Characteristics and Correlates of Perceived Physical and Psychological Health Among Family Caregivers Living With Persons With Advanced Dementia

BACKGROUND

Various factors drive a care setting shift from institutional to home settings for dementia care until the latest stage of the disease, suggesting the critical role of family caregivers living with persons with dementia.

OBJECTIVES

This study explored the characteristics and correlates of self-reported overall physical and psychological (ie, depressive symptoms and stress) health among family caregivers living with persons with dementia in Sweden.

METHODS

This cross-sectional, descriptive study used baseline data from an existing music-based intervention study of persons with dementia and their family caregivers (N = 76). Multivariable linear regression analyses were performed.

RESULTS

On average, caregivers (n = 38; mean age: 74.8 years) were slightly younger than persons with dementia (n = 38; mean age: 78.6 years). Most caregivers were female (n = 24; 63.2%) and spouses or partners of persons with dementia (n = 37; 97.4%). Caregivers' perceived relationship with their family members with dementia was the only factor associated with caregivers' self-reported overall physical health (b = -0.655, p = .046). This suggests caregivers' more frequent feeling of a good relationship with the persons with dementia was linked to better self-rated physical health among family caregivers living with persons with dementia.

CONCLUSIONS

This study highlights the importance of family caregivers' perceived relationship with persons with dementia in the context of caregivers' self-reported physical health. Future research is needed to explore the perceived relationship from the perspectives of persons with dementia and the determinants of caregiving dyads' (persons with dementia and family caregivers) perceived relationship with each other.

Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Midwife Educators' perceptions of the efficacy of the Objective Structured clinical assessment of life-saving interventions - a qualitative interview study in Bangladesh

INTRODUCTION

Objective Structured Clinical Assessment (OSCA) is a way of evaluating students or clinicians in how they are carrying out their duties. The aim of this study was to examine how midwifery educators in Bangladesh perceived using OSCA as an assessment device in midwifery education for student performance in life-saving midwifery interventions.

METHOD

Individual interviews were conducted with 47 academic midwives and clinical midwives using purposive sampling at 38 education institutions in Bangladesh. Content analysis inspired by Elo and Kyngas was used to analyze the data.

RESULTS

The ability of students to perform effectively in the OSCA-evaluated simulation of life-saving skills was related to the educators' understanding of the concept of midwifery. The overarching main category of this study showed that for midwifery educators to be able to effectually teach professional, evidence-based midwifery, they need to be able to synthesize the delivery of practical and theoretical skills with pedagogical skills and knowledge. To implement the OSCA tool more effectively, midwifery educators need to understand the underpinning principles of midwifery values and philosophy including leadership, ownership, responsibility, and personal engagement.

CONCLUSION

There is potential to improve the efficacy of using OSCA to deliver the teaching of life-saving skills. Team sessions with midwives and physicians aiming to practice teamwork and role divisions in life-saving interventions are recommended.

Assessing stress using repeated saliva concentration of steroid hormones in dementia care dyads: results from a controlled pilot care music intervention

Background

Stress-related biomarkers have the potential to provide objective measures of whether interventions directed at people with dementia (PWD) and their family caregivers (FCG) are successful. The use of such biomarkers has been limited by logistical barriers to sample collection.

Objective

Explore saliva concentration of steroid hormones in dementia care dyads during a music intervention.

Methods

Consecutive PWD attending a memory evaluation center and their FCG were allocated to either an intervention-with-music or a non-intervention control group. All were living at home. Stress biomarkers, salivary cortisol and dehydroepiandrosterone sulfate (DHEA-S) samples were collected by the PWD and their FCG, in the morning and evening, 5 days a week, for 8 consecutive weeks. Biomarker concentrations of the intervention and the control groups were compared at week 8, in an intention-to-treat approach with adjustment for baseline value.

Results

Twenty-four PWD in the intervention group and 10 in the control group, and their FCG were included in the analyses. The mean number of morning saliva collections was similar in the intervention and the control groups, ranging from 4.3 to 4.9 per participant weekly during the first 7 weeks, declining to 3.3 during week 8. Median log morning cortisol (pg/mL) among caregivers was lower in the intervention group than in the control group (8.09 vs. 8.57, P = 0.0133).

Conclusion

This study demonstrates that music intervention was associated with lower morning saliva cortisol concentrations for FCGs.

In-home online music-based intervention for stress, coping, and depression among family caregivers of persons with dementia: A pilot study

Little is known about how music affects family caregivers who provide care to persons with dementia at home. We examined the effects of an 8-week online music-based intervention on self-reported stress, coping, and depression among dementia family caregivers. Mann-Whitney U test and Wilcoxon signed-ranked tests were performed to examine between- and within-group differences between intervention (n = 24) and comparison (n = 11) groups from baseline to post-test. The coping subscale yielded a significant difference between the groups at post-test (U=76.50, Z=-1.978, p=0.048), indicating the intervention group had better coping than the comparison group at post-test. Significant within-group differences in overall stress (Z=-2.200, p=0.028) and coping subscale (Z=-1.997, p=0.046) in the comparison group at post-test suggest that overall stress and coping were maintained throughout the study in the intervention group, whereas the comparison group had higher overall stress and lower coping at post-test. Our in-home music-based intervention showed potential benefits for dementia family caregivers.

The Feasibility and Acceptability of In-Home Saliva Collection for Stress in Persons With Dementia and Their Family Caregivers

BACKGROUND

Although increasing attention is being paid to cortisol and the sulfated form of dehydroepiandrosterone (DHEA-S) as stress biomarkers, the feasibility of saliva collection of such biomarkers has yet to be investigated among dementia care dyads (persons with dementia [PWD] and family caregivers) living in a home setting. We explored the feasibility and acceptability of in-home saliva collection for cortisol and DHEA-S as stress biomarkers among dementia care dyads.

METHODS

Dementia care dyads were recruited from a memory evaluation center. After pre-evaluation and education sessions, participants collected their saliva 3 times a day, 5 days a week, for 8 consecutive weeks. We calculated frequency counts and percentages to assess enrollment rate, retention rate, the completion rate of saliva collection, and valid samples of cortisol and DHEA-S. Independent samples t-tests were performed to compare mean differences in the total number of collected samples and valid samples between PWD and family caregivers at each time point of saliva collection.

RESULTS

A total of 46 dyads were referred to this study; 32 dyads (69.6%) agreed to participate, and 26 started collecting saliva. Twenty-four dyads (75%) completed 8 weeks of saliva collection. There were no significant differences (p > 0.05) in the number of collected samples and valid samples between PWD and caregiver participants.

CONCLUSION

This study supports the feasibility of in-home saliva collection for stress biomarker assay and the need for further investigation into self-administered collection of stress biomarkers with a particular focus on dementia care dyads living at home.

Caregiver Singing Intervention: do Emotions and Resistance differ between Vascular dementia and Alzheimer’s?

Persons with dementia in residential care commonly express resistance of aggressiveness. Caregivers Singing (CS) - when caregivers sing for or together with persons with dementia during caring, has shown to reduce these expressions and increase communication and cooperation. Previous studies of CS have included both persons with Alzheimer’s disease (AD) and persons with Vascular dementia (VD), but no studies have been done focusing on possible differences regarding these diagnoses. As disabilities and symptoms differ between these diagnoses, the emotions and expressions, such as resistance may differ regarding response to CS. This polit study aims to describe emotions and resistiveness to care among persons with vascular or Alzheimer’s disease. Participants were five persons with AD and five persons with VD living at two different nursing homes. Video observations (VIO) occurred with them and their caregivers during morning care situations four times without CS and four times with CS. In all, 80 VIOs were rated using the Observed Emotion Rating Scale and the Resistiveness to Care Scale. These were then analyzed with descriptive statistics. Results revealed that for both persons with AD and VD, the positive emotion pleasure were never observed without CS while with CS it increased for both groups. In contrast to the positive emotion effect of CS, the negative emotions and resistiveness decreased more for persons with VD than for persons with AD. For persons with VD, the number of observations without anger increased, while observation without anger or anxiety/fear for persons with AD remind the same.

Feasibility of In-home Saliva Collection of Cortisol and DHEA-S as a Biomarker of Stress in Dementia Care Dyads

Dementia afflicts affected individuals and their family caregivers worldwide. Although a non-pharmacological intervention has been recommended as a first-line approach to minimize adverse outcomes (e.g., stress) in dementia care dyads (persons with dementia [PWD] and their family caregivers), most evaluations of such interventions have relied on subjective (e.g., self- or proxy-report) rather than objective (e.g., biomarkers) measures. We aimed to explore the feasibility of saliva collection of cortisol and dehydroepiandrosterone sulfate (DHEA-S) as a non-intrusive method in dementia care dyads. Dementia care dyads living at home were recruited from the memory center in Sweden. Prior to the saliva collection, participants received a one-hour education session with a hands-on demonstration led by a trained study coordinator. Participants were instructed to collect saliva three times (two for morning, one for evening)/day, five days/week for eight consecutive weeks. Out of 32 care dyads (32 PWD and 32 family caregivers), 24 (75.0%) completed the saliva collection. On average, 105.5 (87.92%) and 105.9 (88.25%) samples were collected from PWD and family caregivers during eight weeks. There were no statistically significant differences (p>0.05) in the average number of saliva samples (i.e., total samples, morning or evening samples) between PWD and family caregivers. The findings of this pilot study showed that saliva collection of cortisol and DHEA-S as a stress measurement was feasible in dementia care dyads living at home. Robust and person-centered procedures, tailored educational materials, and effective communication with dementia care dyads should be considered in future biomarker research on stress in dementia care dyads.

In-home Online Music Therapy for Psychological Health among Caregivers of Persons with Dementia: A Pilot Study

Past research has underscored four key themes prevalent in popular and scientific discourse on successful aging in North America – the emphasis on individual agency and control; continuing productive activity into old age; the value of independence in late life; and an ideal construction of permanent personhood, wherein the realities of mortality and decline are inadequately addressed (Lamb, 2014). Yet, the meanings attached to successful aging differ across cultures and are not very well-understood. The Perceptions of Aging Well in Diverse Populations study aims to acquire a holistic understanding of the attitudes and beliefs around aging well across cultures and to identify the similarities and differences in these perceptions within diverse racial and ethnic groups. This presentation highlights preliminary findings from in-depth, semi-structured qualitative interviews with South Asian Americans 50 years and older (n=19; 9 men, 10 women). Participants shared that a sense of inevitability and aging with “grace”, “dignity”, and “wisdom” were key components of successful aging. Maintaining good health, keeping a positive attitude, and remaining independent in later life appeared motivated primarily by a desire to remain connected to, but not necessarily “burden” adult children with caregiving responsibilities. Religious faith and spiritual well-being, availability of support systems, and a sense of community were key facilitators. Limited English proficiency and loneliness posed challenges to aging well, particularly in late-life immigrants. These findings provide unique insights into subjective perceptions of successful aging and may help inform programs and policies that support the health and well-being of older South Asian Americans.

Life satisfaction and coronary atherosclerosis: The SCAPIS study

BACKGROUND

There is an increasing interest in the potential health benefits of positive psychological states, especially with regard to cardiovascular health. Life satisfaction is thought to be a constituent component of psychological well-being; however, among the few previous studies that have investigated its associations with early stages of the cardiovascular disease process, only one small study has focused on coronary atherosclerosis. The present study aimed to explore associations between life satisfaction and coronary artery disease.

METHODS

The study used cross-sectional data from SCAPIS Malmö (n = 6251 randomly selected men and women, aged 50-64 years), including assessment of life satisfaction and coronary artery calcification. Adjustments were made for sociodemographic factors, depression, and cardiovascular risk factors as assessed with the SCORE instrument.

RESULTS

Higher levels of life satisfaction were associated with lower odds of increased coronary artery calcification. This association persisted after adjusting for sociodemographic factors and depression, but lost significance after adjusting for cardiovascular risk factors. Sub-analyses revealed a significant dose-response relationship between higher life satisfaction and lower grade of coronary calcification in all investigated coronary artery regions.

CONCLUSION

In this population-based sample, life satisfaction was associated with better coronary artery health. However, this association was largely explained by cardiovascular risk factors, indicating that life satisfaction is linked to coronary atherosclerosis through a decreased load of cardiovascular risk factors.

The use of saliva steroids (cortisol and DHEA-s) as biomarkers of changing stress levels in people with dementia and their caregivers: A pilot study

The rationale was to explore the efficacy/sensitivity of using morning and evening cortisol levels as biomarkers for stress reduction in persons with dementia (PWDs) and their family caregivers (FCGs) participating in a music intervention program. Thirty-two PWD and their FGC were recruited to an 8-week, home-based music intervention program. Daily home-based collection of saliva samples took place at bedtime and upon awakening. Cortisol was analyzed in the morning and evening saliva samples and DHEA-s in the morning samples. Trends over 40 workdays (15-40 observations per subject) were assessed using linear regression analysis. Twenty-three PWD (72% of invited, 16 men and 7 women, age 69-93) and 24 caregivers (75%, 8 men and 16 women, age 37-90) completed the intervention for at least 6 weeks and were included in the analysis. One-fourth of the PWD and FCG had decreasing evening cortisol, accompanied by decreasing morning cortisol levels. In one-fourth of the participants the ratio between cortisol and DHEA-S in the morning samples was improved, indicating improved balance between energy mobilization and regeneration. Several participants showed no significant endocrine change. There was a statistically significant (two-sided test) correlation within the PWD-caregiver dyads in evening cortisol trend and a statistically significant decrease (two-sided test) in the morning-evening cortisol slope for the FCG group. Reduction in stress, as measured by evening cortisol, was observed in a substantial number of the participants. Recording endocrine stress is helpful for the unbiased assessment of the intervention.

Proteomic and Metabolomic Characterization of Metabolically Healthy Obesity: A Descriptive Study from a Swedish Cohort

METHOD

Associations between different biomarkers (proteomics, lipidomics, and metabolomics) coupled to either MHO or metabolically unhealthy obese (MUO) individuals were analyzed through principal component analysis (PCA). Subjects were identified from a subsample of 416 obese individuals, selected from the Malmö Diet and Cancer study-Cardiovascular arm (MDCS-CV, n = 3,443). They were further divided into MHO (n = 143) and MUO (n = 273) defined by a history of hospitalization, or not, at baseline inclusion, and nonobese subjects (NOC, n = 3,027). Two distinctive principle components (PL2, PP5) were discovered with a significant difference and thus further investigated through their main loadings.

RESULTS

MHO individuals had a more metabolically favorable lipid and glucose profile than MUO subjects, that is, lower levels of traditional blood glucose and triglycerides, as well as a trend of lower metabolically unfavorable lipid biomarkers. PL2 (lipidomics, p=0.02) showed stronger associations of triacylglycerides with MUO, whereas phospholipids correlated with MHO. PP5 (proteomics, p=0.01) included interleukin-1 receptor antagonist (IL-1ra) and leptin with positive relations to MUO and galanin that correlated positively to MHO. The group differences in metabolite profiles were to a large extent explained by factors included in the metabolic syndrome.

CONCLUSION

Compared to MUO individuals, corresponding MHO individuals present with a more favorable lipid metabolic profile, accompanied by a downregulation of potentially harmful proteomic biomarkers. This unique and extensive biomarker profiling presents novel data on potentially differentiating traits between these two obese phenotypes.

Incretin hormones, insulin, glucagon and advanced glycation end products in relation to cognitive function in older people with and without diabetes, a population-based study

AIM

The aim of this observational study was to investigate relationships between physiological levels of glucometabolic biomarkers and cognitive test results in a population-based setting.

METHODS

Cross-sectional data were obtained from the Swedish population-based Malmö Diet and Cancer Study Re-examination 2007-2012 comprising 3001 older people (mean age 72 years). Through oral glucose tolerance testing (OGTT), fasting and post-load levels of serum insulin, plasma glucagon, serum glucose-dependent insulinotropic peptide (GIP) and plasma glucagon-like peptide-1 (GLP-1) were measured. Insulin resistance and insulin sensitivity levels were calculated. In 454 participants, advanced glycation end products (AGEs) were estimated through skin autofluorescence. Associations between biomarkers and two cognitive tests, the Mini-Mental State Examination (MMSE) and A Quick Test of Cognitive Speed (AQT) respectively, were explored in multiple regression analyses.

RESULTS

Positive associations following adjustments for known prognostic factors were found between MMSE scores and insulin sensitivity (B = 0.822, P = 0.004), 2-h plasma glucagon (B = 0.596, P = 0.026), 2-h serum GIP (B = 0.581, P = 0.040) and 2-h plasma GLP-1 (B = 0.585, P = 0.038), whereas negative associations were found between MMSE scores and insulin resistance (B = -0.734, P = 0.006), fasting plasma GLP-1 (B = -0.544, P = 0.033) and AGEs (B = -1.459, P = 0.030) were found.

CONCLUSIONS

Higher levels of insulin sensitivity, GIP and GLP-1 were associated with better cognitive outcomes, but AGEs were associated with worse outcomes, supporting evidence from preclinical studies. Glucagon was linked to better outcomes, which could possibly reflect neuroprotective properties similar to the related biomarker GLP-1 which has similar intracellular properties. Longitudinal and interventional studies are needed to further evaluate neuromodulating effects of these biomarkers. Abstract presented at the European Association for the Study of Diabetes (EASD) 2019, Barcelona, Spain.

Periodontal disease is associated with carotid plaque area: the Malmö Offspring Dental Study (MODS)

BACKGROUND

Periodontal disease is associated with cardiovascular disease (CVD) but it is unknown if periodontal disease severity is associated with asymptomatic carotid plaque. The aim of the current population-based, observational study was to investigate if signs of periodontal disease are associated with the occurrence of carotid plaque and total plaque area (TPA).

METHODS

The Malmö Offspring Study (MOS) is a population-based study. MOS participants underwent a thorough cardiovascular phenotyping, including carotid ultrasonography. The Malmö Offspring Dental Study (MODS) invited participants of MOS for dental examination, including periodontal charting. Multivariable regression models were used to analyse the presence of carotid plaque and TPA in relation to periodontal parameters.

RESULTS

In all, 831 MODS participants were recruited, out of which 495 belonged to the children generation with mean age of 53 years, 63% had carotid plaque and 38% had moderate or severe periodontal disease. In models adjusted for CVD risk factors, the OR for having carotid plaque in subjects with vs without periodontal disease was 1.75 (95% CI: 1.11-2.78). In a linear model with TPA as dependent and number of periodontal pockets ≥ 4 mm as independent variable, the adjusted beta-coefficient was 0.34 mm² (95% CI 0.16-0.52).

CONCLUSION

Individuals within the highest quartile of periodontal pockets are expected to have 9 mm² larger TPA compared to those without pockets. Our results suggest that intervention studies addressing periodontal disease could be useful for prevention of CVD.

Matrix Metalloproteinases in COPD and atherosclerosis with emphasis on the effects of smoking

Background

Matrix metalloproteinases (MMP´s) are known biomarkers of atherosclerosis. MMP´s are also involved in the pathophysiological processes underlying chronic obstructive pulmonary disease (COPD). Cigarette smoking plays an important role in both disease states and is also known to affect the concentration and activity of MMP´s systemically. Unfortunately, the epidemiological data concerning the value of MMP´s as biomarkers of COPD and atherosclerosis with special regards to smoking habits are limited.

Methods

450 middle-aged subjects with records of smoking habits and tobacco consumption were examined with comprehensive spirometry, carotid ultrasound examination and biomarker analysis of MMP-1, -3, -7, -10 and -12. Due to missing data 33 subjects were excluded.

Results

The remaining 417 participants were divided into 4 different groups. Group I (n = 157, no plaque and no COPD), group II (n = 136, plaque but no COPD), group III (n = 43, COPD but no plaque) and group IV (n = 81, plaque and COPD). Serum levels of MMP-1,-7,-10-12 were significantly influenced by smoking, and MMP-1, -3, -7 and-12 were elevated in subjects with COPD and carotid plaque. This remained statistically significant for MMP-1 and-12 after adjusting for traditional risk factors.

Conclusion

COPD and concomitant plaque in the carotid artery were associated with elevated levels of MMP-1 and -MMP-12 even when adjusting for risk factors. Further studies are needed to elucidate if these two MMP´s could be useful as biomarkers in a clinical setting. Smoking was associated with increased serum levels of MMP´s (except for MMP-3) and should be taken into account when interpreting serum MMP results.

A genetic risk score for hypertension is associated with risk of thoracic aortic aneurysm

A genetic risk score (GRS) based on 29 single nucleotide polymorpysms (SNPs) associated with high blood pressure (BP) was prospectively associated with development of hypertension, stroke and cardiovascular events. The aim of the present study was to evaluate the impact of this GRS on the incidence of aortic disease, including aortic dissection (AD), rupture or surgery of a thoracic (TAA) or abdominal (AAA) aortic aneurysm. More than 25,000 people from the Swedish Malmo Diet and Cancer Study had information on at least 24 SNPs and were followed up for a median ≥ 18 years. The number of BP elevating alleles of each SNPs, weighted by their effect size in the discovery studies, was summed into a BP-GRS. In Cox regression models, adjusted for traditional cardiovascular risk factors including hypertension, we found significant associations of the BP-GRS, prospectively, with incident TAA (hazard ratio (HR) 1.64 (95% confidence interval (CI) 1.081-2.475 comparing the third vs. the first tertile; p = 0.020) but not with either AAA or aortic dissection. Calibration, discrimination and reclassification analyses show modest improvement in prediction using the BP-GRS in addition to the model which used only traditional risk factors. A GRS for hypertension associates with TAA suggesting a link between genetic determinants of BP and aortic disease. The effect size is small but the addition of more SNPs to the GRS might improve its discriminatory capability.

Plasma levels of the proprotein convertase furin and incidence of diabetes and mortality

BACKGROUND

Diabetes mellitus is linked to premature mortality of virtually all causes. Furin is a proprotein convertase broadly involved in the maintenance of cellular homeostasis; however, little is known about its role in the development of diabetes mellitus and risk of premature mortality.

OBJECTIVES

To test if fasting plasma concentration of furin is associated with the development of diabetes mellitus and mortality.

METHODS

Overnight fasted plasma furin levels were measured at baseline examination in 4678 individuals from the population-based prospective Malmö Diet and Cancer Study. We studied the relation of plasma furin levels with metabolic and hemodynamic traits. We used multivariable Cox proportional hazards models to investigate the association between baseline plasma furin levels and incidence of diabetes mellitus and mortality during 21.3-21.7 years follow-up.

RESULTS

An association was observed between quartiles of furin concentration at baseline and body mass index, blood pressure and plasma concentration of glucose, insulin, LDL and HDL cholesterol (|0.11| ≤ β ≤ |0.31|, P < 0.001). Plasma furin (hazard ratio [HR] per one standard deviation increment of furin) was predictive of future diabetes mellitus (727 events; HR = 1.24, CI = 1.14-1.36, P < 0.001) after adjustment for age, sex, body mass index, systolic and diastolic blood pressure, use of antihypertensive treatment, alcohol intake and fasting plasma level of glucose, insulin and lipoproteins cholesterol. Furin was also independently related to the risk of all-cause mortality (1229 events; HR = 1.12, CI = 1.05-1.19, P = 0.001) after full multivariable adjustment.

CONCLUSION

Individuals with high plasma furin concentration have a pronounced dysmetabolic phenotype and elevated risk of diabetes mellitus and premature mortality.

Reshoring drivers and barriers in the Swedish manufacturing industry

Purpose

The purpose of this study is to explore reshoring drivers and barriers from a Swedish manufacturing perspective.

Design/methodology/approach

This paper is a case study, including four Swedish manufacturing companies, with focus on drivers and barriers from the context of the Swedish manufacturing industry. A literature review of previously established drivers and barriers is used to map out the empirical findings and thereby identify potential gaps between the current body of literature and drivers and barriers from a Swedish manufacturing context.

Findings

The findings of the study suggest that quality issues continue to be one of the strongest reshoring drivers. Except for product quality, quality is also connected to host country’s infrastructure, communication and service. The supply chain perspective is a source of several drivers and is identified as a perspective often overlooked in offshoring decisions. Barriers related to firm specifics were more elaborately discussed by the companies, especially concerning calculation of location decision and the need to invest in resources, which allows for a higher level of capacity at the home country facility.

Research limitations/implications

The study develops a structured table of reshoring drivers and barriers which can serve as a base for future research. Future research on the calculation of location decisions is deemed as a crucial step to further understand reshoring and aid companies in the decision-making process.

Practical implications

The drivers and barriers identified in the study can give practitioners insight into reshoring from the perspective of the Swedish manufacturing industry and thus aid in future manufacturing location decisions. The table of drivers and barriers can also be important to understand how Sweden can strengthen its competitive advantage and motivate more companies to reshore manufacturing.

Originality/value

This is one of only few papers from the Nordic countries and also one of few case studies examining reshoring in manufacturing companies.

Plasma stem cell factor levels are associated with risk of cardiovascular disease and death

OBJECTIVE

Stem cell factor (SCF) is a key growth factor for several types of stem and progenitor cells. There is experimental evidence that such cells are of importance for maintaining the integrity of the cardiovascular system. We investigated the association between circulating levels of SCF and risk for development of cardiovascular events and death.

METHODS

SCF was analysed by the proximity extension assay technique in plasma from 4742 subjects participating in the Malmö Diet and Cancer Study. Cardiovascular events and death were monitored through national registers with a mean follow-up time of 19.2 years.

RESULTS

Subjects with high baseline levels of SCF had lower cardiovascular (n = 340) and all-cause mortality (n = 1159) as well as a lower risk of heart failure (n = 177), stroke (n = 318) and myocardial infarction (n = 452). Smoking, diabetes and high alcohol consumption were associated with lower levels of SCF. Single nucleotide polymorphisms in the gene region encoding PDX1 C-terminal inhibiting factor 1 (PCIF1) and matrix metalloproteinase-9 were associated with plasma SCF levels. The highest SCF quartile remained independently associated with a lower risk of a lower risk of cardiovascular [hazard ratio and 95% confidence interval 0.59 (0.43-0.81)] and all-cause mortality [0.68 (0.57-0.81)], heart failure [0.50 (0.31-0.80)] and stroke [0.66 (0.47-0.92)], but not with MI [0.96 (0.72-1.27)] as compared with the lowest quartile when adjusting for traditional cardiovascular risk factors in Cox proportional hazard regression models.

CONCLUSIONS

This prospective population-based study demonstrates that subjects with high levels of SCF have a lower risk of cardiovascular events and death. The findings provide clinical support for a protective role of SCF in maintaining cardiovascular integrity.

Increased blood cadmium levels were not associated with increased fracture risk but with increased total mortality in women: the Malmö Diet and Cancer Study

This study aimed to investigate if high levels of blood cadmium at baseline were associated with increased fracture risk during follow-up in middle-aged women. No increased fracture risk was observed during follow-up, but women with higher levels of cadmium had an increased overall mortality.

INTRODUCTION

Exposure to high levels of cadmium has been associated with an increased fracture risk. The aim was to investigate a perceived association between low levels of blood cadmium (B-Cd) at baseline and risk of first incident fracture.

METHODS

From the population-based Malmö Diet and Cancer Study Cardiovascular cohort, 2920 middle-aged women with available background questionnaire and B-Cd measurements were included. Women were divided into quartiles (Q) according to their cadmium levels (Cd-Q1 <0.18 μg/L, Cd-Q2 0.18-0.28 μg/L, Cd-Q3 0.28-0.51 μg/L, and Cd-Q4 >0.51 μg/L). National registries were analysed for prospective risk of fractures or death. Associations between B-Cd and fracture risk were assessed by survival analysis (Cox regression analysis).

RESULTS

In total, 998 first incident fractures occurred in women during a follow-up lasting 20.2 years (median) (12.5-21.2 years) (25th-75th percentile). Women in Cd-Q4 were more often current smokers than in Cd-Q1 78.4 vs. 3.3% (p < 0.001) and the number of cigarettes smoked per day correlated with B-Cd (r = 0.49; p < 0.001). The risk of fracture was not associated with baseline B-Cd in adjusted models. The hazard ratio (HR) Cd-Q4 vs. Cd-Q1 was 1.06 (95% confidence interval (CI) 0.89-1.27). In the multivariate Cox regression, independent variables for increased fracture risk were history of gastric ulcer and increasing age, whereas increasing body mass index (BMI) lowered fracture risk. Overall mortality was significantly higher for women with high B-Cd, HR 2.06 (95% CI 1.57-2.69).

CONCLUSIONS

Higher blood levels of cadmium did not increase fracture risk in middle-aged women but reduced overall survival.

Measures of bronchodilator response of FEV1, FVC and SVC in a Swedish general population sample aged 50-64 years, the SCAPIS Pilot Study

BACKGROUND

Data are lacking from general population studies on how to define changes in lung function after bronchodilation. This study aimed to analyze different measures of bronchodilator response of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) and slow vital capacity (SVC).

MATERIALS AND METHODS

Data were derived from the Swedish Cardiopulmonary Bioimage Study (SCAPIS) Pilot study. This analysis comprised 1,050 participants aged 50-64 years from the general population. Participants were investigated using a questionnaire, and FEV1, FVC and SVC were recorded before and 15 minutes after inhalation of 400 µg of salbutamol. A bronchodilator response was defined as the relative change from baseline value expressed as the difference in units of percent predicted normal. Predictors of bronchodilator responses were assessed using multiple linear regression models. Airway obstruction was defined as FEV1/FVC ratio below lower limit of normal (LLN) before bronchodilation, and COPD was defined as an FEV1/FVC ratio below LLN after bronchodilation. Physician-diagnosed asthma was defined as an affirmative answer to "Have you ever had asthma diagnosed by a physician?". Asymptomatic never-smokers were defined as those not reporting physician-diagnosed asthma, physician-diagnosed COPD or emphysema, current wheeze or chronic bronchitis and being a lifelong never-smoker.

RESULTS

Among all subjects, the greatest bronchodilator responses (FEV1, FVC and SVC) were found in subjects with asthma or COPD. The upper 95th percentile of bronchodilator responses in asymptomatic never-smokers was 8.7% for FEV1, 4.2% for FVC and 5.0% for SVC. The bronchodilator responses were similar between men and women. In a multiple linear regression model comprising all asymptomatic never-smokers, the bronchodilator response of FEV1 was significantly associated with airway obstruction and height.

CONCLUSION

When the bronchodilator response in asymptomatic never-smokers is reported as the difference in units of predicted normal, significant reversibility of FEV1, FVC and SVC to bronchodilators is ~9%, 4% and 5%, respectively.

Exome array analysis of ischaemic stroke: results from a southern Swedish study

BACKGROUND AND PURPOSE

Genome-wide association (GWA) studies have identified a few risk loci for ischaemic stroke, but these variants explain only a small part of the genetic contribution to the disease. Coding variants associated with amino acid substitutions or premature termination of protein synthesis could have a large effect on disease risk. We performed an exome array analysis for ischaemic stroke.

METHODS

Patients with ischaemic stroke (n = 2385) and control subjects (n = 6077) from three Swedish studies were genotyped with the Illumina HumanOmniExpressExome BeadChip. Single-variant association analysis and gene-based tests were performed of exome variants with minor allele frequency of < 5%. A separate GWA analysis was also performed, based on 700 000 genotyped common markers and subsequent imputation.

RESULTS

No exome variant or gene was significantly associated with all ischaemic stroke after Bonferroni correction (all P > 1.8 × 10^-6 for single-variant and >4.15 × 10^-6 for gene-based analysis). The strongest association in single-variant analysis was found for a missense variant in the DNAH11 gene (rs143362381; P = 5.01 × 10^-6 ). In gene-based tests, the strongest association was for the ZBTB20 gene (P = 7.9 × 10^-5 ). The GWA analysis showed that the sample was homogenous (median genomic inflation factor = 1.006). No genome-wide significant association with overall ischaemic stroke risk was found. However, previously reported associations for the PITX2 and ZFHX3 gene loci with cardioembolic stroke subtype were replicated (P = 7 × 10^-15 and 6 × 10^-3 ).

CONCLUSIONS

This exome array analysis did not identify any single variants or genes reaching the pre-defined significance level for association with ischaemic stroke. Further studies on exome variants should be performed in even larger, well-defined and subtyped samples.

Gene variance in the nicotinic receptor cluster (CHRNA5-CHRNA3-CHRNB4) predicts death from cardiopulmonary disease and cancer in smokers

BACKGROUND

Genetic variation in the cluster on chromosome 15, encoding the nicotinic acetylcholine receptor subunits (CHRNA5-CHRNA3-CHRNB4), has shown strong associations with tobacco consumption and an additional risk increase in smoking-related diseases such as chronic obstructive pulmonary disease (COPD), peripheral artery disease and lung cancer.

OBJECTIVES

To test whether rs1051730 (C/T), a tag for multiple variants in the CHRNA5-CHRNA3-CHRNB3 cluster, is associated with a change in risk of smoking-related mortality and morbidity in the Malmö Diet and Cancer study, a population-based prospective cohort study.

METHODS

At baseline participants were classified as current (n = 6951), previous (n = 8426) or never (n = 9417) smokers. Cox-proportional hazards models were used to determine the correlation between rs1051730 and incidence of first COPD, tobacco-related cancer, other cancer and cardiovascular disease (CVD), and total mortality due to these causes, during approximately 14 years of follow-up.

RESULTS

Amongst current smokers there were 480 first incident COPD events, 852 tobacco-related cancers, 810 other cancers and 1022 CVD events. A total of 1508 deaths occurred, including 500 due to CVD, 102 due to respiratory diseases and 677 due to cancer. In adjusted additive models, an increasing number of T alleles were associated with a gradual increase in total mortality, incident COPD and tobacco-related cancer, even after adjustment for smoking quantity. No significant associations were observed amongst never smokers.

CONCLUSION

Our data suggest that gene variance in the CHRNA5-CHRNA3-CHRNB4 cluster is associated with an increased risk of death, incidence of COPD and tobacco-related cancer in smokers. These findings indicate an individual susceptibility to tobacco use and its complications; this may be important when targeting and designing smoking cessation therapies.

Association between parental depressive symptoms and impaired bonding with the infant

Impaired bonding with the infant is associated with maternal postpartum depression but has not been investigated extensively in fathers. The primary study aim was to evaluate associations between maternal and paternal depressive symptoms and impaired bonding with their infant. A secondary aim was to determine the associations between parents' marital problems and impaired bonding with the infant. The study is part of a population-based cohort project (UPPSAT) in Uppsala, Sweden. The Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks and 6 months postpartum and the Postpartum Bonding Questionnaire at 6 months postpartum were completed by 727 couples. The prevalence of impaired bonding was highest among couples in which both spouses had depressive symptoms. Impaired bonding was associated with higher EPDS scores in both mothers and fathers, as well as with experiencing a deteriorated marital relationship. The association between maternal and paternal impaired bonding and the mothers' and fathers' EPDS scores remained significant even after adjustment for relevant confounding factors. Depressive symptoms at 6 weeks postpartum are associated with impaired bonding with the infant at 6 months postpartum for both mothers and fathers. It is critical to screen for and prevent depressive symptoms in both parents during early parenthood.

The Swedish CArdioPulmonary BioImage Study: objectives and design

Cardiopulmonary diseases are major causes of death worldwide, but currently recommended strategies for diagnosis and prevention may be outdated because of recent changes in risk factor patterns. The Swedish CArdioPulmonarybioImage Study (SCAPIS) combines the use of new imaging technologies, advances in large-scale 'omics' and epidemiological analyses to extensively characterize a Swedish cohort of 30 000 men and women aged between 50 and 64 years. The information obtained will be used to improve risk prediction of cardiopulmonary diseases and optimize the ability to study disease mechanisms. A comprehensive pilot study in 1111 individuals, which was completed in 2012, demonstrated the feasibility and financial and ethical consequences of SCAPIS. Recruitment to the national, multicentre study has recently started.

Red cell distribution width, haemoglobin A1c and incidence of diabetes mellitus

OBJECTIVE

Hyperglycaemia has multiple effects on the red blood cell (RBC), including glycation of haemoglobin, reduced deformability and reduced lifespan. Red cell distribution width (RDW) is a measure of the heterogeneity of erythrocyte volumes. The aim of this study was to explore the relationships between RDW and glucose, haemoglobin A1c (HbA1c) and incidence of diabetes mellitus (DM).

DESIGN, SETTING AND SUBJECTS

RDW and mean corpuscular volume were measured in 26 709 non-diabetic participants (aged 45-73 years) from the population-based Malmö Diet and Cancer cohort. HbA1c and fasting venous blood glucose levels were measured in 4845 subjects.

MAIN OUTCOME MEASURE

Incidence of DM (n = 2944) over 14 years of follow-up was studied by linkage with national and local DM registers.

RESULTS

Individuals with low RDW had significantly higher risk of developing DM [adjusted hazard ratio (HR) 1.48, 95% confidence interval (CI) 1.29-1.70, for 1st vs. 4th quartile], especially in subjects with impaired fasting glucose (n = 416) (HR 2.15, 95% CI 1.12-4.14). Low RDW was also associated with significantly higher waist circumference and glucose, insulin and triglyceride concentrations. By contrast, RDW was significantly and positively associated with HbA1c, corresponding an increase in HbA1c of 0.10% per 1 SD increase in RDW.

CONCLUSION

Low RDW is associated with increased incidence of DM independently of other risk factors. We propose that low RDW could be a surrogate marker of reduced RBC survival, with lower HbA1c due to shorter duration of glucose exposure. RDW is a biomarker that could improve risk assessment for individuals at risk of developing DM.

Depressive symptoms postpartum among parents are associated with marital separation: A Swedish cohort study

Aims: To study whether there is an association between dyadic consensus, depressive symptoms, and parental stress during early parenthood and marital separation 6–8 years after childbirth, among couples in Sweden. Methods: At baseline, 393 couples were included. The couples answered three questionnaires, including: Dyadic consensus at 1 week post-partum, depressive symptoms at 3 months post-partum and parental stress at 18 months post-partum. The parents’ addresses were followed up after 6–8 years, to study the marital separation rate. Results: We found, 6–8 years after childbirth, that 20% of study couples were separated. Separation was associated with less dyadic consensus (mothers p < 0.001; fathers p < 0.001), depressive symptoms (mothers p = 0.022; fathers p = 0.041) and parental stress (mothers p = 0.002; fathers p = 0.040). The hazard ratio (HR) for marital separation was related to dyadic consensus for fathers (HR 0.51; 95% CI 0.28–0.92), depressive symptoms for mothers (HR 1.69; 95% CI 1.01–2.84) and fathers (HR 1.92; 95% CI 1.12–3.28), and the mother’s parental stress (HR 2.16; 95% CI 1.14–4.07). Conclusions:Understanding how dyadic consensus, depressive symptoms and parental stress are associated with marital separation is important for health professionals. It could be useful in developing interventions to provide parents with adequate support during pregnancy and early parenthood. This knowledge is also important for the public. Parents should get support in pregnancy and while bringing up children, which may help prevent marital separation and optimize conditions for the children.

Snus (Swedish smokeless tobacco) use and risk of stroke: pooled analyses of incidence and survival

BACKGROUND

Snus is a moist smokeless tobacco product with high nicotine content. Its use has a short-term effect on the cardiovascular system, but the relationship between snus use and stroke is unclear.

OBJECTIVE

The aim of this study was to assess the associations between use of snus and incidence of and survival after stroke, both overall and according to subtypes.

METHODS

Pooled analyses of eight Swedish prospective cohort studies were conducted, including 130 485 men who never smoked. We estimated hazard ratios (HRs) with 95% confidence intervals (CIs) of incidence and death after diagnosis using Cox proportional hazard regression models and case fatality and survival using logistic regression and Kaplan-Meier methods, respectively.

RESULTS

No associations were observed between the use of snus and the risk of overall stroke (HR 1.04, 95% CI 0.92-1.17) or of any of the stroke subtypes. The odds ratio (OR) of 28-day case fatality was 1.42 (95% CI 0.99-2.04) amongst users of snus who had experienced a stroke, and the HR of death during the follow-up period was 1.32 (95% CI 1.08-1.61).

CONCLUSION

Use of snus was not associated with the risk of stroke. Hence, nicotine is unlikely to contribute importantly to the pathophysiology of stroke. However, case fatality was increased in snus users, compared with nonusers, but further studies are needed to determine any possible causal mechanisms.

Cystatin C identifies cardiovascular risk better than creatinine-based estimates of glomerular filtration in middle-aged individuals without a history of cardiovascular disease

OBJECTIVES

Creatinine- and cystatin C-based estimates of renal function are considered to be cardiovascular disease (CVD) risk factors, but the clinical utility in middle-aged subjects without a history of CVD is controversial.

DESIGN

We related plasma cystatin C and creatinine-based glomerular filtration rate (GFR) [MDRD, CKD-EPI-2009, and CKD-EPI-comb (a combination of creatinine and cystatin C)] to incident CVD, CVD mortality, all-cause mortality, and heart failure in 4650 middle-aged subjects without CVD.

RESULTS

The hazard ratio (HR) per standard deviation increment (95% CI) of cystatin C predicted incident CVD (1.22, 1.11-1.33; P < 0.0001), CVD mortality (1.44, 1.24-1.66; P < 0.0001), all-cause mortality (1.15, 1.05-1.26; P = 0.002), and heart failure (1.27, 1.05-1.55; P = 0.02), whereas MDRD and CKD-EPI-2009 only predicted CVD mortality (0.79, 0.66-0.93; P = 0.006 and 0.78, 0.66-0.92; P = 0.003, respectively). Cystatin C led to a significant increase in the net reclassification improvement for all endpoints, except heart failure. Only within the quartile with the worst renal function were all measures related to all-cause and CVD mortality. The top 25% of cystatin C in the population significantly predicted risk of incident CVD and CVD mortality, whereas MDRD and CKD-EPI-2009 were predictors of CVD mortality only at a GFR < 60 mL/min/1.73 m(2) (11-13% of the population) and of incident CVD only at a GFR < 45 mL/min/1.73 m(2) (<1% of the population).

CONCLUSION

Cystatin C is a better risk marker for CVD morbidity and mortality than creatinine-based GFR. Whether this is explained by cystatin C being a better marker for true GFR or through other effects of cystatin C remains to be shown.

Effects of dog-assisted intervention on behavioural and psychological symptoms of dementia

AIM

To evaluate the effect of a dog-assisted intervention on the behavioural and psychological symptoms of residents with dementia during a six-month period.

METHOD

The study was conducted in eight nursing homes in Sweden. A total of 33 residents with dementia, 20 in the intervention group and 13 in the control group, were recruited. The Cohen-Mansfield Agitation Inventory (CMAI) and the Multi-Dimensional Dementia Assessment Scale (MDDAS) were used to assess the effects of a dog-assisted intervention on participants' behavioural and psychological symptoms. The intervention comprised ten sessions, lasting between 45 and 60 minutes, once or twice a week. Descriptive statistics were used to analyse background data, comparisons between groups at baseline were performed using the Mann-Whitney U test, and the Wilcoxon rank sum test was used to test differences in groups over time.

RESULTS

In the intervention group changes from baseline to follow up immediately after the intervention were not significant, possibly because of the small sample size. Some positive tendencies were observed: the CMAI mean score for physical non-aggressive behaviours decreased from 18.5 at baseline to 15.3 at follow up immediately after the intervention; lower scores indicate fewer symptoms. Mean and median MDDAS scores for behavioural symptoms decreased from 15.3 and 13.5 respectively at baseline to 13.1 and 12.0 respectively at follow up immediately after the intervention; lower scores indicate fewer symptoms. The CMAI mean score for verbal agitation increased significantly (P=0.035) from 17.2 at baseline to 20.6 at follow up six months after the intervention.

CONCLUSION

Dog-assisted intervention may provide an alternative or a complement to pharmacological treatments to reduce behavioural symptoms in people with dementia, but its value and place in care require further evaluation.

Ceruloplasmin and atrial fibrillation: evidence of causality from a population-based Mendelian randomization study

OBJECTIVES

Inflammatory diseases and inflammatory markers secreted by the liver, including C-reactive protein (CRP) and ceruloplasmin, have been associated with incident atrial fibrillation (AF). Genetic studies have not supported a causal relationship between CRP and AF, but the relationship between ceruloplasmin and AF has not been studied. The purpose of this Mendelian randomization study was to explore whether genetic polymorphisms in the gene encoding ceruloplasmin are associated with elevated ceruloplasmin levels, and whether such genetic polymorphisms are also associated with the incidence of AF.

DESIGN

Genetic polymorphisms in the ceruloplasmin gene (CP) were genotyped in a population-based cohort study of men from southern Sweden (Malmö Preventive Project; n = 3900). Genetic polymorphisms associated with plasma ceruloplasmin concentration were also investigated for association with incident AF (n = 520) during a mean follow-up of 29 years in the same cohort. Findings were replicated in an independent case-control sample (The Malmö AF cohort; n = 2247 cases, 2208 controls).

RESULTS

A single nucleotide polymorphism (rs11708215, minor allele frequency 0.12) located in the CP gene promoter was strongly associated with increased levels of plasma ceruloplasmin (P = 9 × 10(-10) ) and with AF in both the discovery cohort [hazard ratio 1.24 per risk allele, 95% confidence interval (CI) 1.06-1.44, P = 0.006] and the replication cohort (odds ratio 1.13, 95% CI 1.02-1.26, P = 0.02).

CONCLUSIONS

Our findings indicate a causal role of ceruloplasmin in AF pathophysiology and suggest that ceruloplasmin might be a mediator in a specific inflammatory pathway that causally links inflammatory diseases and incidence of AF.

Prevalence and quality of clinical pathways in Swedish intensive care units: a national survey

RATIONALE, AIMS AND OBJECTIVES

To identify the prevalence of clinical pathways (CPs) in Swedish intensive care units (ICUs) and to explore the quality, content and evidence base of the documents.

METHODS

A descriptive and explorative survey of all Swedish ICUs (N84) and a review of submitted examples of CPs (n12) were conducted.

RESULTS

CPs were in use at 20% of the Swedish ICUs. There was a significant geographic variation but no relationship between the use of CPs and category of hospital, type of ICU, size of ICU or type of health record applied. In total, 56 CPs were reported within a range of scopes and extensions. The content of the ICUs' CPs, as well as the degree to which they were interprofessional, evidence based, and renewed varied.

CONCLUSIONS

Progress has been made in relation to CPs in recent years, but there is potential for further improvements. None of the ICUs had CPs that contained all key characteristics of a high-quality, interprofessional and evidence-based CP identified in the literature. Greater knowledge sharing and cooperation within the field would be beneficial, and further research is needed.

Red blood cell distribution width is associated with incidence of atrial fibrillation

OBJECTIVES

Red blood cell distribution width (RDW), a measure of variation in erythrocyte volume, has been associated with several cardiovascular disorders, but the relationship with atrial fibrillation (AF) remains unclear. We investigated the association between RDW and incidence of first hospitalization due to AF in a population-based cohort.

DESIGN

Red blood cell distribution width was measured in 27,124 subjects from the general population (age 45-73 years, 62% women) with no history of AF, heart failure, myocardial infarction or stroke. The association between baseline RDW and incidence of AF identified from the Swedish Hospital Discharge Register was evaluated.

RESULTS

During a mean follow-up of 13.6 years, 1894 subjects (53% men) were hospitalized with a diagnosis of AF. After adjustment for potential confounding factors, including cardiovascular disease risk factors, nutrient intake (iron, vitamin B12 and folate) and several haematological parameters (haemoglobin concentration, mean corpuscular volume and corpuscular haemoglobin content), the hazard ratio (HR) for incidence of AF was 1.33 [95% confidence interval (CI) 1.16-1.53] for the fourth versus first quartile of RDW (P for trend <0.001). The results were essentially unchanged when subjects with incident myocardial infarction or hospitalizations because of heart failure were censored from the analysis (HR 1.30, 95% CI 1.13-1.51; P for trend = 0.001).

CONCLUSION

Red blood cell distribution width was associated with incidence of AF independently of several cardiovascular, nutritional and haematological factors in this study of middle-aged subjects from the general population.

Abstract P2-14-08: Plasma pro-enkephalin and pro-neurotensin for the risk prediction of incident breast cancer in healthy women

Experimental settings have indicated that Neurotensin regulates both satiety and breast cancer growth. Proneurotensin 1-117 (pro-NT), which stems from the same precursor as Neurotensin, has been developed as a reliable plasma surrogate biomarker for the unstable Neurotensin and has been shown to be associated with the development of incident breast cancer.

Enkephalins and related opioid peptides may negatively regulate carcinogenesis and the growth of breast tumors through stimulation of the immune tumor defense system as well as direct inhibitory effects on breast cancer cells. However, little is known about their role in the development of breast cancer in humans. Enkephalin can be assessed in plasma by measuring a stable surrogate marker, Pro-Enkephalin A 119-159 (pro-ENK).

OBJECTIVE:

To test if plasma pro-ENK in healthy women is associated with the development of incident breast cancer and if it adds information to pro-NT for the risk prediction.

DESIGN, SETTING, AND PARTICIPANTS:

We measured pro-ENK and pro-NT in fasting plasma from 1929 women (mean age 58 +/- 5.9 years) of the population based Malmo Diet and Cancer Study (MDCS), who were free from breast cancer prior to the baseline exam. We used Cox proportional hazards models to relate pro-ENK and pro-NT to first breast cancer events (n = 123) within 15 years of follow-up.

RESULTS:

Decreasing concentrations of pro-ENK were significantly associated with the risk of women to develop breast cancer: Women belonging to quartiles 3, 2 and 1 of pro-ENK compared to those of quartile 4 had Hazard ratios (HR) for breast cancer of 1.41 (0.74-2.69), 2.3 (1.27-4.14) and 3.19 (1.82-5.62).

Pro-NT: As compared to women belonging to the 1st quartile of pro-NT, women belonging to quartiles 2, 3 and 4 of pro-NT had HRs for the devlopment of breast cancer of 1.24 (0.69-2.24), 1.61 (0.92-2.82) and 2.37 (1.4-4.01).

Pro-ENK significantly added prognostic value to pro-NT (p = 0.00006) and vice versa (p = 0.00002). The HR for women with pro-ENK in the 1st quartile and pro-NT in the 4th quartile (high risk group) was 4.17 (2.48-7.03) as compared to women with pro-ENK in quartiles 2-4 and pro-NT in quartiles 1-3 (low risk group). Women with one of the biomarkers in high risk still had a slightly increased risk (HR 1.71 (1.16-2.52)) as compared to the low risk group.

CONCLUSION:

Biomarker based risk prediction for the development of breast cancer is significantly improved, when plasma pro-ENK is added to pro-NT.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-14-08.

Chromosome 9p21 genetic variation explains 13% of cardiovascular disease incidence but does not improve risk prediction

OBJECTIVES

To evaluate the proportion of cardiovascular disease (CVD) incidence that is explained by genetic variation at chromosome 9p21 and to test whether such variation adds incremental information with regard to CVD prediction, beyond traditional risk factors.

DESIGN, SETTING AND PARTICIPANTS

rs4977574 on chromosome 9p21 was genotyped in 24 777 subjects from the Malmö Diet and Cancer study who were free from CVD prior to the baseline examination. Association between genotype and incident CVD (n = 2668) during a median follow-up of 11.7 years was evaluated in multivariate Cox proportional hazard models. Analyses were performed in quartiles of baseline age, and linear trends in effect size across age groups were estimated in logistic regression models.

RESULTS

In additive models, chromosome 9p21 significantly predicted CVD in the entire population (hazard ratio 1.17 per G allele, 95% confidence interval 1.11-1.23, P < 0.001). Effect estimates increased from the highest (Q4) to the lowest quartile (Q1) of baseline age, but this trend was not significant. The overall population attributable risk conferred by chromosome 9p21 in fully adjusted models was 13%, ranging from 17% in Q1 to 11% in Q4. Addition of chromosome 9p21 to traditional risk factors only marginally improved predictive accuracy.

CONCLUSION

The high population attributable risk conferred by chromosome 9p21 suggests that future interventions interfering with downstream mechanisms of the genetic variation may affect CVD incidence over a broad range of ages. However, variation of chromosome 9p21 alone does not add clinically meaningful information in terms of CVD prediction beyond traditional risk factors at any age.

High levels of cystatin C predict the metabolic syndrome: the prospective Malmö Diet and Cancer Study

OBJECTIVE

Cystatin C is a novel marker of cardiovascular disease (CVD); however, the underlying mechanisms remain unclear. Here, we prospectively investigated whether plasma levels of cystatin C predict new-onset metabolic syndrome (MetS) as well as long-term progression and incidence of the different components of the MetS.

METHODS

Cystatin C was measured in 1502 individuals included in the Malmö Diet and Cancer cardiovascular cohort (mean age 56 years, 59% women) who were free from the MetS at baseline and subsequently underwent a follow-up examination after a median of 16 years. MetS was defined according to the NCEP-ATP-III guidelines. Logistic regression was used to adjust for covariates.

MAIN OUTCOME MEASURES

Metabolic syndrome and long-term progression as well as incidence of the different components of the MetS.

RESULTS

During follow-up, 428 subjects developed new-onset MetS. In age- and sex-adjusted analysis, compared with the lowest quartile of cystatin C, the odds ratios (95% confidence interval) for incident MetS in subjects with cystatin C levels in quartiles 2, 3 and 4 were 1.00 (0.71-1.40), 1.48 (1.06-2.07) and 1.91 (1.37-2.68), respectively (Ptrend  < 0.001); this linear association remained significant even after full multivariate adjustment (Ptrend  = 0.041). Interestingly, in this fully adjusted model, long-term progression of abdominal obesity was the only component of the MetS significantly associated with increasing quartiles of baseline cystatin C levels (Ptrend  = 0.008).

CONCLUSION

These findings suggest that cystatin C may adversely affect metabolic factors, particularly abdominal obesity, thus contributing to development of the MetS. Our results may help to explain the link between cystatin C and development of CVD.

Common carotid intima-media thickness does not add to Framingham risk score in individuals with diabetes mellitus: the USE-IMT initiative

AIMS/HYPOTHESIS

The aim of this work was to investigate whether measurement of the mean common carotid intima-media thickness (CIMT) improves cardiovascular risk prediction in individuals with diabetes.

METHODS

We performed a subanalysis among 4,220 individuals with diabetes in a large ongoing individual participant data meta-analysis involving 56,194 subjects from 17 population-based cohorts worldwide. We first refitted the risk factors of the Framingham heart risk score on the individuals without previous cardiovascular disease (baseline model) and then expanded this model with the mean common CIMT (CIMT model). The absolute 10 year risk for developing a myocardial infarction or stroke was estimated from both models. In individuals with diabetes we compared discrimination and calibration of the two models. Reclassification of individuals with diabetes was based on allocation to another cardiovascular risk category when mean common CIMT was added.

RESULTS

During a median follow-up of 8.7 years, 684 first-time cardiovascular events occurred among the population with diabetes. The C statistic was 0.67 for the Framingham model and 0.68 for the CIMT model. The absolute 10 year risk for developing a myocardial infarction or stroke was 16% in both models. There was no net reclassification improvement with the addition of mean common CIMT (1.7%; 95% CI -1.8, 3.8). There were no differences in the results between men and women.

CONCLUSIONS/INTERPRETATION

There is no improvement in risk prediction in individuals with diabetes when measurement of the mean common CIMT is added to the Framingham risk score. Therefore, this measurement is not recommended for improving individual cardiovascular risk stratification in individuals with diabetes.