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Aims: The aim of the study was to estimate the effect of household relative poverty on the risk of diabetic ketoacidosis at diagnosis of children with type 1 diabetes using an international standard measurement of relative poverty. Methods: A national population‐based retrospective study was conducted. The Swedish National Diabetes Register (NDR) was linked with data from Sweden's public statistical agency (Statistics Sweden). Children who were diagnosed with new‐onset type 1 diabetes in the period of 2014–2019 were common identifiers. The definition of diabetic ketoacidosis was venous pH <7.30 or a serum bicarbonate level <18 mmol/L. The exposure variable was defined according to the standard definition of the persistent at‐risk‐of‐poverty rate used by the statistical office of the European Union (Eurostat) and several other European public statistical agencies. Univariate and multi‐variable analyses were used to calculate the effect of relative poverty on the risk of diabetic ketoacidosis. Results: Children from households with relative poverty had a 41% higher risk of diabetic ketoacidosis (1.41, CI 1.12–1.77, p = 0.004) and more than double the risk of severe diabetic ketoacidosis (pH <7.10) (RR 2.10, CI 1.35–3.25, p = 0.001), as compared to children from households without relative poverty. Conclusions: Relative poverty significantly increases the risk of diabetic ketoacidosis at onset of type 1 diabetes in children, even in a high‐income country with publicly reimbursed health care. [ABSTRACT FROM AUTHOR]

Summary: The relationship between self-reported falls and fracture risk was estimated in an international meta-analysis of individual-level data from 46 prospective cohorts. Previous falls were associated with an increased fracture risk in women and men and should be considered as an additional risk factor in the FRAX® algorithm. Introduction: Previous falls are a well-documented risk factor for subsequent fracture but have not yet been incorporated into the FRAX algorithm. The aim of this study was to evaluate, in an international meta-analysis, the association between previous falls and subsequent fracture risk and its relation to sex, age, duration of follow-up, and bone mineral density (BMD). Methods: The resource comprised 906,359 women and men (66.9% female) from 46 prospective cohorts. Previous falls were uniformly defined as any fall occurring during the previous year in 43 cohorts; the remaining three cohorts had a different question construct. The association between previous falls and fracture risk (any clinical fracture, osteoporotic fracture, major osteoporotic fracture, and hip fracture) was examined using an extension of the Poisson regression model in each cohort and each sex, followed by random-effects meta-analyses of the weighted beta coefficients. Results: Falls in the past year were reported in 21.4% of individuals. During a follow-up of 9,102,207 person-years, 87,352 fractures occurred of which 19,509 were hip fractures. A previous fall was associated with a significantly increased risk of any clinical fracture both in women (hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.33–1.51) and men (HR 1.53, 95% CI 1.41–1.67). The HRs were of similar magnitude for osteoporotic, major osteoporotic fracture, and hip fracture. Sex significantly modified the association between previous fall and fracture risk, with predictive values being higher in men than in women (e.g., for major osteoporotic fracture, HR 1.53 (95% CI 1.27–1.84) in men vs. HR 1.32 (95% CI 1.20–1.45) in women, P for interaction = 0.013). The HRs associated with previous falls decreased with age in women and with duration of follow-up in men and women for most fracture outcomes. There was no evidence of an interaction between falls and BMD for fracture risk. Subsequent risk for a major osteoporotic fracture increased with each additional previous fall in women and men. Conclusions: A previous self-reported fall confers an increased risk of fracture that is largely independent of BMD. Previous falls should be considered as an additional risk factor in future iterations of FRAX to improve fracture risk prediction. [ABSTRACT FROM AUTHOR]

Background. Involving people with acquired brain injury in service development has the potential to improve service and give experience-based knowledge legitimacy. The objective of this study was to explore experiences of sharing experience-based knowledge of living with acquired brain injury with others, with a particular focus on the conditions for sharing and learning, and the legitimacy of experience-based knowledge. Materials and Methods. Using a single case study design, the processes in two groups that were part of a Swedish supportive network for people with acquired brain injury were explored. One group consisted mainly of people with acquired brain injury who authored a blog and the other group consisted of healthcare staff who produced educational material with the involvement of a person with own experience of acquired brain injury. The data consisted of forty-one collective blogs, fifteen semistructured individual interviews, and ten observations from meetings. The data were analysed by utilizing the community of practice framework and the concepts of legitimate peripheral participation and epistemic injustice. Results. The findings showed that both groups developed learning processes with a focus on everyday rehabilitation as a joint enterprise. Mutual engagement developed from doing activities together and legitimacy in the groups came from engagement in these activities. In the education group, the ambition to involve people with own experience of acquired brain injury was never realized in practice. Hence, experience-based knowledge of living with acquired brain injury never got legitimacy in the group. Conclusions. We conclude that integrating experience-based knowledge from people with own experience of acquired brain injury demands careful and deliberate planning with specific consideration to existing power asymmetries between healthcare professionals and people with own experience. Mitigating epistemic injustice and gaining legitimacy for such knowledge require that people with experience of living with acquired brain injury are recognized as knowledge producers. [ABSTRACT FROM AUTHOR]

Summary: A large international meta-analysis using primary data from 64 cohorts has quantified the increased risk of fracture associated with a previous history of fracture for future use in FRAX. Introduction: The aim of this study was to quantify the fracture risk associated with a prior fracture on an international basis and to explore the relationship of this risk with age, sex, time since baseline and bone mineral density (BMD). Methods: We studied 665,971 men and 1,438,535 women from 64 cohorts in 32 countries followed for a total of 19.5 million person-years. The effect of a prior history of fracture on the risk of any clinical fracture, any osteoporotic fracture, major osteoporotic fracture, and hip fracture alone was examined using an extended Poisson model in each cohort. Covariates examined were age, sex, BMD, and duration of follow-up. The results of the different studies were merged by using the weighted β-coefficients. Results: A previous fracture history, compared with individuals without a prior fracture, was associated with a significantly increased risk of any clinical fracture (hazard ratio, HR = 1.88; 95% CI = 1.72–2.07). The risk ratio was similar for the outcome of osteoporotic fracture (HR = 1.87; 95% CI = 1.69–2.07), major osteoporotic fracture (HR = 1.83; 95% CI = 1.63–2.06), or for hip fracture (HR = 1.82; 95% CI = 1.62–2.06). There was no significant difference in risk ratio between men and women. Subsequent fracture risk was marginally downward adjusted when account was taken of BMD. Low BMD explained a minority of the risk for any clinical fracture (14%), osteoporotic fracture (17%), and for hip fracture (33%). The risk ratio for all fracture outcomes related to prior fracture decreased significantly with adjustment for age and time since baseline examination. Conclusion: A previous history of fracture confers an increased risk of fracture of substantial importance beyond that explained by BMD. The effect is similar in men and women. Its quantitation on an international basis permits the more accurate use of this risk factor in case finding strategies. [ABSTRACT FROM AUTHOR]

Background: Pregnancy can make it difficult to cope with demands at work and may affect women's well-being. We investigated if a manager-targeted educational intervention reduced demanding occupational exposures and improved the psychosocial work environment and well-being among pregnant employees. Methods: Data came from a cluster randomised trial in Danish hospitals and day-care institutions. Work units were assigned randomly and were non-blinded to the intervention, where managers were either invited to participate in a three-hour seminar addressing job adjustment in pregnancy or assigned to a control group undertaking their usual practice. Self-reported outcomes by pregnant employees at the work units were the proportion of pregnant employees with demanding occupational exposures, good psychosocial work environment and good well-being. Mixed logistic regression was applied in the population of responders and in intention-to-treat analyses using multiple imputations. Results: We included 915 pregnant employees: 451 in the intervention group and 464 in the control group. Of 216 invited managers, 103 (48%) participated in the seminar. A total of 339 (37%) pregnant employees answered the questionnaire. The proportion of pregnant employees who had demanding occupational exposures, good psychosocial work environment and good well-being in the intervention versus the control group were 36% versus 39% (odds ratio (OR)=0.90, 95% confidence interval (CI) 0.57–1.44), 56% versus 59% (OR=1.01, 95% CI 0.60–1.71) and 77% versus 73% (OR=1.13, 95% CI 0.68–1.87), respectively. Conclusions: This manager-targeted educational intervention did not reduce demanding occupational exposures and did not improve the psychosocial work environment or the well-being among pregnant employees in hospital and day-care settings. Comprehensive and participatory interventions may be considered in future studies. [ABSTRACT FROM AUTHOR]

Background: While dietary fiber intake is low in many children, the current trend to plant-based diets is associated with higher fiber intake in children raised on these diets. As older reports indicate that diets providing high fiber intake in children 0-5 years may affect growth, iron status and bowel function, we summarized the available evidence in this systematic review. Objective: To identify, critically appraise, and synthesize evidence on the effect of high fiber intake on growth, iron and bowel function in children 0-5 years, with relevance to the Nordic and Baltic countries. Methods: Following a pre-registered protocol, we searched MEDLINE, EMBASE, Cochrane Central of Controlled Trials, and Scopus for clinical trials and prospective cohort studies published until November 2021. Two reviewers independently screened retrieved literature, extracted relevant data, and performed risk of bias assessment. Outcomes were growth, iron metabolism and bowel function in children 0-5 years. We narratively described findings from studies that met inclusion criteria. Results: From 5,644 identified records, five articles met the inclusion criteria. Two RCTs had an overall moderate risk of bias, while the three observational studies had serious risk. Overall, we found no robust association between high intake of dietary fiber and growth. In the RCTs, higher intake of fiber had a positive effect on bowel movements and constipation. No studies on fiber intake and iron status were identified. The certainty of the overall evidence was inconclusive for growth and bowel function, while no assessment was made for iron status. Conclusion: We found no clear association between high intake of dietary fiber and growth or bowel function in young children living in affluent countries, albeit with only a limited number of studies. There is a lack of studies investigating health effects of high fiber intake in small children. [ABSTRACT FROM AUTHOR]

Objectives: To systematically review the evidence on the effect of replacing the intake of animal protein with plant protein on cardiovascular disease (CVD) and type 2 diabetes (T2D) and their intermediate risk factors. Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus up to 12th May 2022 for randomized controlled trials (RCTs) or prospective cohort studies that investigated replacement of animal protein with plant protein from foods. Outcomes were CVDs, T2D, and in RCTs also the effects on blood lipids, glycemic markers, and blood pressure. Risk of bias was evaluated with the Cochrane's RoB2, ROBINS-I, and USDA's RoB-NObS tools. Random-effects meta-analyses assessed the effects of plant vs. animal proteins on blood lipids in RCTs. The evidence was appraised according to the World Cancer Research Fund's criteria. Results: After screening 15,090 titles/abstracts, full text of 124 papers was scrutinized in detail, from which 13 RCTs and seven cohort studies were included. Eight of the RCTs had either some concern or high risk of bias, while the corresponding evaluation of cohort studies resulted in moderate risk of bias for all seven. Meta-analyses of RCTs suggested a protective effect on total cholesterol (mean difference -0.11 mmol/L; 95% CI -0.22, -0.01) and low-density lipoprotein cholesterol (-0.14 mmol/L; 95% CI -0.25, -0.02) by replacing animal protein with plant protein. The substitution of animal protein with plant protein (percentage of energy intake) in cohort studies was associated with lower CVD mortality (n = 4) and lower T2D incidence (n = 2). The evidence was considered limited-suggestive for both outcomes. Conclusion: Evidence that the substitution of animal protein with plant protein reduces risk of both CVD mortality and T2D incidence is limited-suggestive. Replacing animal protein with plant protein for aspects of sustainability may also be a public health strategy to lower the risk of CVD mortality and T2D. [ABSTRACT FROM AUTHOR]

Objective: To systematically review the evidence for whether habitual or different levels of experimental intake of vitamin B12 from diet and supplements is sufficient to ensure adequate B12 status in groups most susceptible to vitamin B12 deficiency. Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Scopus up to 21 May 2021, for intervention studies, prospective cohort studies and case-control studies assessing B12 intake from diet and/or supplements in relation to B12 status (s/p-B12, holotranscobalamin, methylmalonic acid, homocysteine or breastmilk B12). Cross-sectional studies were eligible for studies conducted during pregnancy and lactation. Included populations were children (0-18 years), young adults (18-35 years), pregnant or lactating women, older adults (≥65 years) and vegans or vegetarians. Study selection, data extraction and risk of bias assessment were conducted by two assessors independently. The evidence was synthesized qualitatively and classified according to the World Cancer Research Fund. Results: The searches yielded 4855 articles of which 89 were assessed in full text and 18 included. Three studies were conducted during pregnancy and three during lactation or infancy -- all observational. Eight studies were conducted among older adults; most were interventions among B12-deficient participants. Four studies were eligible for vegetarian and vegans, all interventions. The strength of evidence that habitual B12 intake or an intake in line with the current Nordic recommended intake (RI) is sufficient to ensure adequate status was considered Limited -- no conclusion for all included populations. Conclusion: Evidence is insufficient to assess if or which level of B12 intake is sufficient to maintain adequate status for all included populations. Population-based cohort studies and low-to-moderate dose interventions that address this question are highly warranted. [ABSTRACT FROM AUTHOR]

Background: Frailty assessment in the Swedish health system relies on the Clinical Frailty Scale (CFS), but it requires training, in-person evaluation, and is often missing in medical records. We aimed to develop an electronic frailty index (eFI) from routinely collected electronic health records (EHRs) and assess its association with adverse outcomes in hospitalized older adults.Methods: EHRs were extracted for 18 225 patients with unplanned admissions between 1 March 2020 and 17 June 2021 from 9 geriatric clinics in Stockholm, Sweden. A 48-item eFI was constructed using diagnostic codes, functioning and other health indicators, and laboratory data. The CFS, Hospital Frailty Risk Score, and Charlson Comorbidity Index were used for comparative assessment of the eFI. We modeled in-hospital mortality and 30-day readmission using logistic regression; 30-day and 6-month mortality using Cox regression; and length of stay using linear regression.Results: Thirteen thousand one hundred and eighty-eight patients were included in analyses (mean age 83.1 years). A 0.03 increment in the eFI was associated with higher risks of in-hospital (odds ratio: 1.65; 95% confidence interval: 1.54-1.78), 30-day (hazard ratio [HR]: 1.43; 1.38-1.48), and 6-month mortality (HR: 1.34; 1.31-1.37) adjusted for age and sex. Of the frailty and comorbidity measures, the eFI had the highest area under receiver operating characteristic curve for in-hospital mortality of 0.813. Higher eFI was associated with longer length of stay, but had a rather poor discrimination for 30-day readmission.Conclusions: An EHR-based eFI has robust associations with adverse outcomes, suggesting that it can be used in risk stratification in hospitalized older adults. [ABSTRACT FROM AUTHOR]

Background: In Sweden, core treatment for osteoarthritis is offered through a Supported Osteoarthritis Self-Management Programme (SOASP), combining education and exercise to provide patients with coping strategies in self-managing the disease. The aim was to study enablement and empowerment among patients with osteoarthritis in the hip and/or knee participating in a SOASP. An additional aim was to study the relation between the Swedish version of the Patient Enablement Instrument (PEI) and the Swedish Rheumatic Disease Empowerment Scale (SWE-RES-23).Methods: Patients with osteoarthritis participating in a SOASP in primary health care were recruited consecutively from 2016 to 2018. The PEI (score range 0-12) was used to measure enablement and the SWE-RES-23 (score range 1-5) to measure empowerment. The instruments were answered before (SWE-RES-23) and after the SOASP (PEI, SWE-RES-23). A patient partner was incorporated in the study. Descriptive statistics, the Wilcoxon's signed rank test, effect size (r), and the Spearman's rho (rs) were used in the analysis.Results: In total, 143 patients were included in the study, 111 (78%) were women (mean age 66, SD 9.3 years). At baseline the reported median value for the SWE-RES-23 (n = 142) was 3.6 (IQR 3.3-4.0). After the educational part of the SOASP, the reported median value was 6 (IQR 3-6.5) for the PEI (n = 109) and 3.8 (IQR 3.6-4.1) for the SWE-RES-23 (n = 108). At three months follow-up (n = 116), the reported median value was 6 (IQR 4-7) for the PEI and 3.9 (IQR 3.6-4.2) for the SWE-RES-23. The SWE-RES-23 score increased between baseline and three months (p ≤ 0.000). The analysis showed a positive correlation between PEI and SWE-RES-23 after the educational part of the SOASP (rs = 0.493, p < 0.00, n = 108) and at follow-up at three months (rs = 0.507, p < 0.00, n = 116).Conclusions: Patients reported moderate to high enablement and empowerment and an increase in empowerment after participating in a SOASP, which might indicate that the SOASP is useful to enable and empower patients at least in the short term. Since our results showed that the PEI and the SWE-RES-23 are only partly related both instruments can be of use in evaluating interventions such as the SOASP.Trial Registration: ClinicalTrials.gov. NCT02974036 . First registration 28/11/2016, retrospectively registered. [ABSTRACT FROM AUTHOR]

It is important to understand how healthy lifestyle habits can be developed as they are essential in cardiovascular disease (CVD) prevention. There is limited knowledge regarding whether, and how, engaging occupations (things that people do and occupy themselves with) can promote and help sustain healthy lifestyle habits for persons at risk for CVDs, including stroke. The aim was to develop knowledge of how engaging in occupations can contribute to changes in lifestyle habits among persons at risk for stroke. Six adults presenting with stroke risk factors were interviewed on several occasions after participating in an occupation-focused stroke prevention programme. Grounded theory was utilised, and constant comparative methods guided the analysis. Changing lifestyle habits was perceived as a complex process, much like weaving a fabric with many parallel and interlacing threads. Literacy of both health and occupations and participation in engaging occupations were important facilitators for promoting healthy lifestyle habits, yet engagement in health-promoting occupations was described as conditioned behaviour. CVD prevention programmes can benefit from incorporating engaging occupations to promote healthy lifestyle habits and literacy of health and occupations. However, contextual factors conditioning health and occupations should be considered when developing and implementing sustainable interventions. [ABSTRACT FROM AUTHOR]

Objective: To assess whether supplementation with long chain n-3 fatty acids during pregnancy, lactation, or infancy reduces the risk of developing asthma or atopic disease during childhood. Methods: Searches were performed in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus up to 2021-09-20, for randomized controlled trials (RCTs) that investigated the effect of supplemental long chain n-3 fatty acids during pregnancy, lactation, or infancy for the prevention of childhood asthma or allergy. Article selection, data extraction, and risk of bias assessment (Cochrane's Risk of Bias 2.0) were independently conducted by two assessors. The evidence was synthesized qualitatively according to the criteria of the World Cancer Research Fund and meta-analyzed. Results: A total of nine RCTs met inclusion criteria; six were conducted during pregnancy, two during infancy, and one during both pregnancy and infancy. Meta-analysis showed that long chain n-3 fatty acid supplementation during pregnancy significantly reduced the risk of asthma/wheeze in the child (RR 0.62 [95% confidence interval 0.34-0.91], P = 0.005, I² = 67.4%), but not other outcomes. Supplementation during lactation of infancy showed no effects on any outcome. The strength of evidence that long chain n-3 fatty acid supplementation during pregnancy reduces risk of asthma/wheeze in the offspring was considered limited -- suggestive. No conclusion could be made for the effects of long chain n-3 fatty acid supplementation during pregnancy for other atopic diseases, or for supplementation during lactation or infancy for any outcome. Conclusion: The intake of long chain n-3 fatty acid supplements during pregnancy may reduce the risk of asthma and/or wheeze in the offspring, but the strength of evidence is low. There is inconclusive evidence for the effects of long chain n-3 fatty acid supplements during pregnancy for other outcomes, as well as for supplementation during lactation or infancy. [ABSTRACT FROM AUTHOR]

Objective: To identify, critically appraise, and synthesize evidence on the effect of quality of dietary fat intake and different classes of fatty acids on the risk of Alzheimer's disease (AD) and dementia in adults aged ≥50 years. Methods: We searched MEDLINE, EMBASE, Cochrane Central of Controlled Trials, and Scopus for clinical trials and prospective cohort studies published until May 2021. Two reviewers independently screened retrieved literature, extracted relevant data, and performed risk of bias assessment. Classes of fatty acids included were saturated fatty acids (SFAs), trans fatty acids (TFAs), monounsaturated fatty acids (MUFAs), poly-unsaturated fatty acids (PUFAs), and their subtypes and sources. Given between-study heterogeneity, we did not perform meta-analyses but narratively described findings from the studies. Results: From 4,491 identified records, five articles (based on four prospective cohort studies) met the inclusion criteria. Three studies had an overall serious risk of bias, while one study had a moderate risk. Overall, we found no robust association between intake of any fatty acids type and the development of AD and dementia. For example, for SFA and TFA, there was contradictory associations reported on AD: one study found that each unit increase in energy-adjusted intake of SFA (risk ratio [RR] 0.83, 95%CI 0.70-0.98) and TFA (RR 0.80, 95%CI 0.65-0.97) was associated with a decreased risk of AD, but not dementia. For PUFA, one study found that higher quintile intake of marine-based n-3 PUFA was associated with a decreased risk of AD. The intake of other fatty acids was not associated with the outcomes. The certainty of the overall evidence was inconclusive. Conclusion: We found no clear association between the intake of various classes of fatty acids and the risk of AD and dementia in adults. More well-designed prospective studies are required to clarify these findings. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to examine the evidence for an association between the dietary protein intake in children and the growth and risk of overweight or obesity up to 18 years of age in settings relevant for the Nordic countries. Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus up to February 26, 2021 for randomized controlled trials (RCTs) or prospective cohort studies assessing for protein intake from foods (total and from different sources) in children. The outcomes include weight, height/length, adiposity indices, and/or risk of overweight and/or obesity. The risk of bias was evaluated with instruments for each respective design (Cochrane's Risk of Bias 2.0 and RoB-NObS). A meta-analysis of five cohort studies was performed. The evidence was classified according to the criteria of the World Cancer Research Fund. Results: The literature search resulted in 9,132 abstracts, of which 55 papers were identified as potentially relevant. In total, 21 studies from 27 publications were included, of which five were RCTs and 16 were cohort studies. The RCTs found generally null effects of high-protein intake in infants on weight gain, nor that lower protein diets negatively affected growth. All included RCTs had some concern regarding the risk of bias and were limited by small sample sizes. Total protein intake and BMI were assessed in 12 cohorts, of which 11 found positive associations. The meta-analysis revealed a pooled effect estimate of 0.06 (95% CI 0.03, 0.1) kg/m² BMI per one E% increment in total protein (I² = 15.5). Therefore, the evidence for a positive relationship between total protein intake and BMI was considered probable. Furthermore, there was probable evidence for an association between higher intake of animal protein and increased BMI. There was limited, suggestive evidence for an effect of total protein intake and higher risk of overweight and/or obesity, while no conclusions could be made on the associations between animal vs. plant protein intake and risk of overweight and/or obesity. Discussion: In healthy, well-nourished children of Western populations, there is probably a causal relationship between a high-protein intake in early childhood (≤ 18 months) -- particularly protein of animal origin -- and higher BMI later in childhood, with consistent findings across cohort studies. A lack of RCTs precluded a stronger grading of the evidence. [ABSTRACT FROM AUTHOR]

BACKGROUND: Drinking water chlorination by-products have been associated with adverse reproductive outcomes, although the findings for congenital malformations are still inconclusive. OBJECTIVE: We conducted a nationwide register-based prospective study to assess whether first trimester maternal exposure to the four most common trihalomethanes [total trihalomethanes (TTHM)] via municipal drinking water was associated with risk of congenital malformation among newborns. METHODS: We included all births during 2005–2015 (live and stillbirths) of mothers residing in Swedish localities having >10,000 inhabitants, two or fewer operating water works, and sufficient municipal TTHM monitoring data. Individual maternal first trimester exposure was obtained by linking TTHM measurements to residential information, categorized into no chlorination and <5, 5–15, and >15 μg TTHM/L. We also made chlorination treatment-specific analyses (exclusive use of chloramine or hypochlorite). Outcomes and covariates were obtained via linkage to health care and administrative registers. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by logistic regression. RESULTS: Based on 623,468 births and a prevalence of congenital malformation of ~2 cases/100 births, we observed associations between TTHM exposure in areas using chloramine and malformations of the nervous system (OR = 1:82; 95% CI: 1.07, 3.12), urinary system (OR = 2:06; 95% CI: 1.53, 2.78), genitals (OR = 1:77; 95% CI: 1.38, 2.26), and limbs (OR = 1:34; 95% CI: 1.10, 1.64), comparing the highest exposed category with the unexposed. No associations were observed in areas using exclusively hypochlorite as the primary water treatment method. By contrast, for malformations of the heart, a significant inverse association was observed only in areas using hypochlorite. DISCUSSION: TTHM exposure was associated with the increased risk of malformations of the nervous system, urinary system, genitals, and limbs in areas exclusively using chloramine. An association between chloramine-related chlorination by-products and congenital malformations has not previously been highlighted and needs further attention. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although randomized controlled trials (RCTs) have demonstrated that high fluoride increases bone mineral density (BMD) and skeletal fragility, observational studies of low-dose chronic exposure through drinking water (<1.5 mg/L, the maximum recommended by the World Health Organization) have been inconclusive. OBJECTIVE: We assessed associations of fluoride in urine, and intake via diet and drinking water, with BMD and fracture incidence in postmenopausal women exposed to drinking water fluoride ≤ mg/L. METHODS: Data were from participants in the Swedish Mammography Cohort-Clinical, a population-based prospective cohort study. At baseline (2004-2009), fluoride exposure was assessed based on urine concentrations (푛=4,306) and estimated dietary intake (including drinking water) (푛=4,072), and BMD was measured using dual energy X-ray absorptiometry. Incident fractures were ascertained via register-linkage through 2017. Residential history was collected to identify women with long-term consistent drinking water exposures prior to baseline. RESULTS: At baseline, mean urine fluoride was 1.2 mg/g creatinine (±1.9) and mean dietary intake was 2.2 mg/d (±0:9), respectively. During follow up, 850, 529, and 187 cases of any fractures, osteoporotic fractures, and hip fractures, respectively, were ascertained. Baseline BMD was slightly higher among women in the highest vs. lowest tertiles of exposure. Fluoride exposures were positively associated with incident hip fractures, with multivariable-adjusted hazard ratios of 1.50 (95% CI: 1.04, 2.17) and 1.59 (95% CI: 1.10, 2.30), for the highest vs. lowest tertiles of urine fluoride and dietary fluoride, respectively. Associations with other fractures were less pronounced for urine fluoride, and null for dietary fluoride. Restricting the analyses to women with consistent long-term drinking water exposures prior to baseline strengthened associations between fractures and urinary fluoride. DISCUSSION: In this cohort of postmenopausal women, the risk of fractures was increased in association with two separate indicators of fluoride exposure. Our findings are consistent with RCTs and suggest that high consumption of drinking water with a fluoride concentration of ~1 mg/L may increase both BMD and skeletal fragility in older women [ABSTRACT FROM AUTHOR]

Background: Distal radius fractures can adversely affect wrist function; for men with this fracture, the role played by fracture severity, age and osteoporosis on fracture outcome has not been sufficiently studied.Objective: To describe patient-reported outcome and the association with bone integrity, fracture severity and future fracture risk among young and older men with distal radius fracture.Methods: This prospective study includes 133 men with acute distal radius fracture, mean age 54 (range 21-88), who were followed for 12 months. They were categorized as younger (< 65) and older (65+). Main outcome was DASH (Disability of the Arm, Shoulder and Hand) at 12 months; DASH > 15 was defined as poor outcome. Fractures were classified and radiographic displacement identified at initial presentation and follow-up. BMD was measured and FRAX 10-year probability of fracture calculated.Results: Disability was higher in older men (DASHmedian 10 vs 2; p = 0.002); a clinically meaningful difference (ΔDASH = 10, p = 0.017) remained after adjustment for displacement, fracture classification and treatment method. Almost 50% of older men vs 14% in younger had poor outcome, p < 0.001. Bone mineral density did not independently predict outcome. Older men with a displaced fracture at initial presentation had greater disability (DASHmedian, IQR 45, 14;73) and risk of fracture (FRAXmajor osteoporotic 14, 8;21).Conclusion: Men over the age of 65 with a distal radius fracture are more likely to have post-fracture disability regardless of radiographic appearance. Fracture displacement, indicating impaired bone strength, is also more common and associated with an increased risk of fracture within 10-years. Secondary fracture prevention should therefore be considered in men presenting with distal radius fracture. [ABSTRACT FROM AUTHOR]

Purpose Distal radius fracture often compromises working ability, but clinical implications are less studied in men due to its lower incidence. This study therefore describes sick leave in men with distal radius fracture, specifically exploring the impact of patient- and fracture-related factors. Methods Professionally active men aged 20–65 with distal radius fracture were followed prospectively for 1-year (n = 88). Data included treatment method, radiographic parameters pre/post treatment, complications, health, lifestyle and occupational demand. Patient outcomes were self-reported sick leave; Disability of the Arm, Shoulder and Hand (DASH) score; pain (5 likert scale); SF-36: Physical Component Scale (PCS) and Mental Component Scale (MCS). Results Median sick leave was 4 weeks (IQR 0; 8); almost a third reported taking no sick leave. Categorizing sick leave into 3 groups (0–6, 7–12 and > 12 weeks), men with the longest sick leave had 22 points higher DASH score (p = 0.001) and 5 points lower PCS (p = 0.02) at 1 week and the difference remained over time; they were also older and more often treated surgically. The strongest predictors of length of sick leave were one-week post-fracture DASH score (rs = 0.4, p < 0.001), pain intensity (rs = 0.4, p < 0.001) and PCS (rs = − 0.4, p = 0.002). The correlation between sick leave and pain was even stronger analyzing treatment groups separately (closed reduction and cast rs = 0.56, p = 0.007, surgery rs = 0.42, p = 0.04). Conclusions Self-reported disability, pain and global health measurements as early as 1 week post-fracture are the strongest predictors of length of sick leave regardless of treatment; an important finding easily transferrable to clinical management of distal radius fractures. [ABSTRACT FROM AUTHOR]

Background: Autonomic neuropathy (AN) commonly arises as a long-term complication in diabetes mellitus and can be diagnosed from heart rate variability (HRV), calculated from electrocardiogram recordings. Psychosocial stress also affects HRV and could be one of several confounders for cardiac AN. The present work investigated the impact of psychosocial stress on HRV in individuals with type 1 diabetes mellitus (T1DM) and assessed the use of salivary cortisol as a biomarker for psychosocial stress in this context.Methods: A total of 167 individuals 6-60 years old (113 with T1DM and 54 healthy controls) underwent 24-hr ECG recordings with HRV analysis. Salivary cortisol was sampled thrice during the registration day. Perceived psychosocial stress along with other factors of possible importance for the interpretation of HRV was documented in a diary.Results: Heart rate variability (high-frequency power during sleep) was reduced (p < .05) with older age, longer diabetes duration, higher mean glucose levels, physical inactivity, and perceived psychosocial stress. Salivary cortisol levels in the evening were increased (p < .05) in women in ovulation phase, in individuals with preceding hypoglycemia or with hyperglycemia. The amplitude of salivary cortisol was reduced (p < .05) with the presence of perceived psychosocial stress, but only in adult healthy controls, not in individuals with diabetes.Conclusion: Psychosocial stress might be a confounder for reduced HRV when diagnosing cardiac AN in T1DM. Salivary cortisol is, however, not a useful biomarker for psychosocial stress in diabetes since the physiological stress of both hypoglycemia and hyperglycemia seems to overrule the effect of psychosocial stress on cortisol. [ABSTRACT FROM AUTHOR]

Background: Co-exposure to environmental contaminants present in fish could mitigate the beneficial effects of fish consumption and possibly explain the lack of association observed for mortality in some geographical regions.Objective: To assess the independent associations of dietary exposure to polychlorinated biphenyls (PCBs) and long-chain omega-3 fish fatty acids intake with cardiovascular and cancer mortality.Methods: We used the prospective population-based Swedish Mammography Cohort and the Cohort of Swedish Men comprising 32 952 women and 36 545 men, free from cancer, cardiovascular disease and diabetes at baseline in 1998. Validated estimates of dietary PCBs and long-chain omega-3 fish fatty acids [i.e. eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)] intake were obtained via a food frequency questionnaire at baseline. Information on death was ascertained through register linkage.Results: During a mean follow-up of 15.5 years, we ascertained 16 776 deaths. We observed for cardiovascular mortality, comparing extreme quintiles in multivariable models mutually adjusted for PCBs and EPA-DHA, dose-dependent associations for dietary PCB exposure, hazard ratio (HR) 1.31 (CI 95%: 1.08 to 1.57; P-trend 0.005) and for dietary EPA-DHA intake, HR 0.79 (CI 95%: 0.66 to 0.95; P-trend 0.041). For cancer mortality, no clear associations were discerned.Conclusion: The beneficial effect of fish consumption on the cardiovascular system seems compromised by co-exposure to PCBs - one likely explanation for the inconsistent associations observed between fish consumption and mortality. [ABSTRACT FROM AUTHOR]

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Background: Concerns have been raised about the quality of reporting in nutritional epidemiology. Research reporting guidelines such as the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement can improve quality of reporting in observational studies. Herein, we propose recommendations for reporting nutritional epidemiology and dietary assessment research by extending the STROBE statement into Strengthening the Reporting of Observational Studies in Epidemiology-Nutritional Epidemiology (STROBE-nut).Methods and Findings: Recommendations for the reporting of nutritional epidemiology and dietary assessment research were developed following a systematic and consultative process, coordinated by a multidisciplinary group of 21 experts. Consensus on reporting guidelines was reached through a three-round Delphi consultation process with 53 external experts. In total, 24 recommendations for nutritional epidemiology were added to the STROBE checklist.Conclusion: When used appropriately, reporting guidelines for nutritional epidemiology can contribute to improve reporting of observational studies with a focus on diet and health. [ABSTRACT FROM AUTHOR]

Objective To explore the relationship between certain clinical variables and metabolic HbA1c at diagnosis correlated to HbA1c at follow-up (p < 0.001). There was a clear gender difference regarding HbA1c. Girls had higher values both at diagnosis and at follow-up (p < 0.001). Girls also had lower BMI and pH at diagnosis than boys (p < 0.001). In contrast, girls with the highest body mass index ( BMI) at follow-up had higher mean HbA1c at follow-up in 2010 (p < 0.001). Having a mother and/or a father with high BMI implied higher HbA1c at diagnosis (p < 0.003). Conclusions HbA1c at diagnosis seems to predict metabolic control years later. There is a gender difference at diagnosis as female patients have higher HbA1c than males at diagnosis as well as at follow up. As metabolic control is very much correlated to complications there is a need to early identify patients at risk of poor metabolic control. Even though we do not know whether a high HbA1c level is mainly due to severity of the disease or to behavioral patterns, new ways to treat and support these children, especially girls, are needed. [ABSTRACT FROM AUTHOR]

Summary: In a large cohort of elderly women followed for 10 years, we found that balance, gait speed, and self-reported history of fall independently predicted fracture. These clinical risk factors are easily evaluated and therefore advantageous in a clinical setting. They would improve fracture risk assessment and thereby also fracture prevention. Introduction: The aim of this study was to identify additional risk factors for osteoporosis-related fracture by investigating the fracture predictive ability of physical performance tests and self-reported history of falls. Methods: In the population-based Osteoporosis Prospective Risk Assessment study (OPRA), 1044 women were recruited at the age of 75 and followed for 10 years. At inclusion, knee extension force, standing balance, gait speed, and bone mineral density (BMD) were examined. Falls the year before investigation was assessed by questionnaire. Cox proportional hazards regression analysis was used to determine fracture hazard ratios (HR) with BMD, history of fracture, BMI, smoking habits, bisphosphonate, vitamin D, glucocorticoid, and alcohol use as covariates. Continuous variables were standardized and HR shown for each standard deviation change. Results: Of all women, 427 (41 %) sustained at least one fracture during the 10-year follow-up. Failing the balance test had an HR of 1.98 (1.18-3.32) for hip fracture. Each standard deviation decrease in gait speed was associated with an HR of 1.37 (1.14-1.64) for hip fracture. Previous fall had an HR of 1.30 (1.03-1.65) for any fracture; 1.39 (1.08-1.79) for any osteoporosis-related fracture; and 1.60 (1.03-2.48) for distal forearm fracture. Knee extension force did not show fracture predictability. Conclusion: The balance test, gait speed test, and self-reported history of fall all hold independent fracture predictability. Consideration of these clinical risk factors for fracture would improve the fracture risk assessment and subsequently also fracture prevention. [ABSTRACT FROM AUTHOR]

Summary: This longitudinal study investigates the association between C-reactive protein (CRP), osteoporosis, fractures, and mortality in 1044 elderly women. CRP was not an indicator for low bone mineral density (BMD), bone loss, or fracture in elderly women; however, women with elevated CRP levels over a prolonged period lost more bone over the 10-year follow-up, although fracture risk was not increased. Introduction: Inflammation may contribute to the pathophysiology underlying impaired bone metabolism. This study investigates the association between CRP, BMD, bone loss, fracture risk, and mortality in women aged 75 and above. Methods: This longitudinal study is based on 1044 women, all age 75 at inclusion, reassessed at ages 80 and 85, with a mean follow-up time of 11.6 years (maximum 16.9 years). Results: Women in the lowest CRP quartile (mean 0.63 mg/L) had lower BMD compared to those in the highest CRP quartile (mean 5.74 mg/L) at total hip (TH) (0.809 vs. 0.871 g/cm, p < 0.001) and femoral neck (FN) (0.737 vs. 0.778 g/cm, p = 0.007). A single measurement of CRP was not associated with bone loss; however, women with persistently elevated CRP, i.e., ≥3 mg/L at ages 75 and 80 had significantly higher bone loss compared to women with CRP <3 mg/L (TH −0.125 vs. −0.085 g/cm, p = 0.018 and FN −0.127 vs. −0.078 g/cm, p = 0.005) during 10 years of follow-up. Women in the highest CRP quartile had a lower risk of osteoporotic fractures (hazard ratios (HR) 0.76 (95 % confidence intervals (CI) 0.52-0.98)) compared to those in the lowest, even after adjusting for weight and BMD. Mortality risk was only increased among women with the highest CRP levels. Conclusion: CRP was not an indicator for low BMD, bone loss, or fracture in elderly women in this study. Persistently elevated CRP however seemed to be detrimental to bone health and may be associated with a higher rate of bone loss. Only the highest CRP levels were associated with mortality. [ABSTRACT FROM AUTHOR]

Summary: This study of elderly Swedish women investigated the association between chronic vitamin D insufficiency and osteoporotic fractures occurring between ages 80-90. The incidence and risk of hip and major osteoporotic fractures was significantly higher in elderly women with low vitamin D levels maintained over 5 years. Introduction: Vitamin D insufficiency among the elderly is common; however, relatively little is known about the effects of long-term hypovitaminosis D on fracture. We investigated sequential assessment of serum 25(OH)D at age 75 and 80 to determine if continuously low 25(OH)D levels are associated with increased 10-year fracture incidence. Methods: One thousand forty-four Swedish women from the population-based OPRA cohort, all 75 years old, attended at baseline (BL); 715 attended at 5 years. S-25(OH)D was available in 987 and 640, respectively and categorized as: <50 (Low), 50-75 (Intermediate), and >75 nmol/L (High). Incident fracture data was collected with maximum follow-up to 90 years of age. Results: Hip fracture incidence between age 80-85 was higher in women who had low 25(OH)D at both baseline and 5 years (22.2 % (Low) vs. 6.6 % (High); p = 0.003). Between age 80-90, hip fracture incidence was more than double that of women in the high category (27.9 vs. 12.3 %; p = 0.006). Within 5-years, 50 % of women in the continuously low group compared to 34 % in the continuously high 25(OH)D group had an osteoporotic fracture ( p = 0.004) while 10-year incidence was higher compared to the intermediate ( p = 0.020) but not the high category ( p = 0.053). The 10-year relative risk of hip fracture was almost three times higher and osteoporotic fracture risk almost doubled for women in the lowest 25(OH)D category compared to the high category (HR 2.7 and 1.7; p = 0.003 and 0.023, respectively). Conclusion: In these elderly women, 25(OH)D insufficiency over 5-years was associated with increased 10-year risk of hip and major osteoporotic fractures. [ABSTRACT FROM AUTHOR]

The aim of this study was to compare venous leg ulcer patients with and without ulcer pain to see whether ulcer pain affected the use of antibiotic treatment and compression therapy throughout healing. A total of 431 patients with venous leg ulcers were included during the study period. Every patient was registered in a national quality registry for patients with hard-to-heal leg, foot and pressure ulcers. A high incidence of ulcer pain (57%) was found when the patients entered the study. Patients with ulcer pain had been treated more extensively with antibiotics both before and during the study period. Throughout the healing there was a significant reduction of antibiotic use among patients in the 'no pain' group, from 44% to 23% (P=0.008). There was no significant difference between the two groups concerning compression therapy (85% vs. 88%) but 12% of patients in the 'pain' group did not get their prescribed compression compared with 6% of patients in the 'no pain' group. The groups did not differ significantly in terms of ulcer duration, ulcer size or healing time. This study shows a high incidence of ulcer pain, confirming that pain has a great impact on patients with venous leg ulcers. Results further suggest that the presence of ulcer pain increases the prescription of antibiotics but does not affect the use of compression therapy. Several advantages were found from using a national quality registry. The registry is a valuable clinical tool showing the importance of accurate diagnosis and effective treatment. [ABSTRACT FROM AUTHOR]

Background and purpose - Little is known about the characteristics of non-participants in epidemiological studies. We evaluated external validity by comparing fracture and mortality rate in participants and non-participants in a longitudinal study on risk factors for fracture. Methods - 1,604 randomly selected women, 75 years of age, were invited to attend a study on osteoporosis and fracture. 1,044 women attended the study (participants) and 560 women did not participate (non-participants). Fracture data for all were obtained prospectively from radiographic records. Mortality data were obtained through the population register. Mean follow-up was 13 (11-15) years. Cumulative survival was compared with the log-rank test. Fracture incidence rates per 1,000 person-years were compared with Mann-Whitney U-tests. In addition, fracture comparisons were made with the cumulative incidence function and Gray's test. Results - 454 participants (44%) died during the follow-up, as compared to 372 of the non-participants (66%) (p < 0.001). The fracture incidence rate for any type of fracture was 43 for participants and 47 for non-participants (p = 1.0). The fracture incidence rate for typical osteoporotic fracture was 36 for participants and 39 for non-participants (p = 0.6). The corresponding values for distal forearm fracture were 11 and 7 (p = 0.002), they were 8 and 9 for proximal humerus fracture (p = 0.9), 13 and 10 for vertebral fracture (p = 0.007), 15 and 18 for hip fracture (p = 0.8), and they were 6 and 5 for pelvic fracture (p = 0.3). The cumulative incidence function confirmed the results. Interpretation - Our findings suggest that participants had a lower mortality rate than non-participants. Distal forearm and vertebral fractures were more frequent in participants. However, the external validity for fractures in general appeared to be satisfactory. [ABSTRACT FROM AUTHOR]

Background Support in diabetes self-care in school is essential to achieve optimal school performance and metabolic control. Swedish legislation regulating support to children with chronic diseases was strengthened 2009. Objective To compare the results of a national survey conducted 2008 and 2015 measuring parents' and diabetes specialist teams' perceptions of support in school. Method All pediatric diabetes centers in Sweden were invited to participate in the 2015 study. In each center, families with a child being treated for T1DM and attending preschool class or compulsory school were eligible. The parents' and the diabetes teams' opinions were collected in two separate questionnaires. Results Forty-one out of 42 eligible diabetes centers participated and 568 parents answered the parental questionnaire in 2015. Metabolic control had improved since the 2008 survey (55.2 ± 10.6 mmol/mol, 7.2% ± 1.0%, in 2015 compared with 61.8 ± 12.4 mmol/mol, 7.8% ± 1.1% in 2008). The proportion of children with a designated staff member responsible for supporting the child's self-care increased from 43% to 59%, ( P < .01). An action plan to treat hypoglycemia was present for 65% of the children in 2015 compared with 55% in 2008 ( P < .01). More parents were satisfied with the support in 2015 (65% compared with 55%, P < .01). Conclusions This study shows that staff support has increased and that more parents were satisfied with the support for self-care in school in 2015 compared with 2008. More efforts are needed to implement the national legislation to achieve equal support in all Swedish schools. [ABSTRACT FROM AUTHOR]