Epidemiological studies on socioeconomic inequalities and cardiovascular disease : prevention, progression and prognosis

Cardiovascular disease (CVD) accounts for 30% of global mortality and is the most common cause of death in the world. Population-wide prevention strategies as well as healthcare interventions have led to a decrease in CVD incidence and mortality. Socioeconomic position (SEP) is associated with almost the entire developmental course of CVD, from modifiable risk factors and atherosclerosis to incidence, survival, and mortality. The purpose of this thesis was to investigate how absolute and relative SEP inequalities in myocardial infarction (MI) and ischemic stroke (IS) have developed over time in Sweden, and additionally, to investigate the association between SEP and subclinical biomarkers for atherosclerosis, as well as with prescription of CVD preventive drugs. In Study I and II, record linkage of Swedish population register data and time-to-event analysis was used to estimate absolute and relative SEP inequalities in both MI/IS incidence as well as short-term and long-term case-fatality. Swedish Censuses were used to classify SEP into five different groups. Incidence and case-fatality of MI and IS have decreased over time in Sweden across all SEP groups. However, in women the reduction in incidence of MI and IS have been lower than for men. Over time, SEP inequalities persist between the lowest and highest SEP groups in MI and IS incidence and in short-term as well as long-term case-fatality in MI. Regarding IS, SEP inequalities in short-term case-fatality have decreased over time, but seem to be stable in long-term case-fatality. In Study III, we investigated educational differences in several subclinical biomarkers for atherosclerosis in the cohort "Prospective Investigation of Vasculature in Uppsala Seniors" (PIVUS), which includes a range of vascular- and cardiac biomarkers. By using regression analysis, we found associations between longer education and two vascular biomarkers as well as five cardiac biomarkers. Additionally we were able to demonstrate that body mass index mediated the associations between educational level and subclinical biomarkers for atherosclerosis. Given the overall SEP differences in CVD, it is plausible that those in disadvantaged SEP groups are in greater need of preventive drugs for CVD. In Study IV, we investigated whether there are SEP differences in the prescription of CVD preventive drugs according to need. In particular, we wanted to investigate SEP differences in lipid lowering drugs statins and two antihypertensive drugs, ACE-inhibitors and angiotensin receptor blockers (ARBs). According to Swedish guidelines, ACE-inhibitors are the recommended antihypertensive drugs, while ARBs are given as second-line treatment and have fewer side effects. We used a record linkage of Swedish population register data with the Swedish Drug Prescription Register. Statins, ACEinhibitors and ARBs were prescribed largely to socioeconomically disadvantaged groups, this did still not meet their needs. When accounting for need, we were able to report that socioeconomically advantaged groups were prescribed statins and ARBs to larger extend than disadvantaged groups, while almost equally prescription distributions were noted among SEP groups for ACE-inhibitors. In this thesis, we conclude that SEP differences in CVD incidence and case-fatality persist over time in Sweden. SEP is associated with subclinical biomarkers of atherosclerosis as well as CVD preventive drugs. The small inequalities in ACE-inhibitors drugs prescription across SEP may have contributed to the decreased SEP difference in IS short-term case-fatality, which suggest that SEP inequalities may be reduced by targeted guidelines

Associations between birth characteristics and eating disorders across the life course: findings from 2 million males and females born in Sweden, 1975-1998.

Birth characteristics predict a range of major physical and mental disorders, but findings regarding eating disorders are inconsistent and inconclusive. This total-population Swedish cohort study identified 2,015,862 individuals born in 1975-1998 and followed them for anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified until the end of 2010. We examined associations with multiple family and birth characteristics and conducted within-family analyses to test for maternal-level confounding. In total, 1,019 males and 15,395 females received an eating disorder diagnosis. Anorexia nervosa was independently predicted by multiple birth (adjusted hazard ratio = 1.33, 95% confidence interval: 1.15, 1.53) for twins or triplets vs. singletons) and lower gestational age (adjusted hazard ratio = 0.96, 95% confidence interval: 0.95, 0.98) per extra week of gestation, with a clear dose-response pattern. Within-family analyses provided no evidence of residual maternal-level confounding. Higher birth weight for gestational age showed a strong, positive dose-response association with bulimia nervosa (adjusted hazard ratio = 1.15, 95% confidence interval: 1.09, 1.22, per each standard-deviation increase), again with no evidence of residual maternal-level confounding. We conclude that some perinatal characteristics may play causal, disease-specific roles in the development of eating disorders, including via perinatal variation within the normal range. Further research into the underlying mechanisms is warranted. Finally, several large population-based studies of anorexia nervosa have been conducted in twins; it is possible that these studies considerably overestimate prevalence

Маркетинг инноваций как инструмент активизации трансфера знаний

Модель «Тройная спираль» (Triple Helix Model (THM)), основанная на исследовании сложного взаимодействия университетов, бизнеса и власти, является современной моделью развития инновационных систем. В модели ТНМ ведущее значение отводится университетам, которые превращаются в предпринимательские университеты и через собственные каналы для трансфера знаний применяют знания на практике и вкладывают результаты в новые образовательные дисциплины. Университеты все чаще становятся залогом успешного экономического развития региона

Short-term and long-term case-fatality rates for myocardial infarction and ischaemic stroke by socioeconomic position and sex : a population-based cohort study in Sweden, 1990-1994 and 2005-2009

OBJECTIVE: Case-fatality rates (CFRs) for myocardial infarction (MI) and ischaemic stroke (IS) have decreased over time due to better prevention, medication and hospital care. It is unclear whether these improvements have been equally distributed according to socioeconomic position (SEP) and sex. The aim of this study is to analyse differences in short-term and long-term CFR for MI and IS by SEP and sex between the periods 1990-1994 to 2005-2009 for the entire Swedish population. DESIGN: Population-based cohort study based on Swedish national registers. METHODS: We used logistic regression and flexible parametric models to estimate short-term CFR (death before reaching the hospital or on the disease event day) and long-term CFR (1 year case-fatality conditional on surviving short-term) across five distinct SEP groups, as well as CFR differences (CFRDs) between SEP groups for both MI and IS from 1990-1994 to 2005-2009. RESULTS: Overall short-term CFR for both MI and IS decreased between study periods. For MI, differences in short-term and long-term CFR between the least and most favourable SEP group were generally stable, except in long-term CFR among women; intermediate SEP groups mostly managed to catch up with the most favourable SEP group. For IS, short-term CFRD generally decreased compared with the most favourable group; but long-term CFRD were mostly stable, except for an increase for older subjects. CONCLUSION: Despite a general decline in CFR for MI and IS across all SEP groups and both sexes as well as some reductions in CFRD, we found persistent and even increasing CFRD among the least advantaged SEP groups, older patients and women. We speculate that targeted prevention rather than treatment strategies have the potential to reduce these inequalities

Social Class, Social Mobility and Risk of Psychiatric Disorder - A Population-Based Longitudinal Study

<div><p>Objectives</p><p>This study explored how adult social class and social mobility between parental and own adult social class is related to psychiatric disorder.</p> <p>Material and Methods</p><p>In this prospective cohort study, over 1 million employed Swedes born in 1949-1959 were included. Information on parental class (1960) and own mid-life social class (1980 and 1990) was retrieved from the censuses and categorised as High Non-manual, Low Non-manual, High Manual, Low Manual and Self-employed. After identifying adult class, individuals were followed for psychiatric disorder by first admission of schizophrenia, alcoholism and drug dependency, affective psychosis and neurosis or personality disorder (N=24 659) from the Swedish Patient Register. We used Poisson regression analysis to estimate first admission rates of psychiatric disorder per 100 000 person-years and relative risks (RR) by adult social class (treated as a time-varying covariate). The RRs of psychiatric disorder among the Non-manual and Manual classes were also estimated by magnitude of social mobility.</p> <p>Results</p><p>The rate of psychiatric disorder was significantly higher among individuals belonging to the Low manual class as compared with the High Non-manual class. Compared to High Non-manual class, the risk for psychiatric disorder ranged from 2.07 (Low Manual class) to 1.38 (Low Non-manual class). Parental class had a minor impact on these estimates. Among the Non-manual and Manual classes, downward mobility was associated with increased risk and upward mobility with decreased risk of psychiatric disorder. In addition, downward mobility was inversely associated with the magnitude of social mobility, independent of parental class.</p> <p>Conclusions</p><p>Independently of parental social class, the risk of psychiatric disorder increases with increased downward social mobility and decreases with increased upward mobility.</p> </div

Relative risk (x-axis) of psychiatric disorder and two-sided 95% confidence intervals comparing different trajectories of social mobility (y-axis -3 to +3) versus subjects socially stable (stable between parent class to adult class; reference group).

<div><p>For each trajectory (-3, -2 ,..., +3) different relative risks presented for different parental class.</p> <p>Footnote: Trajectories start from high non-manual (HN-M) parental class, low non-manual (LN-M) parental class, high manual (HM) parental class, low manual (LM) parental class by upward (y-axis +1, +2 or +3) and downward mobility ( y-axis -3, -2, -1) with their corresponding RRs and 95% CIs. Subjects=798 660; psychiatric patients:19 533.</p></div

Rate of psychiatric disorder (cases per 100 000 subjects) versus age at diagnosis.

<div><p>Rate developments by adult social class at cohort entry. </p> <p>Footnote: Subjects=1 016 276; psychiatric patients: 24 659. Swedish born in 1949–1959.</p></div

Overview of the time-points at which information for the studied subjects and their parents has been retrieved.

<p>Overview of the time-points at which information for the studied subjects and their parents has been retrieved.</p

Incidence rates of myocardial infarction by socioeconomic position for Swedish men and women in three age groups.

<p>All models were adjusted for birth country and stratified by sex and attained age. Note 1 <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0105279#pone-0105279-g001" target="_blank">Figure 1:</a> The shadowed area indicates a time period for which results cannot be interpreted.</p

Incidence rates of ischemic stroke by socioeconomic position for Swedish men and women in three age groups.

<p>All models were adjusted for birth country and stratified by sex and attained age. Note 1 <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0105279#pone-0105279-g002" target="_blank">Figure 2:</a> The shadowed area indicates a time period for which results cannot be interpreted. Note 2 <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0105279#pone-0105279-g002" target="_blank">Figure 2:</a> The incidence rate of ischemic stroke is increasing until 1997 due to changing in ICD codes 9 and 10, the result until 1997 is uncertain.</p