Long-Term Follow-Up of Newborns with 22q11 Deletion Syndrome and Low TRECs

Background

Population-based neonatal screening using T-cell receptor excision circles (TRECs) identifies infants with profound T lymphopenia, as seen in cases of severe combined immunodeficiency, and in a subgroup of infants with 22q11 deletion syndrome (22q11DS).

Purpose

To investigate the long-term prognostic value of low levels of TRECs in newborns with 22q11DS.

Methods

Subjects with 22q11DS and low TRECs at birth (22q11Low, N=10), matched subjects with 22q11DS and normal TRECs (22q11Normal, N=10), and matched healthy controls (HC, N=10) were identified. At follow-up (median age 16 years), clinical and immunological characterizations, covering lymphocyte subsets, immunoglobulins, TRECs, T-cell receptor repertoires, and relative telomere length (RTL) measurements were performed.

Results

At follow-up, the 22q11Low group had lower numbers of naïve T-helper cells, naïve T-regulatory cells, naïve cytotoxic T cells, and persistently lower TRECs compared to healthy controls. Receptor repertoires showed skewed V-gene usage for naïve T-helper cells, whereas for naïve cytotoxic T cells, shorter RTL and a trend towards higher clonality were found. Multivariate discriminant analysis revealed a clear distinction between the three groups and a skewing towards Th17 differentiation of T-helper cells, particularly in the 22q11Low individuals. Perturbations of B-cell subsets were found in both the 22q11Low and 22q11Normal group compared to the HC group, with larger proportions of naïve B cells and lower levels of memory B cells, including switched memory B cells.

Conclusions

This long-term follow-up study shows that 22q11Low individuals have persistent immunologic aberrations and increased risk for immune dysregulation, indicating the necessity of lifelong monitoring.

Clinical Implications

This study elucidates the natural history of childhood immune function in newborns with 22q11DS and low TRECs, which may facilitate the development of programs for long-term monitoring and therapeutic choices.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10875-021-01201-5.

Thymic exosomes promote the final maturation of thymocytes

Extensive knowledge has been gained the last years concerning mechanisms underlying the selection of single positive thymocytes in the thymic medulla. Less is known regarding other important processes in the thymic medulla such as the regulation of late stage thymocyte maturation. We have previously reported that exosomes are abundant in the thymus with a phenotype that indicates an epithelial cell origin and immunoregulatory properties. In this study we use an in vitro system to investigate the effects of thymic exosomes on the maturation of single positive thymocytes as well as effects on nTreg formation. We show that thymic exosomes promote the maturation of single positive CD4⁺CD25^- cells into mature thymocytes with S1P₁⁺Qa2⁺ and CCR7⁺Qa2⁺ phenotypes. Furthermore, we show that thymic exosomes reduce the formation of CD4⁺CD25⁺FoxP3⁺ thymocytes and that these exosome effects are independent of dendritic cell co-stimulation but require intact exosomal RNA content and surface proteins. An efficient direct uptake of exosomes by both thymocytes and thymic DC's is also demonstrated. In conclusion, this study demonstrates that exosomes may represent a new route of communication within the thymus.

Use of a basophil activation test as a complementary diagnostic tool in the diagnosis of severe peanut allergy in adults

Background

Diagnosis of severe peanut allergy is difficult and delays in making an accurate diagnosis may place the patient at risk. Adults with a history of anaphylaxis must strictly avoid any contact with peanuts or products that may contain traces of peanuts. For these persons, conventional evaluations with skin prick testing (SPT) and IgE tests may not be sufficient to assess the risk of anaphylaxis. Therefore, we investigated whether the basophil activation test (BAT) could be used for the diagnosis of severe peanut allergy in adults. We compared the non-invasive BAT with conventional laboratory diagnostic tests, including SPT and specific IgE to allergen extracts and components, for the diagnosis of severe peanut allergy.

Methods

Forty-seven persons with severe allergy to peanuts and a clinical diagnosis of anaphylaxis (PA-group), 22 subjects with peanut sensitization (PS-group) and 22 control (C-group) subjects, all in the age range of 18–60 years, were recruited retrospectively and prospectively into the study. Thirty-four patients with peanut allergy and 11 peanut-sensitized patients were sensitized to soy, while 36 patients in the PA-group and 20 patients in the PS-group were sensitized to birch pollen. All the patients and control subjects were investigated with BAT and SPT for responses to peanut, soy and birch extracts and their serum samples were assayed for the presence of specific IgE to peanut, soy and birch extracts, as well as IgE to allergen components (ISAC).

Results

In a multivariate factor analysis, severe peanut allergy (PA) was positively associated with SPT to peanut, IgE to peanut, BAT to peanut and IgE to rAra h 1, 2, 3 and 6 peanut components, as well as to soy components (nGly m 5 and nGly m 6). In contrast, peanut sensitization was positively associated with increased levels of IgE to rAra h 8, birch and birch-related components. BAT-detected reactivity to peanut was significantly higher in patients who had a history of severe allergy to peanuts, as compared with patients who were sensitized to peanuts (p < 0.001), and the receiver operating curve (ROC) analysis showed that BAT had high sensitivity and specificity for predicting severe peanut allergy, with a ROC area under the curve of 0.862. However, in the PA-group, the BAT results for peanut correlated only weakly with the levels of IgE to rAra h 1, 2 and 3 and nAra h 6. Study limitations: oral provocation in the patients with a history of severe peanut allergy could not be performed to compare clinical reactivity with the BAT result due to ethical constraints. Neither was it possible to perform BAT with peanut recombinant allergens which were not available at the time the study commenced

Conclusions

BAT is useful in determining the severity of peanut allergy and may be used as a complementary diagnostic tool to ensure accurate diagnosis of severe peanut allergy in adults. Thus, it may reduce the need to subject these patients to further tests, including an open challenge with peanuts.

Electronic supplementary material

The online version of this article (doi:10.1186/s13601-015-0064-9) contains supplementary material, which is available to authorized users.

Altered expression of autoimmune regulator in infant down syndrome thymus, a possible contributor to an autoimmune phenotype

Down syndrome (DS), caused by trisomy of chromosome 21, is associated with immunological dysfunctions such as increased frequency of infections and autoimmune diseases. Patients with DS share clinical features, such as autoimmune manifestations and specific autoantibodies, with patients affected by autoimmune polyendocrine syndrome type 1. Autoimmune polyendocrine syndrome type 1 is caused by mutations in the autoimmune regulator (AIRE) gene, located on chromosome 21, which regulates the expression of tissue-restricted Ags (TRAs) in thymic epithelial cells. We investigated the expression of AIRE and TRAs in DS and control thymic tissue using quantitative PCR. AIRE mRNA levels were elevated in thymic tissue from DS patients, and trends toward increased expression of the AIRE-controlled genes INSULIN and CHRNA1 were found. Immunohistochemical stainings showed altered cell composition and architecture of the thymic medulla in DS individuals with increased frequencies of AIRE-positive medullary epithelial cells and CD11c-positive dendritic cells as well as enlarged Hassall's corpuscles. In addition, we evaluated the proteomic profile of thymic exosomes in DS individuals and controls. DS exosomes carried a broader protein pool and also a larger pool of unique TRAs compared with control exosomes. In conclusion, the increased AIRE gene dose in DS could contribute to an autoimmune phenotype through multiple AIRE-mediated effects on homeostasis and function of thymic epithelial cells that affect thymic selection processes.

Intestinal allergic inflammation in birch pollen allergic patients in relation to pollen season, IgE sensitization profile and gastrointestinal symptoms

BACKGROUND

Birch pollen allergic patients frequently experience gastrointestinal upset accompanied by a local allergic inflammation in the small intestine especially during the pollen season. However, it is not known if the GI pathology is connected to the subjective symptoms of the patient. The objective of this study was to evaluate the immune pathology of the duodenal mucosa and the serum IgE antibody profiles in birch pollen allergic patients in relation to their gastrointestinal symptoms, during and outside the birch pollen season.

METHODS

Thirty-two patients with birch pollen allergy and sixteen healthy controls were enrolled in the study. Twenty allergic patients had gastrointestinal symptoms and twelve did not. All participants underwent an allergy investigation and gastroscopy with duodenal biopsy. The duodenal biopsies were retrieved during the pollen season (May-June) and off-season (November-March). The biopsies were immunostained for mast cells (IgE and tryptase), eosinophils, T cells (CD3), and dendritic cells (CD11c). Pollen-specific IgE antibodies were determined by ImmunoCAP and component microarray (ISAC).

RESULTS

Patients in both pollen allergic groups showed similar degree of intestinal allergic inflammation during the pollen season regardless of gastrointestinal symptoms. The eosinophils, mast cells and dendritic cells were increased in the mucosa. Patients with gastrointestinal symptoms had significantly elevated IgE antibodies to birch (rBet v 1), hazelnut (rCor a 1), and apple (rMal d1) during the pollen season.

CONCLUSIONS

Patients allergic to birch pollen have clear signs of an ongoing allergic inflammation in their intestinal mucosa, which is aggravated during the pollen season. The magnitude of the allergic intestinal inflammation is not associated with subjective gastrointestinal symptoms of the individual patient.

Favourable trends in the incidence and outcome of myocardial infarction in nondiabetic, but not in diabetic, subjects: findings from the MONICA myocardial infarction registry in northern Sweden in 1989-2000

BACKGROUND

The aim of this study was to compare time trends in incidence, case fatality and mortality due to myocardial infarction (MI) in patients with or without diabetes.

METHODS

This study was based on the Northern Sweden MONICA Project MI registry with a target population of about 200,000 inhabitants in the age group 35--64 years in the two northernmost counties of Sweden. During 1989--2000, 6254 patients who had had an MI according to MONICA criteria were included in this study: 4569 patients had a first MI and 1685 had a recurrent MI. Sixteen per cent of the men and 20% of the women had had diabetes mellitus diagnosed prior the MI.

RESULTS

Over the 12-year period, there was a declining trend in incidence and case fatality in first MI. Also, the event rates (first ever and recurrent MI) declined in men without diabetes. In women without diabetes favourable time trends were seen in first ever MI, recurrent MI and in case fatality. There were no favourable time trends for any of these outcomes in patients with diabetes.

CONCLUSION

In nondiabetic subjects below the age of 65, the incidence of, and case-fatality in, MI declined. This led to a decreased mortality over the 12-year period. These favourable trends over time were not observed in diabetic subjects.

The Arctic Oscillation and incidence of acute myocardial infarction

OBJECTIVES

To describe the relation between the Arctic Oscillation (AO) index and the incidence and mortality in acute myocardial infarction (AMI) in the northern, partly subarctic area of Sweden.

DESIGN

Comparison of a time series of daily variations in the AO index and register data on the daily number of fatal and nonfatal AMIs.

SETTING

The northernmost two Swedish counties, Norrbotten and Västerbotten.

SUBJECTS

All inhabitants in the Norrbotten and Västerbotten counties were followed for the occurrence of an AMI between 1985 and 1999 within the framework of the WHO MONICA (multinational MONItoring of trends and determinants of CArdiovascular disease) Project.

MAIN OUTCOME MEASURE

Fatal and nonfatal AMIs.

RESULTS

There was a consistent positive relation between increasing AO index and an increase in AMI incidence and mortality. The maximum impact on AMI incidence of the AO came after a lag phase of 3 days. A one unit increase in AO index was associated with an increase in: the daily number of AMIs (+3.8%), the case fatality in AMI within 28 days (+5.1%), the number of nonfatal AMIs (+3.4%), and the number of sudden cardiac deaths (+8.3%).

CONCLUSIONS

An AO index increase, bringing warmer weather over Scandinavia, was associated with an increase in the incidence and mortality in AMI in northern Sweden.

Trends in sudden cardiac death in the northern Sweden MONICA area 1985-99

OBJECTIVES

To describe time trends in sudden cardiac death (SCD) occurrences between 1985 and 1999.

DESIGN

Cohort study with analysis of a database of all symptomatic and/or fatal acute myocardial infarctions (AMI) in the two northernmost counties in Sweden, partly north of the Arctic Circle.

SUBJECTS

A total of 1139 cases of SCD amongst men and women aged 35-64 years.

MAIN OUTCOME MEASURE

Sudden cardiac death.

RESULTS

Amongst men the proportion of SCD to all AMI deaths (within 28 days of an AMI) was 38% and for women 31%. The mean yearly incidence of SCD in this age group was 65 per 100,000 men and 12 per 100,000 women. Amongst men the mean yearly incidence decreased by 1.8% (95% confidence interval -3.2 to -0.3) and amongst women the decrease was 1.0% (95% confidence interval -4.4 to 2.4). Diabetes mellitus was more common in women compared with men (24% vs. 14%, P = 0.001). Men suffered an SCD more often around noon and on Saturdays, whereas women suffered their SCD on Mondays and Fridays. For season, men and women behaved similarly with a winter peak, although statistical significance was reached only for men.

CONCLUSIONS

The SCD decreased amongst men between 1985 and 1999. There was also a decrease amongst women during the same time period but not to a statistically significant degree, possibly caused by lack of statistical power due to small numbers.

No increase in the prevalence of known diabetes between 1986 and 1999 in subjects 25-64 years of age in northern Sweden

AIMS

A global increase in diabetes is predicted due to higher body weight and less physical activity. Over the period 1986-1999, the body mass index (BMI) of the adult population of northern Sweden increased from 25.3 to 26.2 and the prevalence of obesity (BMI > or = 30) from 11% to 15%, although this was more distal than central adiposity. Our hypothesis was that this would lead to a higher prevalence of diabetes.

METHODS

Four population surveys with new and independent cohorts of 2000 invited subjects, 25-64 years old, in 1986, 1990, 1994 and 1999. In the first three surveys an oral glucose tolerance test was carried out in 47%.

RESULTS

Over the time period 1986-1999 there was no increase in the prevalence of known diabetes. No trends were noted in the finding of previously undiagnosed diabetes or impaired glucose tolerance over the period 1986-1994, although the confidence intervals are wide. Fasting, but not post-load, glucose levels increased with 0.040 mmol/year (95% CI 0.026; 0.055) in men and 0.033 mmol/year (0.023; 0.044) in women.

CONCLUSION

In spite of a marked increase in BMI, we found no increased prevalence of known diabetes over a 13-year observation period, although our data cannot exclude minor increases in undiagnosed diabetes. The development of more distal than abdominal obesity, a diet with less saturated fat and lower glycaemic index and fewer regular smokers in the population may contribute to this. The effects of obesity may thus be attenuated by other secular trends in society and highlight potential ways of curbing the worldwide increase in diabetes.

No covariation between the geomagnetic activity and the incidence of acute myocardial infarction in the polar area of northern Sweden

This study was undertaken to investigate whether there was any relation between the aurora borealis (measured as the geomagnetic activity) and the number of acute myocardial infarctions (AMI) in the northern, partly polar, area of Sweden. The AMI cases were collected from The Northern Sweden MONICA (multinational MONItoring of trends and determinants of CArdiovascular disease) AMI registry between 1985 and 1998, inclusive, and the information on the geomagnetic activity from continuous measurements at the Swedish Institute of Space Physics, Kiruna. In the analyses, both the relation between the individual AMI case and ambient geomagnetic activity, and the relation between the mean daily K index and the daily number of AMI cases were tested. We found no statistically significant relation between the number of fatal or non-fatal AMI cases, the number of sudden deaths or the number of patients with chest pain without myocardial damage, and geomagnetic activity. Our data do not support a relation between the geomagnetic activity and AMI.

Exploring sex differences in case fatality in acute myocardial infarction or coronary death events in the northern Sweden MONICA Project

OBJECTIVES

To investigate sex differences in reaching diagnosis, medical management and case fatality (CF) in acute myocardial infarction (AMI) in the population aged 35-64 years in northern Sweden.

METHODS

Within the framework of the World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) Project, definite AMI was monitored in people aged 35-64 years from 1989 through 1995 (target population 510 000 in 1991).

SETTING

In a population based coronary register, all coronary events were recorded in nine hospitals in 1989-95.

RESULTS

The number of events included in the definite coronary myocardial infarction register was 2483 men and 669 women. On admission, a higher proportion of men with definite AMI had chest pain or ECG changes typical for AMI (P < 0.0001). Disagreement between clinical diagnosis and classification by MONICA criteria occurred more often in women (P=0.008). A significantly higher proportion of men was admitted in the coronary care unit and they were significantly more often treated with thrombolytics, nitroglycerine, beta-blockers, or antiplatelet agents. Women received significantly more diuretics, inotropics or calcium antagonists. Diabetes, conferring a worse prognosis, was more common in women (20 vs. 15%; P=0.003). Prehospital CF was significantly higher in men (24.1 vs. 18.3%; P=0.005), but in patients treated in hospital, the CF was significantly lower in men (12.7 vs. 21.2%; P < 0.001). Total CF was equal in men and women.

CONCLUSIONS

Several factors contributing to the excess in-hospital CF in women were identified, including greater problems in diagnosis of AMI in women which may be one of the reasons for less intensive treatment in women. Differences in co-morbidity, most notably diabetes and medical treatment between men and women with acute AMI may also have played a part.

Marked improvement in survival after acute myocardial infarction in middle-aged men but not in women. The Northern Sweden MONICA study 1985-94

OBJECTIVES

The aim of this study was to analyse time trends in survival after acute myocardial infarction with special emphasis on sex differences.

DESIGN

Within the framework of the population-based WHO MONICA Project, all acute myocardial infarction events were recorded in the age group 25-64 years in northern Sweden during the period 1985-94. All first-ever myocardial infarction patients were followed for information on vital status.

SUBJECTS

A total of 3397 men and 860 women with acute myocardial infarction, during the period between 1985 and 1994.

MAIN OUTCOME MEASURES

Case fatality rates after first-ever acute myocardial infarction.

RESULTS

When compared with the 1985-86 cohort, the age-adjusted odds ratio for death within 1 year after acute myocardial infarction was 0.59 (95% CI 0.46-0.76) in the 1993-94 male cohort but 0.99 (95% CI 0.61-1.60) in the female 1993-94 cohort. Corresponding age-adjusted proportions of death within 1 year were 33.3% and 22.9% in men and 27.5% and 27.3% in women in 1985-86 and 1993-94, respectively. The odds ratio for 3-year case fatality amongst those who survived the first 28 days was 0.34 (95% CI 0.21-0.55) in 1991-92 compared with 1985-86 in men and 0.91 (0.43-1.94) in women.

CONCLUSION

Both short- and long-term survival after AMI have improved markedly in men over the last decade. There is a disturbing sex difference in that, during the same period, survival in women with AMI has not improved at all. This sex difference was not explained by differences in conventional prognostic factors.

Social patterning of myocardial infarction and stroke in Sweden: incidence and survival

Cardiovascular disease morbidity and mortality rates show marked social patterning in industrialized countries. The aim of this study was to analyze if not only incidence but also survival after acute myocardial infarction (AMI) and stroke differ among socioeconomic groups. Within the framework of the population-based World Health Organization's Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Project, all first-ever AMI (ages 25-64 years) and stroke (ages 25-74 years) events were recorded in northern Sweden during the period 1985-1994. The numbers of first-ever AMI and stroke patients included in the study were 3,466 and 4,215, respectively. Incidence rates for both AMI and stroke showed a distinct social pattern, with high rates in workers and self-employed nonprofessionals and low rates in professionals. The pattern was similar in men and women. In men, early survival after an AMI follows the same socioeconomic pattern, whereas it is less clear if socioeconomic differences in survival contribute to explain differences in mortality in AMI among women and mortality in stroke (both sexes). The high case fatality among male workers and self-employed professionals with AMI is, in turn, attributed to a very marked increase in the risk for sudden death.

Smokeless tobacco as a possible risk factor for myocardial infarction: a population-based study in middle-aged men

OBJECTIVES

To explore whether the use of snuff affects the risk of myocardial infarction (MI).

BACKGROUND

Snuff and other forms of smokeless tobacco are widely used in some populations. Possible health hazards associated with the use of smokeless tobacco remain controversial.

METHODS

In a population-based study within the framework of the Northern Sweden center of the World Health Organization Multinational Monitoring of Trend and Determinants in Cardiovascular Disease (WHO MONICA) Project, tobacco habits were compared in 25- to 64-year-old men with first-time fatal or nonfatal MI and referent subjects matched for age and place of living (687 cases, 687 referents).

RESULTS

The unadjusted odds ratio (OR) for MI in regular cigarette smokers as compared with men who never used tobacco was 3.65 (95% confidence interval [CI] 2.67 to 4.99). When nonsmoking regular snuff dippers were compared with never-users of tobacco, the unadjusted OR was 0.96 (0.65 to 1.41). After adjustment for multiple cardiovascular risk factors, the OR was 3.53 (95% CI 2.48 to 5.03) for regular smoking and 0.58 (95% CI 0.35 to 0.94) for regular snuff dipping. Restricting the analyses to fatal cases of myocardial (including sudden death) showed a tendency towards increased risk among snuff dippers 1.50 (95% CI 0.45 to 5.03).

CONCLUSIONS

The risk of MI is not increased in snuff dippers. Nicotine is probably not an important contributor to ischemic heart disease in smokers. A possible small or modest detrimental effect of snuff dipping on the risk for sudden death could not be excluded in this study due to a limited number of fatal cases.

Secular trends in social patterning of cardiovascular risk factor levels in Sweden. The Northern Sweden MONICA Study 1986-1994. Multinational Monitoring of Trends and Determinants in Cardiovascular Disease

OBJECTIVES

In the Northern Sweden MONICA Study, levels of cardiovascular risk factors were determined in 1986, 1990 and 1994. The aim of this study was to assess the trends in cardiovascular risk factors, and to analyse the relationship between levels of risk factors and level of education.

DESIGN

Cardiovascular risk factors were determined in cross-sectional population studies of randomly selected 25-64 year old men and women in 1986, 1990 and 1994 (a total of 4742 individuals).

RESULTS

Throughout the years 1986 to 1994, cardiovascular risk factor levels showed a marked social pattern, generally being more favourable among people with a university education. Serum cholesterol levels declined in all educational groups, but blood pressure declined significantly only in women with a university education. Body mass index increased, most markedly in men with university and in women with a secondary school education. Prevalence of cigarette smoking decreased significantly in young men. It increased markedly in low-educated women so that the social gaps in smoking widened substantially over time. The improved level of education in the population at large was calculated to explain only a little of the risk factor changes between 1986 and 1994.

CONCLUSIONS

Trends in risk factor levels in different educational groups have been more diverging for women than for men. The most marked change in risk factor levels has been the decline in total serum cholesterol for both men and women in all educational groups.

Diabetes as a risk factor for myocardial infarction: population and gender perspectives

OBJECTIVES

To investigate diabetes as a risk factor for acute myocardial infarction (AMI) from a population perspective in a region with high cardiovascular disease (CVD) risk.

DESIGN

Population screenings for diabetes and a population-based AMI register.

SETTING

Northern Sweden MONICA area.

SUBJECTS

Representative sample (Norrbotten and Västerbotten counties) of 2432 men and women 35-64 years was investigated 1990 and 1994. All patients with AMI aged 35-64 years were included, in total 3031 between 1989 and 1993.

RESULTS

The prevalence of diabetes was 5% in men and 4.4% in women. The relative risk (RR) in diabetic men was 2.9; 95% confidence interval (CI) 2.6-3.4, and in diabetic women, RR 5.0; CI 3.9-6.3. The risk for re-infarction was about twice as large in patients with diabetes as in patients without diabetes. In both sexes the overall 28 day case fatality (CF) was significantly higher in diabetic compared to non-diabetic subjects. When compared to the non-diabetic population, the overall mortality from AMI in the diabetic population was 4 times higher among men and 7 times higher among women. The population attributable risk (PAR), a crude estimate of all AMIs ascribed to diabetes, was 11% in men and 17% in women.

CONCLUSIONS

Diabetes increases the risk for AMI attack rate, incidence, case-fatality, recurrence and mortality and is an important contributor to all AMIs in middle-aged people.

Fatalities from myocardial infarction in Nordic countries and Lithuania. The MONICA Investigators

AIM

To investigate fatalities from myocardial infarction at 28 days and one-year among patients aged 35-64 years in the Nordic and Lithuanian centres participating in the World Health Organization MONICA (Monitoring of Trends and Determinants of Cardiovascular Disease) Project.

METHODS AND RESULTS

Altogether 9100 myocardial infarction events registered according to the protocol of the MONICA Project were included in the study. For these events, one-year follow-up was carried out using routine mortality statistics. Fatalities were expressed as age-standardized means per year for a 3-year period from the mid-1980s. The myocardial infarction fatalities at 28 days (including out-of-hospital deaths) in the eight participating populations varied among men, between 36.5% (95% confidence interval 32.6-40.4%) in Iceland and 54.6% (51.2-57.9%) in Kaunas, Lithuania, Among women, it varied from 32.4% (26.4-38.4%) in Iceland to 57.5% (51.8-63.2%) in Glostrup, Denmark. More than half of this mortality occurred suddenly and the patient did not reach hospital alive. Fatalities for the period from day 28 to one year varied among men, from 5.3% (2.9-7.6%) in Iceland to 10.9% (8.0-13.8%) in North Karelia, Finland, and among women from 3.5% (0.4-6.5%) in Kuopio, Finland, to 13.5% (7.2-19.7%) in Glostrup, Denmark.

CONCLUSIONS

Approximately half of the myocardial infarction patients died within one year after the onset of the attack and half of those who died, died out-of-hospital. While the myocardial infarction fatalities differed considerably between the participating populations, differences of this magnitude are unlikely to be totally explained by differences in the registration procedures. Further comparisons of acute coronary care and secondary prevention measures are warranted.

Dental status, diet and cardiovascular risk factors in middle-aged people in northern Sweden

The aim of the present study was to compare the dietary intake and the levels of traditional cardiovascular (CVD) risk factors in edentulous middle-aged individuals and individuals of the same age and sex who still had natural teeth. The study was performed within the framework of the MONICA-project. Population registers were used to sample randomly 1287 men and 1330 women aged 25-64 yr. Data were collected from a mailed questionnaire, blood analyses, registrations of blood pressure and anthropometric measures. The estimated daily energy intake did not differ between the two groups, but edentulous men and women ate more sweet snacks compared to those who still had teeth. Edentulous men also ate less fruits, vegetables and fibre and edentulous women ate more fat than dentates. Edentulous men and women were more obese and had lower serum HDL-cholesterol concentrations than those with remaining teeth. Edentulous women also had significantly higher concentrations of total cholesterol and triglycerides in serum than dentate women. Edentulous men and women were more often regular smokers, but not snuff users, than dentates of the same age and sex. Thus, the presence of two or more cardiovascular risk factors was more common in edentulous individuals than in those who still had natural teeth. In summary, these results support the hypothesis that edentulous middle-aged individuals have a more unfavourable risk factor profile for CVD. Counselling on balanced dietary habits and non-smoking given by dental personnel to orally diseased patients--recommendations given to improve resistance to dental caries or periodontitis--might therefore improve general health and possibly also improve risk factors for CVD.

Tobacco and myocardial infarction: is snuff less dangerous than cigarettes?

OBJECTIVE

To estimate the risk of myocardial infarction in snuff users, cigarette smokers, and non-tobacco users in northern Sweden, where using snuff is traditional.

DESIGN

Case-control study.

SETTING

Northern Sweden.

SUBJECTS

All 35-64 year old men who had had a first myocardial infarction and a population based sample of 35-64 year old men who had not had an infarction in the same geographical area.

MAIN OUTCOME MEASURE

Tobacco consumption (regular snuff dipping, regular cigarette smoking, non-tobacco use) and risk of acute myocardial infarction.

RESULTS

59 of 585 (10%) patients who had a first myocardial infarction and 87 of 589 (15%) randomly selected men without myocardial infarction were non-smokers who used snuff daily. The age adjusted odds ratio for myocardial infarction was 0.89 (95% confidence interval 0.62 to 1.29) for exposure to snuff and 1.87 (1.40 to 2.48) for cigarette smoking compared with non-tobacco users, showing an increased risk in smokers but not in snuff dippers. Regular cigarette smokers had a significantly higher risk of myocardial infarction than regular snuff dippers (age adjusted odds ratio 2.09; 1.39 to 3.15). Smoking, but not snuff dipping, predicted myocardial infarction in a multiple logistic regression model that included age and level of education.

CONCLUSIONS

In middle aged men snuff dipping is associated with a lower risk of myocardial infarction than cigarette smoking.