Objective: To study cumulative incidence and predictors of myocardial infarction (MI) in two random general population samples consisting of middle-aged Swedish men born 30years apart. Method: ...Results from the “Study of Men Born In 1913” and the “Study of Men Born In 1943”, two longitudinal cohort studies performed in the same geographic area and using the same methodology were compared. Both cohorts were followed prospectively from 50 to 70years of age. MI was defined as first myocardial infarction, fatal or non-fatal. Results: Men born in 1943 had a 34% lower cumulative risk of first MI HR 0.66 (0.50–0.88), p = 0.0051 during follow-up as compared to men born in 1913. Interaction analysis showed that hypertension had a significantly higher impact on risk of MI in cohort 1943 than in cohort 1913 HR 2.33 (95% CI 1.41–3.83) and HR 1.10 (0.74–1.62), p = 0.0009 respectively. The population attributable risk for hypertension was 2.5-fold higher in the cohort of men born in 1943 as compared to men born in 1913, and diabetes mellitus and sedentary lifestyle attributed more to MI risk in cohort 1943 than in cohort 1913. On the contrary, smoking and total cholesterol have less attributable risk to MI in cohort 1943 than in cohort 1913. Conclusion: Despite declining incident MI and improved cardiovascular prevention in general, hypertension remains an increasingly important attributable risk factor to MI together with diabetes mellitus and sedentary lifestyle over time.
IMPORTANCE: To prevent blindness, repeated infant eye examinations are performed to detect severe retinopathy of prematurity (ROP), yet only a small fraction of those screened need treatment. Early ...individual risk stratification would improve screening timing and efficiency and potentially reduce the risk of blindness. OBJECTIVES: To create and validate an easy-to-use prediction model using only birth characteristics and to describe a continuous hazard function for ROP treatment. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, Swedish National Patient Registry data from infants screened for ROP (born between January 1, 2007, and August 7, 2018) were analyzed with Poisson regression for time-varying data (postnatal age, gestational age GA, sex, birth weight, and important interactions) to develop an individualized predictive model for ROP treatment (called DIGIROP-Birth Digital ROP). The model was validated internally and externally (in US and European cohorts) and compared with 4 published prediction models. MAIN OUTCOMES AND MEASURES: The study outcome was ROP treatment. The measures were estimated momentary and cumulative risks, hazard ratios with 95% CIs, area under the receiver operating characteristic curve (hereinafter referred to as AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Among 7609 infants (54.6% boys; mean SD GA, 28.1 2.1 weeks; mean SD birth weight, 1119 353 g), 442 (5.8%) were treated for ROP, including 142 (40.1%) treated of 354 born at less than 24 gestational weeks. Irrespective of GA, the risk for receiving ROP treatment increased during postnatal weeks 8 through 12 and decreased thereafter. Validations of DIGIROP-Birth for 24 to 30 weeks’ GA showed high predictive ability for the model overall (AUC, 0.90 95% CI, 0.89-0.92 for internal validation, 0.94 95% CI, 0.90-0.98 for temporal validation, 0.87 95% CI, 0.84-0.89 for US external validation, and 0.90 95% CI, 0.85-0.95 for European external validation) by calendar periods and by race/ethnicity. The sensitivity, specificity, PPV, and NPV were numerically at least as high as those obtained from CHOP-ROP (Children’s Hospital of Philadelphia–ROP), OMA-ROP (Omaha-ROP), WINROP (weight, insulinlike growth factor 1, neonatal, ROP), and CO-ROP (Colorado-ROP), models requiring more complex postnatal data. CONCLUSIONS AND RELEVANCE: This study validated an individualized prediction model for infants born at 24 to 30 weeks’ GA, enabling early risk prediction of ROP treatment based on birth characteristics data. Postnatal age rather than postmenstrual age was a better predictive variable for the temporal risk of ROP treatment. The model is an accessible online application that appears to be generalizable and to have at least as good test statistics as other models requiring longitudinal neonatal data not always readily available to ophthalmologists.
It remains unclear whether readmissions of patients with heart failure (HF) have decreased over time in an era of improved therapy and management of HF. This study aimed to determine the temporal ...short- and long-term trends of cause-specific rehospitalization and their risk factors in a Swedish context.
HF patients in the Swedish Heart Failure Registry (SwedeHF) were investigated. Maximum follow-up time was 1 year. Outcomes included the first occurrence of all-cause, cardiovascular (CV) and HF rehospitalizations. Cox proportional hazards models were performed to determine the impact of increasing years on risk for rehospitalization and its known risk factors.
Totally, 25,644 index-hospitalized HF patients in SwedeHF from 2004 to 2011 were enrolled in the study. For 8 years, the incidence risk of 1-year all-cause rehospitalization remained unchanged, whereas the incidence risk of CV (P = 0.038) or HF (P = 0.0038) rehospitalization decreased. After adjustment for age and sex, a 3% decrease per every second year was observed for 1-year CV and HF rehospitalizations (P < 0.05). However, time to the first occurring all-cause, CV and HF rehospitalization did not change significantly from 2004 to 2011 (P-values 0.13–0.87). When two study periods (2004–2005 vs. 2010–2011) were compared, the risk factor profile for rehospitalization was found to change.
Throughout the 8-year study period, CV- and HF-related rehospitalizations decreased, whereas all-cause rehospitalization remained unchanged, indicating a parallel increase in non-CV rehospitalization in the HF patients.
•Both cardiovascular- and heart failure-related rehospitalizations of patients with heart failure were declined•All-cause rehospitalization remained unchanged, indicating increase of non-cardiovascular-related readmissions•Risk factors for rehospitalization were found to change during the study period•More efforts should be made in multidisciplinary heart failure management and targeting non-cardiovascular comorbidities
Background: Lower extremity amputations in people with diabetes is a major source of disability and distress and it constitutes a significant financial burden for the healthcare system. Risk factors ...and current risks for amputation in persons with type 1 diabetes have not been extensively studied.
Methods: Persons with type 1 diabetes registered in the Swedish National Diabetes Registry with no previous amputation from 1998 and followed until 2019 were included. Time-updated Cox regression and gradient of risk per SD were used to evaluate the impact of risk factors on the incidence of amputation. Age and sex adjusted incidences were estimated over time.
Findings: Of 46,008 persons with type 1 diabetes with no previous amputation and a mean age of 32.5 years (SD 14.5) and 25 354 (55%) male, 1,519 (3.3%) underwent amputation. Median follow-up was 12.4 years. The age and sex adjusted incidence for any amputation decreased over time. The standardized incidence was 1998-2001 2.84 (95% CI 2.32-3.36) per 1000 patient years and decreased to 1.64 (95% CI 1.38-1.90) in 2017-2019 along with improved glycaemic control (0.02% 95% CI 0.02-0.02 per year) and renal function (0.23 ml/min/1.73m² 95% CI 0.21-0.24 per year). Risk factors for amputations were hyperglycemia, renal dysfunction, older age, male gender, cardiovascular comorbidities, smoking and hypertension.
Interpretation: Prognosis has improved considerably regarding the risk of amputations in persons with type 1 diabetes while glycaemic control and renal function improved which were the most prominent risk factors.
Disclosure
S. Hallström: None. A. Svensson: None. A. Pivodic: None. A. F. Olafsdottir: None. M. Londahl: Advisory Panel; Self; Abbott, Speaker’s Bureau; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Lilly Diabetes, Novo Nordisk, Sanofi. H. Wedel: None. M. Lind: Consultant; Self; AstraZeneca, Eli Lilly and Company, Other Relationship; Self; Novo Nordisk, Research Support; Self; Dexcom, Inc.
Funding
Novo Nordisk Foundation; Swedish State
•A single infection with P. aeruginosa is associated with structural lung damage.•Respiratory infections are associated with structural lung damage progression rate.•More structural lung damage at ...the age of 7 years is a risk factor.•FEV1 provides poor insights of the ongoing progression rate of CF lung disease.
Computed tomography (CT) is used to monitor progression of structural lung disease (SLD) in children with cystic fibrosis (CF). Our goals were to identify the risk factors for the annual progression of SLD and the impacts of airway pathogens on SLD.
Seventy-five school-aged children diagnosed with CF underwent 200 CT scans at Gothenburg CF Centre in the period 2003–2015. SLD was evaluated with a quantitative scoring system. Mixed models were used to calculate the yearly progression rates of SLD and FEV1 and to analyse the effects of common airway pathogens in CF.
The yearly mean progression (95% CI) rates for total disease (%Dis), bronchiectasis (%Be), and FEV1 were 0.62 (0.38–0.86), 0.43 (0.28–0.58) and −0.16 (−0.18–0.13), respectively. Adjusting for airway pathogens, the yearly mean progression rates for %Dis, %Be and FEV1 were 0.23 (−0.04–0.51), 0.12 (0.00–0.25), and −0.12 (−0.16–0.08), respectively. A single infection with P aeruginosa was associated with significant increase in lung damage, assessed as %Dis (p = 0.044) and%Be (p = 0.0047), but not in FEV1 (p = 0.96). At age of 7 years, there was a good correlation between the extent of SLD and subsequent progression of %Dis (r = 0.63, p = 0.0042) and %Be (r = 0.74, p = 0.0057) while there was no significant correlation between the FEV1 and the rate of decline of FEV1 (r = −0.22, p = 0.12).
Intermittent respiratory infections with P aeruginosa were associated with significant SLD but no change in FEV1. More SLD at the age of 7 years signals a higher progression rate of SLD subsequently.
Preterm infants with anaemia are treated with recombinant human erythropoietin (rhEPO). It is debated whether rhEPO treatment is a risk factor for retinopathy of prematurity (ROP). We evaluated ...longitudinal EPO and haemoglobin levels, blood transfusions and neonatal morbidities as risk factors for severe ROP.
This prospective study included 78 Swedish infants, born <28 weeks gestational age (GA), screened for ROP. We tested serum EPO levels on postnatal days 1, 7, 14 and 28 and at postmenstrual ages 32, 36 and 40 weeks. Haemoglobin levels and blood transfusions were recorded during postnatal weeks 1-4. Anaemia was defined as haemoglobin ≤110 g/L.
During postnatal week 1, infants with severe ROP requiring treatment (28%) more frequently developed anaemia (42.9% versus 8.0%, P = 0.003) and had higher mean EPO levels (postnatal day 7: 14.2 versus 10.8 mIU/mL, P = 0.003) compared to infants with no or less severe ROP not requiring treatment. In multivariable analyses, GA and anaemia during week 1 remained significant risk factors, but elevated EPO level postnatal day 7 was no longer significant.
Among infants born <28 weeks GA, anaemia during week 1 was a significant risk factor for severe ROP requiring treatment but not elevated EPO levels.
This study identified variables associated with increased risk of atrial fibrillation in people with type 1 diabetes.
We performed a cohort study of people with type 1 diabetes from the Swedish ...National Diabetes Registry followed up between 1 January 2001 and 31 December 2013. Median follow-up was 9.7 years (interquartile range 5.2-13.0). The association between potential risk factors and incident atrial fibrillation was investigated using adjusted Cox regression. To compare the impact of each risk factor, the gradient of risk per 1 SD was estimated.
In this cohort of 36,258 patients with type 1 diabetes, 749 developed atrial fibrillation during follow-up. Older age, male sex, renal complications, increased BMI and HbA
, coronary artery disease, heart failure, and heart valve disease increased the risk of atrial fibrillation. Age, signs of renal dysfunction with macroalbuminuria, and decreasing estimated glomerular filtration rate were associated with the highest gradient of risk for atrial fibrillation. High blood pressure, severe obesity (BMI >35 kg/m
), and elevated levels of HbA
(>9.6%) were associated with increased risk, but no associations were found with hyperlipidemia or smoking.
The most prominent risk factors for atrial fibrillation in people with type 1 diabetes were older age, cardiovascular comorbidities, and renal complications, while obesity, hypertension, and hyperglycemia had more modest affects.
The objective of this study was to evaluate the association of statin use after coronary artery bypass grafting (CABG) and long-term adverse events in a large population-based, nationwide cohort.
All ...35,193 patients who underwent first-time isolated CABG in Sweden from 2006 to 2017 and survived at least 6 months after surgery were included. Individual patient data from the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) and 4 other nationwide registries were merged. Multivariable Cox regression models adjusted for age, sex, comorbidities, and time-updated treatment with other secondary preventive medications were used to evaluate the associations between statin treatment and outcomes. The primary end point was major adverse cardiovascular events (MACE). Median follow-up time to MACE was 5.3 (interquartile range, 2.5-8.2) years.
Statins were dispensed to 95.7% of the patients six months after discharge and to 78.9% after 10 years. At baseline, 1.4% of patients were prescribed low-, 57.6% intermediate-, and 36.7% high-dose statins. Ongoing statin treatment was associated with markedly reduced risk of MACE (adjusted hazard ratio aHR, 0.56 95% CI, 0.53-0.59), all-cause mortality (aHR, 0.53 95% CI, 0.50-0.56), cardiovascular death (aHR, 0.54 95% CI, 0.50-0.59), myocardial infarction (aHR, 0.61 95% CI, 0.55-0.69), stroke (aHR, 0.66 95% CI, 0.59-0.73), new revascularization (aHR, 0.79 95% CI, 0.70-0.88), new angiography (aHR, 0.81 95% CI, 0.74-0.88), and dementia (aHR, 0.74 95% CI, 0.65-0.85; all P < .01), irrespective of the statin dose.
Ongoing statin use was associated with a markedly reduced incidence of adverse events and mortality after CABG. Initiating and maintaining statin medication is essential in CABG patients.
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OBJECTIVE
Continuous glucose monitoring (CGM) reduces HbA1c and time spent in hypoglycemia in people with type 1 diabetes (T1D) treated with multiple daily insulin injections (MDI) when evaluated ...over shorter time periods. It is unclear to what extent CGM improves and helps to maintain glucose control, treatment satisfaction, diabetes distress, hypoglycemic concerns, and overall well-being over longer periods of time.
RESEARCH DESIGN AND METHODS
The GOLD trial was a randomized crossover trial performed over 16 months of CGM treatment in people with T1D treated with MDI. People completing the trial (n = 141) were invited to participate in the current SILVER extension study in which 107 patients continued CGM treatment over 1 year along with the support of a diabetes nurse every 3 months.
RESULTS
The primary end point of the change in HbA1c over 1.0–1.5 years of CGM use compared with previous self-monitoring of blood glucose during GOLD showed a decrease in HbA1c of 0.35% (95% CI 0.19–0.50, P < 0.001). Time spent in hypoglycemia <3.0 mmol/L (54 mg/dL) and <4.0 mmol/L (72 mg/dL) decreased from 2.1% to 0.6% (P < 0.001) and from 5.4% to 2.9% (P < 0.001), respectively. Overall well-being (World Health Organization 5-item well-being index, P = 0.009), treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire, P < 0.001), and hypoglycemic confidence (P < 0.001) increased, while hypoglycemic fear (Hypoglycemia Fear Survey–Worry, P = 0.016) decreased and diabetes distress tended to decrease (Problem Areas in Diabetes Scale, P = 0.06). From randomization and screening in GOLD, HbA1c was lowered by 0.45% (P < 0.001) and 0.68% (P < 0.001) after 2.3 and 2.5 years, respectively.
CONCLUSIONS
The SILVER study supports beneficial long-term effects from CGM on HbA1c, hypoglycemia, treatment satisfaction, well-being, and hypoglycemic confidence in people with T1D managed with MDI.
To investigate the incidence and mortality risk associated with postdischarge major bleeding after coronary artery bypass grafting (CABG), and relate this to the incidence of, and mortality risk ...from, postdischarge myocardial infarction.
All patients undergoing first-time isolated CABG in Sweden in 2006-2017 and surviving 14 days after hospital discharge were included in a cohort study. Individual patient data from the SWEDEHEART Registry and five other mandatory nationwide registries were merged. Piecewise Cox proportional hazards models were used to investigate associations between major bleeding, defined as hospitalisation for bleeding, with subsequent mortality risk. Similar Cox proportional hazards models were used to investigate the association between postdischarge myocardial infarction and mortality risk.
Among 36 633 patients, 2429 (6.6%) had a major bleeding event and 2231 (6.1%) had a myocardial infarction. Median follow-up was 6.0 (range 0-11) years. Major bleeding was associated with higher mortality risk <30 days (adjusted HR (aHR)=20.2 (95% CI 17.3 to 23.5)), 30-365 days (aHR=3.8 (95% CI 3.4 to 4.3)) and >365 days (aHR=1.8 (95% CI 1.7 to 2.0)) after the event. Myocardial infarction was associated with higher mortality risk <30 days (aHR=20.0 (95% CI 16.7 to 23.8)), 30-365 days (aHR=4.1 (95% CI 3.6 to 4.8)) and >365 days (aHR=1.8 (95% CI 1.7 to 2.0)) after the event.
The increase in mortality risk associated with a postdischarge major bleeding after CABG is substantial and is similar to the mortality risk associated with a postdischarge myocardial infarction.
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