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Background: The current study investigated Whiplash Associated Disorders (WAD) and health related quality of life (HRQOL) from the perspective of Swedish patients. Another aim was to assess medicine consumption and income loss due to WAD., Method: The present study was a planned secondary analysis using baseline data from a prospective, multicentre randomized controlled trial. The study participants were WAD patients, victims of four-wheel motor vehicle collisions at least six months but not more than five years ago. Neck Disability Index and HRQOL were measured. HRQOL was measured by the EQ-5D instrument. Cross tabulations, Box Plots, and regression analyses were performed., Trial Registration Section: The study was registered before data collection started (ClinicalTrials.gov Protocol ID: NCT03022812, initial release 12/20/2016)., Results: There were 137 WAD participants (78.8% women), and almost three-fourths (74.5%) were married. The majority (54.7%) of the WAD patients were in white-collar jobs, followed by blue-collar jobs (35%) and students /unemployed (10.2%). Both consumption of medicine for neck pain and income loss due to WAD have a negative relation with the Neck Disability Index (NDI). On average, EQ-VAS for WAD women is 58.21 (± 17.625), and for men, it is 61.11 (± 16.444). WAD patients with a university education have the highest EQ-VAS average of 60.42 (± 17.738)., Conclusions: The low HRQOL seen in WAD patients in this study should warrant the attention of the medical fraternity, researchers and policymakers., Competing Interests: Declarations. Ethics approval and consent to participate: The regional ethical review board approved the study in Linköping, Sweden (2016/135–31; 2016/526–32; 2017/45–32) and strictly followed the norms in accordance with the Declaration of Helsinki. The study protocol has been published elsewhere [21] and the trial was registered with ClinicalTrials.gov (NCT03022812, initial release 12/20/2016) before data collection started, first posted date (12/01/2017). Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Purpose: Hyponatremia is the most common electrolyte disorder, with potentially serious consequences. Studies validating hyponatremia used as a principal diagnosis are lacking. Studying principal diagnoses is important since it indicates the main reason for inpatient care. The aim of this study was to assess the validity of principal diagnoses of hyponatremia according to the International Classification of Diseases, tenth revision (ICD-10) in patients discharged from hospital., Methods: Three independent reviewers retrospectively analyzed medical records of 428 hospitalized patients, ≥18 years old, discharged with a principal diagnosis of either hyponatremia or syndrome of inappropriate anti-diuretic hormone secretion (SIADH) from three different hospitals during 2014-2017. The positive predictive value of hyponatremia as a principal diagnosis was calculated., Results: The median age of the studied population was 73 (IQR 64-81) years and 69% were women. The range of sodium levels was < 100 to 139 mmol/L. The mean sodium level was 119 mmol/L. Of the patients 27% were treated in an intensive care unit (ICU)/high dependency unit (HDU). Hyponatremia was deemed to be the principal cause of inpatient care in 411 out of 428 patients, corresponding to a positive predictive value for hyponatremia as a principal diagnosis of 96% (CI 95% 94-98)., Conclusions: The current study showed that 19 diagnoses out of 20 were correct implying a high validity. Thus, a principal diagnosis of hyponatremia, appears to be a useful measure in clinical and epidemiological studies aiming to target a clinically relevant consequence of hyponatremia in hospitalized patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Bergh Fahlén et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Sarcoidosis associated hypercalcemia (SAHC) is a challenging clinical problem as it can result in severe morbidity. Sunlight exposure and conversion of vitamin D to its active form by macrophages in granulomas have been suggested as possible causes. We aimed to disentangle mechanisms behind SAHC by investigating any associations with season, granuloma burden and lung macrophages. Patients with SAHC were identified from a local cohort. The patients were divided in two groups: mild and severe SAHC. Data on when SAHC occurred, HLA-DRB1 alleles, bronchoalveolar lavage fluid (BALF) macrophages, extrapulmonary manifestations (EPM) and serum angiotensin-converting enzyme (s-ACE) as a marker for granuloma burden were retrieved from medical records. Out of 83 patients with SAHC, severe hypercalcemia was found in 36 patients, 75% of whom presented between May and October (p < 0.001). No seasonal variation was observed for patients with mild hypercalcemia. Elevated s-ACE was more common in patients with severe hypercalcemia (84% of patients), compared to 46% in the group with mild hypercalcemia (p < 0.001). HLA-DRB1*04 was more frequent in the group with severe hypercalcemia, compared to the mild group (67% vs. 32%, p < 0.01). Results support SAHC being associated with sun exposure. Risk factors to be observant of are elevated s-ACE and HLA-DRB1*04., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Due to the high prevalence and great cardiovascular risks of hypertension, we need effective and evidence-based treatment strategies. Health-promoting one-way text messages could be a beneficial complement to antihypertensive drugs. However, this has yet to be proven in a primary healthcare setting. The purpose of this study was to investigate if health-promoting text messages could improve patients' blood pressure in primary care. The PUSHME (Primary care Usage of Health promoting Messages) randomized controlled trial included 401 patients from 10 primary health care centers in southern Sweden. Patients in the intervention group received four text messages weekly for six months along with treatment as usual. The PUSHME study was registered on clinicaltrials.gov (NCT04407962). Patients in both the control group and the intervention group lowered their blood pressure during the study, but there was no significant difference in change between the groups. However, subgroup analyses showed that there was a significantly larger reduction in diastolic blood pressure favoring the intervention for patients with poor self-rated health: -4.5 mmHg vs -1.4 mmHg (p = 0.019), and patients with a sedentary lifestyle: -5.2 mmHg vs -2.4 mmHg (p = 0.034). Our findings indicate that text messages with lifestyle advice to a general hypertensive population do not have any significant effect on blood pressure. However, it could be an effective complement to conventional antihypertensive drug treatment for specific patient groups., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Borgström Bolmsjö et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background and Purpose: The COVID-19 pandemic impacted substantially on cancer healthcare, including the temporary suspension of screening activities. We compared cancer incidence rates and stage during 2020-2021 to pre-pandemic rates in the Nordic countries., Material and Methods: Using data from the national cancer registries in Denmark, Finland, Iceland, Norway, and Sweden, we estimated age-, sex-, and period-adjusted incidence rate ratios, expressed as relative percentage change (%) with 95% confidence intervals (CIs), comparing rates in 2020-2021 to those in 2017-2019 (pre-pandemic)., Results: In 2020-2021, 340,675 cancer cases were diagnosed. The incidence rates declined during the first pandemic wave (Q2 2020), ranging from -21.7% [95% CI: -23.3%; -20.2%] (Sweden) to -7.9% [-17.7%; 3.0%] (Iceland). Incidence rates also declined in the second pandemic wave (Q1 2021), ranging from -8.6% [-10.2%; -6.9%] (Sweden) to -2.3% [-4.6%; 0.1%] (Norway), and in Sweden also by -3.1% [-4.8%; -1.3%] in the third pandemic wave (Q4 2021). Stage I breast cancer incidence declined during 2020 in Denmark/Norway/Sweden, with some catch-up in stage II incidence in 2021. Prostate cancer rates declined in Denmark/Finland/Norway/Sweden during 2020-2021, while melanoma rates declined in Finland in 2020. During 2020, colon cancer rates declined in Denmark and Iceland, while rectal cancer rates declined in Denmark, and lung and kidney cancer rates declined in Norway., Interpretation: During 2020-2021, cancer incidence rates declined across the Nordic countries with the largest declines in Sweden. During the third pandemic wave, the incidence rates were mostly similar to pre-pandemic rates. Changes in cancer stage may reflect reduced screening activities.

Objectives: The aim of this study was to investigate the risk of severe influenza resulting in hospitalisation among adults with type 1 diabetes (T1D)., Design: Nationwide cohort study using register data., Settings: Data from the National Diabetes Register (NDR) linked to the Swedish Patient Register, Statistics Sweden and the Swedish Population Register., Participants: Persons with T1D in the Swedish NDR n=35 596 and control persons from the Swedish Population Register matched on age, sex and county of residence, n=155 590., Primary and Secondary Outcomes: Hospitalisation from seasonal influenza from October 2013 to December 2019. Season-wise incidence and HRs were analysed in the T1D group compared with controls. Secondary outcomes were associations between clinical variables and hospitalisation due to seasonal influenza for persons with T1D., Results: There were 347 (1.0%) influenza admissions in persons with T1D and 332 (0.2%) in the control group. The overall incidence rate was 16.9/10 000 person-years in the T1D group and 3.6/10 000 person-years for the control group. Persons with T1D had an unadjusted HR 4.7 (95% CI 4.0 to 5.5) for risk of hospitalisation from influenza during the study period and HR 3.4 (95% CI 2.9 to 4.0) when adjusted for age, sex, socioeconomic factors and chronic medical conditions at baseline. Within the T1D cohort, individuals hospitalised due to influenza were older, were more often smokers, had lower glomerular filtration rate and more often had a previous history of ischaemic heart disease and stroke., Conclusions: To our knowledge, this is the first large study to highlight that persons with T1D have a threefold higher risk of hospitalisation due to seasonal influenza compared with matched controls from the general population. It is important for healthcare professionals to acknowledge this excess risk, particularly in older persons with T1D, who have cardiovascular risk factors and reduced kidney function., Competing Interests: Competing interests: OM and LS are employees of and may own shares in Sanofi. BE reports personal fees from Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Merck Sharp and Dohme, Mundipharma, Novo Nordisk, RLS Global and Sanofi, all outside the submitted work. KE-O reports personal lecture fees and/or honoraria for consulting from Sanofi, Eli Lilly, Novo Nordisk and Abbott, all outside the submitted work. MG has received research grants from Gilead Sciences and honoraria as speaker, DSMB committee member and/or scientific advisor from Amgen, AstraZeneca, Biogen, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline/ViiV, Janssen-Cilag, MSD, Novocure, Novo Nordic, Pfizer and Sanofi (none related to the current work)., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: The shift to online education due to the COVID-19 pandemic posed significant challenges and opportunities for students, affecting their academic performance, mental well-being, and engagement., Objective: This study aimed to explore the overall learning experience among health informatics master's students at Karolinska Institutet, Sweden, and the strategies they used to overcome learning challenges posed by the COVID-19 pandemic., Methods: Through 3 structured focus groups, this study explored health informatics master's students' experiences of shifting learning environments for classes that started in 2019, 2020, and 2021. All focus group sessions were recorded and transcribed verbatim. Inductive content analysis was used to analyze the data., Results: The results highlight the benefits of increased autonomy and flexibility and identify challenges such as technical difficulties, diminished social interactions, and psychological impacts. This study underscores the importance of effective online educational strategies, technological preparedness, and support systems to enhance student learning experiences during emergencies. The findings of this study highlight implications for educators, students, and higher education institutions to embrace adaptation and foster innovation. Implications for educators, students, and higher education institutions include the need for educators to stay current with the latest educational technologies and design teaching strategies and pedagogical approaches suited to both online and in-person settings to effectively foster student engagement. Students must be informed about the technological requirements for online learning and adequately prepared to meet them. Institutions play a critical role in ensuring equitable access to technology, guiding and supporting educators in adopting innovative tools and methods, and offering mental health resources to assist students in overcoming the challenges of evolving educational environments., Conclusions: This research contributes to understanding the complexities of transitioning to online learning in urgent circumstances and offers insights for better preparing educational institutions for future pandemics., (©Nadia Davoody, Natalia Stathakarou, Cara Swain, Stefano Bonacina. Originally published in JMIR Medical Education (https://mededu.jmir.org), 10.02.2025.)

Background: The COVID-19 pandemic brought with it several changes, both regarding infection with COVID-19 itself as well as measures to combat the spread of infection, that might have affected sickness absence (SA) patterns. The aim was to explore whether incidence and length of SA changed between 2019, 2020, and 2021, as well as to determine factors associated with SA due to COVID-19 or COVID-like diagnoses among privately employed white-collar workers., Methods: A cohort of all privately employed white-collar workers in 2018 in Sweden (n = 1 347 778; 47% women) was followed prospectively during 2019, 2020, and 2021 using linked nationwide register data. We calculated numbers and proportions of people with incident SA (in SA spells > 14 days) due to COVID-19, COVID-like diagnoses (certain respiratory, infectious, and symptom-based diagnoses used in the beginning of the pandemic for suspected COVID-19), and all other SA, respectively, and mean number of SA days with somatic and mental diagnoses. Logistic regression was used to determine odds ratios (OR) and 95% confidence intervals for associations between prior diagnosis-specific SA, sociodemographic and work-related factors and incident SA due to COVID-19 or COVID-like diagnoses., Results: In 2020, 0.6% of the women and 0.3% of the men had incident SA due to COVID-19. For SA with COVID-like diagnoses, the corresponding proportions were 1.2% and 0.5%. The proportion of people with all other SA was stable across the years, at 8.1-8.4% for women and 3.7-3.9% for men. The mean number of SA days per person increased each year for somatic diagnoses but for mental diagnoses it decreased from 2019 to 2020 and increased to 2021 among women and men. Factors associated most strongly with incident SA due to COVID-19 or COVID-like diagnoses were low income (adjusted OR-range 1.36-5.67 compared to the highest income group) and prior SA due to COVID-like diagnoses (OR-range 4.67-5.31 compared to those with no such prior SA)., Conclusions: A small proportion of privately-employed white-collar workers had incident SA spells > 14 days due to COVID-19 or COVID-like diagnoses. The factors associated with SA due to COVID-19 were similar to factors associated with SA due to other diagnoses in previous studies., Competing Interests: Declarations. Ethical approval and consent to participate: The project was approved by the Regional Ethical Review Board in Stockholm and the Swedish Ethical Review Authority (Dnr. 2021-06441-02) who also waived the need for informed consent. All methods were performed in accordance with the relevant guidelines and regulations. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: The treatments of hematological malignancies tend to be intense, and compared with solid tumors, less is known about the health care consumption during end of life (EOL). Therefore, the aim was to study the receipt of specialized palliative care (SPC) and how it affects health care utilization, in relation to sex, age, socioeconomics, and frailty risk (Hospital Frailty Risk Score [HFRS])., Methods: In a retrospective, observational registry study, all patients who died of a hematological malignancy during the years 2015-2021 in the Stockholm County were included and analyzed with descriptive statistics and logistic regression models., Results: Of the 2,858 included patients (mean age 76 years, 41% women), 38% had myeloid malignancies, 41% lymphocytic malignancies, and 21% had myeloma. During the last 3 months of life, 56% received SPC, with an overrepresentation of women, aOR 1.35 (1.16-1.58, p < 0.0001), whereas persons with risk of frailty (HFRS) were underrepresented, aOR 0.74 (0.63-0.86, p < 0.0001). Unplanned ER visits were more likely in persons aged over 80 years (p = 0.004) and in persons with frailty risk (p < 0.0001). Patients receiving SPC had a substantially reduced likelihood of ER visits, aOR 0.34 (0.29-0.40, p < 0.0001). Emergency hospitals as place of death was positively associated with frailty risk, aOR 1.50 (1.23-1.83, p < 0.0001) but negatively associated with age over 80 years (p < 0.0001) and especially with receipt of SPC, aOR 0.05 (0.04-0.06, p < 0.0001)., Interpretation: Receipt of SPC could possibly reduce the need for emergency care in the end of life and the Stockholm model might facilitate referral to SPC for hematological patients.

Decision-making for temporomandibular disorders (TMDs) is reported being a clinical challenge, partly due to uncertainities in assessment of long-term prognosis. Therefore, our aim was to explore variations over time in TMD symptoms and possible sex or age differences. In this cohort study, data were prospectively collected 2010-2017 from the general population in Västerbotten, Northern Sweden. Adults were eligible if they had undergone at least two routine dental check-ups that included screening for TMDs (3Q/TMD) from which states were defined as absence or presence of TMD pain and/or jaw catching/locking. The rate of transitions was estimated between TMD states within a time span of one year. A total of 94,769 individuals were included (49.9% women) with 205,684 repeated visits and 9,006 state transitions recorded over the 8-year period. Compared to men, women had higher rates of transitions from no TMDs to any TMD symptoms. Furthermore, women had a lower rate of transition from TMD pain only to no TMDs. The finding of a poorer prognosis in women, as well as previously reported potential gender differences in pain perception and reporting, reinforces that gender differences should be accounted for in the treatment planning stage for patients with onset of TMDs., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Aims: Early identification of patients with increased bleeding risk increases the possibility to individualize antithrombotic treatment. We validated the PRECISE-DAPT score, originally developed to estimate bleeding risk in patients on dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI), in coronary artery bypass grafting (CABG) patients., Methods and Results: All patients who underwent the first time, isolated CABG in Sweden 2009-2020 and survived until discharge were included. The four-item PRECISE-DAPT score, based on age, estimated glomerular filtration rate, pre-operative haemoglobin concentration, and previous spontaneous bleeding, was calculated in patients discharged on DAPT (n = 6838), or antiplatelet monotherapy (n = 15 406). High bleeding risk was defined as a score ≥25 in accordance with previous studies and major bleeding as hospitalization due to bleeding. Associations were assessed by C-statistics and Cox regression models. Major bleeding occurred during the first post-operative year in 130 patients (1.9%) in the DAPT group, and in 197 patients (1.3%) in the monotherapy group. The score identified 32.9% of the patients in the DAPT group and 38.2% in the monotherapy groups as having high bleeding risk. The area under the ROC-curve for the score was 0.67 (95%CI 0.62-0.72) for DAPT and 0.71 (0.67-0.74) for monotherapy. The hazard ratio for high bleeding risk vs. very low risk was 4.14 (2.07-8.26) for DAPT patients, and 4.95 (2.61-9.39) for monotherapy patients, both P < 0.001., Conclusion: The PRECISE-DAPT identifies patients with increased risk for major bleeding after discharge following CABG with moderate accuracy. The accuracy is comparable to what previously has been reported for patients after PCI., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Cholinesterase inhibitors (ChEIs) have beneficial effects on the heart. Associations between ChEI-use and reduced mortality and cardiovascular events in Alzheimer's disease (AD) have been shown. Whether these associations exist in those with both heart failure (HF) and AD is unknown., Methods and Results: A propensity score (PS) matched cohort with patients with HF and AD was obtained through linking registers for cognitive/dementia disorders, comorbidities, drug prescription, and death, in Sweden, to analyse associations between ChEI-use and risk of mortality or hospitalization for HF, stroke, or myocardial infarction, were examined. In 455 patients with and 455 without ChEI treatment, ChEI use was associated with reductions of mortality and hospitalization due to HF by 21% [0.79; (confidence interval) CI 0.66-0.96] and 47% (0.53; CI 0.38-0.75), respectively. Donepezil and galantamine but not rivastigmine were associated with a lower risk of death compared with non-users. Donepezil was associated with a lower risk of hospitalization due to HF compared with non-users. There was no significant difference in hospitalization for bradycardia, AV block, or implantation of pacemaker between ChEI use and non-use., Conclusion: This study suggests that in persons with HF and AD, treatment with ChEIs is associated with improved survival and a decreased risk of hospital care for HF, but results due to the type of ChEI vary., (© The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The use of inotropic agents in treating cardiogenic shock (CS) remains controversial. This study investigates the effect of inotropes on 30-day mortality in CS patients using data from the SWEDEHEART registry (The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies)., Methods and Results: Data were sourced from the national SWEDEHEART registry for all CS patients in Sweden from 2000 to 2022. The primary endpoint was 30-day all-cause mortality. We employed multilevel Cox proportional-hazards regression with instrumental variable and inverse probability weighting propensity score to adjust for confounders. The treatment-preference instrument was the quintile of preference for inotrope use at the treating hospital. A total of 16 214 patients (60.5% men, 39.5% women) were included; 23.5% had diabetes, 10.2% had a previous myocardial infarction (MI), and 13.8% had previous heart failure (HF). The median age was 70 years [interquartile range (IQR); 19], with 66.4% over 70. Acute coronary syndrome (ACS) caused CS in 82.9%. Inotropes were administered to 43.8% of patients, while 56.2% did not receive them. There were 7875 (48.1%) deaths. Patients treated with inotropes were, on average, 2 years younger and more likely to have ACS, while those not treated had more previous MI and were less likely to undergo percutaneous coronary intervention (PCI). The number of CS cases decreased by 12% per year (Ptrend < 0.001), and inotrope use increased by 5% per year (Ptrend < 0.001). Unadjusted mortality in CS rose by 2% per calendar year (Ptrend < 0.001). Inotropes were associated with higher mortality [adjusted hazard ratio (HR) 1.72; 95% CI 1.26-2.35; P = 0.001], with significant interactions between inotrope treatment, age, and diagnosis (Pinteraction < 0.001 and Pinteraction = 0.018)., Conclusion: In this observational study, inotropes were linked to higher mortality in CS patients, particularly those younger than 70. While CS cases decreased, inotrope use and mortality increased in Sweden., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Accumulating studies reported that several phosphodiesterases (PDEs) inhibitors might have cardiovascular benefits., Objectives: This study aimed to explore the relationship between genetically-predicted PDEs and ischaemia heart disease via drug target Mendelian randomization (MR) approach, and then examine the effect of inhibitors of identified target on the outcomes by using real-world data., Methods and Results: In the two-sample MR study, the expression of genes encoding PDEs was used to proxy the level of PDEs and available expression quantitative trait loci (eQTLs) for each target gene were identified as the genetic instruments. The outcomes included coronary heart disease (CHD) and myocardial infarction (MI). In the real-world study, a retrospective cohort was conducted to compare the incidence of outcomes between PDE5 inhibitors and alprostadil use by linking Swedish nationwide registers. MR analyses identified two types of PDEs, PDE5, and PDE8, genetically-predicted expression in blood of the encoded genes was significantly associated with the risk of CHD [odds ratio (OR)PDE5A = 1.22,95% confidence interval (CI) = 1.06-1.40; ORPDE8A = 1.26,95% CI = 1.07-1.49] and MI (ORPDE5A = 1.27,95% CI = 1.09-1.48; ORPDE8A = 1.24,95% CI = 1.04-1.48). Notably, the highest expression of PDE5A was observed in artery aorta, which was also positively related to CHD (OR = 1.17,95% CI = 1.05-1.32) and MI (OR = 1.15,95% CI = 1.02-1.30). Real-world study provided supportive evidence that as compared to alprostadil use, PDE5 inhibitors use significantly reduced the incidence of CHD (adjusted HR = 0.70,95% CI = 0.66-0.73) and MI (adjusted HR = 0.79,95% CI = 0.73-0.84)., Conclusion: This study provided observational and genetic evidence about the protective role of PDE5 inhibition against ischaemic heart disease, indicating the potential of these drugs to be repurposed for ischemia heart disease prevention and treatment., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Diagnosing mild intellectual disability (ID) in children is very often challenging and may require multiple assessments over time to confirm the diagnosis with confidence. In Sweden, this diagnosis is typically made within the school health services, where close collaboration between psychologists, school doctors, and educators is essential. Children diagnosed with mild ID are entitled to attend specially adapted schools. It is important to recognise that many children with mild ID also experience other developmental, neurological, or neuropsychiatric conditions (ESSENCE). Beyond the initial evaluation in school health services, it is crucial that children be referred to specialised paediatric clinics for further investigation of potential underlying causes. In some cases, a child psychiatry consultation may also be necessary. Given the frequent presence of comorbidities, children with mild ID require ongoing clinical follow-up to support their development over time.

Background and Purpose: There is an urgent need to improve patient-selection to surgical treatment in advanced ovarian cancer as our results showed that cytoreductive surgery was without effect or even detrimental in a yet unknown subgroup of women. With an ageing population, 30% of women with advanced ovarian cancer in Sweden are >75 years. Nevertheless, there are no recommendations on patient-selection, albeit treating an unselected population in a public and centralized health care setting. Little attention has been placed on frailty assessments in oncology, despite their potential to stratify the risk of adverse outcome and mortality. Consequently, we hypothesize that frailty is a predictor of poor survival., Patients and Methods: In this Swedish multi-centre prospective cohort study, where the exposure is frailty, consecutive women with advanced ovarian cancer scheduled for surgery with curative intent are eligible for inclusion. Three different frailty instruments are evaluated preoperatively, blinded to the caregiver. The primary outcome is 2-year overall survival. With a fixed sample size of 450 patients, a two-sided α of 0.05 and β of 0.20, the study is powered to detect a difference in 2-year survival of 12.5% by frailty, assuming a 20% prevalence of frailty. The result of the study will have a direct impact on clinical management and patient-selection as the results are expected to have a high external validity. Total study-time is 5 years, with 3 years of accrual. All participating centres started accrual by September 2024. Presentation of data on primary outcome is expected 2029., Study Registration: ClinicalTrials.gov NCT06298877.

Introduction: Preterm delivery risk is increased for women with a previous cesarean section, which are becoming more common worldwide. However, this risk is based on studies which have not fully accounted for selection bias, and the studied outcomes have been limited to the study of early deliveries. This study aimed to determine the impact of previous delivery modes on the incidence of deviant duration of subsequent pregnancies., Material and Methods: This retrospective cohort study used clinical data registered in the Swedish Medical Birth Register. 612 935 women with their first two pregnancies and 157 581 women with their first three pregnancies were included. The outcome was the gestational duration of the last pregnancy of the series, depending on previous delivery modes. The associations were analysed with multivariable logistic regression (with the gestational duration categorised) and survival models including Cox regression analyses., Results: When using standard logistic regression, previous cesarean section was associated with an increased risk of both spontaneous preterm birth (adjusted odds ratio [aOR] 1.67, 95% CI 1.57-1.77) and postterm birth (aOR 1.55, 95% CI 1.49-1.62). However, the more appropriate survival models only showed an association between cesarean section and longer gestational duration of the subsequent pregnancy (adjusted hazard ratio 0.72, 95% CI 0.71-0.73)., Conclusions: The survival model handles bias related to management differences between the exposure and reference groups better than standard logistic regression, making it the statistical method of choice when conducting studies on this research topic. This study shows that the main association between cesarean section and the gestational duration of the subsequent pregnancy is the prolonging of it, which stands in contrast with previous research on the topic., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Evers et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The genetic contributions to early onset heart failure (HF) are incompletely understood. Genetic testing in advanced HF patients undergoing heart transplantation (HTx) may yield clinical benefits, but data is limited. We performed deep-coverage whole genome sequencing (WGS) in 102 Swedish HTx recipients. Gene lists were compiled through a systematic literature review. Variants were prioritized for pathogenicity and classified manually. We also compared polygenic HF risk scores to a population-based cohort. We found a pathogenic (LP/P) variant in 34 individuals (34%). Testing yield was highest in hypertrophic (63% LP/P carriers), dilated (40%) and arrhythmogenic right ventricular (33%) cardiomyopathy and lower in ischemic cardiomyopathy (10%). A family history was more common in LP/P variant carriers than in non-carriers but was present in less than half of carriers (44% vs 13%, P < 0.001), whereas age was similar. Polygenic risk scores were similar in HTx recipients and the population cohort. In conclusion, we observed a high prevalence of pathogenic cardiomyopathy gene variants in individuals with early-onset advanced HF, which could not accurately be ruled out by family history and age. In contrast, we did not observe higher polygenic risk scores in early onset advanced HF cases than in the general population., Competing Interests: Declarations. Competing interests: R.T.L reports research grants from Pfizer and consultancy fees from FITFILE and HealthLumen, unrelated to the present work. P.N. reports research grants from Allelica, Amgen, Apple, Boston Scientific, Genentech / Roche, and Novartis, personal fees from Allelica, Apple, AstraZeneca, Blackstone Life Sciences, Creative Education Concepts, CRISPR Therapeutics, Eli Lilly & Co, Foresite Labs, Genentech / Roche, GV, HeartFlow, Magnet Biomedicine, Merck, and Novartis, scientific advisory board membership of Esperion Therapeutics, Preciseli, and TenSixteen Bio, scientific co-founder of TenSixteen Bio, equity in MyOme, Preciseli, and TenSixteen Bio, and spousal employment at Vertex Pharmaceuticals, all unrelated to the present work. Other authors have no conflicts to declare., (© 2025. The Author(s).)

Background: Pain is a frequent reason for contacting the Emergency Medical Services (EMS), and effective pain management constitutes one of its cornerstones. The aims of this study have been: (a) to describe the prevalence of pain intensity ratings in EMS care of patients with pain-related conditions; (b) to describe pain treatment in the EMS setting in terms of drugs administered and the proportion of patients receiving analgesics and (c) to investigate the relationship between patients' self-reported pain intensity and vital signs., Methods: This is a retrospective observational cohort study using data from 394,700 EMS missions conducted 2021 and 2022, as recorded in the Swedish Ambulance Registry. The study focused on patients who contacted the EMS due to pain, trauma, or injury. Pain intensity was recorded using the Numeric Rating Scale (NRS). NRS scores of 5-10 were considered as high-level pain and NRS ≤ 4 as low-level. Descriptive statistics were used to present categorical and continuous variables. Chi-square tests were applied for dichotomous variables, while Kruskal-Wallis tests were used for ordinal data. Logistic regression analysis was carried out to identify factors associated with pain intensity and analgesic treatment. p value < 0.001 was considered statistically significant., Results: Pain intensity was recorded in 23.6% of cases. Most patients rated their pain as high-level (NRS 5-10, 57.4% of those assessed). Analgesics were administered in 27.5% of cases, with higher administration rates observed when pain intensity was documented. Female sex, higher breathing rates, and higher systolic blood pressure were associated with higher pain intensity, while increasing age was associated with lower odds of reporting high-level pain intensity. No significant association was found between heart rate and pain intensity., Conclusion: This 2-year cohort study highlights significant deficiencies in recorded pain assessment and management in the Swedish EMS. Only 22.5% of the patients had their pain assessed with a validated scale, while 27.5% received analgesics, although pain-related conditions were a common reason for contacting the EMS. The findings indicate a lack of systematic pain assessment which puts many patients at risk of insufficient pain relief., Competing Interests: Declarations. Ethics approval and consent to participate: The study protocol was reviewed by the Swedish Ethical Review Authority (Dnr 2023-02599-01). As the study only handle anonymised data without any possibility for identification of specific individuals the review board established that no ethical approval was needed in accordance with Swedish legislation (Act (2003:460) on Ethical Review of Research Involving Humans). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: As we age, staying physically active and reducing sedentary behavior becomes crucial. To understand how to achieve this, factors related to daily physical function such as five-time sit-to-stand (STS) time should be explored. This study aimed to investigate the associations between STS time, self-rated physical activity, physical function, health-related quality of life, physical and mental health in community-dwelling older adults aged ≥ 60 years., Method: Cross-sectional design with self-reported and objectively measured data from adults aged ≥ 60 years (n = 819), acquired from the Swedish National Study on Aging and Care. Data was analyzed through multiple linear regression., Results: The model (R 2  = 0.268) showed that STS time was predicted by grip strength (β' = -0.204, p < 0.05), age (β' = 0.202, p < 0.05), health-related quality of life (β' = -0.192, p < 0.05), having fallen within the preceding twelve months (β' = -0.127, p < 0.05), physical activities of perceived light to moderate intensity (β' = -0.121, p < 0.05), one-leg stand (β' = -0.099, p < 0.05), and education level (β' = -0.092, p < 0.05). For STS time, health-related quality of life (β = -0.354, confidence interval [CI] (-0.509)-(-0.199)), having fallen within the preceding twelve months (β = -0.222, CI (-0.365)-(-0.078)), and physical activities of perceived light to moderate intensity (β = -0.166, CI (-0.278)-(-0.053)) were the most prominent predictors., Conclusion: The model highlights the importance of grip strength and health-related quality of life in predicting STS time in older adults. Clinicians can use these insights to develop interventions that maintain physical function by regularly assessing and monitoring these factors. Future research should explore the relationship between fall history, faster STS time, and the impact of grip strength and health-related quality of life on sedentary behavior among older adults., Competing Interests: Declarations. Ethics approval and consent to participate: The study adhered to the ethical principles outlined in the Declaration of Helsinki [11] and was approved by the ethics committee of Lund University (LU 128–00, LU 604–00). All participants provided written informed consent before entering the SNAC and received written information. Personal data were processed in accordance with the General Data Protection Regulation [32]. In connection with the survey, the participants received written information and gave written informed consent for participation. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Importance: It is unclear whether a higher dose (150-160 mg) or a lower dose (75 mg) of aspirin should be used to prevent preeclampsia., Objectives: To compare the risk of preeclampsia and bleeding complications between women using 150 to 160 mg of aspirin and those using 75 mg of aspirin for preeclampsia prevention., Design, Setting, and Participants: This nationwide cohort study included 13 828 women giving birth at 22 weeks' gestation or later in Sweden between January 2017 and December 2020 who used low dose aspirin (75-160 mg) during pregnancy. Data were analyzed from October to November 2023., Exposure: The use of 150 to 160 mg or 75 mg of aspirin in pregnancy., Main Outcome and Measures: The main outcome was a preeclampsia diagnosis recorded in the maternal birth record at the time of hospital discharge. The main safety outcome was postpartum hemorrhage, defined as bleeding more than 1000 mL after delivery. Relative risks (RRs) and 95% CIs were estimated using a doubly robust inverse probability-weighted regression adjustment model controlling for background characteristics., Results: In the total cohort of 13 828 women, the mean (SD) age was 33.0 (5.5) years and 3003 women (21.7%) were nulliparous. Of the women, 4687 (33.9%) were prescribed 150 to 160 mg of aspirin, and 9141 (66.1%) were prescribed 75 mg of aspirin. A total of 10 635 women (76.9%) had at least 2 dispensed prescriptions of low-dose aspirin. Among women using 150 to 160 mg of aspirin, 443 (9.5%) developed preeclampsia compared with 812 (8.9%) of those using 75 mg of aspirin (adjusted RR [aRR], 1.07; 95% CI, 0.93-1.24). Additionally, the risk of postpartum hemorrhage between the groups was similar, with 326 women (6.9%) using 150 to 160 mg of aspirin experiencing a postpartum hemorrhage compared with 581 (6.4%) in the 75-mg group (aRR, 1.08; 95% CI, 0.90-1.30)., Conclusions and Relevance: In this cohort study of 13 828 women, no difference was found in preeclampsia incidence or bleeding complications between those using 150 to 160 mg of aspirin vs 75 mg of aspirin during pregnancy for preeclampsia prevention. These findings suggest that either dose may be a reasonable choice when using aspirin to prevent preeclampsia. However, large randomized trials investigating aspirin dose in pregnancy are still needed.

Background: The study aimed to explore which sociodemographic, health-related, and work-related factors were associated with the number of sickness absence days during 18 months among employees on sickness absence due to common mental disorders., Methods: A longitudinal study with participants from a cluster-randomized controlled trial was conducted. Participants from both intervention and control groups were treated as one cohort. Factors included in the analysis were sociodemographic, health-related, and work-related variables collected through questionnaires at baseline. The outcome was cumulative net sickness absence days for sickness absence spells exceeding 14 days and was collected from a national register. Data was analyzed using generalized estimating equations., Results: The sample consisted of 197 employees. Lower-rated work ability in relation to physical demands ([exp (B) 1.19], 95% CI 1.02-1.40) and higher-rated job demands ([exp (B) 1.28], 95% CI 1.01-1.61), were associated with increased number of sickness absence days during the 18 months follow-up. Higher certainty of return to work within three months ([exp (B) 0.63], 95% CI 0.48-0.83) was associated with a decreased number of sickness absence days during the 18 months follow-up., Conclusions: Our study suggests that work-related factors, i.e., high job demands and impaired work ability, are associated with an increased number of days on sickness absence. Additionally, the certainty of returning to work within three months is associated with fewer days on sickness absence. The results highlight the importance of addressing specific workplace factors when designing interventions aimed at decreasing sickness absence for employees on sickness absence due to CMDs. The results could be used to inform a dialogue between healthcare personnel and employees on sickness absence due to CMDs, and to serve as basis for a structured inventory to assist healthcare personnel in addressing workplace factors., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical approval was obtained for the original cluster-RCT at the local Review Board in Gothenburg (nr 496 − 17). Participants signed informed consent before inclusion in the study. Additional ethical approval for the research question in the study at hand was obtained from the Swedish Ethical Review Authority (nr 2021/01768). This study was carried out in accordance with the Declaration of Helsinki [54]. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Childhood adversity places individuals in a vulnerable position, resulting in potentially enduring disadvantage across life domains like health and work. Studying the manifestation of this disadvantage is crucial for understanding which resources society can provide to mitigate or prevent it, which makes this subject a fundamental public health concern. This study investigated whether disadvantage patterns after childhood adversity differ by gender and educational level, using out-of-home care as proxy for early adversity., Methods: We used register data from a 1953 Swedish birth cohort. Distinct profiles of socioeconomic and health disadvantage in individuals with out-of-home care experience were identified using group-based multi-trajectory modelling. Multinomial logistic regression was then used to determine whether gender and education, individually or in interaction with each other, predict group membership., Results: In the population without history of out-of-home care, adulthood disadvantage was highly gendered, with women being more likely to experience disadvantage related to unemployment and poor health, while criminality and substance misuse was more common among men. History of out-of-home care was associated with a general increase in adulthood disadvantage, but the gender differences were largely absent. Women in this group were however less likely than men to experience disadvantage across multiple life domains (complex disadvantage OR = 0.56, p = 0.046; unemployment-related disadvantage OR = 0.51, p = 0.005). Higher level of education was associated with reduced likelihood of membership in the group marked by disabling health disadvantage (OR = 0.55, p = 0.002) and complex disadvantage (OR = 0.37, p = 0.001). An interaction term between gender and education was not significant., Conclusions: Adulthood disadvantage was more common in the group with history of out-of-home care. The gender differences in disadvantage present in the full cohort were largely attenuated among individuals with out-of-home care history. We showed that using administrative data on outcomes across multiple life domains can provide rich descriptions of adult experiences after childhood adversity. Future research could examine gender differences in mechanisms translating into resilient or vulnerable trajectories, including the protective potential of education in relation to specific disadvantage patterns., Competing Interests: Declarations. Ethics approval and consent to participate: This study was based on anonymised individual-level register data and, therefore, the need for informed consent was deemed unnecessary according to national regulation. All methods were carried out in accordance with relevant guidelines and regulations. Ethical approval of this study was granted by the Swedish Ethical Review Authority (no. 2019–04376). The Regional Ethical Review Board in Stockholm approved the creation of the dataset, SBC Multigen (no. 2017/34 − 31/5; 2017/684 − 32). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Psychotic major depressive disorder (MDD), a subtype of MDD characterised by psychotic symptoms that occur exclusively during mood episode, is clinically significant yet underexplored genetically due to its rarity. This study comprehensively examines the genetic basis of psychotic MDD and elucidates its position within the mood-psychotic spectrum., Methods: This population-based cohort study used Swedish and Danish registry data for over 5.1 M individuals born between 1958 and 1993/1996. Specialist-diagnosed psychotic MDD was defined using ICD-10 sub-codes of MDD, F32.2/F32.3. We estimated familial aggregation/coaggregation using generalised estimating equations, heritability and genetic correlations using structural equation modelling. We also analysed ∼30,000 genotyped MDD cases from the UK Biobank and a Swedish cohort to explore which polygenic risk score (PRS) may predispose individuals to psychotic MDD., Findings: With over 10,000 psychotic MDD identified from the two nationwide patient registers, this study highlights the familial aggregation of psychotic MDD, co-aggregation with mood and psychotic disorders, and its stronger genetic correlation with schizophrenia compared to non-psychotic MDD. The familial risks increased with closer biological relatedness, suggesting genetic influence. Pedigree-heritability of psychotic MDD was 30.17% (95% CI 23.53-36.80%). While the genetic correlation between psychotic and non-psychotic MDD was high (0.82, 95% CI 0.73-0.92), the psychotic subgroup showed a higher genetic correlation with schizophrenia than non-psychotic MDD (0.67 vs 0.46, p-value 7.55∗10 -4 ). Within 30,000 genotyped MDD cases, individuals with psychotic MDD had higher mean PRS for schizophrenia and BD but a lower MDD PRS than non-psychotic MDD. PRS for BD type-I was associated with increased odds of psychotic MDD, while BD type-II PRS showed no significant association with psychotic MDD., Interpretation: This study provides evidence for the genetic basis of psychotic MDD, underscoring its unique position bridging the spectrum of mood and psychotic disorders. These findings advance our understanding of the aetiology of psychotic MDD and contribute to the limited body of evidence on this phenotype by utilising large-scale population-based data., Funding: European Research Council; US National Institutes of Mental Health; European Union Horizon 2020 Program; Swedish Research Council; Research Council of Norway; Swedish Foundation for Strategic Research; Hjärnfonden., Competing Interests: Declaration of interests PFS was a paid advisor and shareholder for Neumora Therapeutics. ML has received lecture honoraria from Lundbeck pharmaceuticals outside the submitted work. OA is a consultant to Cortechs.ai and Precision-Health.AI and has received speaker’s honorarium from Otsuka, Lundbeck, Janssen and Sunovion. HL has received grants from Shire/Takeda, lecture honoraria from Shire/Takeda, Medici and Elovan, all outside the submitted work Coauthors declare no conflict of interest., (Copyright © 2025 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: A better understanding of body-brain links may provide insights on targets for preventing cognitive decline. The aim was to explore associations of body composition with neuroimaging biomarkers and cognitive function among dementia-free 70-year-olds., Methods: Dual-energy X-ray absorptiometry body composition measures in relation to neuroimaging measures of cortical thickness, hippocampal volume, small vessel disease, predicted brain age, and cognitive performance were explored in a cross-sectional study of 674 dementia-free 70-year-olds from the Swedish Gothenburg H70 Birth Cohort study. Linear or ordinal regression analyses were performed., Findings: Higher quantity of muscle mass was associated with lower predicted brain age (β: -0.31 [95% CI: -0.45, -0.16], p: 0.00013). Those with normal level muscle mass (>7.0 men, >5.5 women kg/height m 2 ) had overall thicker cortex (β: 0.043 [95% CI: 0.023, 0.064], p: 0.00016), thicker cortex in Alzheimer's disease signature regions (β: 0.051 [95% CI: 0.025, 0.076], p: 0.00040), and larger hippocampal volume (β: 111.52 [95% CI: 25.28, 197.75], p: 0.030) compared to those with sarcopenic level muscle mass. Higher accumulation of visceral fat was associated with overall thinner cortex (β: -0.017 [95% CI: -0.028, -0.005], p: 0.024). Faster gait speed and higher handgrip strength were associated with indicators of better brain health., Interpretation: Improving muscle mass fitness and lower visceral fat may be beneficial for brain health. Intervention studies are needed to confirm that targeting body composition can promote healthy brain ageing and reduce the risk of cognitive impairment among older adults., Funding: The Swedish Research Council, Hjärnfonden, and Alzheimerfonden., Competing Interests: Declaration of interests The authors of this manuscript declares that there are no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Smoking and obesity interact to exacerbate the risk of hypertension, diabetes, and cardiovascular disease, but their potential synergistic effects on outcomes in multiple sclerosis (MS) have not been well studied. We aimed to study whether smoking and obesity interact to affect disease progression and cognitive function in patients with MS., Methods: Incident cases from the population-based case-control study Epidemiological Investigation of MS (EIMS) were categorized by smoking and obesity status at diagnosis and followed up to 15 years postdiagnosis through the Swedish MS registry (n = 3336). Cox regression was used to analyze outcomes, including clinical disease worsening (CDW), progression to Expanded Disability Status Scale (EDSS) levels 3 and 4, physical worsening as measured by a 7.5-point increase in the MS Impact Scale (MSIS) physical score, and cognitive decline, defined as an 8-point or greater reduction on the Symbol Digit Modalities Test (SDMT). Interaction effects on the additive scale were assessed by combining dichotomous variables for smoking (nonsmoker = 0, smoker = 1) and obesity (nonobese = 0, obese = 1), yielding four categories: 0/0 (reference category), 0/1, 1/0, and 1/1., Results: Additive interactions between smoking and obesity were identified for CDW (attributable proportion due to interaction [AP] 0.18, 95% CI 0.03-0.30), progression to EDSS 4 (AP 0.18, 95% CI 0.08-0.26), MSIS-Physical score worsening (AP 0.32, 95% CI 0.21-0.42), and cognitive decline (AP 0.27, 95% CI 0.19-0.35)., Conclusions: Smoking and obesity appear to synergistically worsen MS progression and cognitive functioning, with the observed additive interactions across most outcomes suggesting that these factors partly share common biological pathways contributing to disease progression., (© 2025 The Author(s). European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Purpose: This cross-sectional survey study aimed to explore the phacoemulsification techniques among Swedish cataract surgeons, and investigate the association between technique preferences and surgical outcomes, particularly posterior capsular rupture (PCR)., Methods: A survey questionnaire was responded by 170 cataract surgeons and data from 192 494 cases, linked to the surgeons, were analysed from the Swedish National Cataract Registry (SNCR) for 2021-2022. Surgeons' demographic characteristics, surgical techniques and complications were assessed. Associations between surgical technique preferences and outcomes were analysed with binary logistic regression., Results: The chopping technique (stop and chop or direct chop) was favoured by 64.6% of surgeons, followed by divide and conquer (32.4%), and tilt and tumble (7.6%). Surgeons' annual caseloads varied widely (range 11-2687). No significant correlation was found between technique preference and PCR rates, which was consistently 0.5%-0.6% in all groups, except for a trend suggesting reduced risk with tilt and tumble. Mentoring activity (35.0%) and public surgical setting (40.3%) was highest in the direct chop group. Notably, 75% of the surgeries were performed by surgeons with more than 10 years' experience. Confounding factors, such as high-volume surgeons having a low frequency of complications, have been accounted for in a logistic regression., Conclusion: This study provides insights into cataract surgery practices in Sweden and suggests that surgeons can choose their preferred approach without significantly affecting complication rates. This research also underscores the need for continued exploration of surgical practices and their impact on patient outcomes, particularly in the case of the tilt and tumble technique, which is less commonly employed., (© 2024 The Author(s). Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Objectives: To investigate if receipt of measles-mumps-rubella (MMR) vaccine following the third dose of diphtheria-tetanus-acellular pertussis (DTaP3) is associated with reduced rates of non-targeted infectious disease hospitalisations., Methods: Register based cohort study following 1,397,027 children born in Denmark, Finland, Norway, and Sweden until 2 years of age. Rates of infectious disease hospitalisations with minimum one overnight stay according to time-varying vaccination status were compared using Cox proportional hazards regression analysis with age as the underlying timescale and including multiple covariates. Summary estimates were calculated using random-effects meta-analysis., Results: Compared with DTaP3 and no MMR vaccine, MMR after DTaP3 was associated with reduced rates of infectious disease hospitalisations: aHR was 0.86 (0.83-0.89) in Denmark, 0.70 (0.64-0.75) in Finland, 0.71 (0.68-0.74) in Norway, and 0.71 (0.65-0.77) in Sweden: summary estimate was 0.75 (0.65 to 0.84). A beneficial association was also seen in a negative control exposure analysis (3 vs. 2 DTaP doses): summary estimate aHR was 0.81 (0.75-0.87)., Conclusions: Having MMR as the most recent vaccine was consistently associated with reduced rates of infectious disease hospitalisation. However, bias may account for at least some of the observed association. Randomised controlled trials are warranted to inform the optimal timing of MMR for both its specific and potential non-specific effects., Competing Interests: Declaration of Competing Interest All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/http://www.icmje.org/disclosure-of-interest/ and declare: All authors had financial support from NordForsk (grant number: 83839) and LG had financial support from Odense University Hospital Research fund (A-number: 2519) and the faculty scholarship from the University of Southern Denmark for the submitted work; Finnish Institute for Health and Welfare (THL) has conducted Public-Private Partnership with vaccine manufacturers and has received research funding from Sanofi Inc., Pfizer Inc., and GlaxoSmithKline Biologicals SA. HN, ML, and AAP have been investigators in these studies, but they have received no personal remuneration; no other relationships or activities that could appear to have influenced the submitted work. Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, receives institutional research funding from public and private entities for studies of medicines and vaccines, to and administered by Aarhus University. None of these are relevant to the current study. SS is a salaried employee of Department of Clinical Epidemiology., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Purpose: To study the prioritization effects of the of COVID-19 pandemic on Swedish cataract surgery using a national healthcare registry with high coverage., Setting: A study from the Swedish National Cataract Register (NCR), involving all patients undergoing cataract surgery in Sweden during 2019-2022 - before, during and after the COVID-19 pandemic., Results: With the pandemic outbreak, the number of cataract surgeries fell by 22% in 2020 (15 369 procedures), albeit with large regional differences (-43% to +58%). The numbers recovered in 2021, and in 2022, a new top notation was seen (n = 149 952). On a national level, the patients were younger (-0.46 years, p < 0.001), with a larger proportion of less difficult cases (p < 0.001) and the proportion of males was higher (p < 0.001) during the pandemic, but all these variables also differed substantially between different regions and clinics., Conclusion: A national registry with high coverage can map the consequences of an event disrupting elective surgery in detail. During the COVID-19 pandemic, the impact on Swedish cataract surgery varied largely between different regions, clinics, and healthcare providers, leading to inequality in the availability of surgery. These differences likely owed to variations in healthcare policy approaches in different parts of the country. The present study shows that outcomes at one clinic or region cannot be extrapolated to larger regions under these circumstances. It actualizes the need to aim for a healthcare on equal terms, but it also shows a system that delivers care to many despite difficult times., (© 2024 The Author(s). Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Background: Currently, approximately 100 million people are displaced worldwide, including children and young adults. Previous studies showed exposure to violence and posttraumatic stress disorder (PTSD) are common in this sub-population. However, we still lack comprehensive data on well-being, mental health, and the ability to function., Methods: This study included 291 adolescent (aged 12-17 years) and young adult (18-25 years) refugees recruited nationwide in Sweden between 2019 and 2022. Sociodemographic, mental health and well-being-related data (well-being, post-traumatic stress symptoms, psychiatric diagnoses, and functional ability) were collected using semi-structured interviews with structured components. Associations between accompanied status and well-being/depression/suicidal thoughts, generalized anxiety disorder/panic disorder/PTSD symptoms, and functional ability were analyzed using linear and logistic regression, adjusted for age, gender, parental education, asylum status, and region of origin., Findings: Most study participants (mean age 17·9 years) originated from the Middle East and North Africa (70·6 %) or Sub-Saharan Africa (27·0 %). 16·1 % of adolescents and 32·3 % of young adults were unaccompanied. Nearly the entire study sample had experienced violence (92·8 %). However, the sample had a low prevalence of psychiatric diagnoses. For example, only 5·9 % fulfilled the criteria for clinical depression. Self-reported well-being (WHO-5, 71·09 (23·91)) and observer-rated functional ability (GAS/GAF, 81·76 (14·15)) were high. There were no significant differences in diagnosis prevalence by gender. However, significant differences existed between accompanied versus unaccompanied groups. Being an unaccompanied refugee individual was associated with a higher risk of suicidal thoughts, adjusted odds ratio, aOR 5·66 (95 % CI 2·15-14·88), higher rates of post-traumatic stress disorder symptoms β = 0·72 (0·39-1·05), lower mental well-being β = -10·86 95 % CI (-18·23- -3·48) and lower functional ability β = -9·38 (-13·84- -4·92). There were no differences in outcomes by gender except for worse well-being in males (β = 6·83 (1·01-12·66))., Interpretation: In this sample, we found lower prevalence rates for all psychiatric diagnoses compared to earlier published studies. Being an unaccompanied refugee individual was a risk factor for all adverse outcomes. Future studies need to confirm the relatively low rates of psychiatric diagnoses. Regardless, the results highlight the heterogeneous needs among newly arrived refugees., Competing Interests: Declaration of competing interest EM has been partly employed by Save the Children Sweden. AK declares no conflict of interest. JA declares no conflict of interest. HK declares no conflict of interest. LK heads Barnafrid, the Swedish National Competence Centre on Violence Against Children at Linköping University. Barnafrid has a governmental assignment to disseminate knowledge about violence against children. LK also acknowledges funding from The Swedish Research Council (2018–02623, 2018–05820), Region Östergötland (RÖ-795611, RÖ-897641, RÖ-982104, FORSS-807001) and the EU (project IDs 734,791, 101,005,422, 101,056,647, 101,096,768). The views expressed are entirely those of the authors., (Copyright © 2025 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To examine the prevalence of self-reported cataract and cataract surgery, and the incidence of cataract surgery, in relation to smoking and use of the moist smokeless tobacco product snus., Methods: In 2014/2015, individuals born in 1951 (n = 18 055) in the Västra Götaland County, Sweden, were invited to participate. Of these, 9743 (54%) accepted participation and 9316 (52%) remained after exclusion criteria were applied. Participants answered a questionnaire with items about eye conditions, smoking, snus, gender, education, asthma, chronic obstructive pulmonary disease, corticosteroid use, diabetes mellitus, weight and height. Prevalence ratios (PRs) for self-reported cataract and cataract surgery were calculated. The incidence of cataract surgery was assessed, and hazard ratios (HRs) were presented., Results: Having ever smoked was associated with a higher prevalence ratio of self-reported cataract (PR 1.19, 95% confidence interval [CI] 1.04-1.35) and cataract surgery (PR 1.27, 95% CI 1.06-1.53), compared to those who had never been daily smokers. Currently, a smoker was associated with a higher HR of cataract surgery (HR 1.34, 95% CI 1.04-1.74), as well as having been a former smoker (HR 1.27, 95% CI 1.03-1.56). Total years of smoking were associated with an increased risk for cataract surgery (HR 1.05, 95% CI 1.02-1.08 for 5 years of smoking). Snus use was not associated with an increased prevalence of cataract or incidence of cataract surgery, except among women who were current snus users (HR for cataract surgery 2.04, 95% CI 1.16-3.60 n = 108)., Conclusion: Smoking is associated with a higher prevalence of cataracts, and a higher incidence of cataract surgery, indicating a dose-response relationship. However, there was no firm association between snus use and cataract., (© 2024 The Author(s). Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Objective: Elevated healthcare use before multiple sclerosis (MS) onset suggests earlier opportunity to identify MS. Yet their timing and sociodemographic effects are unclear. We examined rates of healthcare use (and by age/sex) for >two decades pre-MS onset., Methods: We identified people with MS (PwMS) using administrative data from Canada (Ontario) and Sweden (1991-2020) ("administrative" cohort), and the Swedish MS Registry ("clinical" cohort). The first MS/demyelinating diagnostic code (administrative) or symptom onset (clinical) defined MS onset. We compared annual rates of healthcare use (hospital, physician, and emergency-room [ED]) pre-onset between PwMS and up to five matched population controls using negative binomial regression, and by age/sex., Results: The administrative cohort = 35,018/136,007 PwMS/controls (Ontario), and 10,269/51,297 (Sweden). Rates of healthcare use were higher for PwMS than controls up to 28 (of 29) years (Ontario) and up to 15 (of 19) years (Sweden) pre-onset. Annual healthcare use rose steadily as onset approached, particularly escalating 7 years pre-onset in Ontario (e.g., hospital visit rate ratios [RRs] exceeded 1.30), and 6 years in Sweden (physician visit RRs > 1.10). RRs peaked the year pre-onset (ED visits [Ontario] = 3.04; 95% CI: 2.94-3.13, physician visits [Sweden] = 2.51; 95% CI: 2.44-2.59). In the year pre-onset, RRs were disproportionately higher for males (ED RRs [Ontario] = 3.30; 95% CI: 3.13-3.48 vs. females = 2.90; 95% CI: 2.79-3.02), and dropped steadily by age (physician visit RRs [Sweden] = 2.61/2.27/1.97/1.72 for 50/40/30/20-year-olds). The smaller clinical cohort (7604/37,974 PwMS/controls) exhibited similar patterns, albeit more modest, with RRs elevated up to 5 years pre-onset (physician visit RR [year-5] = 1.08; 95% CI: 1.02-1.14; RR [year-1] = 1.39;1.33-1.46)., Interpretation: Higher healthcare use was evident decades before MS onset, escalating 6-7 years pre-onset, peaking the year before, being disproportionately higher for males and older PwMS., (© 2024 The Author(s). Annals of Clinical and Translational Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.)

Background and Aims: Patients with alcohol-related liver disease (ALD) might be at increased risk of acute pancreatitis (AP), but large-scale data are lacking., Methods: Population-based cohort study using data from the Swedish National Patient Register on 37,062 patients with ALD from 1969 to 2020. Patients were matched to ≤10 general population comparators (n = 352,931). We used logistic regression to estimate the risk of acute or chronic pancreatitis prior to ALD diagnosis and Cox regression to estimate rates for hospitalization for AP after ALD diagnosis., Results: Median age at ALD diagnosis was 59 years; 72% were men, and 67% had cirrhosis at baseline. Overall, 7% had experienced pancreatitis before ALD diagnosis, resulting in 9-fold higher odds of pancreatitis compared to comparators. The 10-year cumulative incidence of hospitalization for AP was 2.7% (95%CI = 2.5-2.8) in ALD and 0.6% (95%CI = 0.58-0.63) in comparators, yielding an adjusted HR of 6.3 (95%CI = 5.8-6.9). Younger age, male sex, and diagnoses of alcohol use disorders and chronic obstructive pulmonary disease were independent risk factors for developing AP in ALD. Continued drinking after baseline was associated with a higher risk of AP (adjusted hazard ratio [aHR] 2.6, 95%CI = 2.29-2.85)., Conclusions: ALD is associated with 9-fold higher odds of prevalent pancreatitis compared to the general population. The hospitalization rate for AP following ALD diagnosis is 6-fold higher. About 10% of patients with ALD have or develop AP, suggesting that assessing history of pancreatitis and its sequelae might be relevant for patients with ALD., (© 2024 The Author(s). Journal of Internal Medicine published by John Wiley & Sons Ltd on behalf of Association for Publication of The Journal of Internal Medicine.)

Background: Problem gambling and gambling disorder cause severe social, psychiatric, and financial consequences, and voluntary self-exclusion is a common harm reduction tool used by individuals with gambling problems., Objective: The aim of this study was to explore users' experience of a novel nationwide, multioperator gambling self-exclusion service, "Spelpaus," in Sweden and to inform stakeholders and policy makers in order to improve harm reduction tools against gambling problems., Methods: Semistructured interviews were conducted with 15 individuals who reported self-perceived gambling problems and who had experience of having used the self-exclusion service Spelpaus in Sweden. Interviews were transcribed and analyzed through qualitative content analysis., Results: We identified 3 categories and 8 subcategories. The categories were (1) reasons for the decision to self-exclude, (2) positive experiences, and (3) suggestions for improvement. The subcategories identified a number of reasons for self-exclusion, such as financial reasons and family reasons, and positive experiences described as a relief from gambling; in addition, important suggestions for improvement were cited, such as a more gradual return to gambling post-self-exclusion, better ways to address loopholes in the system, and transfer from self-exclusion to treatment., Conclusions: Voluntary self-exclusion from gambling, using a nationwide multioperator service, remains an appreciated harm-reducing tool. However, transfer from self-exclusion to treatment should be facilitated by policy making, and loopholes allowing for breaching of the self-exclusion need to be counteracted., (©Johanna Tjernberg, Sara Helgesson, Anders Håkansson, Helena Hansson. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 31.01.2025.)

Peyronie's disease (PD) is a disorder of the penis that is associated with poor mental health, lowered psychosocial- and sexual wellbeing, which may increase the risk of childlessness in men affected by the disorder. Although this is an issue of significant clinical importance, it has not been addressed in research to date. We conducted a longitudinal cohort study based on data from Swedish national registers utilizing a large sample of help-seeking men with PD, along with matched subjects from the general population. We assessed the probability and odds ratio of childlessness, modeled with logistic regressions, and offspring rate ratio, modeled with Poisson regression. We found that the probability of childlessness was somewhat lowered for men with PD aged between 35 and 71 years at end of follow-up. Men with PD aged 35 or less showed slightly elevated probabilities of childlessness. Specifically, odds ratios for childlessness were between 0.5 and 1.0 for men aged above 35, and between 1 and 1.5 for men aged less than 35, although the confidence intervals for increased odds partly included the null. Analyses of men's rate of offspring showed similar pattern, with higher rate ratios for older men and lower for younger men. Although more research is needed, the findings of this study suggest that clinical urological practice may be enhanced by a proactive discussions about the potential issue of childlessness in younger men with PD., Competing Interests: Henrik Larsson reports receiving grants from Shire Pharmaceuticals; personal fees from and serving as a speaker for Medice, Shire/Takeda Pharmaceuticals and Evolan Pharma AB; and sponsorship for a conference on attention-deficit/hyperactivity disorder from Shire/Takeda Pharmaceuticals and Evolan Pharma AB, all outside the submitted work. Henrik Larsson is also editor-in-chief of JCPP Advances., (Copyright: © 2025 Kuja-Halkola et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To compare work loss after starting tumour necrosis factor inhibitors (TNFi), rituximab, abatacept or tocilizumab in patients with rheumatoid arthritis (RA)., Methods: We used data from the Swedish Rheumatology Quality Register to identify patients aged 19-62 years who were treated with TNFi (n=15 093), rituximab (n=2123), abatacept (n=1877) or tocilizumab (n=1720) between 2007 and 2020. Data on work loss (0-365 days per year) from sick leave and disability pension were retrieved from linkage to the Social Insurance Agency. Patients in the different treatment arms were balanced regarding baseline covariates using inverse probability weighting (IPTW)., Results: Work loss increased for patients with RA until drug treatment initiation, reached a peak in the month after treatment initiation and then levelled off. Following IPTW, at 3 years before starting the treatment, there were no statistically significant differences in the mean annual adjusted work loss days between rituximab, abatacept or tocilizumab vs TNFi (mean difference vs TNFi: rituximab 1.1 days, 95% CI -4.5 to 6.7; abatacept 3.3, 95% CI -2.6 to 9.2; tocilizumab 1.2, 95% CI -4.9 to 7.3). At 3 years after starting the treatment (latest January 2021), there were also no statistically significant differences in the mean annual adjusted work loss days (mean difference: rituximab -4.8 days, 95% CI -11.3 to 1.7; abatacept 5.3, 95% CI -1.8 to 12.3; tocilizumab -0.6, 95% CI -7.7 to 6.5)., Conclusions: Taking channelling into account, patients with RA treated with TNFi, rituximab, abatacept or tocilizumab had similar trajectories of work loss from sick leave and disability pension until treatment initiation, and similar trend breaks and plateau 3 years thereafter., Competing Interests: Competing interests: ‘C.T. has received consulting fees from Abbvie and Boehringer-Ingelheim, and speaker fees from Abbvie, Bristol-Myers Squibb, Nordic Drugs, Pfizer, and Roche. J.A. has acted as principal investigator in agreements between Karolinska Institutet and the following entities, mainly for the safety monitoring of rheumatology immunomodulators via the national ARTIS programme: Abbvie, BMS, Eli Lilly, Janssen, Merck, Pfizer, Roche, Samsung Bioepis, and Sanofi.‘, (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Introduction: The COVID-19 pandemic forced leaders and employees in health care services to take difficult decisions to manage risks associated with employee health and the organizations' functioning. This study aims to identify the changes in employee working routines, job demands, and job resources within Swedish maternal healthcare during the COVID-19 pandemic, and how these changes affected workload and health., Methods: Data were derived from the longitudinal COPE Staff study involving midwives and physicians within maternal healthcare. Three focus group discussions with midwives and physicians (n = 13), and open-ended survey responses (n = 604) during the third wave of the pandemic (January to May 2021) were analyzed using deductive content analysis based on the Job Demands-Resources model. Quantitative measures of workload and burnout from three survey waves, both during the pandemic (January to May 2021 [n = 782] and January to March 2022 [n = 503]) and after the pandemic (February to March 2023 [n = 759]), were analyzed., Results: Multiple changes in working routines were implemented to adhere to national and local guidelines aiming to decrease the spread of Sars-CoV-2. As a result, midwives and physicians experienced increased job demands, including an increased workload and higher emotional and cognitive demands. To balance these demands, new working routines were introduced, and managers increased their efforts to communicate and support the employees. Collegial support also grew. When surveyed, however, most of the maternal healthcare workers said they experienced a high workload. It was found that between 3-7% likely experienced burn out, while another 10% were at risk of burnout during and after the pandemic., Conclusions: The pandemic had a large effect on maternal healthcare employees. Strategies and adaptations on an organizational, managerial, and individual level played an important role in modifying the impact on the organization's operations and employees., Competing Interests: Declarations. Ethics approval and consent to participate: This study was approved by the Swedish Ethical Review Authority on August 27, 2020 (approval number 2020–03446), with amendments on November 12, 2020 (2020–05747) and March 1, 2021 (2021–00854). The participants agreed to participate after giving their informed consent. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Unit-to-unit transfer of critically ill patients infers hazards that may cause adverse events. Circumstantial factors associated with mortality after intensive care include days in the ICU, night-time or weekend discharge and capacity transfer as compared to other reasons for transfer. Distance travelled may also constitute an indirect risk. The aim of this study was to assess potential associations between these circumstantial factors and the risk of death 30 days after transfer., Methods: Data from 2015 to 2019 was retrieved from the Swedish Intensive Care Registry. Logistic regression was used for risk analysis., Results: Among 4,327 patients, 965 (22%) were deceased 30 days after transfer. 1351 patients undergoing capacity transfer had a higher morbidity than patients transferred for other reasons. Using univariable logistic regression, days spent in the referring ICU before transfer, capacity transfer as compared to clinical transfer and repatriation as well as SAPS3 in the receiving ICU were associated with a higher risk of death at 30 days. However, after multivariable regression with adjustment for ICD-10 diagnosis and Standardised Mortality Rate in the receiving ICU, these associations were lost., Conclusion: Our results suggest that inter-hospital transfer is safe to carry out at any time of day and over shorter as well as longer distances., Competing Interests: Declarations. Ethics approval and consent to participate: The study was approved by the Swedish Ethical Review Authority on December 18, 2020 (Dnr 2020-07089). Patient consent was waived due to the retrospective nature of the analysis based on existing data. Consent for publication: Not applicable. Competing interests: All authors declare that they do not have any competing interests., (© 2025. The Author(s).)

Background: Many studies have found more severe COVID-19 outcomes in migrants and ethnic minorities throughout the COVID-19 pandemic, while recent evidence also suggests higher risk of longer-term consequences. We studied the risk of a long COVID diagnosis among adult residents in Sweden, dependent on country of birth and accounting for known risk factors for long COVID., Methods: We used linked Swedish administrative registers between March 1, 2020 and April 1, 2023, to estimate the risk of a long COVID diagnosis in the adult population that had a confirmed COVID-19 infection. Poisson regressions were used to calculate incidence rate ratios (IRR) of long COVID by country/region of birth. The contribution of sex, preexisting health status, disease severity, vaccination status, and socioeconomic factors to differences in long COVID diagnosis by country/region of birth were further investigated., Results: Of the 1,869,188 persons diagnosed with COVID-19 that were included, 7539 had received a long COVID diagnosis. Compared with residents born in Sweden, we found higher risks of long COVID among migrants from East Europe (IRR: 1.44 CI: 1.29-1.60), Finland (IRR: 1.36 CI: 1.15-1.61), South Asia (IRR: 1.28 CI: 1.03-1.59), Other Asia (IRR: 1.35 CI: 1.13-1.62), Other Africa (IRR: 1.48 CI: 1.17-1.87), and the Middle East (IRR: 1.43 CI: 1.27-1.63) in models adjusted for age and sex. We discovered that disease severity, i.e., whether the person was hospitalized (IRR: 18.6 CI: 17.3-20.0) or treated in an intensive care unit (IRR: 120.5 CI: 111.7-129.8), primarily contributed to the higher risk of long COVID found in migrants while the contribution of vaccinations and social conditions were moderate. Preexisting health problems did not contribute to the increased risk of long COVID in migrants., Conclusions: The greater exposure and impact of the COVID-19 virus among migrants also affected longer-term consequences. Disease severity was the most important risk factor for long COVID in migrants. The findings emphasize the need for targeted health interventions for migrant communities during an infectious disease pandemic, such as strategic vaccination campaigns and extending social insurance schemes, focusing on reducing disease severity to mitigate the longer-term health consequences of an infection., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical approval for this study was granted by the Ethical Review Board (Dnr 2022–01892-02). Consent for publication: Consent from participants is not required since the study uses pseudonymized personal identification numbers. Competing interests: TB reports grants from Novo Nordisk Foundation, Lundbeck Foundation, Simonsen Foundation, GSK, Pfizer, Gilead, Kai Hansen Foundation and Erik and Susanna Olesen’s Charitable Fund; personal fees from GSK, Pfizer, Bavarian Nordic, Boehringer Ingelheim, Gilead, MSD, Pentabase ApS, Becton Dickinson, Janssen and Astra Zeneca; outside the submitted work., (© 2025. The Author(s).)

Background: Endogenous sex hormones in postmenopausal women have been associated with risk of cardiovascular diseases. The aim of this study was to determine the association between endogenous sex hormones and the revised Framingham Stroke Risk Profile (rFSRP) in postmenopausal women., Methods: This is an observational cross-sectional study on the Vara-Skövde cohort, a Swedish population-based study for longitudinal surveillance of the development and progress of type 2 diabetes and hypertension. The participants were physically examined in 2002-2005 and sex hormones were analysed with liquid chromatography-tandem mass spectrometry assay (LC-MS/MS). Women who were ≥55 years old, with estradiol levels below 20 pg/mL, not using hormonal therapy, and with no self-reported history of stroke, were included (N = 133). The outcome variable was rFSRP. Regression analyses of log-transformed rFSRP were fitted against levels of sex hormones (17-α-OH-progesterone, estrone, estradiol, progesterone, dihydrotestosterone, dehydroepiandrosterone, testosterone and androstenedione), adjusting for body mass index (BMI) or waist-to-hip ratio (WHR), C-reactive protein (CRP) and cholesterol level., Results: Levels of estrone and estradiol were positively associated with rFSRP in the crude model (estrone β = 0.208, 95% CI = 0.081;0.336, P = 0.002; estradiol β = 0.170, CI = 0.034;0.305, P = 0.015). Adjustments for BMI revealed significant positive associations between progesterone (β = 0.155 95% CI = 0.025;0.285, P = 0.020), estrone (β = 0.167, 95% CI = 0.037;0.297, P = 0.013) and 17-α-OH-progesterone (β = 0.146, 95% CI = 0.014; 0.277, P = 0.030) and rFSRP, and adjustments for WHR revealed a significant positive association between testosterone and rFSRP (β = 0.152, CI = 0.026;0.278, p = 0.018)., Conclusions: Increase of estrone was associated with higher rFSRP, also in the fully adjusted model, whereas progesterone, 17-α-OH-progesterone and testosterone were significant only in the models adjusting for BMI and WHR respectively. Larger studies studying stroke events are warranted to confirm these findings., Clinical Trial Number: Not applicable., Competing Interests: Declarations. Ethics approval: All participants gave their written consent to participate, and the Regional Ethical Review Board in Gothenburg, Sweden approved the study (registration numbers Ö 199-01). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Aims: To study differences in cardiovascular prevention and hypertension management in primary care in men and women, with comparisons between public and privately operated primary health care (PHC)., Methods: We used register data from Region Stockholm on collected prescribed medication and registered diagnoses, to identify patients aged 30 years and above with hypertension. Age-adjusted logistic regression was used to calculate odds ratios (ORs) with 99% confidence intervals (99% CIs) using public PHC centers as referents., Results: In total, 119,267 patients with a registered hypertension diagnosis at their primary care center were included; 58,239 men and 61,028 women. In terms of co-morbidities and medications, there were some differences between privately and publicly run PHC: registered diagnosis of dementia, which was higher at private PHC, age-adjusted OR 1.80 (1.24-2.69). For lifestyle counseling, privately run PHC had a higher rate of registered counseling for tobacco 1.17 (1.06-1.29), physical activity 1.13 (1.06-1.17), unhealthy diet 1.08 (1.04-1.13), and counseling according to highest prioritized level of advice stated by national guidelines 1.14 (1.09-1.18). Differences in comorbidities between men and women were found, with higher frequencies of coronary heart disease, congestive heart failure, atrial fibrillation, stroke, diabetes, and gout among men. Regarding antihypertensive treatment, women received less treatment of calcium channel blockers and ACE inhibitors, but more of angiotensin receptor blockers., Conclusions: These findings highlight the need for targeted preventive efforts in PHC, especially for male patients, to address disparities in cardiovascular health outcomes. Small differences in preventive measures between public and privately run PHC suggest generally consistent care across healthcare ownership models., Competing Interests: Declarations. Ethics approval and consent to participate: This study received ethical approval from Zhongshan Hospital, Fudan University (B2021-605). The online questionnaire includes a checkbox for respondents to make sure whether they give their voluntary informed consent before their involvement. The study was conducted in accordance with the Declaration of Helsinki. All authors gave their consent for publication. Ethical approval was obtained from the Ethics Review Authority, number 2020–07076 with an amendment 2121-06102-02. Consent to Participate declarations from the participants were not applicable as we used data from health record register, however, the use of these data was approved from Ethics Review in Stockholm. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: The in-home work environment is the main work environment for home care workers, but it has only been sparsely studied. Our aim was to investigate the in-home work environment for home care workers by exploring challenges that arise regardless of a pandemic and by investigating Covid-19-specific challenges., Methods: Two cross-sectional studies were conducted, one before (2017) and one during the pandemic (2021/2022) in three Swedish regions (Jämtland/Härjedalen, Västerbotten and Västernorrland), in which 1,154 (58%) out of 2,000 and 629 (33%) of 1,900 invited home care workers participated, respectively. Participants responded to a questionnaire asking about 10 problems associated with the in-home work environment as well as Covid-19-related challenges. Comparisons were conducted between regions and between study years using univariable analyses., Results: Daily problems with the in-home work environment were common before the pandemic, and they increased statistically significantly during the pandemic for, among other things, non-ergonomic beds (29% vs. 37%), impractical bathrooms (40% vs. 50%), indoor smoking (24% vs. 31%), and pets (19% vs. 25%). There were major concerns about the risk of getting infected with Covid-19 for both staff (42%) and the home care recipients (50%). There were statistically significant differences between regions, e.g. many problems were more common in the Västerbotten region than in the other two regions during the pandemic, while challenges with protective equipment was most common in the Västernorrland region., Conclusions: In-home work environment problems are common for home care workers and worsen in a more strained situation. Efforts are needed to strengthen the work environment for home care workers., Competing Interests: Declarations. Ethics approval and consent to participate: Study participants were informed in the questionnaire about the purpose of the study and the handling of personal data, including confidentiality. Participants consented to participate when they handed in their questionnaire. Ethical approval was obtained from the Regional Ethical Board in Umeå, Sweden, (Dnr 2016–68-31 M) and the Swedish Ethical Review Authority (Dnr 2021–02058). Research was conducted in accordance with the ethical guidelines of the Declaration of Helsinki. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Tick-borne encephalitis (TBE) is an increasing health threat in Sweden and elsewhere in Europe. TBE vaccination is commonly recommended in Sweden, but limited data are available on uptake, effectiveness, and impact of TBE vaccination. General population surveys conducted in 2019-2022 were used to estimated TBE vaccine uptake. TBE vaccine effectiveness (VE) was estimated using the screening method utilizing the surveys and public health TBE surveillance data, which predominately includes hospitalized TBE cases, from 2018 to 2022. Impact of TBE vaccination was calculated based on disease incidence and observed VE. In 2018-2022, 2,015 TBE cases were reported in Sweden; 82.8% (1,564/1,890) of cases with known TBE vaccination history were unvaccinated. Among persons surveyed from the general population with known vaccination history, 52.0% (11,562/22,247) were unvaccinated. Three dose VE against TBE was 89.0% (95% confidence interval 84.3-92.4). When stratified by age group, VE was 86.0% (55.7-95.6) in 1-15 years-of-age and 93.8% (87.5-96.9) in 16-49 years-of-age. In a conservative estimate, despite suboptimal compliance with TBE vaccination recommendations, vaccination averted an estimated thousand TBE cases, most resulting in hospitalization, in Sweden from 2018 to  2022. To prevent additional TBE cases in Sweden, enhanced efforts to increase TBE vaccine uptake and compliance to the TBE vaccination schedule are needed., Competing Interests: Declarations. Competing interests: Pfizer sponsored the study and was involved in the study design, analysis, interpretation of data, writing of the report, and in the decision to submit the article for publication. All authors (AP, FJA, PZ, AP, JS, JCM and LJ) are employees of Pfizer Inc. and hold stock and stock options in Pfizer Inc., (© 2025. The Author(s).)

Aims: Although individuals with lower socio-economic position (SEP) have a higher prevalence of mental health problems than others, there is no conclusive evidence on whether mental healthcare (MHC) is provided equitably. We investigated inequalities in MHC use among adults in Stockholm County (Sweden), and whether inequalities were moderated by self-reported psychological distress., Methods: MHC use was examined in 31,433 individuals aged 18-64 years over a 6-month follow-up period, after responding to the General Health Questionnaire-12 (GHQ-12) in 2014 or the Kessler Six (K6) in 2021. Information on their MHC use and SEP indicators, education, and household income, were sourced from administrative registries. Logistic and negative binomial regression analyses were used to estimate inequalities in gained MHC access and frequency of outpatient visits, with psychological distress as a moderating variable., Results: Individuals with lower education or income levels were more likely to gain access to MHC than those with high SEP, irrespective of distress levels. Education-related differences in gained MHC access diminished with increasing distress, from a 74% higher likelihood when reporting no distress (odds ratio, OR = 1.74 [95% confidence interval, 95% CI: 1.43-2.12]) to 30% when reporting severe distress (OR = 1.30 [0.98-1.72]). Comparable results were found for secondary care but not primary care i.e., lower education predicted reduced access to primary care in moderate-to-severe distress groups (e.g., OR = 0.63 [0.45-0.90]), and for physical but not digital services. Income-related differences in gained MHC access remained stable or increased with distress, especially for secondary care and physical services., Conclusions: Overall, individuals with lower education and income used MHC services more than their counterparts with higher socio-economic status; however, low-educated individuals faced inequities in primary care and underutilized non-physician services such as visits to psychologists.

Objective: Alcohol and Other Drug (AOD) disorders cause substantial harm. Effective Substance Use Treatment (SUT) exists, but long-term outcomes remain inconclusive. This study used a 20-year prospective follow-up of 1248 service users entering SUT in Stockholm, Sweden, in 2000-2002 to elaborate on how different dimensions of long-term outcomes may be measured by register-based indicators. Baseline characteristics and attrition bias were explicated, and register-based outcomes were examined., Results: Register-based indicators are valuable, but they also have inherent limitations such as the lack of substance use data and inability to differentiate between un/met treatment needs and access. Significant variations in long-term outcomes were evident depending on which register-based indicator was used, and whether used in isolation or combinations. Six out of 10 service users were still alive after 20 years, but as many as 8 out of 10 of the survivors remained in treatment, and only two out of 10 had a stable economic situation. Hence, the register indicators identified only a few survivors, with stable economic and social situations, and without recent treatment contacts 20 years after treatment entry. The long-term outcomes were concerning and even more so when combining outcome dimensions., Competing Interests: Declarations. Ethics approval and consent to participate: The study was performed in accordance with the Declaration of Helsinki, approved by the Swedish Ethical Review Authority, approval number 2021 − 00916, and relied upon appropriate participants’ informed consent. Participants in the baseline study were informed about the follow-ups and those who agreed to this signed a written informed consent for (a) follow-up interviews, and/or (b) register studies. This procedure was repeated at the 1- and 5-year follow-ups. Since this study involves vulnerable participants, data were anonymized and the codebook separated from data. Furthermore, Statistics Sweden created a new coding when adding the register data. The material has thereby been anonymized twice. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Introduction: This study aimed to investigate if individuals with childhood-onset type 1 diabetes having a parent with the same condition (parental diabetes) had worse metabolic control and an increased risk of death and renal failure compared with those with parents without type 1 diabetes (sporadic diabetes)., Research Design and Methods: We conducted a population-based cohort study using data from the Swedish Childhood Diabetes Register, including cases with onset of type 1 diabetes before the age of 15 and recorded between 1977 and 2010. The cohort was linked to national registers to compare mortality, renal failure, and glycated hemoglobin (HBA1c) levels., Results: We identified 16 572 incident cases of childhood-onset type 1 diabetes. Of these, 15 701 had data on parental diabetes status, with 1390 (8.9%) having at least one parent with this condition. HbA1c data were available in 9105 individuals at 20-30 years of age, with the parental group showing higher levels compared with the sporadic diabetes group (8.4% (68 mmol/mol) vs 8.2% (66 mmol/mol), p=0.004). The Cox proportional HR for death in parental diabetes was 1.33 (95% CI 1.00 to 1.75), and the competing risk HR for renal failure was 1.27 (95% CI 1.08 to 1.50). Women in the parental diabetes group had a higher risk of early death (HR 1.79, 95% CI 1.17 to 2.72) compared with the sporadic diabetes group., Conclusions: Individuals with parental diabetes had slightly higher HbA1c and elevated risks of renal failure and death compared with those with sporadic diabetes, especially pronounced in women. Although the exact mechanisms behind these differences are unclear, we suggest that individualized care may benefit individuals with parental type 1 diabetes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: Pediatric obesity is a growing global health challenge, with long-term implications for individuals and healthcare systems. Existing studies on the association between pediatric obesity and healthcare use in adulthood are limited and often rely on mathematical simulation models. This study aims to provide real-world data on the impact of adolescent obesity on specialized healthcare utilization and costs in early adulthood., Methods: This study analyzed data from two longitudinal cohorts: a population-based cohort from Norway (Young-HUNT) and a clinical cohort from Sweden (BORIS), the latter with matched general population comparators. Individuals included were born between 1987 and 1994, with BMI measurements at ages 13-19, and follow-up data from ages 20 to 30 years. Healthcare utilization and costs were assessed using national patient registries., Results: A total of 7592 individuals from Norway (5.7% with adolescent obesity) and 1543 individuals from Sweden with adolescent obesity, accompanied with 7330 matched general population comparators, were included. Among females, adolescent obesity was associated with significantly higher specialized healthcare utilization and costs in young adulthood, e.g., in Sweden, females with adolescent obesity had a 57% probability of annual specialized healthcare visits at ages 25-29, compared to 49% among the general population, p < 0.0001. In Norway, a similar pattern was observed. Among males, the association between obesity and healthcare utilization/annual specialized visits was less prominent. Annual excess costs for females with a history of adolescent obesity ranged from €578 to €835, while males showed minimal or no annual excess costs., Conclusions: Analyses of real-world data cohorts from Norway and Sweden reveal that adolescent obesity is associated with increased healthcare utilization and costs in young adulthood, exceeding previous estimates. A distinct sex difference was evident, with females incurring higher costs compared to males., Competing Interests: Declarations. Ethics approval and consent to participate: An opt-out approval was required from the patient/guardian to record data in the Swedish Childhood Obesity Treatment Register. The regional Ethics Committee in Stockholm, Sweden, approved the study (No. No. 2016/922–31/1, 2020–02707). For the HUNT cohort all participants consented to the use of their data and the present study was approved by the Regional Committee of Ethics in Medical Research (2016/537). Consent for publication: Not applicable. Competing interests: EH reports commissioned research for Novo Nordisk (2023), but not for the current study; honoraria for lectures for Novo Nordisk; a leadership or fiduciary role on scientific/medical committee: Member of the steering committee for the Swedish Childhood Obesity Treatment Register. CM reports consulting fees from Novo Nordisk,Rhythm, Oriflame Wellness, DeFaire Medical, and Evira AB; honoraria for lectures from Novo Nordisk, Oriflame Wellness, and AstraZeneca; payment for expert testimony from Novo Nordic Foundation and Rhythm; leadership or fiduciary role on scientific/medical committee: board member of European Society for Paediatric Endocrinology (ESPE) Obesity working group, board member of the Swedish Pediatric Obesity Society, and Register holder for the Swedish Childhood Obesity Treatment Register. RRP, VH, CHE, MWB and RAØ declare no competing interests., (© 2025. The Author(s).)

Background: Cardiovascular, respiratory, and musculoskeletal disease are among the leading causes of disability in middle-aged and older people. Health and lifestyle factors in youth have known associations with cardiovascular or respiratory disease in adulthood, but largely unknown associations with musculoskeletal disease., Methods and Findings: We included approximately 40,000 18-year-old Swedish males, who completed their conscription examination in 1969 to 1970, followed up until age of 60 years. Exposures of interest were physical health: body mass and height, blood pressure, pulse at rest, muscle strength, cardiorespiratory fitness, and hematocrit; self-reported lifestyle: smoking, alcohol, and drug use; self-reported health: overall, headache and gastrointestinal. We followed the participants through the Swedish National Patient Register for incidence of common musculoskeletal (osteoarthritis, back pain, shoulder lesions, joint pain, myalgia), cardiovascular (ischemic heart disease, atrial fibrillation), and respiratory diseases (asthma, chronic obstructive pulmonary disease, bronchitis). We analyzed the associations using general estimating equations Poisson regression with all exposures included in one model and adjusted for parental education and occupation. We found that higher body mass was associated with higher risk of musculoskeletal (risk ratio [RR] per 1 standard deviation [SD] 1.12 [95% confidence interval, CI 1.09, 1.16]), cardiovascular (RR 1.22 [95% CI 1.17, 1.27] per 1 SD) and respiratory diseases (RR 1.14 [95% CI 1.05, 1.23] per 1 SD). Notably, higher muscle strength and cardiorespiratory fitness were associated with higher risk of musculoskeletal disease (RRs 1.08 [95% CI 1.05, 1.11] and 1.06 [95% CI 1.01, 1.12] per 1 SD difference in exposure), while higher cardiorespiratory fitness was protective against both cardiovascular and respiratory diseases (RRs 0.91 [95% CI 0.85, 0.98] and 0.85 [95% CI 0.73, 0.97] per 1 SD exposure, respectively). We confirmed the adverse effects of smoking, with risk ratios when comparing 11+ cigarettes per day to non-smoking of 1.14 (95% CI 1.06, 1.22) for musculoskeletal, 1.58 (95% CI 1.44, 1.74) for cardiovascular, and 1.93 (95% CI 1.60, 2.32) for respiratory diseases. Self-reported headache (category "often" compared to "never") was associated with musculoskeletal diseases (RR 1.38 [95% CI 1.21, 1.58]) and cardiovascular diseases (RR 1.29 [95% CI 1.07, 1.56]), but had an inconclusive association with respiratory diseases (RR 1.13 [95% CI 0.79, 1.60]). No large consistent associations were found for other exposures. The most notable associations with specific musculoskeletal conditions were for cardiorespiratory fitness and osteoarthritis (RR 1.23 [95% CI 1.15, 1.32] per 1 SD) and for muscle strength and back pain (RR 1.18 [95% CI 1.12, 1.24] per 1 SD) or shoulder diseases (RR 1.27 [95% CI 1.19, 1.36] per 1 SD). The main limitations include lack of adjustment for genetic factors and environmental exposures from childhood, and that the register data were available for males only., Conclusions: While high body mass was a risk factor for all 3 studied groups of diseases, high cardiorespiratory fitness and high muscle strength in youth were associated with increased risk of musculoskeletal disease in middle age. We speculate that these associations are mediated by chronic overload or acute trauma., Competing Interests: ME declares consultancy for Grünenthal Sweden AB and Key2Compliance. AK acts as a part-time scientific advisor for Joint Academy providing a digital self-management program for musculoskeletal pain. AT is associate editor for statistics at Osteoarthritis and Cartilage journal. ST was supported by a career grant from the Swedish Research Council (2019-02082). Other authors declare no conflict of interest., (Copyright: © 2025 Turkiewicz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The goal of this work is to investigate the sociodemographic characteristics and health status of women with breast cancer (BC) in association with COVID-19 by menopausal status. In a Swedish register-based cross-sectional study, we compared women with BC and with or without a positive COVID-19 test, stratified by menopausal status (age ≥ 51 years). Socioeconomic characteristics and health status (represented by diagnoses registered in 5 years- and prescription dispensed in 2 years preceding Jan 2020) were considered in association with COVID-19 diagnosis. The study population included 38,523 women with BC. Median age at BC diagnosis was 45 years (IQR = 40-48) for premenopausal- and 67 (IQR = 60-73) for postmenopausal BC. A logistic regression model was used and found the significant covariate effects (adjusted odds ratios, ORs) for a positive COVID-19 test among women with premenopausal BC to be being born outside of Europe: 1.29, (1.13-1.46), being married: 1.23, (1.12-1.36), being unemployed 1.92 (1.59-2.30), having upper secondary school education 1.25 (1.01-1.54), having > 15 outpatient visits: 1.31, (1.07-1.61), and a history of being admitted to hospital 1-5 times: 1.12 (1.01-1.25). Corresponding significant covariate effects among women with postmenopausal BC were being born outside of Europe: 1.61 (1.41-1.83), being married: 1.12 (1.04-1.21), and being unemployed 1.54 (1.40-1.69). Postmenopausal women furthermore had more outpatient visits or hospital admissions before the pandemic in COVID-19 positive patients compared to patients without a COVID-19 positive test, e.g. 1.47 (1.26-1.71) for > 15 outpatient visits compared with no visit and 6.35 (3.33-12.11) for > 15 hospital admissions compared with no admission. Varied socioeconomical and clinical conditions were more frequent among patients with a positive COVID-19 test compared to patients without a positive test among women with BC in pre- or post-menopausal status. We conclude that some characteristics of women such as unemployment, country of birth or health status measured by number of prescribed drugs were more prevalent among women who developed COVID-19 compared to women without COVID-19 diagnosis and either of menopausal status of breast cancer., Competing Interests: Declarations. Competing interests: The authors declare no competing interests. Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethical Review Authority (2020 − 01800 with subsequent amendments). Consent to participate: Since this was a register-based observational study the Swedish Ethical Review Authority waived informed consent, as normally done for this type of study. Consent to publish: All authors approved the final version for publication., (© 2025. The Author(s).)

Objectives: The objective of this study was to investigate the role of infections in the pathogenesis of Kawasaki disease., Methods: The investigation was a nationwide epidemiological case-control study, comprising all cases of Kawasaki disease diagnosed in Sweden 1987-2018. Controls were randomly sampled from the general population, matched on sex, age, and area of residency. Data on infections were obtained from the Swedish National Patient Register, which prospectively collects data on all Swedish residents. Infections were classified by organ system, infectious agent and by temporal proximity to Kawasaki disease diagnosis date. Prescription of antibiotics and infections in family members were also considered in separate analyses., Results: The study comprised n=1774 (61% male) cases and n=17 731 controls. Overall, a history of infections was associated with Kawasaki disease with an OR of 2.3 (95% CI 2.0 to 2.5). Respiratory, skin, urogenital and gastrointestinal tract infections were all associated with Kawasaki disease. Temporal stratification revealed a prominent clustering of infections during the weeks before a Kawasaki diagnosis, but also higher frequencies of infections several months preceding Kawasaki disease with OR ranging from 5.1 (95% CI 3.6 to 7.1) 15-28 days to 1.3 (95% CI 1.1 to 1.6) 181-365 days prior Kawasaki disease. A dose-response relationship was observed, with repeated infections associating with higher ORs of Kawasaki., Conclusions: The findings suggest that infections are closely linked with Kawasaki disease, and with a wider temporal association than previously known. Further, the data imply that many different agents may induce the disease., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)