Synergistic effects of a cremophor EL drug delivery system and its U0126 cargo in an ex vivo model

Neuroprotection has proven clinically unsuccessful in subarachnoid hemorrhage. We believe that this is because the major component in the early damage pathway, the vascular wall, has not been given the necessary focus. U0126 is a potent inhibitor of vascular phenotypical changes, exemplified by functional endothelin B (ET_B) receptor upregulation. The current study aimed to determine the optimal dose of U0126 ex vivo and test the toxicology of this dose in vivo. To find the optimal dose and test a suitable in vivo delivery system, we applied an ex vivo model of blood flow cessation and investigated functional ET_B receptor upregulation (using a specific agonist) as the primary endpoint. The secondary endpoint was depolarization-induced contractility assessed by 60 mM K⁺ stimuli. Furthermore, an in vivo toxicology study was performed on the optimal selected doses. U0126 (10 µM) had a strong effect on the prevention of functional ET_B receptor contractility, combined with minimal effect on the depolarization-induced contractility. When cremophor EL was chosen for drug delivery, it had an inhibitory and additive effect (combined with U0126) on the ET_B receptor contractility. Hence, 10 µM U0126 in 0.5% cremophor EL seems to be a dose that will be close to the maximal inhibition observed ex vivo on basilar arteries, without exhibiting side effects in the toxicology studies. U0126 and cremophor EL are well tolerated at doses that have effect on ET_B receptor upregulation. Cremophor EL has an additional positive effect, preventing functional ET_B receptor upregulation, making it suitable as a drug delivery system.

Enhanced contractility of intraparenchymal arterioles after global cerebral ischaemia in rat - new insights into the development of delayed cerebral hypoperfusion

AIM

Delayed cerebral hypoperfusion is a secondary complication found in the days after transient global cerebral ischaemia that worsens the ischaemic damage inflicted by the initial transient episode of global cerebral ischaemia. A recent study demonstrated increased cerebral vasoconstriction in the large arteries on the brain surface (pial arteries) after global cerebral ischaemia. However, smaller arterioles inside the brain (parenchymal arterioles) are equally important in the regulation of cerebral blood flow and yet their pathophysiology after global cerebral ischaemia is largely unknown. Therefore, we investigated whether increased contractility occurs in the intraparenchymal arterioles.

METHODS

Global cerebral ischaemia was induced in male Wistar rats by bilateral common carotid occlusion for 15 min combined with hypovolaemia. Regional cerebral blood flow was determined by quantitative autoradiography. Intraparenchymal arterioles were isolated and pressurized, and concentration-response curves to endothelin-1 with and without the endothelin B receptor-selective antagonist BQ788 was generated. Endothelin B receptor expression was investigated by quantitative flow cytometry and immunohistochemistry.

RESULTS

We observed increased endothelin-1-mediated contractility of parenchymal arterioles correlating with reduced cerebral blood flow of the cortex, hippocampus and caudate nucleus 48 h after global cerebral ischaemia. The increased endothelin-1-mediated contractility was abolished by BQ788, and the vascular smooth muscle cell-specific expression of endothelin B receptors was significantly increased after global cerebral ischaemia.

CONCLUSION

Increased endothelin-1-mediated contractility and expression of endothelin B receptors in the intraparenchymal vasculature contributes to the development of delayed cerebral hypoperfusion after global cerebral ischaemia in combination with vascular changes of the pial vasculature.

Cerebrovascular endothelin-1 hyper-reactivity is associated with transient receptor potential canonical channels 1 and 6 activation and delayed cerebral hypoperfusion after forebrain ischaemia in rats

AIM

In this study, we aimed to investigate whether changes in cerebrovascular voltage-dependent calcium channels and non-selective cation channels contribute to the enhanced endothelin-1-mediated vasoconstriction in the delayed hypoperfusion phase after experimental transient forebrain ischaemia.

METHODS

Experimental forebrain ischaemia was induced in Wistar male rats by a two-vessel occlusion model, and the cerebral blood flow was measured by magnetic resonance imaging two days after reperfusion. In vitro vasoreactivity studies, immunofluorescence and quantitative PCR were performed on cerebral arteries from ischaemic or sham-operated rats to evaluate changes in vascular voltage-dependent calcium channels, transient receptor potential canonical channels as well as endothelin-1 receptor function and expression.

RESULTS

The expression of transient receptor potential canonical channels 1 and 6 in the vascular smooth muscle cells was enhanced and correlated with decreased cerebral blood flow two days after forebrain ischaemia. Furthermore, under conditions when voltage-dependent calcium channels were inhibited, endothelin-1-induced cerebrovascular contraction was enhanced and this enhancement was presumably mediated by Ca(2+) influx via upregulated transient receptor potential canonical channels 1 and 6.

CONCLUSIONS

Our data demonstrates that endothelin-1-mediated influx of extracellular Ca(2+) activates transient receptor potential canonical channels 1 and 6 in cerebral vascular smooth muscle cells. This seems to have an important role in the enhanced cerebral vasoconstriction in the delayed post-ischaemic hypoperfusion phase after experimental forebrain ischaemia.

Bariatric surgery in adolescents: what do we know so far?

Introduction:

Obesity represents a vast and rapidly increasing global burden. Bariatric surgery is the only intervention achieving sustained weight loss, among its wide-ranging benefits.

Methods:

In this article, we describe the growing challenges presented by adolescents with severe obesity and review the literature on surgical and other treatment options.

Results:

Outcomes in terms of weight loss, metabolic and quality of life improvement, reversal of obstructive sleep apnea, insulin resistance, type II diabetes mellitus, hypertension, and dyslipidemia appear comparable to those seen in adults. However, long-term data on safety and sustainability are lacking. There is a growing acceptance of the need for surgery as a treatment for the morbidly obese adolescent population, and the number of studies reporting outcomes after adolescent bariatric surgery is increasing.

Conclusion:

Accumulating evidence suggests that the benefits seen in adult bariatric surgery can be reproduced in adolescents. Thus, adolescent bariatric surgery appears to be safe and effective in achieving benefits desired in terms of weight control and improvements in metabolic health and quality of life. However, particular care must be taken when treating a young population, and long-term outcomes are awaited to properly define indications and limitations.

Valid symptom reporting at upper endoscopy in a random sample of the Swedish adult general population: the Kalixanda study

BACKGROUND

Upper oesophagogastroduodenoscopy is considered to be the gold standard for upper gastrointestinal disease assessment, but is currently seldom used in epidemiological studies. One concern is that the procedure may bias sampling among volunteers in a general adult population. The aim of this study was to explore whether the procedure affects symptom reporting.

METHODS

A random sample of 3000 adults aged 20-81 years (mean age 50.4), from two Swedish municipalities (n=21,610) was surveyed using a validated postal questionnaire (the Abdominal Symptom Questionnaire) assessing gastrointestinal symptoms. A subsample of the responders was invited, in random order, to undergo an upper endoscopy and repeated symptom reporting using the same questionnaire, as well as a serology test for Helicobacter pylori.

RESULTS

The response rate to the initial questionnaire was 74.2% and the participation rate for those eligible for the upper endoscopy was 73.3% (n = 1001, mean age 54.0 years, 48.8% male). No major social or symptom sampling error was encountered from the selection process, with the exception of an excess of symptom reporters among the youngest subjects. The prevalence of reflux symptoms, dyspeptic symptoms and irritable bowel symptoms was 40%, 37.6% and 29.6%, respectively, which is relatively high, but in no way extreme.

CONCLUSIONS

The upper endoscopy survey strategy was successful. The response rate was high and there was no major selection bias of clinical relevance. The cohort selected for this study appears to be representative of the general Swedish adult population.

Validation of the translation and cross-cultural adaptation into Finnish of the Abdominal Symptom Questionnaire, the Hospital Anxiety and Depression Scale and the Complaint Score Questionnaire

BACKGROUND

Epidemiological surveys require questionnaires to be validated in the native language of the participants. The aim of this study was to validate the Finnish translations of the Abdominal Symptom Questionnaire (ASQ), the Hospital Anxiety and Depression Scale (HAD) and the Complaint Score Questionnaire (CSQ).

METHODS

A random sample of adults (n = 3000) in a northern Swedish bilingual district was surveyed using a mailed ASQ offered in both SwedIsh and Finnish, and 2122 responded (239 in Finnish). A random subsample of the responders (n = 1001, 123 preferring Finish) was then surveyed once more using the ASQ, the HAD and the CSQ. The first 50 responders of the latter survey were then given the three questionnaires again within two weeks. The Finnish versions had been put through a comprehensive translation procedure

RESULTS

A factor analysis comparison between the responders using either language in the mailed survey gave a comparable factor construction, and this was also comparable with an earlier analysis of the Swedish version. The Finnish responses to the second survey were further evaluated by testing internal consistency reliability, convergent validity towards previously validated relevant instruments (ShortForm-36 and the Gastrointestinal Symptom Rating Scale) and the test/re-test accuracy of the three questionnaires. These were found to be reliable, as was the correlation between the ASQ and the CSQ, for relevant domains.

CONCLUSION

The Finnish translations of the ASQ, HAD and CSQ questionnaires all seem to be robust and usable for population-based surveys among Finnish adults.

MONTH OF BIRTH, SOCIOECONOMIC BACKGROUND AND DEVELOPMENT IN SWEDISH MEN

Season of birth has been shown to correlate with many aspects of somatic and mental disorders, development and social adaptation (so-called ‘birth-date effects’). In a sample of young Swedish men, corresponding roughly to a one-year birth cohort, the results of intelligence tests, psychologists’ ratings of psychological function, school achievement, body height, weight and self-reported health during childhood, were found to be correlated with month of birth, and – more strongly – father’s socioeconomic status. The results were more favourable for men who were born during March–May (the period of highest birth rate), and whose fathers were of higher socioeconomic status, than for those born in November and December (the period of lowest birth rate), and whose fathers were in the lower socioeconomic group. It seems reasonable to conclude, from this study and previously reported findings, that these so-called ‘birth-date effects’ are determined by varying and often interacting biological and psychosocial factors. Among these factors, the light-induced entrainment of circadian and annual rhythms in the fetus and/or infant seems to be of pivotal importance. The organization of children into one-year age classes therefore produces an unfair lack of equality of possibilities.

Diabetes mellitus in Turkish immigrants in Sweden

This study analyses the risk of self-reported diabetes mellitus among Turkish-born immigrants in Sweden. Two simple random samples were used: The Swedish National Board of Health and Welfare Immigrant Survey, and the Swedish Survey of Living Conditions, both from 1996. Totally 526 Turkish immigrants, 285 men and 241 women, were compared with 2854 Swedish controls, 1425 men and 1429 women, all in ages 27-60 years. Data were analysed by sex in an age-adjusted model, and a full model also included education, employment status, BMI and country of birth (logistic regression). Among Turkish men, age-adjusted diabetes prevalence was not higher than among Swedish men, odds ratio (OR) 1.04 (95% confidence interval (CI) 0.35-3.11). Among Turkish women, age-adjusted diabetes prevalence was higher than among Swedish women, OR 3.22 (95% CI 1.36-7.64), but when also adjusting for educational level, employment status and BMI, OR was 1.22 (95% CI 0.41-3.66). We conclude, that age-adjusted presence of known diabetes was higher among Turkish-born women than among Swedish women, but was explained by lower employment rate, lower educational status and a higher level of overweight and obesity.

Sociodemographic and health behaviour factors among dietary supplement and natural remedy users

OBJECTIVE

To investigate which subgroups of the Swedish adult population use dietary supplements and natural remedies, taking into account sociodemographic and health behaviour factors.

DESIGN

A cross-sectional survey conducted in 1996/1997 by Statistics Sweden was used for the analyses. In face-to-face interviews participants reported consumption of dietary supplements and natural remedies during the previous 2 weeks.

SETTING

Sweden

SUBJECTS

A nationally representative sample of 11 422 adults (5596 men, 5826 women) aged 16-84 y. The response rate was 78%.

RESULTS

Overall, 33% of Swedish women and 22% of Swedish men reported use of dietary supplements; prevalence of natural remedy users was 14 and 7%, respectively. The best predictors for use of dietary supplements and natural remedies were age, sex and subjective health. Women and older individuals were more likely to be dietary supplement and/or natural remedy users. Obese men and women were less likely to use dietary supplements than underweight ones. Among men subjective health was significantly related to use of these preparations. Men who reported excellent health ate less than men reporting poor health. This association was weaker among women. Exercise was another important factor. Both men and women (except female dietary supplement users) who reported moderate or heavy exercise were significantly more frequent users of these preparations than those who reported practically no exercise.

CONCLUSION

Use of dietary supplements and natural remedies is associated with several sociodemographic and health behaviour factors.

SPONSORSHIP

Karolinska Institutet Research Fund.

The effects of alcohol consumption on mortality and morbidity: a 26-year follow-up study

OBJECTIVE

To investigate the long-term effects of the consumption of alcohol on mortality and morbidity.

METHOD

A sample of 32,185 (50.5% female) individuals was randomly selected from the 450,000 inhabitants of Stockholm County, Sweden, in 1969. Alcohol consumption data were obtained from postal questionnaires; response rate was 87% (n = 28,001). Data on mortality and morbidity were obtained from the National Cause of Death Register, the Cancer Register and the Inpatient Register 1971-1996.

RESULTS

The reference groups were moderate consumers of alcoholic beverages. High-consumption men had increased risks of mortality from cardiovascular diseases (relative risk ratio [RR] = 1.28; 95% confidence interval [CI]: 1.12-1.46), accidents or poisoning (RR = 2.10; CI: 1.67-2.65) and gastrointestinal diseases (RR = 4.65; CI: 2.93-7.36). High-consumption women had an increased risk of mortality only from accidents or poisoning (RR = 2.95; CI: 1.82-4.78) and gastrointestinal diseases (RR = 3.60; CI: 1.40-9.24). For low-consumption women, there was an increased risk of mortality from cardiovascular diseases (RR = 1.25; CI: 1.07-1.47). Low-consumption men also had an increased mortality from cardiovascular diseases (RR = 1.23; CI: 1.05-1.44). The results with respect to morbidity almost mirrored the results for mortality, with one exception; for low-consumption men, the morbidity from cardiovascular diseases was not increased.

CONCLUSIONS

The mortality and morbidity associated with different levels of alcohol consumption are associated with the same diseases, which suggests that alcohol may be one of the causative factors for these diseases. The reasons for the differences between genders, regarding responses to the negative effects of alcohol consumption, are still unknown.

Sustaining habits of attending cultural events and maintenance of health: a longitudinal study

The purpose of this study was to assess how changes in the habit of attending cultural events in the community might predict self-reported health. This study made use of data based on two interviews, 8 years apart, with 3793 adults aged 25-74 years from a simple random sample of the Swedish population. The subjects were interviewed in 1982-1983 and re-interviewed using the same questionnaire in 1990-1991. The setting was a Swedish interview survey of living conditions comprising a random sample of the adult population. Self-reported health status was the main outcome measure. The variables used for control purposes were baseline health status according to the survey of 1982-1983, age (at baseline), type of residence, geographical region of domicile, and socio-economic status (level of education). A correlation was found between perceived poor health and all the independent variables, as well as an influence in the expected direction for all of them; poor education, increasing age and a low degree of urbanization all predicted poorer perceived health. In the full model (including all nine independent variables), those who became culturally less active between the first and second occasion, or those who were culturally inactive on both occasions, ran a 65% excess risk of impaired perceived health compared with those who were culturally active on both occasions. Furthermore, those who changed from being culturally less active to being more active had about the same level of perceived risk as those active on both occasions. These results could be in agreement with a causal influence of stimulation and suggest that cultural stimulation is a 'perishable commodity'. While recruiting new consumers would in that case promote health, continued frequent replenishment of the cultural stimulation may be just as important.

Ethnicity, self reported psychiatric illness, and intake of psychotropic drugs in five ethnic groups in Sweden

STUDY OBJECTIVE

This study hypothesises that the presumed increased risk of self reported longstanding psychiatric illness and intake of psychotropic drugs among Iranian, Chilean, Turkish, and Kurdish adults, when these groups are compared with Polish adults, can be explained by living alone, poor acculturation, unemployment, and low sense of coherence.

DESIGN

Data from a national sample of immigrants/refugees, who were between the ages of 20-44 years old, upon their arrival in Sweden between 1980 and 1989. Unconditional logistic regression was used in the statistical modelling.

SETTING

Sweden.

PARTICIPANTS

1059 female and 921 male migrants from Iran, Chile, Turkey, Kurdistan and Poland and a random sample of 3001 Swedes, all between the ages of 27-60 years, were interviewed in 1996 by Statistics Sweden.

MAIN RESULTS

Compared with Swedes, all immigrants had an increased risk of self reported longstanding psychiatric illness and for intake of psychotropic drugs, with results for the Kurds being non-significant. Compared with Poles, Iranian and Chilean migrants had an increased risk of psychiatric illness, when seen in relation to a model in which adjustment was made for sex and age. The difference became non-significant for Chileans when marital status was taken into account. After including civil status and knowledge of the Swedish language, the increased risks for intake of psychotropic drugs for Chileans and Iranians disappeared. Living alone, poor knowledge of the Swedish language, non-employment, and low sense of coherence were strong risk factors for self reported longstanding psychiatric illness and for intake of psychotropic drugs. Iranian, Chilean, Turkish and Kurdish immigrants more frequently reported living in segregated neighbourhoods and having a greater desire to leave Sweden than their Polish counterparts.

CONCLUSION

Evidence substantiates a strong association between ethnicity and self reported longstanding psychiatric illness, as well as intake of psychotropic drugs. This association is weakened by marital status, acculturation status, employment status, and sense of coherence.

Use of dietary supplements and natural remedies increased dramatically during the 1990s

OBJECTIVES

To estimate the prevalence and trends in dietary supplement and natural remedy use in Sweden during the 1980s and 1990s.

DESIGN

Three nationally representative, cross-sectional surveys conducted in 1980-81, 1988-89 and 1996-97 were used for analysis. In face-to-face interviews participants reported consumption of dietary supplements and natural remedies during the previous 2 weeks.

SETTING

Sweden.

SUBJECTS

The samples consisted totally of 38 594 adults aged 16-84 years (14 642 in the 1980-81 survey, 12 391 in the 1988-89 survey and 11 561 in the 1996-97 survey). Main outcome measures. Changes in prevalence of dietary supplement and natural remedy users between 1980 and 1997.

RESULTS

The 70% increase in the prevalence of dietary supplement users amongst both men and women [odds ratio (OR), 1.7; 95% confidence interval (CI), 1.6-1.9, OR, 1.7; 95% CI, 1.5-1.8, respectively] occurred mainly between 1988-89 and 1996-97. The increase in the prevalence of natural remedy users was even more dramatic - more than threefold in men (OR, 3.3; 95% CI, 2.9-4.0) and almost threefold in women (OR, 2.6; 95% CI, 2.3-2.9) - and the systematic increase started already in the 1980s. The increase was observed in all age groups and in all socio-economic groups, except for farmers. In 1996-97 the prevalence of dietary supplement users was 22% amongst men and 33% amongst women, and of natural remedies 7 and 14%, respectively.

CONCLUSIONS

During the last two decades, the use of dietary supplements and natural remedies amongst the adult Swedish population has dramatically increased.

A hierarchical analysis of long-term illness and mortality in socially deprived areas

This article is a multilevel analysis of the effects on self-reported long-term illness and mortality of the socio-economic position of the neighbourhood. Using data from the Swedish Level of Living Survey, neighbourhood social position is measured by a composite Care Need Index, (CNI) together with such indicators of individual socio-economic position as occupation and housing tenure, with adjustment for age, sex, marital status and social network. Data came from 22,236 people aged 25-74, and were collected from 1988 to 1992. The cross-sectional data were analysed using a hierarchical logistic regression model. In a second analysis, each participant was followed from the initial interview until his or her death, or until the termination of data collection (31 December 1996). A neighbourhood's low social position and an individual resident's low socio-economic position (i.e., a manual worker, or person renting a flat) were found to be associated with increased risk of long-term illness. We conclude that a neighbourhood's low socio-economic position, that is, a high score on the CNI, is a risk factor for long-standing illness above and beyond an individual's socio-economic position. The differences in mortality could be explained by the included independent individual variables.

Sense of coherence and lack of control in relation to outcome after orthopaedic injuries

This study aimed to investigate whether sense of coherence (SOC) and lack of control are related to outcome after moderate orthopaedic injuries. One hundred and eleven patients with orthopaedic injuries were included. The patients were followed up 1 year after the injury (physical examination, Disability Raring Index (DRI), Visual Analogue Scale, Beck's Depression Inventory and SF-36). At a minimum of 2 years after the injury, the patients filled out a questionnaire, which included three SOC questions and one question about sense of lack of control. The results showed that a low sense of coherence, sense of having less control over one's life, and signs of depression were associated with an increased risk of having a less good clinical and functional outcome 1 year after the injury (odds ratios varied between 2 and 11). We conclude that these factors seem to be predictive of the outcome and should be taken into consideration when designing rehabilitation programs for injured patients.

Visual rating and volumetry of the medial temporal lobe on magnetic resonance imaging in dementia: a comparative study

OBJECTIVES

It has been shown that atrophy of medial temporal lobe structures such as the hippocampus and entorhinal cortex shown on MRI may distinguish patients with Alzheimer's disease from healthy controls. However, the diagnostic value of visual inspection and volumetry of medial temporal lobe atrophy (MTA) on MRI in a clinical setting is insufficiently known.

METHODS

Medial temporal lobe atrophy in 143 patients was visually rated from hard copies, using a 0-4 rating scale and a comparison was made with the volumes (cm(3)) of the medial temporal lobe as estimated with volumetry, using a stereological method. All patients were recruited in an unselected way in a clinical setting in the centre for memory impairments at the Huddinge University Hospital. Patients with Alzheimer's disease (n=41), patients with other dementias (vascular dementia, frontotemporal dementia, and unspecified dementia; n=36) as well as non-demented subjects (n=66) were included. Medial temporal atrophy and volumetry were evaluated as a diagnostic tool by performing logistic regression analysis including age, sex, and mini mental state examination (MMSE) score and calculating the sensitivity and specificity and percentage correct classification.

RESULTS

Visual and volumetric analysis yielded statistically significant differences between patients with Alzheimer's disease and non-demented subjects, as well as between those with other dementias and non-demented subjects. Combining MMSE scores and visually rated MTA ratings yielded a sensitivity of 95% for Alzheimer's disease, 85% for other dementias. Non-demented subjects were identified with a specificity of 96%. Volumetry did not have an added value over the MMSE score alone.

CONCLUSIONS

Visual rating of MTA is a clinically useful method for differentiating Alzheimer's disease from controls and is both quicker and more accurate than volumetry.

First symptoms--frontotemporal dementia versus Alzheimer's disease

Frontotemporal dementia (FTD) is often misdiagnosed as Alzheimer's disease (AD). We hypothesized that the first symptoms associated with FTD would be different from those seen in AD and that the first symptoms in FTD would reflect loss of function in the frontal region with the greatest degree of degeneration. The objective of the study was to compare the earliest symptoms in patients with FTD and AD, and to delineate the symptoms that were associated with right, left or bilateral frontotemporal degeneration in FTD. The first symptoms in 52 FTD and 101 AD patients were determined in retrospect. Based on functional imaging studies, the FTD patients were divided into those with predominantly bilateral (n = 15), left-sided (n = 19) and right-sided (n = 18) patterns of atrophy. The results showed that disinhibition, social awkwardness, passivity and loss of executive function were more common in FTD, while memory loss was more common in AD. Disinhibition was greatest in the asymmetric right-sided group, language dysfunction was commonest in the asymmetric left-sided group and loss of executive function was most frequent in the bilateral group. In summary, different first symptoms appeared in FTD and AD, which may help distinguish between the diseases. The anatomic site for FTD largely determined the kind of first symptoms.

Visiting the cinema, concerts, museums or art exhibitions as determinant of survival: a Swedish fourteen-year cohort follow-up

The aim of this study was to ascertain the possible influence of attending various kinds of cultural events or visiting cultural institutions as a determinant of survival. A cohort of individuals aged 25-74 years from a random sample were interviewed by trained non-medical interviewers in 1982 and 1983. The interviews covered standard-of-living variables. Our independent variables covered visiting cultural institutions and attendance at cultural events, reading books or periodicals, and music making. The non-response rate was about 25%. The cohort was followed with respect to survival for 14 years up to 31st December 1996. The background covariates that were used for control purposes were age, sex, cash buffer, educational standard, long-term disease, smoking, and physical exercise. Our setting was the Swedish survey of living conditions among the adult Swedish population aged 25-74 years. About 10,609 individuals were interviewed in 1982 and 1983. The outcome measure was survival until 31st December 1996. In all, 916 men and 600 women died during this period. We found a higher mortality risk for those people who rarely visited the cinema, concerts, museums, or art exhibitions compared with those visiting them most often. The significant relative risks ranging between RR 1.14 (95% CI. 1.01-1.31) of attending art exhibitions, and RR 1.42 (CI. 1.25-1.60) of attending museums, when adjusting for the nine other variables. Visits to the cinema and concerts gave significant RR in between. We could not discern any beneficial effect of attending the theatre, church service or sports event as a spectator or any effect of reading or music making. Our conclusion is that attendance at certain kinds of cultural events may have a beneficial effect on longevity.

Quantitative electroencephalography in mild cognitive impairment: longitudinal changes and possible prediction of Alzheimer's disease

The present study evaluated the clinical course of patients with mild cognitive impairment (MCI), the pattern of electroencephalography (EEG) changes following cognitive deterioration, as well as the potential of neurophysiological measures in predicting dementia. Twenty-seven subjects with MCI were followed for a mean follow up period of 21 months. Fourteen subjects (52%) progressed (P MCI) to clinically manifest Alzheimer's disease (AD), and 13 (48%) remained stable (S MCI). The two MCI subgroups did not differ in baseline EEG measures between each other and the healthy controls (n = 16), but had significantly lower theta relative power at left temporal, temporo-occipital, centro-parietal, and right temporo-occipital derivation when compared to the reference AD group (n = 15). The P MCI baseline alpha band temporo-parietal coherence, alpha relative power values at left temporal and temporo-occipital derivations, theta relative power values at frontal derivations, and the mean frequency at centro-parietal and temporo-occipital derivations overlapped with those for AD and control groups. After the follow-up, the P MCI patients had significantly higher theta relative power and lower beta relative power and mean frequency at the temporal and temporo-occipital derivations. A logistic regression model of baseline EEG values adjusted for baseline Mini-Mental Test Examination showed that the important predictors were alpha and theta relative power and mean frequency from left temporo-occipital derivation (T5-O1), which classified 85% of MCI subjects correctly.

Social mapping of the obesity epidemic in Sweden

OBJECTIVE

The aim of the present study is to describe the evolution of the obesity epidemic in Sweden, with specific attention to the socioeconomic gradient.

DESIGN

Data from the Swedish Surveys of Living Conditions were used. Three such surveys were undertaken in 1980/81, 1988/89, and 1996/97, each of which was based on a simple random sample from the national population registry.

SUBJECTS

A total of 38,284 observations are used in this analysis, including males and females aged 16-84. The sample is approximately equally divided among the 3 survey periods and by gender.

MEASUREMENTS

The following body weight categories are used to describe changing prevalences: overweight (BMI>/=25), obesity (BMI>/=30) and underweight (BMI<18.5). Because body weight and heights were self-reported, recorded values were adjusted for estimating gender-specific obesity prevalences. Education was used as a proxy for socioeconomic status.

RESULTS AND CONCLUSIONS

The prevalence of BMI>/=30 increased significantly over the 16-year observation period. At the time of the 1980/81 survey, the adjusted estimates were 8.8% in women and 6.6% in men, compared to 11.9% and 10.0% respectively, in 1996/97. The prevalence of BMI>/=25 was also analyzed for time trends, with specific attention to populations at risk. The largest proportionate changes occurred in women aged 16-44, among whom the prevalence of overweight doubled. The inverse educational gradient with respect to obesity is still present in both sexes, but there is no indication that it has increased in magnitude between 1980/81-1996/97.

High demand, low control, and impaired general health: working conditions in a sample of Swedish general practitioners

This cross-sectional survey of 1,004 Swedish general practitioners (GPs) aged 32 64 years analyses the extent to which low control, high work demand, and other work-related conditions are associated with self-rated impaired general health and impaired quality of life among Swedish GPs. The first part of the questionnaire contained "SF-36 Health Survey", from which we chose five psychosocial multi-item scales as dependent variables. The second part of the questionnaire had questions about working conditions from "The Swedish Survey of Living Conditions". Unconditional logistic regression was used. Female and male GPs with high job strain, i.e. low control and high work demand, exhibited a more than threefold increased risk of impaired general health compared with those with medium job strain. Low job strain among male GPs was associated with a low risk of impaired health. The finding of significant associations between psychosocial working conditions and impaired general health and impaired, quality of life in GPs in 1996 highlights the need to improve working conditions in Swedish primary healthcare, for example, by reducing number of inhabitants per full-time GP to 1,500.

Impact of ethnicity, violence and acculturation on displaced migrants: psychological distress and psychosomatic complaints among refugees in Sweden

This study uses data collected in 1996 by the Swedish National Board of Health and Welfare. By means of interviews with 1980 foreign-born immigrants, an attempt was made to determine the impact of a) migration status (country of birth/ethnicity), b) exposure to violence, c) Antonovsky's sense of coherence, d) acculturation status (knowledge of Swedish), e) sense of control over one's life, f) economic difficulties, and g) education, both on psychological distress (using General Health Questionnaire 12) and psychosomatic complaints (daytime fatigue, sleeping difficulties, and headache/migraine). Iranians and Chileans (age-adjusted) were at great risk for psychological distress as compared with Poles, whereas Turks and Kurds exhibited no such risk. When the independent factors were included in the model, the migration status effect decreased to insignificance (with the exception of Iranian men). A low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties were strongly associated with the outcomes, generally accounting for a convincing link between migration status and psychological distress. Furthermore, a low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties in exile seemed to be stronger risk factors for psychological distress in this group than exposure to violence before migration.

Major risk factors for cardiovascular disease in elderly migrants in Sweden

OBJECTIVE

The knowledge of elderly migrants' health, particularly those who are retired or in transition to retirement is limited. The purpose of this study was to analyse the association between migration, socio-economic status (SES), and risk factors for cardiovascular disease (CVD).

DESIGN

A simple random sample of 253 foreign-born persons and 2847 Swedish-born persons aged 55-74 were drawn from the Swedish Population Registry. They were interviewed by Statistics Sweden in 1988-89. Outcome variables were leisure-time physical inactivity, smoker/non-smoker status, body mass index (BMI), hypertension, and diabetes mellitus. Explanatory variables were sex, age, marital status, migration status (country of birth), and SES (income). Logistic and linear regression were used.

RESULTS

Elderly foreign-born people ran an increased risk of engaging in no physical activity (men only), being a current smoker, and having an increased BMI after adjustment for background factors. In addition, a low income (first tertile) was an independent risk factor for physical inactivity (men only), as was being a current smoker (men only), BMI, hypertension, and diabetes mellitus. Thus, the burden of being an elderly migrant increases the risk of a disadvantaged lifestyle between 50 and 80% compared with Swedes.

CONCLUSIONS

This study shows that migrants who are retired or in transition to retirement have a disadvantaged risk profile for cardiovascular disease. It might be possible to improve this situation by intervention, as for example by increasing a person's interest in walking.

Psychosocial support in rehabilitation after orthopedic injuries

OBJECTIVE

Several studies have shown that psychosocial factors play a significant role in the recovery process after injuries. The aim of this study was to investigate whether psychosocial support would have a beneficial effect on outcome.

METHODS

A total of 151 patients with orthopedic injuries were randomized into an intervention group and a control group. The intervention group was offered a psychosocial support program during the early phase of rehabilitation.

RESULTS

One year after the injury, patients in the control group had an excess risk of having psychiatric complaints compared with patients in the intervention group (odds ratio = 2.74). They also reported a poorer quality of life according to Short Formula 36 Health Survey subscores for General Health (odds ratio = 2.3) and Vitality (odds ratio = 2.45). The length of the sick leave period did not differ between the groups.

CONCLUSION

Psychosocial support during the early phase of rehabilitation after orthopedic injuries may have a beneficial effect on outcome when measured as quality of life.

Change in lifestyle factors and their influence on health status and all-cause mortality

BACKGROUND

The purpose of this study was to analyse both cross-sectional associations and how longitudinal changes in lifestyle factors from one state in 1980-1981 to another in 1988-1989 influence self-reported health status. Another aim was to estimate the hazard ratios for all-cause mortality for the changes in lifestyle factors and self-reported hypertension during the same period of time.

METHOD

The cross-sectional and the longitudinal analyses are based on the same simple random sample of 3,843 adults, aged 25-74, interviewed in 1980-1981 and 1988-1989 and is part of the Swedish Annual Level-of-Living Survey. About 85% of the respondents in the first interview participated in a second interview in 1988-1989. Cross-sectional odds ratios, based on a marginal model, were estimated using the generalized estimating equations. The transitional models were analysed using unconditional logistic regression. A proportional hazard model was applied to investigate the influence of lifestyle transitions on mortality.

RESULTS

Physical inactivity, being a current or former smoker and obesity (women only) were strong risk factors for poor health either as main effects and/or combined (interactions). There was a strong interaction between physical activity and smoking, and for women, also between body mass index (BMI) and physical activity. Smoking, physically inactive and obese women had about a ten times higher risk of poor health status than non-smoking, physically active, and normal-weight women. The corresponding risk for men was about five times higher. Physically active, but smoking and obese individuals showed only moderately increased risks for poor health status. The transitional model showed that those who were physically inactive in 1980-1981, but did exercise in 1988-1989, improved their health after adjustments for sociodemographic and other lifestyle factors. Continuing to smoke or being physically inactive or having hypertension at both points in time were all associated with higher hazard ratios for all-cause mortality (1.6, 1.9 and 1.8, respectively) than those who reported that they were in good status at both points in time.

CONCLUSIONS

We found that physical activity protects against poor health irrespective of an increased BMI and smoking. The major clinical implications are the long-standing benefits of physical activity and not smoking.

Ten-year trends in all-cause mortality and coronary heart disease mortality in socio-economically diverse neighbourhoods

OBJECTIVE

Although all-cause mortality and coronary heart disease (CHD) mortality is declining in Sweden, as in most other countries in the industrialised world, we have limited information about the distribution and trends of mortality in deprived and affluent neighbourhoods.

DESIGN

This study analyses the extent to which the decline in all-cause mortality and CHD mortality (over the age range 25-74 y) differs between affluent and deprived neighbourhoods during the decade 1984-1993. Incidence density ratios (IDR), estimated by Poisson regression, were calculated for small areas, grouped into population deciles, by both the care need index (CNI) and the Townsend deprivation score. On average, there were about 14 500 residents and 560 deaths in each decile over the period.

SETTING

A large Swedish city.

MAIN OUTCOME MEASURES

All-cause mortality and mortality from CHD.

RESULTS

The most deprived neighbourhoods had the highest IDR for all-cause mortality and CHD mortality. Over the period from 1984-1988 to 1989-1993 there was an overall decrease in all-cause mortality and CHD mortality, which was significantly higher in the most affluent areas. The mortality ratios for the most deprived neighbourhoods were almost three times higher than those of the most affluent areas.

CONCLUSIONS

People liviing in more affluent neighbourhoods have had the benefit of most of the last decade's decline in CHD mortality.

Cardiovascular risk factors and the neighbourhood environment: a multilevel analysis

BACKGROUND

This article examines whether the neighbourhood environment influences intermediate cardiovascular disease (CVD) risk factors, such as obesity (body mass index [BMI]), and lifestyle factors, such as no physical activity and smoking, when adjusted for the individual socioeconomic status (SES).

METHODS

The study consists of face-to-face interviews from the Swedish Annual Level of Living Survey (SALLS) matched with the social status of the respondents' residential areas measured by two composite indices, the Care Need Index (CNI) and the Townsend score. The response rate was about 80%. This study was limited to the residents aged 25-74 years and consists of 9240 interviews from the years 1988-1989, when there were extended items in the SALLS about health and lifestyle. The data were analysed using a hierarchical logistic regression model.

RESULTS

There was a gradient within every SES group so that respondents with a low (or intermediate or high) educational level exhibited an increasing proportion of daily smokers, physically inactive people and obese individuals with increasing neighbourhood deprivation. The multilevel model showed that respondents living in the most deprived neighbourhoods had an increased risk for being a daily smoker, engaging in no physical activity and being obese when adjusted for the individual SES.

CONCLUSIONS

We showed that the area level has an important influence on risk factors for CVD which goes beyond the individual educational attainment. An increased level of living standard, more resources for primary health care and health promotion targeting the community level should be beneficial.

The influence of social deprivation as measured by the CNI on psychiatric admissions

The purpose of this study was to examine the importance of social deprivation for psychiatric admissions and its correlation with two different deprivation scores. Care Need Index (CNI) and Townsend scores were calculated at the small area level in Malmö, a city in southern Sweden. Admission rates for all psychiatric inpatients from Malmö aged 20-79 years, admitted to the psychiatric and alcohol clinics from 1 January 1991 to 31 December 1994, were calculated. The relationship between the CNI and psychiatric admissions was analysed by applying a Poisson regression model. The results are shown as incidence density ratios (IDR) with 95% confidence intervals (CI). From the most deprived areas, the first psychiatric admission rate was more than four times higher than in the most affluent areas. The rates of second and third admission were even higher. Admissions to the alcohol clinic were similar to psychiatric admissions, but the most deprived areas had first admission rates about ten times higher than in the most affluent areas. About 27% of first admissions, including patients from both psychiatric and alcohol clinics, had a diagnosis of psychosis, and 43% were substance abusers. There were differences between the patients' diagnoses in different areas. The correlation between the CNI and Townsend scores was very high. The most important finding of this study is the strong correlation between social deprivation, based on different deprivation indices, and first admissions to psychiatric and alcohol clinics.

Neighborhood environment and self-reported health status: a multilevel analysis

OBJECTIVES

This study examined whether neighborhood socioeconomic environment helps to explain the proportion of community members with self-reported poor health status.

METHODS

A random sample of 9240 persons aged 25 to 74 years were interviewed during 1988 and 1989. The socioeconomic environment of each respondent's neighborhood was measured with the Care Need Index (CNI) and the Townsend score. The data were analyzed with a multilevel model adjusted for the independent variables. The second-level variables were the 2 neighborhood scores.

RESULTS

There was a clear gradient for poor health and education within every CNI interval so that with an increasing CNI (indicating more deprivation), the prevalence of poor health increased in all 3 education groups (P = .001). In the full model, decreasing educational level, obesity, length and frequency of smoking, physical inactivity, and increasing CNI were associated with poor health. Persons living in the most deprived neighborhoods had a prevalence ratio of 1.69 (95% confidence interval = 1.44, 1.98) for poor health compared with those living in the most affluent areas.

CONCLUSIONS

Both neighborhood socioeconomic environment and individual educational status are associated with self-reported poor health.

Impaired health status, and mental health, lower vitality and social functioning in women general practitioners in Sweden. A cross-sectional survey

OBJECTIVE

The aim was to analyse differences between female and male general practitioners (GPs) in health status and lifestyle and compared with the general population in health-related quality of life.

DESIGN

A simple random sample of 1004 GPs from the whole of Sweden (71.2%) participated in a survey in May 1996 about self-reported health status, smoking habits, physical activity, and SF-36 quality of life survey. They were compared as regards SF-36 with the general population in Sweden in three approximately similar-sized age groups of women and men aged 30-44, 45-49, and 50-64.

RESULTS

Female GPs had a higher risk than male GPs of impaired health status. Of the female GPs aged 45-49, 22.8% reported that their health was impaired compared with 12.6% of male GPs. Less than 5% of the GPs younger than 45 were daily smokers. Female GPs had higher means for physical functioning but lower means for vitality, social functioning, and role emotional and mental health compared with the general population.

CONCLUSIONS

The significant increased risk in poor health among female GPs, especially those aged 45-49, is worrying and argues for appropriate analysis and prevention that are tailored to their working conditions.

Prescribing patterns for analgesics in relation to underprivileged area (UPA) score, mortality and suicide in 33 municipalities in the province of Skåne, southern Sweden

BACKGROUND

Although it is well known that analgesics contribute to suicide, there is little knowledge about how much of the mortality and suicide can be explained by socioeconomic deprivation or by sales of analgesics.

METHODS

This ecological study analyses the relationships between the sales (defined daily doses per 1000 inhabitants per day) of dextropropoxyphene, dextropropoxyphene combinations, paracetamol, codeine and paracetamol combinations, and other codeine combinations and the Swedish UPA (underprivileged area) score, mortality and suicide rates in 33 municipalities in Skåne in 1987 and 1994 for people aged 20-64 years. The association of each of the subgroups of analgesics with all-cause mortality, and with standardised mortality rates for suicide, adjusted for UPA score, was investigated by using weighted (by population size) regression analysis.

RESULTS

In 1994 there was a moderate to strong significant correlation between sales of analgesics and UPA scores, mortality and suicide (r = 0.49-0.78). Although UPA score explained 68.9% and 67.4% respectively of the variance between the analgesics and all-cause mortality and suicide, codeine and paracetamol combinations explained a further 10.1% of the variance in suicide. Dextropropoxyphene and codeine and paracetamol combinations explained an additional 3.8% and 2.9% respectively of the variance in mortality.

CONCLUSIONS

Local prescription rates for analgesics were associated with mortality and suicide, when adjusted for socioeconomic deprivation defined as UPA score.

Body mass index and distribution of body fat in female Bosnian refugees--a study in primary health care

Between 1992 and 1996 more than one million refugees, mostly women, received asylum in the USA, Canada and Germany and about 47,000 of them sought refuge in Sweden. Little is known about their cardiovascular health. Using data from a cross-sectional study of a simple random sample of non-patients, female Bosnian refugees (n = 98) aged 18-59 and Swedish-born controls (n = 95) we examined six primary diet cardiovascular risk factors: S-triglycerides, S-cholesterol, high-density lipoprotein cholesterol, body mass index (BMI), waist circumference, and sagittal diameter of the abdomen. Bosnian women aged 42-59 y had substantially higher levels of BMI, larger waist and sagittal diameter of the abdomen measurements, higher levels of S-triglycerides, and lower HDL cholesterol indicating a more disadvantaged diet (CVD risk profile) than Swedish women. Younger Bosnian women aged 18-41 y had a higher sagittal diameter of the abdomen and lower high-density lipoprotein cholesterol than Swedish women. In conclusion this is the first study to report large differences in blood lipids, obesity and abdominal obesity after adjustment for socioeconomic status between Bosnian and Swedish women. These findings underscore the critical need to improve early detection obesity-related conditions in Bosnian women in exile.

Gender, marital status and ethnicity. A Swedish retrospective study of criminality, morbidity and mortality among victims of non-fatal firearm injuries

OBJECTIVE

To study gender and ethnic aspects in a population consisting of patients treated for non-fatal firearm injuries at public hospitals in Stockholm, Sweden, during a period of 21 years.

DESIGN

Retrospective study. Ethnicity was defined as being a foreign-born individual or a native Swede. The morbidity and criminality data were analysed with unconditional logistic regression and the mortality data were analysed by a proportional hazard model.

RESULTS

Females and foreign-born persons were more often victims of attempted murder than males or native Swedes. Attempted suicide was more common among native Swedes. Male patients, single persons and Finnish immigrants treated for a firearm injury all showed an increased risk of being registered for criminality or committing a violent crime. There was no difference between native Swedes and foreign-born persons concerning the number of hospitalisations during the follow-up period. Living alone and being of male gender were associated with an increased risk of hospitalisation. Firearm victims, independently of ethnicity, had an increased mortality rate compared to a Swedish population; the standardised mortality ratio (SMR) for males was almost 3 and for females almost 8 compared to the SMR of 1 for the whole Swedish population.

CONCLUSION

Firearm victims constitute a population at risk from social, psychological as well as from medical points of view. The present study shows an association between gender, ethnicity, criminality, and morbidity among firearm victims underlining the importance of ethnic- and gender-specific violence prevention strategies.

Self-reported long-standing psychiatric illness as a predictor of premature all-cause mortality and violent death: a 14-year follow-up study of native Swedes and foreign-born migrants

The present study focuses on the associations between self-rated long-standing psychiatric illness, ethnicity, all-cause mortality and violent death (accidents and suicide), in a sample of 39,155 Swedish-born and foreign-born individuals. The study was designed as a longitudinal follow-up study, covering the period between 1 January 1979 and 31 December 1996. The data were analysed by a proportional hazard model and the results are given as hazard ratios (HR) with 95% confidence intervals (CI). Self-reported long-standing psychiatric illness was a strong risk factor for total mortality: women had an HR of 2.13 (CI = 1.78-2.54) and men an HR of 1.84 (CI = 1.53-2.21), when adjusted for background factors such as country of birth, civil status and socio-economic factors. Finnish men had an increased risk of all-cause mortality compared to Swedes in the final model, when adjusted for socio-economic factors. Long-standing psychiatric illness was also a strong risk factor for violent death, with an HR of 3.51 (CI = 2.32-5.32). The risk of violent death was 2.4 times higher for men than for women. The conclusions of the present study are that self-reported long-standing psychiatric illness is a strong predictor of an increased all-cause mortality and increased mortality from violent death. The increased age-adjusted mortality risk for foreign-born men could be explained by disadvantaged social and economic conditions. Only Finnish men demonstrated an independent increased all-cause mortality risk.

Immigration, moving house and psychiatric admissions

This study was designed to elucidate psychiatric admission rates for native Swedes and foreign-born individuals during the period 1991-1994, when Sweden had a great influx of refugees. During the same period, and even earlier, psychiatric in-patient care had been reduced. Tests of differences between Swedes and foreign-born individuals in first psychiatric admission rates were performed using Poisson regressions, and the risk of a readmission was assessed using a proportional hazard model. Foreign-born individuals and native Swedes, both males and females, showed a similar admission pattern with regard to the number of admissions. Foreign-born males under 55 years of age and foreign-born females under 35 years of age had significantly higher admission rates than native Swedes. In total, native Swedes, both males and females, were hospitalized for a significantly longer period than the foreign-born subjects. About 43% of the patients were readmitted. The risk of a readmission was significantly increased among those with a high rate of internal migration. The high admission rates for young foreign-born individuals might be explained by a high incidence of mental illness owing to the trauma of being violently forced to migrate, acculturation difficulties, or unsatisfactory social circumstances such as high unemployment. The shorter hospitalization time could be due to undertreatment or less serious mental illness.

Cognitive and behavioral differentiation of frontal lobe degeneration of the non-Alzheimer type and Alzheimer's disease

Neuropsychological differences between 14 patients with a clinical diagnosis of frontal lobe degeneration of non-Alzheimer type (FLD) and 15 patients with a clinical diagnosis of Alzheimer's disease (AD) were studied. The most efficient psychometric predictors of FLD were Digit Symbol, estimation tasks, word list recall, and particularly the FAS word fluency test. Behavioral predictors of FLD and AD showed a double dissociation: regression and impulsivity characterized FLD, whereas lack of motivation and slowness were typical of AD. Cognitive and behavioral differences between groups were not related to the degree of dementia, as measured by Mini Mental State Examination, indicating that differences remained during progression of the diseases.

Indices of need and social deprivation for primary health care

This study aimed to examine two indices of need, the underprivileged area (UPA) score and a Swedish Care Need Index (CNI, in Swedish vårdbehovsindex) with weightings from British and Swedish GPs respectively, and an index of material deprivation, Townsend score at SAMS (Small Area Market Statistics) level and at municipality level for the whole of Sweden. One third of primary health care physicians from the whole of Sweden received a questionnaire about their workload. CNI, UPA and Townsend scores were calculated using information from the Swedish census of 1990 and the registers of unemployment and migration for 1992. The Swedish GPs weighted some of the variables quite differently from the GPs in the UK. This may be important, especially at the SAMS level. The GPs in both countries considered that older people living alone contributed most to their workload. However, in Sweden the physicians ranked foreign-born people high compared with the English doctors, and in England the GPs ranked children under five years much higher than the doctors in Sweden. The correlation between the scores was high.

[Somatic health is poorer among foreign-born than native Swedes]

In a study based on data derived from the Swedish Survey of Living Conditions conducted from 1990 to 1993, differences in the prevalences of long-term somatic illnesses between native and foreign-born Swedes were analysed. Of the 18,242 randomly selected participants, aged 25-74 years. Eleven per cent were foreign-born, a figure consistent with the proportion of immigrants in the population as a whole. For the purpose of analysis, the foreign-born participants were divided into four subgroups: Finns, Southern Europeans, those from Western countries, and all others (i.e. from East Europe, Asia, Africa, and Latin America). As compared with native Swedes, and after adjustment for sex, age, marital status and level of education, the Finnish, Southern European and 'all other' subgroups were characterised by significantly higher prevalence rates for for longterm somatic illness (odds ratios, 1.62, 1.49 and 1.24, respectively). The same three subgroups also manifested significantly higher age- and sex-adjusted prevalences of musculo-skeletal diseases. Although the study design did not permit determination of whether susceptibility to poor somatic health was exacerbated by migration trauma or acculturative stress, the results suggest immigration to have an adverse effect on health.

Low educational status is a risk factor for mortality among diabetic people

Diabetes mellitus and its complications are an important cause of mortality in Western populations. The purpose of the present study was to examine the relationship between self-reported diabetes mellitus, gender, attained level of education, and socio-economic resources to all-cause mortality risk in a simple random sample of 39055 subjects, aged 25 to 74 years. Follow-up data were obtained for a maximum of 16 years, from baseline (1979-1985) to 31 December 1995. Diabetic males (2.2% of the male study group) had a relative risk (RR) for total mortality of 2.24 (CI = 1.96-2.57), adjusted for age, education, marital status, housing tenure, and car ownership, compared with non-diabetic males. The corresponding figure for females with diabetes (1.9%) was RR = 3.67 (CI = 3.16-4.27). Diabetic women had the highest age-adjusted mortality risk for coronary heart disease (CHD) of 8 compared with non-diabetic women. The corresponding RR for men was just below 3 (p<0.0001). Males and females (with and without diabetes) of low attained educational level had a RR = 1.26 (CI = 1.15-1.39) and RR = 1.54 (CI = 1.31-1.81), respectively. When analysing all people with diabetes separately, adjusting for sex and age, low-educated subjects had a 40% excess all-cause mortality compared with high-educated subjects. We conclude that diabetic women have a very high relative risk for CHD mortality compared to non-diabetic women. Furthermore, diabetic people with a low attained level of education, have an increased vulnerability to, and a higher total mortality.

The influence of socioeconomic status, ethnicity and lifestyle on body mass index in a longitudinal study

BACKGROUND

Few studies have attempted to disentangle the complex relationship between socioeconomic status (SES) and ethnicity and its influence on body mass index (BMI) and on change in BMI over a decade. The present study highlights the influence of ethnicity (country of birth) and SES on BMI, adjusting for certain lifestyle factors.

METHODS

The longitudinal self-reported data, based on a simple random sample, were obtained from 1972 women and 1871 men, aged 25-74, interviewed in 1980/81 and re-interviewed in 1988/89 using the same questionnaire. The influence of the independent variables on BMI was analysed by the Generalized Estimation Equation (GEE) method. The change in BMI for different states of the independent variables was analysed in a linear model with the difference in BMI between 1988/89 and 1980/81 as dependent variable, by sex.

RESULTS

There was a graded relationship between male SES, defined as educational status, and BMI when adjusted for background variables, while for females, only a low educational level was associated with a higher BMI. Southern European men and Finnish women showed a higher increase in BMI than the reference group (Swedes and West Europeans) when adjusted for age, smoking, exercise, education, marital status, and health status. Not taking exercise was related to a higher BMI compared with those who were taking exercise. The BMI levels and smoking habits were little changed between 1980/81 and 1988/89, while exercise habits showed a more variable pattern. When the focus was on change in BMI, former smokers had a larger increase in BMI than never smokers. Further, men who ceased taking exercise had a larger increase in BMI than those who were taking regular exercise on both occasions.

CONCLUSION

When adjusted for smoking and the other background variables, SES and ethnicity are two separate independent factors influencing BMI in men and women. When the focus was on change in BMI, former smokers had a larger increase in BMI than never smokers. Further, men who ceased taking exercise had a larger increase in BMI than those who took regular exercise on both occasions.

Impaired mobility and impaired working capacity among foreign born people and native born Swedes

OBJECTIVE

The aim of this study is to analyse the influence of country of birth and attained level of education, on impaired mobility and impaired working capacity adjusted for age, sex, and other background variables.

SETTING

Sweden.

DESIGN

A random sample of 5798 men and 6072 women ages 55-74 years were interviewed face to face by Statistics Sweden 1986-1993. Dependent variable: impaired mobility and impaired working capacity.

INDEPENDENT VARIABLES

sex, age, country of birth (Swedes, Finns, Western countries, south Europeans, and all others), attained level of education, marital status, form of tenure, and social network. This study was designed as a cross sectional study. The data were analysed with unconditional logistic regression in main effect models. The results are shown as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

In general, poor health, defined as impaired working capacity or impaired mobility, proved to be more frequent among foreign born people and in all socially disadvantaged groups such as those with a low educational status, people renting a dwelling or with a poor social network. Impaired working capacity and impaired mobility were more frequent among female "all others". The impaired mobility among men and women born in south Europe was high with OR = 2.65 (CI = 1.34, 5.25) and OR = 3.17 (CI = 1.44, 7.00) in the full model. Men and women from Finland and all other countries had high risks for impaired mobility when adjusted for all background variables. Finnish men and south European women had the highest odds ratios for impaired working capacity. There was a clear gradient between educational status and impaired working capacity, with the highest odds ratios for men and women, 2.39 and 1.92, with a low attained level of education, when adjusting for the independent variables.

CONCLUSION

Country of birth and educational status are two important independent factors with influence on poor health defined as impaired mobility and impaired working capacity in age 55-74.

Poor quality of life and health in young to middle aged Bosnian female war refugees: a population-based study

OBJECTIVE

To evaluate whether female Bosnian refugees have a poorer quality of life than Swedish women.

DESIGN

A cross-sectional study of quality of life using a slightly modified 'Göteborg Quality of Life' instrument. The women rated their global well-being (19 items) on a 7 degree scale ranging from 'very bad' (1) 'to excellent, could not be better'. The second part of the questionnaire consisted of 29 yes/no items about somatic and psychological symptoms which should take less than 5 min to complete. Factor analysis was performed in order to reduce the number of variables. Differences between mean ranks were tested by the Krusakal-Wallis test. Differences in distributions of the yes/no-questions in the different groups were tested with a likelihood ratio chi 2 test.

SETTING

Malmö and Lund, two cities in Southern Sweden.

SUBJECTS

A simple random sample of 120 women aged 18-59, born in Bosnia-Hercegovina with accepted refugee status, and registered in Lund and Malmö, was interviewed. The control group for this was 292 Swedish women of the same age, registered in Dalby (Lund). The response rate for Bosnian women was 74% and for Swedish women 75%.

MAIN OUTCOME MEASURES

The factor analysis resulted in one factor, 'global health', to which all the well-being variables were related.

RESULTS

38% of the Bosnian and 23% of the Swedes had bad global health. Bosnian women with bad global health had lower mean rankings than Swedish women, namely low quality of life in 'appetite', 'memory', 'leisure time', and aspects of mental well-being such as 'energy', patience', 'sleep', 'mood', and 'health'. They also had larger proportions of symptoms than Swedish women.

CONCLUSIONS

Bosnian women irrespective of health status had poorer quality of life in most variables and more symptoms than Swedish women with good global health.

The UPA (underprivileged area) score and mortality in Swedish municipalities

OBJECTIVE

To analyse the association between the Swedish underprivileged area (UPA) score and the standardized mortality ratio in Swedish municipalities.

SETTING

All 284 municipalities in Sweden.

DESIGN

The UPA-score was calculated for municipalities using the proportion of persons in the following groups: elderly persons living alone, children under five, persons in one-parent families, unskilled (SEI 1), unemployed, persons living in crowded households, those who have moved house in the last year, and persons of minority ethnic origin. After transformation (arc sin square root of) and standardization, each of the eight variables was weighted by the UK general practitioners' average weighting and added to give a composite index of socioeconomic deprivation--the UPA-score. The strength of the relationship between the UPA-score and premature mortality in Sweden was investigated by regression analysis using SMR, for people aged 20-64 years, 1989-93, as the dependent variable.

RESULTS

The mean UPA-score (standard deviation) of the 284 municipalities was 0 (10.0) and the range -43 to 28. The mean SMR for all persons was 1 and the range 0.46 to 1.81. The association between UPA-score and SMR was statistically significant and the UPA-score explained 20% of the variation between municipalities in SMR.

CONCLUSION

The range of social deprivation at the municipality level in Sweden, as measured by a composite index such as the UPA score, is wide. A two-fold variation at municipality level was also found in premature mortality. There was a significant association between high rates of mortality and social deprivation.

Indicators of socio-economic position and their relation to mortality in Sweden

This paper estimates the effects on mortality of some indicators of socio-economic position such as employment status (SEI), education and housing tenure. The data from 32,853 persons aged 25-64 were collected from seven independent samples of the Swedish population in 1979-1985. The study was designed as a longitudinal follow-up study ranging from day of interview to December 1993. Information on the dependent variable was obtained from the Cause of Death Register by the personal registration number. The data were analysed by a proportional hazard model. Being a low educated female or renting a flat was associated with increased mortality when tested simultaneously for all independent variables. The excess mortality among unskilled persons and skilled labourers/lower level employees (males) disappeared in successive models when one variable at a time was included in the main models. Sickness pension for males and females, long-term unemployment for males, and ethnicity were also related to increased mortality.

Accidental firearm injury in childhood--a predictor of social and medical outcome?

This paper reports register data on a consecutive series of 141 children and teenagers hospitalized due to firearm injuries during a 21-year period in a community with restrictive firearm laws. Most of the injuries were minor and hospitalization was short. Shot by an air gun resulting in an eye injury was the most frequent reason for hospitalization. The patients hospitalized due to firearm injuries were compared with a control group composed of 141 individuals matched pair-wise for sex and age. The total morbidity during the follow-up period of on average 10 years was higher among patients compared with controls concerning both somatic diseases and injuries. All cases of severe psychopathology were found in the patient group. Criminality was higher among patients compared with controls and the former were younger at the time of the first crime compared with the latter. This study indicates that, irrespective of firearm laws, young people suffering from firearm injuries, even if the injury is classified as accidental, run a higher risk of becoming psychosocially disadvantaged and criminal as adults. This makes preventative measures highly necessary not only from a societal point of view, but also to avoid individual suffering in this high-risk group of youngsters.

The influence of ethnicity and social and demographic factors on Swedish suicide rates. A four year follow-up study

The aim of this follow-up study, based on individual data, was to analyse the influence of ethnicity and other demographic and social factors on suicide rates between 1986 and 1989 for the Swedish population according to the 1985 census. The data were analysed by sex and age using a Poisson regression model. During the study period there were 8,310 cases of suicide and undetermined death. The main finding in this study was that ethnicity, defined as being foreign-born, was a significant risk factor for suicide in both sexes and in all age groups except for males aged 30 to 49 years. Not being married was a significant risk factor in all age groups for both males and females. Form of tenure, i.e. living in rented flats, was a significant risk factor for suicide in middle-aged males and females, while over-crowding was a risk factor for middle-aged males and for the over 50's of both sexes. As ethnicity, defined as foreign-born, was an important variable related to suicide, the association between different ethnic groups and suicide will be evaluated in forthcoming studies.

The influence of country of birth on mortality from all causes and cardiovascular disease in Sweden 1979-1993

BACKGROUND

Epidemiological data on ethnicity and health in Sweden have mostly been derived from small populations and focused on morbidity. The present study highlights the relation between country of birth, adjusted for other social variables, and total mortality and mortality from circulatory diseases and coronary heart disease (CHD).

METHODS

The interviews with 21,420 males and 21,977 females aged 20-74 were conducted during a 7-year period, 1979-1985. The data consist of seven independent samples of the Swedish population. The present investigation was designed as a longitudinal follow-up study ranging from the day of the interview to 31 December 1993. Mortality data were obtained from the Cause of Death Register based on the Swedish national registration number. Person-years at risk were calculated from the date of the interview until death, or for those who survived, until the end of the follow-up period. The data were analysed by sex, using a proportional hazard model.

RESULTS

Men born in Finland had an increased mortality from all causes of death. Women born in Finland had an increased mortality risk for circulatory diseases with a relative risk (RR) of 2.15 (95% confidence interval [CI] : 1.45-3.20) when adjusted for age, marital status, form of housing tenure and years of education. The relationship between being a woman born in Finland or Eastern Europe and mortality for coronary heart disease (CHD) was significant with an RR of 2.18 (95% CI : 1.24-3.81) and 3.02 (95% CI : 1.24-7.34) respectively. The form of housing tenure was significantly associated with mortality in all models. Education showed a graded relation to total mortality and to mortality from circulatory diseases and CHD.

CONCLUSIONS

The increased mortality risk for Finnish males and females and, in addition the increased circulatory disease mortality risk for Finnish females and the strongly increased risk for CHD mortality for females born in Finland and Eastern Europe could not be explained by confounding by age, marital status or socioeconomic position.

Ethnicity, social factors, illness and suicide: a follow-up study of a random sample of the Swedish population

The aim of this longitudinal study was to determine the influence of ethnicity, social factors and self-reported long-term somatic and psychiatric illness on suicide in a random sample of the Swedish population. The study is based on face-to-face interviews conducted between 1979 and 1985 with a random sample of the Swedish population consisting of 47,762 Swedish-born subjects and 4407 individuals born elsewhere. The sample has been followed via register data concerning cases of suicide (suicides and undetermined deaths) until 31 December 1993. In total, 102 males and 46 females committed suicide prior to this date. Living alone and self-reported somatic illness with impaired health status were very strong risk factors for suicide, with risk ratios of 2.15 (CI, 1.51-3.05) and 1.80 (1.19-2.72), respectively. Ethnicity, defined as being born outside Sweden, had a risk ratio of 1.87 (1.18-2.97) in a model controlled for sex and age. However, this risk decreased with increasing age in the final model. Furthermore, an increased risk of suicide was found among female subjects living in rented flats and among male subjects irrespective of form of tenure, as well as among residents of large urban areas. Respondents with a self-reported long-term psychiatric illness with impaired health status also had a high risk of suicide, which decreased with increasing age. The main finding of this study is that somatic diseases and psychiatric disorders, which are known risk factors for suicide, may be revealed in surveys conducted by interviewers without medical training. Thus self-reported psychiatric and somatic illness appear to have a good potential for predicting suicide, even if the prevalence of psychiatric disorders is to some extent underestimated.