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Abstract Background Assessment of Rehabilitation Needs Checklist (ARNC), has been developed to assess rehabilitation need in cancer patients and is recommended by the Confederation of Regional Cancer Centres in Sweden, known as Hälsoskattningen. The aim of the study was to test the reliability and validity of the ARNC, mainly by comparing it with the Distress thermometer and EORTC QLQ-C30. Methodology A sample of 993 persons identified in the Swedish cancer register. The study participants were diagnosed with cancer in 2021 in the Mid Sweden region. The psychometric methods tested reliability and validity including factor analysis. Results The response rate was 38%. The test-retest analysis showed that ICC was 0.80 or higher for 12 of the ARNC items. A strong or modarete correlation between ARNC and the other instruments was found in all functional scales and for most items. CFA of the 13-item two-factor model showed a RMSEA value of 0.04, CFI and TLI values of 0.97 and 0.96, and a SRMR value of 0.05, indicating a satisfactory model fit. Conclusion The evaluation of the ARNC suggests that it is an acceptable and reliable screening instrument for detecting symptoms and signs indicating a possible need of rehabilitation. The medium to strong correlations between ARNC items and the EORTC QLQ- C30 items and scales suggest that ARNC could be an alternative also for research purposes when a shorter and less comprehensive instrument is needed. The simple design could be an advantage as it lowers the burden on cancer patients.

Abstract Objective: The aim of this study was to investigate factors associated with reported need of weight loss support among adults with overweight or obesity in the general population. Design: A cross-sectional population study based on a survey questionnaire sent to a random population sample. Multivariate odds ratios for reported need of weight loss support were calculated for socio-economic, lifestyle and health indicators, in total and by gender and age group. Setting: Five counties in Sweden in 2022. Participants: The study includes 10 069 persons with overweight or obesity (BMI ≥ 25 kg/m2) aged 30–69 years. BMI was based on self-reported weight and height. Results: In total, about 20 % reported needing weight loss support. The factors most strongly associated with reported need of weight loss support were obesity and female gender. Lack of social support, economic difficulties, physical inactivity, poor self-rated health, musculoskeletal pain and depression were also associated with reported need of weight loss support, whereas diabetes and hypertension were not. Some differences in these associations were observed between age groups. Conclusion: Reported need of weight loss support is more common among women than among men and associated with obesity, lack of social support, economic difficulties, physical inactivity, poor self-rated health, musculoskeletal pain and depression in both genders. These factors are important for planning preventive and weight-control measures among adults with overweight or obesity.

Abstract Background The World Health Organization Disability Assessment Schedule (WHODAS 2.0) is a generic questionnaire that captures health and disability-related functioning information corresponding to six major life domains: Cognition, Mobility, Self-care, Getting along, Life activities, and Participation. The WHODAS 2.0 is used in a wide range of international clinical and research settings. A psychometric evaluation of WHODAS 2.0, Swedish version, in the general population is lacking, together with national reference data to enable interpretation and comparison. This study aims to evaluate the psychometric properties of the Swedish 36-item version of WHODAS 2.0 and describe the prevalence of disability in a Swedish general population. Methods A cross-sectional survey was performed. Internal consistency reliability was assessed with Cronbach’s alpha. The construct validity was evaluated with item-total correlation, Pearson’s correlation between the WHODAS 2.0 domains and the RAND-36 subscales, analysis of known groups by one-way ANOVA, and analysis of the factor structure by confirmatory factor analysis. Results Three thousand four hundred and eighty two adults aged 19–103 years (response rate 43%) participated. Significantly higher degrees of disability were reported by the oldest age group (≥ 80 years), adults with a low level of education, and those on sick leave. Cronbach’s alpha was from 0.84 to 0.95 for the domain scores and 0.97 for the total score. The item-scale convergent validity was satisfactory, and the item-scale discriminant validity was acceptable except for the item about sexual activity. The data partially supported the factor structure, with borderline fit indices. Conclusion The psychometric properties of the self-administered Swedish 36-item version of the WHODAS 2.0 are comparable to those of other language versions of the instrument. Data of the prevalence of disability in Swedish general population enables normative comparisons of WHODAS 2.0 scores of individuals and groups within clinical practice. The instrument has certain limitations that could be improved on in a future revision. The test–retest reliability and responsiveness of the Swedish version of WHODAS 2.0 for different somatic patient populations remain to be evaluated.

One of the main sources of uncertainty in carbon budgets is that continental landscapes are made up of a heterogeneous mosaic of ecosystems. Here the authors put forward an integrative framework to improve estimates of land-atmosphere carbon exchange based on the accumulation of carbon in the landscape as constrained by its lateral export through rivers.

Objective This study aimed to investigate the associations between general health expectations and patient satisfaction with treatment for the two common spine surgery procedures diskectomy for lumbar disk herniation (LDH) and decompression for lumbar spinal stenosis (LSS).Design Register study with prospectively collected preoperative and 1-year postoperative data.Setting National outcome data from Swespine, the national Swedish spine register.Participants A total of 9929 patients, aged between 20 and 85 years, who were self-reported non-smokers, and were operated between 2007 and 2016 for one-level LSS without degenerative spondylolisthesis, or one-level LDH, were identified in the national Swedish spine register (Swespine). We used SF-36 items 11c and 11d to assess future health expectations and present health perceptions. Satisfaction with treatment was assessed using the Swespine satisfaction item.Interventions One-level diskectomy for LDH or one-level decompression for LSS.Primary outcome measures Satisfaction with treatment.Results For LSS, the year 1 satisfaction ratio among patients with negative future health expectations preoperatively was 60% (95% CI 58% to 63%), while it was 75% (95% CI 73% to 76%) for patients with positive future health expectations preoperatively. The corresponding numbers for LDH were 73% (95% CI 71% to 75%) and 84% (95% CI 83% to 85%), respectively.Conclusions Patients operated for the common lumbar spine diseases LSS or LDH, with negative future general health expectations, were significantly less satisfied with treatment than patients with positive expectations with regard to future general health. These findings are important for patients, and for the surgeons who counsel them, when surgery is a treatment option for LSS or LDH.

The concentration of colored dissolved organic matter (CDOM) in lakes is strongly influenced by climate, land cover, and topographic settings, but it is not known how drought may affect the relative importance of these controls. Here, we evaluate the controls of CDOM during two summers with strongly contrasting values of the Palmer drought index (PDI), indicating wet vs. dry conditions. We hypothesized that lake CDOM during a wet summer season is regulated mainly by the surrounding land cover to which the lakes are hydrologically connected, while, during drought, the lakes are disconnected from the catchment and CDOM is regulated by climatic and morphometric factors that govern the internal turnover of CDOM in the lakes. A suite of climate, land cover, and morphometric variables was assembled and used to explain remotely sensed CDOM values for 255 boreal lakes distributed across broad environmental and geographic gradients in Sweden and Norway. We found that PDI explained the variability in CDOM among lakes in a dry year, but not in a wet year, and that severe drought strongly decreased CDOM during the dry year. Large lakes, especially, with a presumed high degree of catchment uncoupling, showed low CDOM during the dry year. However, in disagreement with our hypothesis, climate, land cover, and morphometry all showed a stronger impact on lake CDOM in wet vs. dry years. Thus, drought systematically weakened the predictability of CDOM variations at the same time as CDOM was offset toward lower values. Our results show that drought not only has a direct effect on CDOM, but also acts indirectly by changing the spatial regulation of CDOM in boreal lakes.

ABSTRACT Objective: To compare health-related quality of life (HRQoL) of patients primarily treated with a no-touch saphenous vein graft with that of patients who received a conventional graft. Methods: The study included all individuals treated with a percutaneous coronary intervention (PCI) on a saphenous vein graft (SVG) between January 2006 and June 2020. The RAND-36 health survey was used to assess HRQoL. The Mann-Whitney U test was used to test differences in HRQoL between the two groups. Effect size was estimated via Cohen’s d. The average treatment effect between the groups was tested by propensity score matching (PSM). Results: Of the 346 patients treated with a PCI in a stenosed or occluded SVG, 165 responded to RAND-36 (no-touch: n=48; conventional: n=117). Patients with a no-touch graft reported better mean values on seven of the eight health survey domains. Statistically significant differences were observed for four of the domains, all in favour of the no-touch group. The effect size estimates indicated a small difference for five domains, with the highest values (>0.40) seen for the general health and energy/fatigue domains. PSM confirmed a statistically significant difference for the physical functioning and general health domains. Conclusion: At a mean follow-up of 5.4 years, patients who received a PCI in no-touch vein grafts showed significantly better HRQoL than those who received a PCI in conventional vein grafts.

Abstract Background Previous studies have shown that patients with different lumbar spine diseases report different SF-36 profiles, but data on the stability of the SF-36 profiles are limited. The primary aim of the current study was to evaluate the stability of the SF-36 profile for lumbar spine diseases. Methods Patients, surgically treated between 2007 and 2016 for three lumbar spine diseases, lumbar spinal stenosis (LSS) with degenerative spondylolisthesis (DS), LSS without DS, and lumbar disk herniations (LDH), were identified in the Swedish spine register. Preoperative and 1 year postoperative SF-36 data for a total of 27,302 procedures were available for analysis. The stability of the SF-36 profiles over the 10-year period was evaluated using graphical exploration, linear regression, difference in means, and 95% confidence intervals. The responsiveness of the SF-36 domains to surgical treatment was evaluated using the standardized response mean (SRM). Results LSS and LDH have different SF-36 profiles. LSS with DS and LSS without DS have similar SF-36 profiles. The preoperative and the 1 year postoperative SF-36 profiles were stable from 2007 to 2016 for all three diagnoses. There were no major changes in the effect size of change (SRM) during the study period for all three diagnoses. For LSS with DS, the number of fusions peaked in 2010 and then decreased. The postoperative SF-36 profiles for LSS with DS were unaffected by changes in surgical treatment trends. Conclusions Patients with lumbar spinal stenosis and lumbar disk herniations have different SF-36 profiles. Concomitant degenerative spondylolisthesis had no impact on the SF-36 profile of lumbar spinal stenosis. Adding fusion to the decompression did not alter the postoperative SF-36 profile of lumbar spinal stenosis. The SF-36 health profiles are stable from a 10 years perspective.

CH4 inputs to Arctic lakes via groundwater discharge are an important pathway that links CH4 production in thawing permafrost to emission via lakes. Here the authors unravel the role and drivers of groundwater inflows for CH4 emissions from Arctic lakes.

Background and purpose — There are several national value sets for SF-6D. For studies conducted in countries without a country-specific value set the authors may use a value set from a neighboring or culturally similar county. We evaluated the consequences of using different national value sets in SF-6D index-based outcome analyses. Patients and methods — Patients surgically treated for lumbar spinal stenosis or lumbar disk herniation between 2007 and 2017 were recruited from the national Swedish spine register. 16,398 procedures were eligible for analysis. The SF-6D health states were coded to SF-6D preference indices using value sets for 9 countries. The SF-6D index distributions were then estimated with kernel density estimation. The change in SF-6D index before and after treatment was evaluated with the standardized response mean (SRM). Results — There was a marked variability in mean and shape for the resulting SF-6D index distributions. There were considerable differences in SF-6D index distribution shape before and after treatment using the same value set. The effect sizes of 2-year change (SRM) were in most cases similar when the 9 value sets were applied on pre- and post-treatment data. Interpretation — We found a marked variability in SF-6D index distributions when a single large data set was applied to 9 national SF-6D value sets. Consequently, we recommend that SF-6D index data from studies conducted in countries without country-specific SF-6D value sets is interpreted with caution.

Abstract Background This study aims to evaluate data quality, scaling properties, and reliability of the Swedish RAND-36 in a general population sample and to present reference data for the Swedish population. Methods Testing of data quality, scaling assumptions and reliability followed methods recommended for the International Quality of Life Assessment Project, previously used for psychometric testing of SF-36 and RAND-36. Data were collected via regular mail for a random stratified sample of the general population in a Swedish county. Weighted means for RAND-36 scores were used and differences by sex, age, education, and occupational groups were tested. Results The response rate was 42%, and the sample comprised 3432 persons (45% men, 55% women) with a median age of 56.9 years. The internal consistency reliability was satisfactory, with Cronbach’s alphas > 0.80 for all eight scales. The percentage of missing items was low, ranging between 1.3% and 3.2%. No floor effects (≥15%) were noted, while ceiling effects were observed for physical functioning, role-functioning/physical, pain, role-functioning/emotional, and social functioning. Item–scale correlations were satisfactory (r ≥ 0.40). Correlations among the physical health scales were strong (range 0.58–0.68) as were the correlations among the mental health scales (range 0.58–0.73). Men reported significantly better health-related quality of life (HRQoL) on all scales, although the gender differences were small. Comparisons among age groups showed approximately equal scores among those 20–29, 30–39, and 40–49 years, while significant decreases in physical health were observed in the older age groups. Substantially worse physical health scores were observed in the oldest age group (80+). Significant differences among age groups were noted also for the mental health scales; however, better energy/fatigue and emotional well-being scores were seen in the older age groups, except for the oldest (80+). Those with university education reported significantly better scores on all scales compared to those with mandatory education. Conclusions The study suggests that the Swedish version of RAND-36 is an acceptable and reliable instrument for measuring HRQoL in the general population. The study provides reference data that can be used for norm-based comparisons.

Abstract Measures of environmental DNA (eDNA) concentrations in water samples have the potential to be both a cost‐efficient and a nondestructive method to estimate fish population abundance. However, the inherent temporal and spatial variability in abiotic and biotic conditions in aquatic systems have been suggested to be a major obstacle to determine relationships between fish eDNA concentrations and fish population abundance. Moreover, once water samples are collected, methodological biases are common, which introduces additional sources of variation to potential relationships between eDNA concentrations and fish population abundance. Here, we evaluate the performance of applying the droplet digital PCR (ddPCR) method to estimate fish population abundance in experimental enclosures. Using large‐scale enclosure ecosystems that contain populations of nine‐spined stickleback (Pungitius pungitius), we compared the concentrations of fish eDNA (COI mitochondrial region, 134 bp) obtained with the ddPCR method with high precision estimates of fish population abundance (i.e., number of individuals) and biomass. To evaluate the effects of contrasted concentrations of humic substances (potential PCR inhibitors) on the performance of ddPCR assays, we manipulated natural dissolved organic carbon (DOC) concentrations (range 4–11 mg/L) in the enclosures. Additionally, water temperature (+2°C) was manipulated in half of the enclosures. Results showed positive relationships between eDNA concentration and fish abundance and biomass estimates although unexplained variation remained. Still and importantly, fish eDNA estimates from high DOC enclosures were not lowered by potential inhibitory effects with our procedure. Finally, water temperature (although only 2°C difference) was neither detected as a significant factor influencing fish eDNA estimates. Altogether, our work highlights that ddPCR‐based eDNA is a promising method for future quantification of fish population abundance in natural systems.

Abstract Background Pectus excavatum (PE) is the most common congenital chest wall deformity. Most individuals with PE suffer from psychosocial problems, with low self-esteem and poor body image. Correctional surgery for PE is available, the most widely used is the Nuss procedure. The Nuss procedure has previously been reported to improve self-esteem, body image and health-related quality of life (HRQoL). To assess HRQoL among individuals with PE, the Nuss Questionnaire modified for Adults (NQ-mA) and Single Step Questionnaire (SSQ) has been developed. The aim of the current study was to translate and culturally adapt NQ-mA and SSQ to fit a Swedish context, and to evaluate the psychometric properties, and validate the culturally adapted versions. Methods Individuals who had undergone the Nuss procedure for pectus excavatum were invited to participate in a multicentre study with cross-sectional design. HRQoL was assessed by NQ-mA, SSQ and RAND-36. Psychometric properties for NQ-mA and SSQ were evaluated by content validity index and construct validity (exploratory factor analysis, confirmatory factor analysis, and inter-scale correlations). Known-groups validity, as well as floor and ceiling effects, were evaluated. Internal consistency reliability was examined using Cronbach’s alpha. Results In total 236 individuals participated in the study. Content validity index for NQ-mA showed satisfactory results, except for two items. Factor analysis for NQ-mA suggested a two-factor model, with exclusion of two items. Subscales correlated adequately with RAND-36’s domains. Known-groups validity for NQ-mA demonstrated high sensitivity for between-group differences. Ceiling effects were present in several items. Cronbach’s alpha for NQ-mA was .89. Confirmatory factor analysis for SSQ resulted in a three-factor model, with exclusion of five items. However, this model was shown to be unstable through further exploratory factor analysis testing, and no further psychometric tests were conducted for SSQ. Conclusion The 10-item Swedish version of NQ-mA was shown to be valid for research and clinical assessment of HRQoL in individuals with pectus excavatum. The Swedish version of SSQ requires revision of items before further validation can be performed.

Summary Objective Obesity is associated with reduced health‐related quality of life (HRQoL). Outcomes of nonsurgical weight loss treatment on HRQoL are inconsistent and it is unclear how much weight reduction, or what type of treatment, is required for significant improvements. This study aimed to evaluate the effects of a lifestyle intervention program on weight, eating behaviors, and HRQoL, and to describe participants' experiences of treatment. Methods This 2‐year intervention trial in persons with class II or III obesity comprised a 3‐month liquid low‐energy diet (880 kcal/d) followed by a 3‐month reintroduction to regular foods, combined with behavioral group treatment. Results Fifty‐five participants (73% women) were included, mean (SD) age 43.2 (12.4) years, and mean body mass index 42.0 (6.0) kg/m2. Mean weight loss at 6, 12, and 24 months was 18.9%, 13.7%, and 7.2%, respectively. Short‐ and long‐term effects on eating behavior were favorable. Twelve of 14 HRQoL domains were improved at 6 months, compared to eight domains at 12 months. After 24 months, 2 of 14 domains, physical and psychosocial functioning, were improved. The treatment program was well accepted by the participants. Conclusions Substantial weight loss after 6 months was associated with extensive improvements in HRQoL, comprising the physical, psychosocial, and mental domains. Significant weight regain was observed between 6 and 24 months follow‐up. Modest weight loss after 24 months was associated with moderate improvement in physical functioning and large improvement in psychosocial functioning. The effect on psychosocial functioning is most likely related to both weight loss and behavioral treatment.

Rivers and lakes are thought to be a major conduit of loss for the massive amounts of carbon locked away in high-latitude systems, but such losses are poorly constrained. Here the authors quantify carbon emissions from rivers and lakes across Western Siberia, finding that emissions are high and exceed carbon export to the Arctic Ocean.

Abstract Widespread increases in dissolved organic matter (DOM) concentration across northern lakes can alter rates of primary production by increasing nutrient availability and decreasing light availability. These dual effects of DOM generate a unimodal relationship in pelagic primary production and primary producer biomass among lakes over a gradient of DOM concentration. However, the responses of benthic algae to variation in DOM loading are less clear because of their potential to access sediment nutrients. We tested algal production and nutrient limitation along a DOM gradient in northern Sweden. Without added nutrients, benthic algal production showed a unimodal relationship with DOM, similar to reported pelagic responses. Nutrient addition revealed widespread nitrogen limitation, with decreasing severity in lakes with higher DOM. Because the majority of northern Swedish lakes currently fall below the inflection point in this unimodal relationship, moderate increases in DOM have the potential to increase benthic primary production, particularly for epilithic algae.

Summary Objective Evidence‐based methods to lose weight are important in tackling increasing obesity trends in adult populations. More knowledge about persons who want to lose weight and do not/do need weight loss support is necessary to design effective preventive practices. Thus, the aim of the study was to investigate the prevalence of desire to lose weight in the general population and the prevalence of health problems and health‐related factors in persons with overweight or obesity who want to lose weight and believe that they do not/do need weight loss support. Methods The study included 14 126 persons aged 30 to 69 years who responded to a questionnaire sent to a random sample. Persons with overweight or obesity (BMI ≥ 25 kg/m2) were divided into three groups: those who do not want to lose weight (n = 1236), those who want to lose weight but do not believe they need support (n = 5484), and those who want to lose weight and believe they need weight loss support (n = 1462). Results In total, 69% of the women and 59% of the men reported that they wanted to lose weight. The prevalence of hypertension, musculoskeletal pain, poor self‐rated health, anxiety/worry, and depression was highest among persons with overweight or obesity who wanted to lose weight and believed they need weight loss support. They were also more physically inactive and reported less social support. Conclusions To want to lose weight is very common among adults. People with overweight or obesity who want to lose weight and believe they need weight loss support have higher frequency of various health problems, including mental health problems, and less social support.

Scientific Significance Statement Metabolic stoichiometry predicts that dissolved oxygen (O2) and carbon dioxide (CO2) in aquatic ecosystems should covary inversely; however, field observations often diverge from theoretical expectations. Here, we propose a suite of metrics describing this O2 and CO2 decoupling and introduce a conceptual framework for interpreting these metrics within aquatic ecosystems. Within this framework, we interpret cross‐system patterns of high‐frequency O2 and CO2 measurements in 11 northern lakes and extract emergent insights into the metabolic behavior and the simultaneous roles of chemical and physical forcing in shaping ecosystem processes. This approach leverages the power of high‐frequency paired O2–CO2 measurements, and yields a novel, integrative aquatic system typology which can also be applicable more broadly to streams and rivers, wetlands and marine systems.

The Ob River floodplain is the second largest floodplain in the world. Despite its vast area, estimates of carbon (C) emissions from the Ob River floodplain are largely absent. Here we present seasonal C emission and water area extent from the main channel and the floodplain along a ~4 km reach in the boreal zone of the Ob River. We found strong seasonality in water area extent of the Ob main channel (~1.8 km2) and floodplain (~3 km2) with water covering 34% of land during flood and subsequently declining to ~16% and ~14% during summer and autumn baseflow, respectively. The C emissions also varied seasonally over the open water period, ranging from −0.1 to 0.6 g C m−2 d−1 for the Ob main channel and from 0 to 9 g C m−2 d−1 for the floodplain. The dissolved organic carbon positively affected CO2 concentrations and fluxes in the floodplain during all seasons, whereas pH and oxygen concentration negatively impacted CO2 concentrations and fluxes. Some nutrients (ammonia and phosphate) positively correlated with CO2 and CH4 concentrations in summer. The total C emission from the study reach (1.8 km2 main channel, 3 km2 floodplain) during moderate flooding was 236 ± 51 tons C yr−1 (>99% CO2,

Accounting for temporal changes in carbon dioxide (CO _2 ) effluxes from freshwaters remains a challenge for global and regional carbon budgets. Here, we synthesize 171 site-months of flux measurements of CO _2 based on the eddy covariance method from 13 lakes and reservoirs in the Northern Hemisphere, and quantify dynamics at multiple temporal scales. We found pronounced sub-annual variability in CO _2 flux at all sites. By accounting for diel variation, only 11% of site-months were net daily sinks of CO _2 . Annual CO _2 emissions had an average of 25% (range 3%–58%) interannual variation. Similar to studies on streams, nighttime emissions regularly exceeded daytime emissions. Biophysical regulations of CO _2 flux variability were delineated through mutual information analysis. Sample analysis of CO _2 fluxes indicate the importance of continuous measurements. Better characterization of short- and long-term variability is necessary to understand and improve detection of temporal changes of CO _2 fluxes in response to natural and anthropogenic drivers. Our results indicate that existing global lake carbon budgets relying primarily on daytime measurements yield underestimates of net emissions.

Methane (CH4) is an important component of the carbon (C) cycling in lakes. CH4 production enables carbon in sediments to be either reintroduced to the food web via CH4 oxidation or emitted as a greenhouse gas making lakes one of the largest natural sources of atmospheric CH4. Large stable carbon isotopic fractionation during CH4 oxidation makes changes in 13C:12C ratio (δ13C) a powerful and widely used tool to determine the extent to which lake CH4 is oxidized, rather than emitted. This relies on correct δ13C values of original CH4 sources, the variability of which has rarely been investigated systematically in lakes. In this study, we measured δ13C in CH4 bubbles in littoral sediments and in CH4 dissolved in the anoxic hypolimnion of six boreal lakes with different characteristics. The results indicate that δ13C of CH4 sources is consistently higher (less 13C depletion) in littoral sediments than in deep waters across boreal and subarctic lakes. Variability in organic matter substrates across depths is a potential explanation. In one of the studied lakes available data from nearby soils showed correspondence between δ13C-CH4 in groundwater and deep lake water, and input from the catchment of CH4via groundwater exceeded atmospheric CH4 emissions tenfold over a period of 1 month. It indicates that lateral hydrological transport of CH4 can explain the observed δ13C-CH4 patterns and be important for lake CH4 cycling. Our results have important consequences for modelling and process assessments relative to lake CH4 using δ13C, including for CH4 oxidation, which is a key regulator of lake CH4 emissions.

Background: The purpose of this study was to evaluate the impact of using different country-specific value sets in EQ-5D-5L based outcome analyses. Methods: We obtained data on patients surgically treated with total hip arthroplasty (THA) between 2017 and 2019 from the national Swedish Hip Arthroplasty Register. Preoperative and one-year postoperative data on a total of 28,902 procedures were available for analysis. The EQ-5D-5L health states were coded to the EQ-5D-5L preference indices using 13 European value sets. The EQ-5D-5L index distributions were then estimated with kernel density estimation. The change in EQ-5D-5L index before and one year after treatment was evaluated with the standardized response mean (SRM). The lifetime gain in quality-adjusted life years (QALYs) was estimated with a 3.5% annual QALY discount rate. Findings: There was a marked variability in means and shapes of the resulting EQ-5D-5L index distributions. There were also considerable differences in the EQ-5D-5L index distribution shape before and after the treatment using the same value set. The effect sizes of one-year change (SRM) were similar for all value sets. However, the differences in estimated QALY gains were substantial. Interpretation: The EQ-5D-5L index distributions varied considerably when a single large data set was applied to different European EQ-5D-5L value sets. The most pronounced differences were between the value sets based on experience-based valuation and the value sets based on hypothetical valuation. This illustrates that experience-based and hypothetical value sets are inherently different and also that QALY gains derived with different value sets are not comparable. Our findings are of importance in study planning since the results and conclusions of a study depend on the choice of value set. Funding: None.

Background: Reproductive life plan counseling (RLPC) is a tool to encourage women and men to reflect upon their reproduction, to avoid unintended pregnancies and negative health behavior that can threaten reproduction. The aim was to evaluate the effect of RLPC among women attending contraceptive counseling. Outcomes were knowledge about fertility and awareness of preconception health, use of contraception, and women’s experience of RLPC. Material and methods: Swedish-speaking women, aged 20–40 years, were randomized to intervention group (IG) or control group (CG). Participants (n = 1,946) answered a questionnaire before and two months after (n = 1,198, 62%) the consultation. All women received standard contraceptive counseling, and the IG also received the RLPC, i.e. questions on reproductive intentions, information about fertility, and preconception health. Results: Women in the IG increased their knowledge about fertility: age and fertility, chances of getting pregnant, fecundity of an ovum, and chances of having a child with help of IVF. They also increased their awareness of factors affecting preconception health, such as to stop using tobacco, to refrain from alcohol, to be of normal weight, and to start with folic acid before a pregnancy. The most commonly used contraceptive method was combined oral contraceptives, followed by long-acting reversible contraception. Three out of four women (76%) in the IG stated that the RLPC should be part of the routine in contraceptive counseling. Conclusions: Knowledge about fertility and awareness of preconception health increased after the intervention. The RLPC can be recommended as a tool in contraceptive counseling.

Objectives Decisions regarding implantable cardioverter defibrillators (ICDs) must consider information about presumed health-related quality of life (HRQL). The purpose of the study was to assess HRQL in patients with ICD and compare it to a Swedish age-matched and sex-matched population.Design Cross-sectional observational trial.Setting Swedish ICD cohort.Interventions Short form 36 (SF-36) questionnaires from ICD recipients implanted 2007–2017 (response rate 77.2%) were analysed using Mann-Whitney U test and effect size (ES).Results In total, 223 patients (mean age 71.1±9.7 years, 82.1% men) were included. In most SF-36 domains (physical functioning (PF), role physical, general health (GH), vitality, social functioning and mental health), the score for patients with ICD was significantly lower (ES range 0.23–0.41, ie, small difference) than norms, except for bodily pain and role emotional. Both the physical component summary (PCS) and the mental component summary (MCS) scores had ES=0.31. Men and women had similar scores. Primary and secondary prevention patients scored similarly, except for worse GH in primary prevention (p=0.016, ES=0.35). Atrial fibrillation was associated with worse PF (ES=0.41) and PCS (ES=0.38). Appropriate therapy, inappropriate shock or complications requiring surgery were not associated with lower scores in any domain. In primary prevention due to ischaemic versus non-ischaemic cardiomyopathy, no domain was significantly different. PCS decreased with higher age strata (p=0.002) in contrast to MCS (p=0.986).Conclusions Patients with ICDs have lower physical and mental HRQL than age-matched and sex-matched norms; however, the ESs are small. HRQL is similar regardless of sex, primary/secondary prevention indication, appropriate therapy, inappropriate shock or complications, but decreases with advancing age.

Respiration is a key metabolic process in the marine environment and contemporary phytoplankton production (PhP) is commonly assumed the main driver. However, respiration in the absence of contemporary PhP, termed baseline respiration, can influence the energetics of an ecosystem and its sensitivity to hypoxia. Direct studies of baseline respiration are currently lacking. This study aims to obtain a first estimate of baseline respiration in a sub-arctic estuary and determine its contribution to plankton community respiration. Three approaches used to define baseline respiration determined the average rate to be 4.1 ± 0.1 (SE) mmol O2 m–3 d–1. A hypsographic model at the basin scale accounting for seasonal variation estimated an annual contribution of 30% baseline respiration to planktonic respiration. There was no correlation between plankton respiration and PhP, but a significant linear dependence was found with the total carbon supply from phytoplankton and riverine input. The sum of dissolved organic carbon transported by rivers, provided by both benthic and pelagic algae, could sustain 69% of the annual plankton respiration, of which as much as 25% occurred during winter. However, only 32% of the winter season respiration was explained, indicating that unknown carbon sources exist during the winter. Nitrification had a negligible (≤2.4%) effect on baseline respiration in the system. The results show that baseline respiration accounted for a significant percentage of coastal plankton respiration when allochthonous sources dominated the carbon supply, weakening the respiration-to- PhP relationship.

Abstract The ice‐covered period on lakes in the northern hemisphere has often been neglected or assumed to have less importance relative to the open water season. However, recent studies challenge this convention, suggesting that the winter period is more dynamic than previously thought. In this review, we synthesize the current understanding of under‐ice carbon dioxide (CO2) and methane (CH4) dynamics, highlighting the annual importance of CO2 and CH4 emissions from lakes at ice‐melt. We compiled data from 25 studies that showed that the ice‐melt period represents 17% and 27% of the annual CO2 and CH4 emissions, respectively. We also found evidence that the magnitude and type of emission (i.e., CO2 and CH4) varies with characteristics of lakes including geographic location, lake morphometry, and physicochemical conditions. The scarcity of winter and spring carbon data from northern lakes represents a major gap in our understanding of annual budgets in these lakes and calls for future research during this key period.

Abstract Sediments of northern lakes sequester large amounts of organic carbon (OC), but direct evidence of the relative importance of their sources is lacking. We used stable isotope ratios of nonexchangeable hydrogen (δ2Hn) in topsoil, algae, and surface sediments in order to measure the relative contribution of terrestrial OC in surface sediments of 14 mountainous arctic and lowland boreal lakes in Sweden. The terrestrial contribution to the sediment OC pool was on average 66% (range 46–80) and similar between arctic and boreal lakes. Proxies for the supply of terrestrial and algal OC explained trends in the relative contribution of terrestrial OC across lakes. However, the data suggest divergent predominant sources for terrestrial OC of sediments in Swedish lakes, with dissolved matter dominating in lowland boreal lakes and particulate OC in mountainous arctic lakes.

Objectives The aim was to examine health-related quality of life (HRQoL), patient characteristics and reasons for visits to general practitioners (GPs) by frequent attenders (FAs) and a comparison group (CG) in primary care.Methods Patients aged 18–64 years were eligible for the study. Medical records were scrutinised concerning reasons for visits. Questionnaires including short-form health survey (SF-36) were mailed to 331 FAs (≥5 visits at GPs during 2000) and 371 patients in a CG randomly selected from two healthcare centres and returned by 49% and 57%, respectively. FAs’ SF-36 health profiles were compared both to CG and general Swedish population norms.Results FAs report lower HRQoL than CG and below the general Swedish population norms in all eight SF-36 domains including both mental and physical component summary scores (MCS and PCS). Effect sizes (ESs) for differences between FAs and norms ranged from 0.79 to 1.08 for specific domains and was 0.94 for PCS and 0.71 for MCS. ESs of FAs versus CG ranged between 0.60 and 0.95 for the domains and was 0.76 for PCS and 0.49 for MCS. There were no significant differences between the FAs and CG with regard to sex, being married or cohabiting, number of children in household or educational level. FAs were more often unemployed, obese, slightly older and used complementary medicine more frequently. Except for injuries, all health complaints as classified in 10 categories were more common among FAs than CG, particularly musculoskeletal pain and psychosocial distress related to compromised HRQoL.Conclusion The HRQoL is compromised in FAs, both when compared with patients who do not often seek care and to general Swedish population norms. Commonly reported reasons for visiting GPs among FAs were musculoskeletal pain and psychosocial distress. Thus, perceived ill health, particularly pain and distress, seems important for high utilisation of healthcare resources.

The authors wish to make the following correction to Table 7 in this paper [...]

Nutrient limitation of primary producers and their consumers can have a large influence on ecosystem productivity. The nature and strength of nutrient limitation is driven both by external factors (e.g., nutrient loading) and internal processes (e.g., consumer‐driven nutrient regeneration). Here we present results from a field study in 10 low productive headwater lakes in northern subarctic Sweden, where nitrogen (N) deposition is low and phytoplankton is primarily N‐limited. We assessed the carbon:nitrogen:phosphorus (C:N:P) stoichiometry of seston and zooplankton and estimated the N:P ratio of consumer‐driven nutrient regeneration. Based on stoichiometric models, the estimated elemental imbalances between seston and zooplankton suggest that zooplankton were mainly N‐limited and regenerated nutrients with low N:P ratios (median 11.9, atomic ratio). The predicted N:P regeneration ratios were consistent with results from phytoplankton nutrient limitation bioassays in mid‐summer, i.e., the N:P regeneration was predicted to be low when phytoplankton were N‐limited, and high when phytoplankton were P‐limited. During other seasons, when water discharge was high, nutrient loading from the surrounding catchments apparently had the strongest effect on phytoplankton nutrient limitation. We propose that lakes with higher N:P ratios than the open ocean is an effect of N deposition, that N‐limitation of consumers and phytoplankton is further enhanced by low nutrient regeneration N:P ratios, and that in the absence of N deposition, lake and ocean N:P stoichiometry are similar.

Owing to the significant societal value of inland water resources, there is a need for cost-effective monitoring of water quality on large scales. We tested the suitability of the recently launched Sentinel-2A to monitor a key water quality parameter, coloured dissolved organic matter (CDOM), in various types of lakes in northern Sweden. Values of a(420)CDOM (CDOM absorption at 420 nm wavelength) were obtained by analyzing water samples from 46 lakes in five districts across Sweden within an area of approximately 800 km2. We evaluated the relationships between a(420)CDOM and band ratios derived from Sentinel-2A Level-1C and Level-2A products. The band ratios B2/B3 (460 nm/560 nm) and B3/B5 (560 nm/705 nm) showed poor relationships with a(420)CDOM in Level-1C and 2A data both before and after the removal of outliers. However, there was a slightly stronger power relationship between the atmospherically-corrected B3/B4 ratio and a(420)CDOM (R2 = 0.28, n = 46), and this relationship was further improved (R2 = 0.65, n = 41) by removing observations affected by light haze and cirrus clouds. This study covered a wide range of lakes in different landscape settings and demonstrates the broad applicability of a(420)CDOM retrieval algorithms based on the B3/B4 ratio derived from Sentinel-2A.

Seasonal patterns in assimilation of externally produced, allochthonous, organic matter into aquatic food webs are poorly understood, especially in brown-water lakes. We studied the allochthony (share biomass of terrestrial origin) in cladoceran, calanoid and cyclopoid micro-crustacean zooplankton from late winter to fall during two years in a small humic lake (Sweden). The use of allochthonous resources was important for sustaining a small population of calanoids in the water column during late winter. However, in summer the calanoids shifted to 100% herbivory, increasing their biomass several-fold by making efficient use of the pelagic primary production. In contrast, the cyclopoids and cladocerans remained at high levels of allochthony throughout the seasons, both groups showing the mean allochthony of 0.56 (range in mean 0.17-0.79 and 0.34-0.75, for the respective group, depending on model parameters). Our study shows that terrestrial organic matter can be an important resource for cyclopoids and cladocerans on an annual basis, forming a significant link between terrestrial organic matter and the higher trophic levels of the food web, but it can also be important for sustaining otherwise herbivorous calanoids during periods of low primary production in late winter.

A common and established view is that increased inputs of nutrients to the sea, for example via river flooding, will cause eutrophication and phytoplankton blooms in coastal areas. We here show that this concept may be questioned in certain scenarios. Climate change has been predicted to cause increased inflow of freshwater to coastal areas in northern Europe. River waters in these areas are often brown from the presence of high concentrations of allochthonous dissolved organic carbon (humic carbon), in addition to nitrogen and phosphorus. In this study we investigated whether increased inputs of humic carbon can change the structure and production of the pelagic food web in the recipient seawater. In a mesocosm experiment unfiltered seawater from the northern Baltic Sea was fertilized with inorganic nutrients and humic carbon (CNP), and only with inorganic nutrients (NP). The system responded differently to the humic carbon addition. In NP treatments bacterial, phytoplankton and zooplankton production increased and the systems turned net autotrophic, whereas the CNP-treatment only bacterial and zooplankton production increased driving the system to net heterotrophy. The size-structure of the food web showed large variations in the different treatments. In the enriched NP treatments the phytoplankton community was dominated by filamentous >20 µm algae, while in the CNP treatments the phytoplankton was dominated by picocyanobacteria

Aims. Evaluation of bariatric surgery as secondary prevention in obese patients with ischemic heart disease (IHD). Methods. Analysis of data from 4047 subjects in the Swedish Obese Subjects (SOSs) study. Thirty-five patients with IHD are treated with bariatric surgery (𝑛=21) or conventional treatment (𝑛=14). Mean follow-up is 10.8 years. Results. Bariatric surgery resulted in sustained weight loss during the study period. After 2 years, the surgery group displayed significant reductions in cardiovascular risk factors, relief from cardiorespiratory symptoms, increments in physical activity, and improved quality of life. After 10 years, recovery from hypertension, diabetes, physical inactivity, and depression was still more common in the surgery group. There were no signs of increased cardiovascular morbidity or mortality in the surgery group. Conclusion. Bariatric surgery appears to be a safe and feasible treatment to achieve long-term weight loss and improvement in cardiovascular risk factors, symptoms, and quality of life in obese subjects with IHD.

As the permafrost region warms, its large organic carbon pool will be increasingly vulnerable to decomposition, combustion, and hydrologic export. Models predict that some portion of this release will be offset by increased production of Arctic and boreal biomass; however, the lack of robust estimates of net carbon balance increases the risk of further overshooting international emissions targets. Precise empirical or model-based assessments of the critical factors driving carbon balance are unlikely in the near future, so to address this gap, we present estimates from 98 permafrost-region experts of the response of biomass, wildfire, and hydrologic carbon flux to climate change. Results suggest that contrary to model projections, total permafrost-region biomass could decrease due to water stress and disturbance, factors that are not adequately incorporated in current models. Assessments indicate that end-of-the-century organic carbon release from Arctic rivers and collapsing coastlines could increase by 75% while carbon loss via burning could increase four-fold. Experts identified water balance, shifts in vegetation community, and permafrost degradation as the key sources of uncertainty in predicting future system response. In combination with previous findings, results suggest the permafrost region will become a carbon source to the atmosphere by 2100 regardless of warming scenario but that 65%–85% of permafrost carbon release can still be avoided if human emissions are actively reduced.