indicate a very stable regulation of growth between 18 months and 12 years of age. The children dropped temporarily in mean one standard deviation (SD) corresponding to about 4 cm, from one year before the start of treatment to the end of the three years of treatment. It seems, however, that it is possible for the body to repair such a temporary growth inhibition as is seen in the catch-up growth during the following two years. Height measured in SD for the group two years after discontinuing treatment was practically the same as height at the time of the start of treatment. Children with leukemia during the first years of life and during the pubertal period may not show a similar growth pattern.

Ethanol intake and risk of lung cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC)

Within the European Prospective Investigation into Cancer and Nutrition (EPIC), the authors examined the association of ethanol intake at recruitment (1,119 cases) and mean lifelong ethanol intake (887 cases) with lung cancer. Information on baseline and past alcohol consumption, lifetime tobacco smoking, diet, and the anthropometric characteristics of 478,590 participants was collected between 1992 and 2000. Cox proportional hazards regression was used to calculate multivariate-adjusted hazard ratios and 95% confidence intervals. Overall, neither ethanol intake at recruitment nor mean lifelong ethanol intake was significantly associated with lung cancer. However, moderate intake (5-14.9 g/day) at recruitment (hazard ratio (HR) = 0.76, 95% confidence interval (CI): 0.63, 0.90) and moderate mean lifelong intake (HR = 0.80, 95% CI: 0.66, 0.97) were associated with a lower lung cancer risk in comparison with low consumption (0.1-4.9 g/day). Compared with low intake, a high (> or =60 g/day) mean lifelong ethanol intake tended to be related to a higher risk of lung cancer (HR = 1.29, 95% CI: 0.93, 1.74), but high intake at recruitment was not. Although there was no overall association between ethanol intake and risk of lung cancer, the authors cannot rule out a lower risk for moderate consumption and a possibly increased risk for high lifelong consumption.

Antiatherosclerotic effects of beta-blockers

Accumulating data from studies in animals and humans indicate that beta-blockade has antiatherosclerotic effects. To date, 2 long-term ultrasound studies provide the strongest evidence. The Beta-Blocker Cholesterol-Lowering Asymptomatic Plaque Study (BCAPS) trial reported favorable effects with beta-blockade on early stages of atherosclerosis in patients with carotid plaque but no symptoms of carotid artery disease. Compared with placebo, metoprolol controlled release/extended release (CR/XL) 25 mg once daily significantly reduced plaque thickness after 18 months of treatment (net difference -0.058 mm/year; p <0.001) and at 3 years' follow-up (net difference -0.023 mm/year; p = 0.018). The Effects of Long-Term Treatment of Metoprolol CR/XL on Surrogate Variables for Atherosclerotic Disease (ELVA) trial demonstrated that beta-blockers and statins affect different mechanisms in the atherosclerotic process and have additive beneficial effects. Patients with hypercholesterolemia were randomized to metoprolol CR/XL 100 mg once daily or placebo once daily and concomitant statin therapy. The metoprolol CR/XL group had a significantly lower rate of progression of the composite carotid bulb intima-media thickness (IMT) plus common carotid IMT than the placebo group, both at 1 year (-0.08 vs -0.01 mm; p = 0.004) and after 3 years' follow-up (-0.06 vs +0.03 mm; p = 0.011). Several factors may contribute to the mechanism of benefit in these trials, including reduced sympathetic activity, improved hemodynamic parameters, and direct effects on the vascular endothelium.

Socioeconomic differences in smoking cessation: the role of social participation

Objectives: The aim of this study was to investigate whether psychosocial resources explain socioeconomic differences in smoking cessation and its maintenance. Methods: A subpopulation of 11,837 individuals from the Malmö Diet and Cancer Study interviewed in 1992-94, age range 45-64 years, was investigated in this cross-sectional study. A multivariate logistic regression model was used to assess relative risks of having stopped smoking, adjusting for age, country of origin, previous/ current diseases, and marital status. Results: An odds ratio of 1.9 (1.4-2.5; 95% CI) for men and 2.0 (1.4-2.7; 95% CI) for women of having stopped smoking was found for higher non-manual employees when compared with unskilled manual workers. A decrease in these odds ratios was found when social participation was introduced into the model. The other three social network and social support variables were non-significant. Conclusion: High social participation is a predictor of maintenance of smoking cessation. It seems possible to interpret parts of the socioeconomic differences in smoking cessation and its maintenance as a consequence of differing social network resources and social capital between socioeconomic groups.

Monitoring 24-hour blood pressure in a drug trial. Evaluation of a noninvasive device

To test the usefulness of noninvasive ambulatory 24-hour blood pressure recording, the Del Mar Avionics system was used in a double-blind clinical trial in which 31 hypertensive patients were randomly allocated to receive placebo or pafenolol (25 mg or 50 mg), a novel, long-acting, highly selective beta-blocker, once daily. The results of 24-hour blood pressure and heart rate recording after 4 weeks of treatment were compared with a previous 24-hour recording performed after a 4-week placebo run-in period using the 3-hour mean of recordings performed every 7.5 minutes both day and night. Furthermore, 24-hour means were analyzed in each patient before and after 4 weeks. The system was easy to use and, judging from two placebo periods in the same patients, the reproducibility was good. The 24-hour blood pressure and heart rate recordings showed a clear dose-response relationship for pafenolol that could not be detected by ordinary casual readings. A daily dose of 25 mg of pafenolol significantly reduced blood pressure during the 9 hours after tablet intake (p less than 0.01), while 50 mg per day of pafenolol resulted in a significant reduction throughout the 24-hour period (p less than 0.01). The same pattern was seen for heart rate, which indicates a greater degree of beta-blockade during treatment with the higher dose. These results indicate that the tested noninvasive equipment is a useful tool for monitoring ambulatory 24-hour blood pressure. It gives important information impossible to obtain from single casual readings. This noninvasive method should be further evaluated to define its place in clinical work and as a research tool.

High fat and alcohol intakes are risk factors of postmenopausal breast cancer: a prospective study from the Malmö diet and cancer cohort

Associations between intakes of relative fat, total alcohol and alcoholic beverages and risk of breast cancer were examined in a subsample of 11726 postmenopausal women from the MDC cohort. The MDC conducted baseline examinations from 1991 to 1996; the end of follow-up was 31 December 2001. Data were obtained by an interview-based diet history method, a structured questionnaire, anthropometric measurements and national and regional cancer registries. During 89602 person-years of follow-up, 342 incident cases were documented. Cox regression analysis examined breast cancer risks adjusted for potential confounders. Two energy-adjustment approaches (i.e., adjusting for total energy vs. adjusting for nonalcohol energy) were used. High total alcohol intake was associated with a nonsignificantly elevated risk. High wine intake was associated with a significantly elevated breast cancer risk (relative risk = 2.12, 95% CI 1.24-3.60). There were significant trends of increased breast cancer risk across quintiles of relative fat intake. Mutual adjustment did not affect risk estimates for total alcohol or relative fat intakes. The specific energy-adjustment approach did not influence associations differentially.

Antihypertensive effect of diet compared with drug treatment in obese men with mild hypertension

OBJECTIVE

To determine whether dietary treatment has a similar antihypertensive effect to conventional drug treatment while being superior to drugs in improving serum lipid concentrations in obese men with mild hypertension.

DESIGN

Six week run in period followed by randomisation to either diet or drug treatment groups for one year.

SETTING

Outpatient clinic in city hospital.

PATIENTS

61 Men aged 40-69 years, body mass index greater than or equal to 26, diastolic blood pressure 90-104 mm Hg when untreated. Exclusion criteria were signs of organ damage secondary to hypertension and diseases that might have interfered with compliance or with interpretation of results.

INTERVENTIONS

Dietary treatment was based on weight reduction, restriction of sodium, and decrease of excess alcohol intake (defined as greater than or equal to 250 g alcohol per week). Drug treatment used a stepped care approach with atenolol as drug of first choice.

MAIN OUTCOME MEASURES

Diastolic blood pressure less than 90 mm Hg; absolute reductions in blood pressure and serum lipid concentrations.

RESULTS

Mean body weight decreased 7.6 kg in the diet group and increased 0.9 kg in the drug treatment group (p less than 0.0001), and mean sodium excretion decreased 42 and 10 mmol/24 h respectively (p = 0.019). There was no difference in reported alcohol intake. Mean systolic blood pressure decreased 4 mm Hg in the diet group and 16 mm Hg in the drug group (p = 0.003) and diastolic blood pressure 3 and 11 mm Hg respectively (p = 0.002). Diastolic blood pressure of 90 mm Hg was attained by 29% of the diet group (nine men) and 73% (22) of those receiving drug treatment (mean difference 44%, 95% confidence interval 21 to 67%, p = 0.001). Dietary treatment produced decreases in mean serum concentrations of total and low density lipoprotein cholesterol as well as triglycerides and an increase in high density lipoprotein cholesterol concentration. In the drug treatment group the changes were in the opposite direction, and the groups differed significantly in all but total cholesterol.

CONCLUSIONS

Dietary treatment was inferior to conventional drug treatment in controlling mild hypertension but superior in lowering serum concentrations of lipids.

Evidence for leptin regulation of food intake in humans

The adipocyte hormone leptin regulates body weight in mice by decreasing food intake and increasing energy expenditure. Whether leptin is of physiological importance for these processes in humans is, however, not clear. We therefore studied the relation between leptin and habitual food intake in 64 healthy postmenopausal women. Dietary habits were assessed with a modified diet history method. Body fat content was measured using bioelectrical impedance. In the 64 women, aged 58.6+/-0.4 yr (mean+/-SD), serum leptin was 19.3+/-12.7 ng/mL, body mass index was 25.0+/-3.5 kg/m2, body fat content was 31.6+/-4.3%, fasting glucose was 4.6+/-0.5 mmol/L, and fasting insulin was 56+/-21 pmol/L. Leptin levels were negatively correlated to total energy intake (r=-0.34; P=0.006), carbohydrate intake (r=-0.36; P=0.004), and total (r=-0.27; P=0.034) as well as saturated fat intake (r=-0.31; P=0.014). Leptin was correlated to the absolute, but not to the percent, intake of these nutrients. When normalized for body fat content, the correlations remained significant. Our results suggest that plasma leptin is involved in the physiological regulation of food intake in humans, and that leptin is related to the quantity rather than the quality of habitual food intake.

Family burden of cardiovascular mortality: risk implications for offspring in a national register linkage study based upon the Malmö Preventive Project

OBJECTIVE

To investigate the adjusted relative risk of cardiovascular disease (CVD) events in offspring of parents with cardiovascular mortality before 75 years.

SETTING

The city of Malmö, Sweden.

DESIGN

A follow-up study based on register linkage analyses.

SUBJECTS AND METHODS

In the Malmö Preventive Project (MPP), a total of 22,444 men and 10,902 women attended the screening programme between 1974 and 1992. At the screening conventional risk factors for CVD were measured (blood pressure, lipids, glucose, smoking and social class).

MAIN OUTCOME MEASURES

Parental CVD mortality was determined via register linkage analysis between the Multiple-Generation Register and the National Mortality Register (NMR). CVD events (morbidity and mortality) in offspring were collected from national registers. The relative risk for CVD events in offspring, in relation to parental CVD mortality, was adjusted for age and risk factors at screening.

RESULTS

The age-adjusted relative risk (RR; 95%CI) for a son to experience a CVD event was increased in relation to a maternal positive family history of CVD mortality before 75 years when compared with no maternal history, RR 1.74 (1.43-2.11). This RR decreased to 1.51 (1.23-1.84; P < 0.001) after full adjustment for risk factors. The corresponding fully adjusted RRs for father-son heritage was RR 1.22 (1.02-1.47; P < 0.05), mother-daughter RR 0.87 (0.54-1.41), and father-daughter RR 1.20 (0.83-1.73).

CONCLUSION

The existence of maternal CVD mortality before the age of 75 years implies a substantial risk increase for CVD morbidity and mortality in sons that cannot be explained by social background, lifestyle, or conventional cardiovascular risk factors in the adult offspring.

Occupation and risk of lymphoma: a multicentre prospective cohort study (EPIC)

OBJECTIVES

Evidence suggests that certain occupations and related exposures may increase the risk of malignant lymphoma. Farming, printing and paper industry, wood processing, meat handling and processing, welding, shoe and leather manufacturing and teaching profession are among the categories that have been implicated in previous studies. The relationship between occupation and malignant lymphoma has been investigated in a large European prospective study.

METHODS

We investigated occupational risks for lymphomas in the European Prospective Investigation into Cancer and Nutrition (EPIC). The mean follow-up time for 348,555 subjects was 9 years (SD: 2 years). The analysis was based on 866 and 48 newly diagnosed cases of non-Hodgkin's lymphoma (NHL) and Hodgkin's lymphoma (HL). These were identified in the EPIC subcohorts with occupational data. Data on 52 occupations were collected through standardised questionnaires. Cox proportional hazard models were used to explore the association between occupation and risk of malignant lymphoma.

RESULTS

The following occupations were positively associated with malignant NHL after adjustment for study centre, age, sex, socioeconomic status (SES), smoking and alcohol: butchers (HR=1.53, 95% CI 1.05 to 2.48, including multiple myeloma/plasmacytoma; HR=1.30, 95% CI 1.00 to 2.66, excluding multiple myeloma/plasmacytoma) and car repair workers (HR=1.50, 95% CI 1.01 to 2.00, including multiple myeloma/plasmacytoma; HR=1.51, 95% CI 1.01 to 2.31, excluding multiple myeloma/plasmacytoma). HL was associated with gasoline station occupation (HR=4.59, 95% CI 1.08 to 19.6).

CONCLUSION

The findings in this current study of a higher risk of NHL among car repair workers and butchers and a higher risk of HL among gasoline station workers suggest a possible role from occupationally related exposures, such as solvents and zoonotic viruses, as risk factors for malignant lymphoma.

Socioeconomic differences in the progression of carotid atherosclerosis in middle-aged men and women with subclinical atherosclerosis in Sweden

While the persistence of socioeconomic differences in cardiovascular disease (CVD) has been recognized for many years, less is known about whether socioeconomic factors are of importance to CVD before symptoms of the disease appear. In this study the associations among educational level, occupational status and progression of atherosclerosis were investigated in 1016 Swedish middle-aged men and women with signs of subclinical atherosclerosis, i.e., carotid plaque (defined as focal intima-media thickness (IMT) > 1.2 mm). IMT in the common carotid artery (CCA) and in the carotid bifurcation area, as well as carotid plaque score, was determined by B-mode ultrasound. Results showed only weak associations between educational level, occupational status and age-, sex- and baseline IMT-adjusted progression of IMT in the CCA. However, in the age, sex- and baseline IMT-adjusted analyses, those in unskilled manual occupations showed a significantly higher yearly progression of carotid IMT in the bifurcation area compared to those in high- or medium-level non-manual occupations. Those with primary education tended to show a higher yearly progression of carotid IMT in the bifurcation area compared to those with completed secondary education. After adjustment for risk factors, the magnitude of these associations were somewhat attenuated. Similar patterns of associations were seen for the change of carotid plaque score. We conclude that low socioeconomic status (SES) is associated with progression of atherosclerosis in a middle-aged population with signs of subclinical atherosclerosis. Even though socioeconomic differences in cardiovascular risk factor levels could explain part of the found differences in progression rate in women, the mechanisms involved remain to be further established.

Maternal mood disorders and lithium exposure in utero were not associated with poor cognitive development during childhood

AIM

This study evaluated whether maternal mood disorders (MMD), particularly bipolar disorder, and lithium treatment during pregnancy influenced the neonatal health and cognition of children born from 2006 to 2010.

METHODS

Our study at Karolinska University Hospital, Stockholm, Sweden, focused on women with and without mood disorders and their children. Information on pharmacotherapy, mental health, delivery and neonatal complications was retrospectively collected from electronic patient records. Children were tested in a blinded manner at four to five years of age with the Wechsler Preschool and Primary Scale of Intelligence, 3rd edition. Maternal health, child health and social situations were evaluated.

RESULTS

Of the 39 children, 20 were exposed to lithium and MMD during pregnancy, eight were exposed to MMD but not lithium and 11 were not exposed to MMD or lithium. The children's full scale intelligence quotient (IQ), performance IQ and verbal IQ results did not differ significantly between the groups. The processing speed quotient was significantly lower in children exposed to mood disorders, but there was a high level of missing data for this subtest.

CONCLUSION

This small, clinical cohort showed no significant association between mothers' prenatal exposure to lithium or mood disorders and their offspring's IQ.

Mortality rates in treated hypertensive men with additional risk factors are high but can be reduced: a randomized intervention study

The aim was to examine the feasibility and efficacy of a multifactorial risk factor intervention program in hypertensive patients at high cardiovascular risk. Treated hypertensive men, aged 50 to 72 years, with at least one of the following: serum cholesterol concentration > or = 6.5 mmol/L, diabetes mellitus, or smoking were randomized to multifactorial risk factor intervention (n = 253) or usual care (n = 255). The specific intervention was based on group meetings to encourage a lipid lowering diet and smoking cessation. Cholestyramine, nicotinic acid, fibrates, and later statins were used either as single drug therapy or in combination, following agreed guidelines in patients in whom the nonpharmacological intervention was judged to be insufficient. Usual care was given according to clinical practice. The median follow-up time was 6.6 years. Sixty-four patients (25.1%) died in the usual care group, compared with 41 patients (16.2%) in the intervention group (P = .016; 95% confidence interval, relative risk 0.42 to 0.92). The overall risk for fatal and nonfatal cardiovascular events was 29% lower in the intervention group than in the usual care group (P = .041). Relative to usual care, the intervention program lowered mean in-trial serum concentrations of total cholesterol (6.3%, P < .0001), LDL cholesterol (9.1%, P < .0001), and blood glucose (0.2 mmol/L, P < .05). Among smokers, at entry, cotinine-adjusted quit rates were 28% in the intervention group and 11% in the usual care group (P = .012) after 3 years. This study illustrates the very high cardiovascular risk in hypertensive patients 50 to 72 years of age with additional risk factors. The results indicate, however, that the gloomy prognosis may be improved by a dedicated risk factor intervention program.

Immune responses against fibronectin modified by lipoprotein oxidation and their association with cardiovascular disease

OBJECTIVES

Accumulation and subsequent oxidation of LDL in the arterial wall are considered as key events in the development of atherosclerosis. We have investigated the possibility that LDL oxidation results in release of aldehydes that modify surrounding matrix proteins and that this may target immune responses against the plaque extracellular matrix and modulate the disease progression.

RESULTS

Using custom-made ELISAs we demonstrate that human plasma contains autoantibodies against aldehyde-modified fibronectin (FN) and to a lesser extent also other extracellular matrix proteins including collagen type I, type III, and tenascin-C. Immunohistochemistry and western blot analysis showed that aldehyde-modified FN is present in human atherosclerotic plaques and that aldehydes generated by oxidation of LDL formed adducts with FN in vitro. We also demonstrate that aldehyde-modification of FN results in a loss of its ability to promote basal secretion of cytokines and growth factors from cultured macrophages without affecting the ability of the cells to respond to stimulation with LPS. A prospective clinical study demonstrated that subjects that subsequently developed acute myocardial infarction or sudden cardiac death had lower baseline levels of autoantibodies against aldehyde-modified FN than matched controls.

CONCLUSIONS

These observations demonstrate that oxidation of LDL in the arterial wall may lead to aldehyde-modification of surrounding extracellular matrix proteins and that these modifications may affect macrophage function and activate autoimmune responses of pathophysiological importance for the development of atherosclerosis.

COHb% as a marker of cardiovascular risk in never smokers: Results from a population-based cohort study

Aim: Carbon monoxide (CO) in blood as assessed by the COHb% is a marker of the cardiovascular (CV) risk in smokers. Non-smokers exposed to tobacco smoke similarly inhale and absorb CO. The objective in this population-based cohort study has been to describe inter-individual differences in COHb% in never smokers and to estimate the associated cardiovascular risk. Methods: Of the 8,333 men, aged 34—49 years, from the city of Malmö, Sweden, 4,111 were smokers, 1,229 ex-smokers, and 2,893 were never smokers. Incidence of CV disease was monitored over 19 years of follow up. Results: COHb% in never smokers ranged from 0.13% to 5.47%. Never smokers with COHb% in the top quartile (above 0.67%) had a significantly higher incidence of cardiac events and deaths; relative risk 3.7 (95% CI 2.0—7.0) and 2.2 (1.4—3.5), respectively, compared with those with COHb% in the lowest quartile (below 0.50%). This risk remained after adjustment for confounding factors. Conclusion: COHb% varied widely between never-smoking men in this urban population. Incidence of CV disease and death in non-smokers was related to COHb%. It is suggested that measurement of COHb% could be part of the risk assessment in non-smoking patients considered at risk of cardiac disease. In random samples from the general population COHb% could be used to assess the size of the population exposed to second-hand smoke.

Reduced utilisation of specialist care among elderly cancer patients: a randomised study of a primary healthcare intervention

The aim of this study was to evaluate the effect of an individual support (IS) intervention including intensified primary healthcare on the utilisation of specialist care among cancer patients, and to investigate if such an effect was modified by the patient's age (less than 70 years or 70 years and more). Newly diagnosed cancer patients (n=416) were randomised between the intervention and a control condition, and data were collected on the utilisation of specialist care within 3 months from inclusion. Intensified primary healthcare comprised extended information from the specialist clinics, and education and supervision in cancer care for general practitioners (GPs) and home-care nurses. The support given also included interventions designed to diminish problems of weight loss and psychological distress. The intervention reduced the number of admissions (NoA) and the days of hospitalisation (DoH) after adjustment for weight loss and psychological distress, but only for older patients. Older patients randomised to the intervention (n=82) experienced 393 fewer DoH than the older control patients (n=79). In addition, the proportion of older patients in the IS group who utilised acute specialist care was smaller compared with older control patients group. The conclusion is that older cancer patients' utilisation of specialist care may be reduced by intensified primary healthcare services.

Bayesian methods for meta-analysis of causal relationships estimated using genetic instrumental variables

Genetic markers can be used as instrumental variables, in an analogous way to randomization in a clinical trial, to estimate the causal relationship between a phenotype and an outcome variable. Our purpose is to extend the existing methods for such Mendelian randomization studies to the context of multiple genetic markers measured in multiple studies, based on the analysis of individual participant data. First, for a single genetic marker in one study, we show that the usual ratio of coefficients approach can be reformulated as a regression with heterogeneous error in the explanatory variable. This can be implemented using a Bayesian approach, which is next extended to include multiple genetic markers. We then propose a hierarchical model for undertaking a meta-analysis of multiple studies, in which it is not necessary that the same genetic markers are measured in each study. This provides an overall estimate of the causal relationship between the phenotype and the outcome, and an assessment of its heterogeneity across studies. As an example, we estimate the causal relationship of blood concentrations of C-reactive protein on fibrinogen levels using data from 11 studies. These methods provide a flexible framework for efficient estimation of causal relationships derived from multiple studies. Issues discussed include weak instrument bias, analysis of binary outcome data such as disease risk, missing genetic data, and the use of haplotypes.

Dietary patterns in high and low consumers of meat in a Swedish cohort study

The objective was to examine relationships between meat and other food items which have been associated with higher risk of cancer in the colon and prostate in some epidemiological studies. The study was conducted as a population-based cohort study comprising 11648 subjects (4816 male and 6742 female) born between 1926 and 1945 and living in the city of Malmö, Sweden. Data on mean daily intake of foods and nutrients were assessed with a diet history method combining a 7-day menu book and a food frequency questionnaire. Increasing meat intake, expressed in quintiles and adjusted for energy, was associated with decreasing intakes of poultry, fish, fruits, bread, cereals and cheese in both sexes. Low negative correlations between meat intake and ascorbic acid (r= -0.11) and fiber (r= -0.16 to -0.20) were noted. The average intake of fat from meat out of total fat intake was 13.6% in men and 11.9% in women. No major associations were noted between meat and the cholesterol raising fatty acids C:12:0, C:14:0, C:160 nor for C:20:4 or its precursor C:18:2. In conclusion, our findings indicate that meat consumption is negatively associated with food groups rich in antioxidants and fiber and the positive covariance reported between meat and cancer and coronary heart disease might, therefore, not be directly linked to components in meat.

Intraosseous salivary gland tissue of the mandible mimicking a periapical lesion

A case of an unusual site of salivary gland tissue is presented. The lesion appeared as a radiolucency between the apices of the lateral incisor and canine in a 57-year-old male patient and simulated a periapical lesion. The canine was found vital.