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The present study investigates academic stress in two different cultures, the Iranian as a collectivist culture, and the Swedish as an individualist culture. A total of 616 university students (312 Iranian and 304 Swedish) participated in the study. The results show that Swedish students experience more academic stress than Iranian students. Academic stress was found to be related to difficulties in and outside class, and managing work, family and leisure activities. There was no cultural difference in terms of interacting with the university administration, teachers and friends. There was a gender difference, with females experiencing more academic stress than males, an effect that was more pronounced in Sweden than in Iran. Subset analyses (92 Swedes and 100 Iranians) revealed a tendency of Iranian students to balance positive and negative emotions in comparison to students from Sweden. Partial correlations showed that negative affect was the sole affect to significantly correlate with academic stress in Sweden. Negative and positive affect correlated in unison with academic stress in Iran. These results are discussed on an individualist-collectivist dimension. Cultural differences between the educational systems in the two countries may also explain the differing emotion/affect-health relationships.

Introduction: Use of antipsychotic drugs, especially second‐generation agents, has been suggested to cause acute pancreatitis in multiple case reports; however, such an association has not been corroborated by larger studies. This study examined the association of antipsychotic drugs with risk of acute pancreatitis. Methods: Nationwide case–control study, based on data from several Swedish registers and including all 52,006 cases of acute pancreatitis diagnosed in Sweden between 2006 and 2019 (with up to 10 controls per case; n = 518,081). Conditional logistic regression models were used to calculate odds ratios (ORs) in current and past users of first‐generation and second‐generation antipsychotic drugs (dispensed prescription <91 and ≥91 days of the index date, respectively) compared with never users of such drugs. Results: In the crude model, first‐generation and second‐generation antipsychotic drugs were associated with increased risk of acute pancreatitis, with slightly higher ORs for past use (1.58 [95% confidence interval 1.48–1.69] and 1.39 [1.29–1.49], respectively) than for current use (1.34 [1.21–1.48] and 1.24 [1.15–1.34], respectively). The ORs were largely attenuated in the multivariable model—which included, among others, alcohol abuse and the Charlson comorbidity index—up to the point where only a statistically significant association remained for past use of first‐generation agents (OR 1.18 [1.10–1.26]). Conclusion: There was no clear association between use of antipsychotic drugs and risk of acute pancreatitis in this very large case–control study, indicating that previous case report data are most likely explained by confounding. [ABSTRACT FROM AUTHOR]

Background: Proton pump inhibitors (PPIs) are associated with microbiome changes of the gut, which in turn may affect the progression of colorectal cancer (CRC). This study aims to assess the associations between PPI use and all-cause and CRC-specific mortality.Methods: We selected all patients registered in the Swedish Prescribed Drug Registry who were diagnosed with CRC between 2006 and 2012 (N = 32,411, 54.9% PPI users) and subsequently followed them through register linkage to the Swedish Causes of Death Registry until December 2013. PPI users were patients with ≥1 post-diagnosis PPI dispensation. Time-dependent Cox-regression models were performed with PPI use as time-varying exposure.Results: Overall 4746 (14.0%) patients died, with an aHR of 1.38 (95% CI 1.32-1.44) for all-cause mortality comparing PPI users with PPI nonusers. Higher-magnitude associations were observed among male, cancer stage 0-I, rectal cancer and patients receiving CRC surgery. The PPI-all-cause mortality association was also more pronounced comparing new users to non-users (aHR = 1.47, 95%CI 1.40-1.55) than comparing continuous users to non-users (aHR = 1.32, 95%CI 1.24-1.39). The risk estimates for CRC-specific mortality comparing PPI users to PPI nonusers were similar to those for all-cause mortality.Conclusion: PPI use after the CRC diagnosis was associated with increased all-cause and CRC-specific mortality. [ABSTRACT FROM AUTHOR]

Summary: Background: Menopausal hormone therapy (MHT) has been associated with various malignancies. Aims: To investigate the association of various MHT regimens with the risk of colorectal cancer (CRC). Methods: All MHT ever‐users (n = 290 186) were included through the Swedish Prescribed Drug Registry, with a 1:3 group‐level matching to non‐users. Ever‐users were defined as women who received ≥1 dispensed prescription of systemic MHT during 2005‐2012 in Sweden. All CRC cases after drug initiation were extracted from the Swedish Cancer Registry. The association was assessed by multivariable conditional logistic and Cox regression models, presented as odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs) considering different regimens, duration and age at treatment initiation. Results: Compared with non‐users, MHT users had an overall reduced odds for colon (OR = 0.67, 95% CI 0.63‐0.72) and rectal adenocarcinoma (OR = 0.66, 95% CI 0.60‐0.73), especially among women aged 40‐60 years. Current users of oestrogen‐only preparations (E‐MHT) showed a reduced odds (colon OR = 0.73, 95% CI 0.65‐0.82; rectal OR = 0.76, 95% CI 0.64‐0.90) compared to non‐users, particularly with oestradiol and oestriol. Past E‐MHT use showed stronger odds reductions (colon OR = 0.49, 95% CI 0.43‐0.56; rectal OR = 0.36, 95% CI 0.28‐0.45). Current use of oestrogen combined progestin therapy (EP‐MHT) indicated a less prominent odds reduction (colon adenocarcinoma OR 0.62, 95% CI 0.54‐0.72; rectal adenocarcinoma OR = 0.60, 95% CI 0.49‐0.74) than past users. Tibolone showed an increased risk of left‐sided colorectal adenocarcinoma. Oral and cutaneous MHT usage showed similar patterns. Conclusions: MHT use may decrease colorectal adenocarcinoma risk, for both E‐MHT and EP‐MHT, and especially in past users. [ABSTRACT FROM AUTHOR]

Background: The long-term safety of proton pump inhibitors (PPIs) is increasingly questioned. The aim of our study was to assess the risk of pancreatic cancer among long-term PPI users in Sweden.Methods: This population-based nationwide Swedish cohort study including 796,492 adult long-term PPI users has been used to calculate the standardized incidence rate ratios (SIRs) and 95% confidence intervals (CI) for pancreatic cancer, stratifying by indications of use, age, sex, and duration of use. The risk among all 20,210 long-term H2-receptor antagonist users was assessed as comparison.Results: Pancreatic cancer was found in 1733 long-term PPI users, and 25 H2-receptor antagonist users. For PPI users, the risk of pancreatic cancer was increased overall (SIRs = 2.22; 95% CI 2.12-2.32) and in all subgroup analyses, with the highest risk among PPI-users younger than 40 years (SIR = 8.90, 95% CI 4.26-16.37), and among individuals with a history of Helicobacter pylori (SIR = 2.99, 95% CI 2.54-3.49). After the first year after enrolment (during which PPI use may be because of early symptoms of pancreatic cancer), the risk remained increased over time, with SIR = 1.57 (95% CI 1.38-1.76) after 5 years. No associations were found for H2-receptor antagonists (SIR = 1.02, 95% CI 0.66-1.51).Conclusions: This large study showed an increased risk of pancreatic cancer in long-term users of PPIs in Sweden, in particular among the youngest users. [ABSTRACT FROM AUTHOR]

Purpose: An incident episode of acute pancreatitis is often followed by recurrent attacks and/or progression to chronic pancreatitis, especially if the etiology is non-gallstone-related. We examined whether overall diet quality influences the natural history of non-gallstone-related acute pancreatitis.Methods: Three hundred and eighty-six individuals (born 1914-1952) were included in a prospective study, all of whom had an incident diagnosis of non-gallstone-related acute pancreatitis in the Swedish National Patient Register between 1998 and 2013. Participants were already enrolled in two population-based cohorts and had completed a food frequency questionnaire in 1997. Overall diet quality was calculated using a recommended food score (RFS), which was based on 25 food items. Post-diagnosis follow-up was conducted throughout 2014 for recurrence of acute pancreatitis and/or progression to chronic pancreatic disease (including cancer). Hazard ratios were estimated using Cox models.Results: During 1859 person-years of follow-up, 23.3% of the study population (n = 90) developed recurrent or progressive pancreatic disease. An inverse association was observed between the RFS and risk of recurrent and progressive pancreatic disease after adjustment for age and sex (hazard ratio for each 2-unit increase 0.90, 95% confidence interval 0.81-1.01) (Poverall association = 0.06). However, the association became weaker and was not statistically significant after adjustment for other potential confounders, including alcohol drinking and cigarette smoking (Poverall association = 0.27).Conclusions: In this prospective study of individuals with non-gallstone-related acute pancreatitis, there was no clear association between overall diet quality and risk of recurrent and progressive pancreatic disease. [ABSTRACT FROM AUTHOR]

Only one previous study has examined the association between coffee consumption and risk of acute pancreatitis, and it found a reduced risk for alcohol-related episodes among high consumers of coffee. Therefore, we examined (1) the association between coffee consumption and risk of non-gallstone-related acute pancreatitis and (2) whether this association was modified by alcohol intake. Data were obtained from two prospective cohorts, the Cohort of Swedish Men and the Swedish Mammography Cohort, including 76 731 men and women (born 1914–1952). Coffee consumption was assessed at baseline with a FFQ, and the cohorts were followed up between 1998 and 2012 via linkage to national health registries. Hazard ratios were estimated using Cox models, with adjustment for potential confounding factors. During 1 035 881 person-years of total follow-up, 383 cases (246 in men and 137 in women) of incident non-gallstone-related acute pancreatitis were identified. Overall, and irrespective of whether a categorical or a continuous exposure model was used, we observed no association between coffee consumption and risk of non-gallstone-related acute pancreatitis (e.g. the multivariable-adjusted hazard ratio for each 1 cup/d increase in coffee consumption was 0·97; 95 % CI 0·92, 1·03). There was no evidence of effect modification by alcohol intake (Pinteraction=0·77). In conclusion, coffee consumption was not associated with risk of non-gallstone-related acute pancreatitis in this large prospective cohort study. Because of the limited number of epidemiological studies and their conflicting results, further research is needed to elucidate this potential association. [ABSTRACT FROM AUTHOR]

Background.The strong female predominance of biliary tract cancer (BTC) may be related to reproductive factors. We aimed to clarify whether parity or age at first birth influence the risk of BTC. Methods.This was a population-based, case-control study including Swedish female and male cases of cancer of the gallbladder (GBC), extra hepatic bile ducts (EHCC), or the ampulla of Vater (AVC) between 1960 and 2008. For each case, 10 age- and sex-matched controls were randomly selected. Conditional logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CIs), adjusted for potential confounders. Results.In total, 1169 cases of GBC, 432 cases of EHCC and 295 cases of AVC were included. Multi- and nulliparous women and men had an increased risk of all tumor locations in the biliary tract compared to uniparous women and men, respectively. Whereas higher age at first birth was associated with a decreased risk of GBC in women, no such association was found in men. There were no clear differences in the risk of EHCC and AVC between women and men. Conclusion.Sex hormones may play a role in the etiology of GBC. The associations between reproductive factors and EHCC and AVC are similar in women and men, which do not support the sex hormone hypothesis. [ABSTRACT FROM AUTHOR]

Background Injuries are responsible for much child and adolescent mortality in the world. Objective To study the effect of parental birth country on the risk of fatal unintentional injuries. Methods We established a cohort by linkages between Swedish national registers through personal identification number. The main variable was country of birth of parents. Children with both parents born in Sweden were the reference group. The cohort was followed up from the starting date of the study (1 January 1961) or date of birth, whichever occurred last, until the exit date, which was death due to unintentional injury, first emigration or end of the follow-up (31 December 2007), whichever came first. We calculated HRs with 95% CIs adjusted for age at exit, parental education and calendar period of birth by Cox proportional hazards models. Results We found a significantly higher risk of fatal unintentional injuries among children with a foreign background than among native children. We found a higher risk of fatal transportation-related injuries and drowning among boys with a foreign background and a higher risk of fatal burns/fire and falls among girls with a foreign background than among same sex native children. We also found a higher risk of fatal unintentional injuries among children with a foreign background at older ages than among native children at the same ages. Conclusions Injury prevention work against unintentional injuries among children of foreign origin is more complex than that among native children. We recommend designing specific studies to find out the factors responsible and planning preventive interventions aiming at this particular group of children with a foreign background. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to investigate the association between migration status and education level and the use of recommended drugs after first acute myocardial infarction (MI). Methods: A nationwide cohort study performed in Sweden from January 1, 2006 to August 1, 2008. The cohort consisted of 49,037 incident cases of first acute MI. In total, 37,570 individuals survived 180 days after MI, of whom 4782 (12.7 %) were foreign-born. We used logistic regression to estimate the odds ratio (OR) with 95 % confidence interval (CI) of the association between migration status and education level and prescribed drugs after MI. Results: One third of the patients who were not on any recommended cardiovascular drugs before MI continued to be without recommended cardiovascular drugs after MI. Among those with no cardiovascular drugs before MI, we found no difference in recommended drug use after MI by migration status (OR 1.00, 95 % CI 0.89-1.12). Among those with some but not all recommended cardiovascular drugs before MI, foreign-born cases had a slightly non-significant lower use of recommended drugs (OR 0.92, 95 % CI 0.83-1.03). Foreign-born patients with low education had a slightly lower use of recommended drug compared to Sweden-born. Women with low education had a lower use of drugs after MI (Sweden born, OR 0.85; 95 % CI 0.74-0.96 and foreign born OR 0.51; 95 % CI 0.34-0.77). Conclusion: There is no apparent difference between foreign-born and Sweden-born in recommended drug use after MI. However, our study reveals an inequity in secondary prevention therapy after myocardial infarction by education level. [ABSTRACT FROM AUTHOR]

Background: Epidemiologic data on the role of diet in acute pancreatitis are sparse. Objective: We examined the association of total fish consumption, as well as of consumption of fatty fish and lean fish separately, with risk of non-gallstone-related acute pancreatitis. Design: We used data from 2 prospective cohorts, the Cohort of Swedish Men and the Swedish Mammography Cohort, that included 39,267 men and 32,191 women who were aged 45-84 y at the start of a 13-y follow-up period (1998-2010). Fish consumption was assessed by using a food-frequency questionnaire at baseline, and cases of incident non-gallstone-related acute pancreatitis were identified by linkage to the Swedish National Patient Register. HRs were estimated by using Cox proportional hazard models. Results: During a total follow-up of 860,176 person-years, 320 cases (209 cases in men and 111 cases in women) of incident non-gallstone-related acute pancreatitis were identified. We observed that total fish consumption ≤ 2.0-3.0 servings/wk was associated with a significantly decreased risk of the disease (P-nonlinearity = 0.017). In comparison with 0.9 servings/wk, multivariable-adjusted HRs were 0.86 (95% CI: 0.76, 0.96), 0.77 (95% CI: 0.62, 0.96), and 0.85 (95% CI: 0.65, 1.10) for 1.4, 2.4, and 3.5 servings/wk, respectively. In the analysis of fatty fish and lean fish, we observed that the consumption of each subtype had a similarly shaped association with risk of non-gallstone-related acute pancreatitis as that observed for total fish consumption, although neither was significant. Multivariable-adjusted HRs were 0.83 for fatty fish (95% CI: 0.65, 1.04) and 0.87 for lean fish (95% CI: 0.69, 1.11) when 0.6-2.0 servings/wk was compared with ≤0.5 servings/wk. Conclusion: Our data suggest that the consumption of total fish (fatty fish and lean fish combined) may be associated with decreased risk of non-gallstone-related acute pancreatitis. The Swedish Mammography Cohort was registered at clinicaltrials.gov as NCT01127698. The Cohort of Swedish Men was registered at clinicaltrials.gov as NCT01127711. [ABSTRACT FROM AUTHOR]

Introduction: Migrant studies may provide valuable clues to the etiology of chronic diseases such as cancer. We conducted a migrant study to examine cancer incidence among Iranian immigrants in Sweden. Methods: A cohort of Iranian immigrants in Sweden in 1960-2004 was followed through record linkages with Swedish registers of cancer, death, and migration. We compared Age-Standardized Incidence Rates (ASRs) with corresponding ASRs in Tehran and Sweden and estimated Standard Rate Ratios with 95% confidence intervals (CI). In addition, ASRs were stratified by follow-up time. Results: In total 1,041 cancers occurred among 60,718 Iranian immigrants. The ASRs for all cancers combined were 182.3 and 175.5 per 100,000 person-years among men and women, respectively. For men, this rate was slightly and non-significantly higher than in Iran, while for women the excess (24%) was statistically significant. However, their ASRs were significantly lower than those for native Swedes: men had 37% (95% CI 27- 47%) and women 35% (95% CI 33-37%) lower ASRs. Compared to male Iranians living in Tehran, ASRs of esophageal and gastric cancer were lower while ASRs of colorectal and prostate cancer were higher, and both of the latter increased with time since immigration. In women, the ASR of non-melanoma skin cancer was lower and that of breast cancer higher and increasing. Conclusion: In male first-generation immigrants, incidence rates of esophageal, gastric, colorectal, and prostate cancer change in the direction of prevailing rates in Sweden, likely due to changes in exposure to environmental risk factors. A similar adjustment occurs for breast and non-melanoma skin cancer among female immigrants. [ABSTRACT FROM AUTHOR]

Background. Incidence rates of cancers of the pancreas and biliary tract, typically derived from cancer registers, have been reported to be decreasing. This study tested whether pancreatic and biliary tract cancers are underreported in the Swedish Cancer Register (CR). Methods. The concordance of pancreatic and biliary tract cancer diagnoses in 1990-2009 between CR and the Swedish Patient Register (PR) were evaluated through record linkage. To further assess the completeness of these cancer diagnoses in both CR and PR, record linkage was also made to the Swedish Causes of Death Register (DR). Results. A total of 31 067 cases of pancreatic cancer and 14 273 cases of biliary tract cancer were identified in CR or PR. Altogether, 44% of the pancreatic cancers and 44% of the biliary tract cancers were registered in PR only, and not in CR. The concordance between CR and PR declined from 63% in the years 1990-1994 to 44% in 2005-2009 for pancreatic cancer. The corresponding figures for biliary tract cancer were 60% and 37%. This decline in concordance was also observed with increasing age, e.g. the concordance between CR and PR for pancreatic cancer declined from 62% in patients < 60 years to 36% among patients ≥ 80 years. The corresponding figures for biliary tract cancer were 52% and 38%. Conclusion. There is an overwhelming underreporting of pancreatic and biliary tract cancers within the Swedish Cancer Register, which has increased during recent years. The reported decreasing incidence rates for pancreatic and biliary tract cancers might therefore be incorrect. [ABSTRACT FROM AUTHOR]

Background: Injury risk during childhood and adolescence vary depending on socio-economic factors. The aim of this study was to study if the risk of fatal and non-fatal unintentional injuries among foreign-born children was similar across parental educational level or not. Methods: In this retrospective cohort study we followed 907,335 children between 1961 and 2007 in Sweden. We established the cohort by linkage between Swedish national registers including cause of death register and in-patient register, through unique Personal Identification Numbers. The main exposure variable was parental (maternal and paternal) educational level. The cohorts was followed from start date of follow-up period, or date of birth whichever occurred last, until exit date from the cohort, which was date of hospitalization or death due to unintentional injury, first emigration, death due to other causes than injury or end of follow-up, whichever came first. We calculated hazard ratios (HR) with 95% confidence intervals (95% CI) by Cox proportional hazards regression models. Results: Overall, we found 705 and 78,182 cases of death and hospitalization due to unintentional injuries, respectively. Risk of death and hospitalization due to unintentional injuries was statistically significantly 1.48 (95% CI: 1.24-1.78) and 1.10 (95% CI: 1.08-1.12) times higher among children with lowest parental educational level (9 years and shorter years of study) compared to children with highest parental educational level (+13 years of study). We found similar results when stratified our study group by sex of children, by maternal and paternal educational level separately, and injury type (traffic-related, fall, poisoning, burn and drowning). Conclusions: It seems injury prevention work against unintentional injuries is less effective among children with low parental education compared with those with higher parental education. We recommend designing specific preventive interventions aiming at children with low parental education. [ABSTRACT FROM AUTHOR]

We acquired a high-resolution 2D seismic profile to test the capability of the seismic method in imaging a sulfide ore body at Garpenberg, central Sweden. Delineation of the geologic structures, which surround and host the ore body, is another goal of the survey. Due to the 3D geology of the structures, a cross-dip correction performed to image out-of-the-plane reflections, resulting in a clear high amplitude anomaly at a time and location to that to be expected from near the top of the ore body. Furthermore, DMO processing and migration are applied to the data, providing images of four main reflection groups. The reflections have been interpreted as corresponding to geologic rock units in the area that partly interfere with the potential ore body signal. To further investigate the seismic response of the ore body, forward modeling by ray-tracing is applied using the ore body geometry as mapped by drilling. We use two ray-tracing approaches: standard 3D ray-tracing and an exploding reflector approach. Seven representative samples from the mine area are used to determine P-wave velocities. The measurements show a considerable contrast between the ore body and host rock. By comparing the modeled and observed data, we find that the high amplitude signal in the real seismic section most likely emanates from near the top of one concentrated ore which lies inside the larger mapped ore body that has been modeled as a resource. The base of the ore body is only observed on the synthetic data whereas a signal penetration analysis suggests that the seismic signal penetrated efficiently along the entire survey line. Presence of disseminated ore and lower fold toward the northern end of the profile could be combined reasons that make imaging the base of the ore body difficult. [ABSTRACT FROM AUTHOR]

Background: There are no nationwide studies on mortality after coronary artery bypass grafting (CABG) among foreign-born populations that include detailed information about country of birth and information about socioeconomic position. The objective was to investigate the risk of mortality after CABG considering socioeconomic position, sex and country of birth. Material and Methods: We included all 72 333 patients undergoing a first isolated CABG in Sweden, during 1995 - 2007 of whom 12.7% were foreign-born. The patients were classified according to educational level, sex, and country of birth and were followed up to December 2007. We estimated the risk of short and long term mortality after CABG in a multivariable model adjusted for age, calendar year of surgery, diabetes, educational level, and waiting time for surgery. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated based on the Cox proportional hazard model. Findings: There were 15,284 deaths during the follow-up, 10.4% of whom were foreign-born. The foreign-born patients were 3 to 4 years younger than Sweden-born patients at the time of CABG surgery. There were no significant differences in overall early or late mortality between foreign-born and Sweden-born men and women after CABG. All-cause mortality differed in between regions and was highest in foreign-born men from Eastern Africa (HR 3.80, 95% CI 1.58–9.17), China (HR 3.61, 95% CI 1.50–8.69), and in Chile (HR 2.12, 95% CI 1.01–4.47). Patients with low level of education had worse survival compared to those with longer than 12 years of education irrespective of sex and country of birth. This difference was more pronounced among foreign-born women (HR 1.50, 95% CI 1.00–2.33). Conclusion: This national study showed higher CABG mortality in patients from lower socioeconomic position. Early and late mortality did not differ after isolated CABG in foreign-born and Sweden-born patients. [ABSTRACT FROM AUTHOR]

Abstract: In order to compare the risk of gynaecologic cancer among foreign-born women to the risk among those born in Sweden and to elucidate risk of cancer in relation to age at migration and duration of residence, we followed a cohort of 5.3 million women between 1969 and 2004 in Sweden. Through linkage with the national cancer register, we estimated cancer risk as rate ratios (RRs) with 95% confidence intervals (CIs) using Poisson regression. We reported RRs adjusted for age, calendar year of follow-up and years of education. Overall, 18,247 cases of cervical, 35,290 cases of endometrial and 32,227 cases of ovarian cancers occurred during 117 million person-years of follow-up. We found that adjusted RRs of all the three cancers were lower or the same among foreign-born women compared to those born in Sweden. As for cervical cancer, women aged 35–49 years born in Poland and Bosnia and women aged 50 years or more born in South America showed an increased risk, which was related to increasing age at migration. The risk was lowest among women born in Iran, Iraq, Organisation for Economic Cooperation & Development (OECD) and Finland, and highest among women born in Bosnia and Eastern Europe during their first 5 years since immigration. RRs for endometrial and ovarian cancers did not vary by duration of residence or by age at migration. Health care providers should be aware of the higher risk of cervical cancer among immigrants from high-risk areas, especially among those who immigrate at older ages. On the other hand, protective factors for ovarian and endometrial cancers seem to be retained upon migration. [Copyright &y& Elsevier]

The geographical and social differences between Spain and Sweden, two non-English language European countries, led to our review of the impact factors (IF) and self-citation rates of scientific journals published in these two countries. The study endeavours to compare the trends of citation rates and impact factors for all Spanish and Swedish journals indexed in the Journal Citation Reports during the time period 2000-2005. [ABSTRACT FROM AUTHOR]

Introduction: Incidence of breast cancer is increasing around the world and it is still the leading cause of cancer mortality in low- and middle-income countries. We utilized Swedish nationwide registers to study breast cancer incidence and case fatality to disentangle the effect of socioeconomic position (SEP) and immigration from the trends in native Swedes.Methods: A nation-wide cohort of women in Sweden was followed between 1961 and 2007 and incidence rate ratio (IRR) and hazard ratio (HR) with 95% confidence intervals (CIs) were estimated using Poisson and Cox proportional regression models, respectively.Results: Incidence continued to increase; however, it remained lower among immigrants (IRR = 0.88, 95% CI = 0.86 to 0.90) but not among immigrants' daughters (IRR = 0.97, 95% CI = 0.94 to 1.01) compared to native Swedes. Case fatality decreased over the last decades and was similar in native Swedes and immigrants. However, case fatality was significantly 14% higher if cancer was diagnosed after age 50 and 20% higher if cancer was diagnosed in the most recent years among immigrants compared with native Swedes. Women with the highest SEP had significantly 20% to 30% higher incidence but had 30% to 40% lower case fatality compared with women with the lowest SEP irrespective of country of birth. Age at immigration and duration of residence significantly modified the incidence and case fatality.Conclusions: Disparities found in case fatality among immigrants by age, duration of residence, age at immigration and country of birth emphasize the importance of targeting interventions on women that are not likely to attend screenings or are not likely to adhere to the therapy suggested by physicians. The lower risk of breast cancer among immigrant women calls for more knowledge about how the lifestyle factors in these women differ from those with high risk, so that preventative measures may be implemented. [ABSTRACT FROM AUTHOR]

Purpose: There is limited research on individuals undergoing self-initiated health examinations, and the Werlabs cohort will be a base for such research., Participants: All individuals aged 18 or older who had undertaken a self-initiated health examination at Werlabs AB with at least one recorded value of creatinine or cholesterol in Sweden (from 1 January 2015 through 31 December 2023) was included. Medical history and anthropometric measurements were self-reported through an online questionnaire. We describe cohort baseline characteristics, demographic variables and cardiometabolic risk factors., Findings to Date: The study population includes 149 556 individuals who provided at least one health screening. The median (IQR) age was 43 (33-54) years and 54% were women. The most common self-reported chronic disease was hypertension (4.5%), followed by cardiovascular disease (0.9%) and 12.6% reported values of obesity. The prevalence was 2.1% for diabetes, 1.2% for kidney disease (including an estimated glomerular filtration rate of <60 mL/min/1.73 m 2 ), 57.8% for a low-density lipoprotein cholesterol level of >3.0 mmol/L and 4.1% for anaemia (haemoglobin <120 g/L and <130 g/L for women and men, respectively). Interestingly, 1.5% of the individuals had a glucose measurement of >7.0 mmol/L, without reporting a previous diagnosis of diabetes. In an analysis restricted to 621 individuals with recorded blood pressure data between the age of 40 and 70 years and without existing cardiovascular disease, diabetes or kidney disease, 35,4% were classified as high or very high cardiovascular risk according to the 2021 ESC guidelines on cardiovascular disease prevention and with lipid levels that made them eligible for lipid-lowering therapy., Future Plans: The Werlabs cohort comprises a rather healthy and young population that can provide opportunities for future studies on individuals undergoing self-initiated health examinations and has the potential to impact treatment of cardiometabolic risk factors., Competing Interests: Competing interests: HCA, NBF, DPA and OH are employed by Werlabs AB. LK is a former employee of Werlabs. NBF and DPA are shareholders in Werlabs AB. AN and KB have contributed with medical and scientific advice to Werlabs AB, and non-reimbursed (AN and KB) in the later years. PU declares no conflict of interest and all other authors declare no further conflicts of interest., (© 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: Helicobacter pylori (H. pylori) is an established gastric carcinogen, also associated with an increased risk of colorectal cancer. Therefore, we suspected that H. pylori eradication lowers the risk of colorectal cancer., Material and Methods: We assessed if H. pylori eradication therapy is associated with a reduced risk of colorectal adenocarcinoma in a population-based nationwide cohort study. This study included all Swedish adults with at least one recorded H. pylori eradication episode between July 2005 and December 2012, based on the high-quality Swedish health registries. Colorectal adenocarcinoma risks were compared to the Swedish background population, presented as standardized incidence ratios (SIRs) and 95% confidence intervals (CIs), accounting for age, sex, calendar period, tumor location (left or right sided), stage, and number of eradication episodes, from 1 year after eradication and onward., Results: Among 80,381 individuals receiving H. pylori eradication therapy (average follow-up 4.1 years), 282 were diagnosed with colorectal cancer (97.2% adenocarcinoma). Overall, H. pylori eradication was associated with an elevated risk of colorectal adenocarcinoma (SIR 1.27, 95% CI: 1.12-1.43). The colorectal adenocarcinoma risk was increased 1-2 years after eradication (SIR 1.42, 95% CI: 1.17-1.72), then decreased 2-4 years (SIR 0.80, 95% CI: 0.65-0.98) and 4-6 years (SIR 0.76, 95% CI: 0.57-0.99), yet not ≥ 6 years (SIR 1.36, 95% CI: 0.78-2.21) after eradication compared to the general population. Overall, right-sided (SIR 1.47, 95% CI: 1.21-1.76) and left-sided (SIR 1.35, 95% CI: 1.09-1.67) colon adenocarcinomas risks were higher among eradicated individuals than the general population., Conclusion: H. pylori eradication was not associated with a clear and consistent reduction of colorectal cancer in our Swedish cohort., (© 2024 The Author(s). Helicobacter published by John Wiley & Sons Ltd.)

Individuals with mental illness are at higher risk of severe COVID-19 outcomes. However, previous studies on the uptake of COVID-19 vaccination in this population have reported conflicting results. Using data from seven cohort studies (N = 325,298) included in the multinational COVIDMENT consortium, and the Swedish registers (N = 8,080,234), this study investigates the association between mental illness (defined using self-report measures, clinical diagnosis and prescription data) and COVID-19 vaccination uptake. Results from the COVIDMENT cohort studies were pooled using meta-analyses, the majority of which showed no significant association between mental illness and vaccination uptake. In the Swedish register study population, we observed a very small reduction in the uptake of both the first and second dose of a COVID-19 vaccine among individuals with vs. without mental illness; the reduction was however greater among those not using psychiatric medication. Here we show that uptake of the COVID-19 vaccine is generally high among individuals both with and without mental illness, however the lower levels of vaccination uptake observed among subgroups of individuals with unmedicated mental illness warrants further attention., (© 2024. The Author(s).)

Objectives: We aimed to evaluate the risk of colorectal adenocarcinoma (CRA) associated with long-term use of proton pump inhibitors (PPIs) in a large nationwide cohort., Design: Retrospective cohort study., Setting: This research was conducted at the national level, encompassing the entire population of Sweden., Participants: This study utilised Swedish national registries to identify all adults who had ≥180 days of cumulative PPI use between July 2005 and December 2012, excluding participants who were followed up for less than 1 year. A total of 754 118 maintenance PPI users were included, with a maximum follow-up of 7.5 years., Interventions: Maintenance PPI use (cumulative≥180 days), with a comparator of maintenance histamine-2 receptor antagonist (H 2 RA) use., Primary and Secondary Outcome Measures: The primary outcome measure was the risk of CRA, presented as standardised incidence ratios (SIRs) with 95% confidence intervals (CIs). Subgroup analyses were performed to explore the impact of indications, tumour locations, tumour stages and the duration of follow-up. A multivariable Poisson regression model was fitted to estimate the incidence rate ratios (IRRs) and 95% CIs of PPI versus H 2 RA use., Results: Maintenance PPI users exhibited a slightly elevated risk of CRA compared to the general population (SIR 1.10, 95% CI=1.06 to 1.13) for both men and women. Individuals aged 18-39 (SIR 2.79, 95% CI=1.62 to 4.47) and 40-49 (SIR 2.02, 95% CI=1.65 to 2.45) had significantly higher risks than the general population. Right-sided CRA showed a higher risk compared to the general population (SIR 1.26, 95% CI=1.20 to 1.32). There was no significant difference in the risk of CRA between maintenance PPI users and maintenance H 2 RA users (IRR 1.05, 95% CI=0.87 to 1.27, p <0.05)., Conclusions: Maintenance PPI use may be associated with an increased risk of CRA, but a prolonged observation time is needed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Biliary tract cancer (BTC) often goes undetected until its advanced stages, resulting in a poor prognosis. Given the anatomical closeness of the gallbladder and bile ducts to the pancreas, the inflammatory processes triggered by acute pancreatitis might increase the risk of BTC., Objective: To assess the association between acute pancreatitis and the risk of BTC., Methods: Using the Swedish Pancreatitis Cohort (SwePan), we compared the BTC risk in patients with a first-time episode of acute pancreatitis during 1990-2018 to a 1:10 matched pancreatitis-free control group. Multivariable Cox regression models, stratified by follow-up duration, were used to calculate hazard ratios (HRs), adjusting for socioeconomic factors, alcohol use, and comorbidities., Results: BTC developed in 0.94% of 85,027 acute pancreatitis patients and in 0.23% of 814,993 controls. The BTC risk notably increased within 3 months of hospital discharge (HR 82.63; 95% CI: 63.07-108.26) and remained elevated beyond 10 years of follow-up (HR 1.82; 95% CI: 1.35-2.47). However, the long-term risk of BTC subtypes did not increase with anatomical proximity to the pancreas, with a null association for gallbladder and extrahepatic tumors. Importantly, patients with acute pancreatitis had a higher occurrence of early-stage BTC within 2 years of hospital discharge than controls (13.0 vs. 3.6%; p-value <0.01)., Conclusion: Our nationwide study found an elevated BTC risk in acute pancreatitis patients; however, the risk estimates for BTC subtypes were inconsistent, thereby questioning the causality of the association. Importantly, the amplified detection of early-stage BTC within 2 years after a diagnosis of acute pancreatitis underscores the necessity for proactive BTC surveillance in these patients., (© 2024 The Authors. United European Gastroenterology Journal published by Wiley Periodicals LLC on behalf of United European Gastroenterology.)

Purpose: The Swedish Pancreatitis Cohort (SwePan) was designed to study long-term outcomes following an episode of acute pancreatitis. It can also be used to study various risk factors for developing acute pancreatitis., Participants: The SwePan is a register-based nationwide matched cohort. It includes all Swedish cases of acute pancreatitis during 1990-2019. It contains 95 632 individuals with acute pancreatitis and 952 783 pancreatitis-free individuals matched on sex, age and municipality of residence. Follow-up was censored at death, emigration or end of study (31 December 2019). The dataset includes comprehensive information based on several registries, and includes diagnoses, prescribed medications and socioeconomic factors both prior to inclusion and during follow-up., Findings to Date: During the study period, the number of cases of acute pancreatitis in Sweden has more than doubled from 1977 cases in 1990 to 4264 cases in 2019. The median age of first episode of acute pancreatitis has increased from 58 years (IQR 44-73 years) in 1990 to 64 years (IQR 49-76 years) in 2019. Cases with acute pancreatitis were generally less healthy compared with the pancreatitis-free individuals (Charlson Comorbidity Index of 0 in 59.2% and 71.4%, respectively)., Future Plans: SwePan will be used to determine the incidence of acute pancreatitis in Sweden over time and assess long-term all-cause and cause-specific mortality after an episode of acute pancreatitis. Some examples of additional planned studies are (1) assessment of long-term risk of diabetes and (2) risk of malignancy in adjacent organs following acute pancreatitis and (3) assessment of risk factors for development of acute pancreatitis including various drugs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Chemoprevention for biliary tract cancers (BTC), which comprise intrahepatic cholangiocarcinoma (iCCA), extrahepatic cholangiocarcinoma (eCCA), and gallbladder cancer, is controversial. We examined associations between low-dose aspirin, statins, NSAIDs, and metformin with BTC risk., Methods: We used a population-based cohort of 5.7 million persons over age 18 without personal history of cancer (except nonmelanoma skin cancer), receiving at least one commonly prescribed drug between July 1, 2005, and December 31, 2012, from the Swedish Prescribed Drug Registry. Hazard ratios (HR) were calculated using age-scaled multivariable-adjusted Cox models., Results: 2,160 individuals developed BTC. Low-dose aspirin was not associated with BTC risk [HR, 0.93; 95% confidence interval (CI), 0.81-1.07], iCCA (HR, 1.21; 95% CI, 0.93-1.57), eCCA (HR, 0.80; 95% CI, 0.60-1.07), or gallbladder cancer (HR, 0.87; 95% CI, 0.71-1.06). Statins were associated with lower risk of BTC (HR, 0.66; 95% CI, 0.56-0.78), iCCA (HR, 0.69; 95% CI, 0.50-0.95), eCCA (HR 0.54; 95% CI, 0.38-0.76), and gallbladder cancer (HR, 0.72; 95% CI, 0.57-0.91). For all BTC subtypes, combined low-dose aspirin and statins were not associated with lower risk than statins alone. NSAIDs were associated with higher risk of BTC and its subtypes. Metformin was not associated with BTC risk (HR, 0.98; 95% CI, 0.82-1.18), iCCA (HR, 1.06; 95% CI, 0.77-1.48), eCCA (HR, 1.15; 95% CI, 0.82-1.61), or gallbladder cancer (HR, 0.84; 95% CI, 0.63-1.11)., Conclusions: Statins were associated with a decreased risk of BTC and its subtypes. Low-dose aspirin alone was not associated with a decreased risk, and use of both was not associated with further decrease in risk beyond statins alone., Impact: Statins were most consistently associated with a decreased risk of BTC and its subtypes., (©2022 American Association for Cancer Research.)

Background and Aims: Biliary tract cancer is a group of highly aggressive malignant disorders, yet risk factors are poorly understood. In this study, we aim to assess whether prolonged use of proton pump inhibitors (PPIs) increases the risk of incident biliary tract carcinoma in a nation-wide population-based cohort in Sweden., Approach and Results: Using nation-wide registries, we identified all adults who received maintenance PPIs (≥180 days) according to the Swedish Prescribed Drug Register from 2005 through 2012. Data on incident biliary tract cancer were retrieved from the Swedish Cancer, Death and Outpatient Registers. Risk of biliary tract cancer in persons who received PPI treatment was compared with the general population of the corresponding age, sex, and calendar year yielding standardized incidence ratios (SIRs) with 95% CIs. Of 738,881 PPI users (median follow-up of 5.3 years), 206 (0.03%) developed gallbladder cancer and 265 (0.04%) extrahepatic and 131 (0.02%) intrahepatic bile duct cancer corresponding to SIRs of 1.58 (95% CI, 1.37-1.81), 1.77 (95% CI, 1.56-2.00), and 1.88 (95% CI, 1.57-2.23), respectively. In sensitivity analyses restricted to persons without a history of gallstones or chronic liver or pancreatic diseases, SIRs were 1.36 (95% CI, 1.17-1.57) and 1.47 (95% CI, 1.19-1.80) for extra- and intrahepatic duct cancer, respectively. The risk remained higher than the corresponding general population with ≥5 years of PPIs use, ruling out confounding by indication., Conclusions: In this study, long-term use of PPIs was associated with an increased risk of gallbladder, intrahepatic, and extrahepatic bile duct cancer compared with the general population., (© 2021 The Authors. Hepatology published by Wiley Periodicals LLC on behalf of American Association for the Study of Liver Diseases.)

Background: Recent reports from western countries have indicated an increased incidence and a decreased mortality in acute pancreatitis. However, the incidence assessment has often been hampered by the inclusion of both first-time and recurrent episodes of acute pancreatitis., Methods: In this retrospective cohort study, all Swedish residents hospitalized with a first-time episode of acute pancreatitis between 1990 and 2013 were identified using national registers. Sex- and age-standardized incidence rates per 100,000 individuals and year were calculated, as were annual percent changes (APC) from joinpoint regression models., Results: Overall, between 1990 and 2013, 66,131 individuals had a first-time episode of acute pancreatitis in Sweden. Comparing the first five years (1990-1994) to the last four years (2010-2013) of the study period, the overall incidence of acute pancreatitis increased from 25.2 (95% confidence interval (CI): 24.1, 26.3) to 38.3 (95% CI: 37.0, 39.5) cases per 100,000 individuals and year. An increase in incidence was observed irrespective of the subtypes of acute pancreatitis as well as the sex and age of the patients. Although the incidence of complicated acute pancreatitis declined in both men and women between 1990 and 2004, it started to increase in both sexes (APC 3.0; 95% CI: 0.5, 5.5 in men; APC 5.4; 95% CI: 2.6, 8.2 in women) from 2005 onwards., Conclusion: Based on nationwide data, the incidence of first-time acute pancreatitis has increased in Sweden over a period of 24 years. The incidence of disease-related complications has also been on the rise during the past few years, after declining for more than 15 years before that.

Pathogenic germline TP53 variants predispose to a wide range of early onset cancers, often recognized as the Li-Fraumeni syndrome (LFS). They are also identified in 1% of families with hereditary breast cancer (HrBC) that do not fulfill the criteria for LFS. In this study, we present a total of 24 different TP53 variants identified in 31 Swedish families with LFS or HrBC. Ten of these variants, nine exonic and one splice, have previously not been described as germline pathogenic variants. The nine exonic variants were functionally characterized and demonstrated partial transactivation activity compared to wild-type p53. Some show nuclear localization similar to wild-type p53 while others possess cytoplasmic or perinuclear localization. The four frameshift variants (W91Gfs*32, L111 Wfs*12, S227 Lfs*20 and S240Kfs*25) had negligible, while F134 L and T231del had low level of p53 activity. The L111 Wfs*12 and T231del variants are also deficient for induction of apoptosis. The missense variant R110C retain p53 effects and the nonsense E349* shows at least partial transcription factor activity but has reduced ability to trigger apoptosis. This is the first functional characterization of novel germline TP53 pathogenic or likely pathogenic variants in the Swedish cohort as an attempt to understand its association with LFS and HrBC, respectively., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Importance: Clinicians' experience and findings from recent natural history studies suggest that multiple sclerosis (MS) may now be running a more slowly progressing course than before., Objective: To investigate whether the risk of reaching MS disability milestones has changed over the last decade in Sweden., Design, Setting, and Participants: A nationwide population-based retrospective cohort study. By April 2017, 12 512 patients with available information on demographics, MS phenotype, and date of MS onset and diagnosis were registered in the Swedish MS Registry of which 7331 patients with at least 2 recorded Expanded Disability Status Scale scores (EDSS) and diagnosed between January 1995 and December 2010 were included. No further exclusion criteria were applied. Patients were followed up until December 2016 with a median duration follow-up of 8.5 (interquartile range, 4.7-13.8) years. Statistical analysis began in April 2017., Main Outcomes and Measures: Patients were followed up from MS onset date to the date of sustained EDSS 3.0, 4.0, and 6.0. To handle interval-censored observations, a Weibull model was fit, and the change in the risk of EDSS 3.0, 4.0, and 6.0 over calendar years was estimated and hazard ratios (HRs) with corresponding CIs were calculated., Results: Of 7331 patients, 5196 (70.9%) were women, and the mean (SD) age at diagnosis was 38.3 (11.7) years. Adjusting for sex, number of clinic visits, diagnostic delay, and onset age, a 3% decrease per calendar year of diagnosis for the risk of sustained EDSS 3.0 (HR, 0.97; 95% CI, 0.96-0.97), a 6% decrease for the risk of EDSS 4.0 (HR, 0.94; 95% CI, 0.93-0.95), and a 7% decrease for the risk of EDSS 6.0 (HR, 0.93; 95% CI, 0.91-0.94) among patients with relapsing-onset MS was found. The trends were not significant for patients with progressive-onset MS (EDSS 3.0: HR, 1.01; 95% CI, 0.98-1.03; EDSS 4.0: HR, 1.00; 95% CI, 0.98-1.02; EDSS 6.0: HR, 1.00; 95% CI, 0.98-1.02)., Conclusions and Relevance: Risk of reaching major disability milestones has significantly decreased over the last decade in patients with relapsing-onset MS in Sweden. Several factors could potentially be responsible for this observation. However, given that no change was seen in disability accrual of patients with progressive-onset MS and the absence of efficacious treatment option in this group, increased use of more efficacious disease-modifying treatments could be a possible driver of this change.

Background: Acute pancreatitis is linked to pancreatic cancer, but the direction of this association is not fully elaborated., Methods: This was a population-based cohort study including all Swedish residents diagnosed with a first-time episode of acute pancreatitis between 1997 and 2013 and corresponding matched pancreatitis-free individuals from the general population. Hazard ratios for the association between acute pancreatitis and pancreatic cancer were estimated using multivariable Cox regression models., Results: Overall, 49,749 individuals with acute pancreatitis and 138,750 matched individuals without acute pancreatitis were followed up for 1,192,134 person-years (median 5.3 years). A total of 769 individuals developed pancreatic cancer, of whom 536 (69.7%) had a history of acute pancreatitis. The risk of pancreatic cancer was substantially increased during the first few years after a diagnosis of acute pancreatitis but declined gradually over time, reaching a level comparable to the pancreatitis-free population after >10 years of follow-up. In those with non-gallstone-related acute pancreatitis, the risk of pancreatic cancer declined to a level comparable to the pancreatitis-free population only when follow-up time was censored for a second episode of acute pancreatitis or a diagnosis of chronic pancreatitis. Increasing number of recurrent episodes of acute pancreatitis was associated with increased risk of pancreatic cancer., Conclusion: These findings imply a delay in the diagnosis of pre-existing pancreatic cancer, if clinically presented as acute pancreatitis. Any association between non-gallstone-related acute pancreatitis and pancreatic cancer in the long-term (>10 years) could be mediated through recurrent acute pancreatitis or chronic pancreatitis.

Background: The incidence trends of biliary tract cancer need to be established. This study investigated the incidence and mortality of biliary tract cancer in Sweden in 1970-2010., Methods: Sex-specific biliary tract cancer incidence and mortality rates were evaluated using data from the Swedish Cancer Register, Patient Register and Causes of Death Register. Case registration was separate for each register. Gallbladder cancer and cancers of the extra-hepatic bile ducts were analyzed separately. Standardized incidence rates were calculated and joinpoint regression was used to calculate annual percent changes (APC) with 95% Confidence Intervals (CIs)., Results: The incidence of non-gallbladder extra-hepatic cancers assessed from the Cancer Register decreased in men and women from the mid 1980's (APC: -4.0, 95% CI -5.3 - -2.7 and APC -6.3, 95% CI -7.7 - -4.8, respectively), whereas the mortality of non-gallbladder extra-hepatic cancers rather increased until 1990 (APC: 2.1, 95% CI 1.4-2.8 and APC 2.7, 95% CI 1.3-4.1, in men and women respectively). Notably, the mortality rate was greater than the incidence rate as assessed from the Cancer Register from the early 1990's and onwards. The incidence of non-gallbladder extra-hepatic cancers derived from the Patient Register also increased over time. Gallbladder cancer incidence and mortality rates generally decreased. However, incidence rates assessed from the Patient Register decreased to a lesser extent., Conclusions: The incidence of gallbladder cancer seems to have decreased over the past decades in Sweden. The incidence trends for extra-hepatic tumors other than gallbladder cancer may however be obscured by under-reporting., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: The aim of this study was to identify factors influencing the long-term clinical progression of multiple sclerosis (MS). A special objective was to investigate whether early treatment decisions influence outcome., Methods: We included 639 patients diagnosed with MS from 2001 to 2007. The median follow-up time was 99 months (8.25 years). Cox regression models were applied to identify factors correlating with the outcome variable defined as time from treatment start to irreversible score 4 of the Expanded Disability Status Scale (EDSS)., Results: Patients initiated on treatment later had a greater risk of reaching EDSS 4 (hazard ratio of 1.074 (95% confidence interval (CI), 1.048-1.101)), increased by 7.4% for every year of delay in treatment start after MS onset. Patients who started treatment after 3 years from MS onset reached the outcome sooner with hazard ratio of 2.64 (95% CI, 1.71-4.08) compared with the patients who started treatment within 1 year from MS onset. Baseline EDSS and age at onset were found to be predictive factors of disability progression., Conclusion: Early treatment initiation was associated with a better clinical outcome. In addition, we confirmed the well-established prognostic factors of late age at onset and early disability.

Background: The trade-off between the benefits of surgery for gallstone disease for a large population and the risk of lethal outcome in a small minority requires knowledge of the overall mortality., Methods: Between 2007 and 2010, 47 912 cholecystectomies for gallstone disease were registered in the Swedish Register for Cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) (GallRiks). By linkage to the Swedish Death Register, the 30-day mortality after surgery was determined. The age- and sex-standardized mortality ratio (SMR) was estimated by dividing the observed mortality with the expected mortality rate in the Swedish general population 2007. The Charlson Comorbidity Index (CCI) was estimated by International Classification of Diseases (ICD) codes retrieved from the National Patient Register., Results: Within 30 days after surgery, 72 (0.15%) patients died. The 30-day mortality was close [SMR = 2.58; 95% confidence interval (CI): 2.02-3.25] to that of the Swedish general population. In multivariable logistic regression analysis, predictors of 30-day mortality were age >70 years [odds ratio (OR) 7.04, CI: 2.23-22.26], CCI > 2 (OR 1.93, CI: 1.06-3.51), American Society of Anesthesiologists (ASA) > 2 (OR 13.28, CI: 4.64-38.02), acute surgery (OR 10.05, CI:2.41-41.95), open surgical approach (OR 2.20, CI: 1.55-4.69) and peri-operative complications (OR 3.27, CI: 1.74-6.15)., Discussion: Mortality after cholecystectomy is low. Co-morbidity and peri-operative complications may, however, increase mortality substantially. The increased mortality risk associated with open cholecystectomy could be explained by confounding factors influencing the decision to perform open surgery., (© 2014 International Hepato-Pancreato-Biliary Association.)

Objective: Esophageal cancer surgery carries a risk of splenic injury, which may require splenectomy, but predictors of such events remain uncertain. Moreover, the hypothesis that incidental splenectomy carries a worse prognosis deserves attention., Design: A population-based, nationwide cohort study was conducted on 1679 patients who underwent resection for esophageal cancer in Sweden in 1987 to 2010, with follow-up until February 2012. Predictors of splenic injury and incidental splenectomy were analyzed using multivariable logistic regression, providing odds ratios (ORs) with 95% confidence intervals (CIs). Associations between incidental splenectomy and risk of mortality and severe infections were analyzed using multivariable Cox regression, providing hazard ratios (HRs) with 95% CIs., Results: Higher surgeon volume of esophageal cancer resection decreased the risk of splenic injury and incidental splenectomy (OR: 0.58; 95% CI: 0.41-0.80; and OR: 0.41; 95% CI: 0.25-0.66, respectively, comparing the highest to lowest category). In patients with splenic injury, progression to incidental splenectomy decreased by 92% during the study period. Sex, age, tumor stage, previous abdominal surgery, neoadjuvant therapy, and surgical radicality did not influence these risks. Incidental accidental splenectomy increased the overall risk of mortality (HR: 1.29; 95% CI: 1.03-1.61) and severe infections (HR: 2.79; 95% CI: 1.35-5.79)., Conclusion: The inverse association between surgeon volume and splenic injury supports centralization of esophageal cancer surgery. The increased risk of mortality and severe infections after incidental splenectomy should be kept in mind during surgery, and we should encourage efforts to preserve an injured spleen and stress the relevance of vaccination after splenectomy.

Background: Second myocardial infarction (SMI) is a significant health problem. There are no nationwide studies on SMI among foreign-born populations that include detailed information about country of birth., Design: Nationwide cohort study of 331,748 men and 186,755 women aged 30-84, living in Sweden, and diagnosed with first myocardial infarction (FMI) between January 1987 and December 2007., Methods: Trends in, and risk of, SMI after day 28 of FMI association with gender, educational level, and country of birth were analysed. A hazard ratio (HR) with a 95% confidence interval (CI) yielded a risk estimate of SMI among FMI patients based on the Cox proportional hazard model., Results: Men had a higher risk of SMI than women (HR 1.14, 95% CI 1.12-1.55) with a downward trend over time, regardless of country of birth (p-trend <0.0001). Low educational level increased the HR of SMI irrespective of gender or country of birth. Foreign-born men and women had a slightly increased HR than Sweden-born. Men born in India, Palestine, Uganda, Algeria, and Tunisia and women born in India, Palestine, and Lebanon had approximately a 2-fold risk. Men born in the Netherlands had the lowest risk (HR 0.65, 95% CI 0.44-0.94). Foreign-born who had lived in Sweden for less than 35 years had a higher risk than those that had lived there for 35 years or longer., Conclusions: Although the risk of SMI continued to decrease over time, low socioeconomic position independent of country of birth and gender remained an important risk indicator deserving further attention.

Background & Aims: Obesity and type 2 diabetes--diseases linked to glucose intolerance and insulin resistance--have been positively associated with the risk of acute pancreatitis. However, it is unclear whether consumption of foods that increase postprandial glycemia and insulinemia have similar associations. We examined the association between dietary glycemic load and risk of non-gallstone-related acute pancreatitis., Methods: We performed a prospective study of 44,791 men and 36,309 women (aged 45-84 years), without a history of acute pancreatitis, from the Cohort of Swedish Men and the Swedish Mammography Cohort. Glycemic loads were calculated from food frequency questionnaire data collected in 1997, and participants were followed for the development of non-gallstone-related acute pancreatitis through 2010 via linkage to the Swedish National Patient Register. Hazard ratios (HRs) were estimated using Cox proportional hazard models., Results: During a total follow-up of 967,568 person-years, there were 364 cases of incident non-gallstone-related acute pancreatitis (236 in men and 128 in women). Incidence rates, standardized for age and sex, were 49 cases per 100,000 person-years in the highest quartile of glycemic load and 33 cases per 100,000 person-years in the lowest. The multivariate-adjusted HR of non-gallstone-related acute pancreatitis was 1.60 (95% confidence interval [CI], 1.17-2.18) for the highest compared with the lowest quartile. Every 50-unit increase in glycemic load per day (∼ 3 servings of white bread) had an HR of 1.38 in men (95% CI, 1.11-1.72) and women (95% CI, 1.02-1.86)., Conclusions: Based on a large, prospective cohort study, diets with high glycemic load are associated with an increased risk of non-gallstone-related acute pancreatitis., (Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Several case reports have suggested that women's use of exogenous sex hormones is associated with acute pancreatitis; however, relevant epidemiologic data are sparse. We examined the association between postmenopausal hormone replacement therapy and risk of acute pancreatitis., Methods: We conducted a prospective study involving 31,494 postmenopausal women (aged 48-83 yr) from the population-based Swedish Mammography Cohort. Participants completed a baseline questionnaire in 1997 assessing their use of hormone replacement therapy. We linked the cohort to the hospital-based Swedish National Patient Register to determine hospital admissions for acute pancreatitis through 2010. Relative risks (RRs) were calculated using Cox proportional hazard models., Results: Over a total follow-up of 389,456 person-years, we identified 237 cases of incident acute pancreatitis. The age-standardized incidence rates per 100,000 person-years were 71 cases among women who had ever used hormone replacement therapy and 52 cases among women who had never used such hormones. Among ever users of hormone replacement therapy, the multivariable-adjusted RR of acute pancreatitis was 1.57 (95% confidence interval [CI] 1.20-2.05) compared with never users. The risk did not differ by current or past use, but it seemed to be higher among women who used systemic therapy (RR 1.92, 95% CI 1.38-2.66) and among those with duration of therapy of more than 10 years (RR 1.87, 95% CI 1.11-3.17)., Interpretation: Use of postmenopausal hormone replacement therapy was associated with increased risk of acute pancreatitis. Physicians should consider this potential increase in risk when prescribing such therapy.

Objective: Our aim of this study was to examine the association between the use of postmenopausal HRT and risk of cholecystectomy in Sweden, where the most common regimen of HRT (oral oestradiol in combination with testosterone-like progestin) has been different from those investigated in previous studies., Material and Methods: We performed a prospective study of 27 892 postmenopausal women (aged 48-83 years) from the population-based Swedish Mammography Cohort. Use of HRT was assessed by a self-reported questionnaire at baseline in 1997, and the cohort was followed up through 2011 for procedures of cholecystectomy by linkage to the Swedish Patient Register. Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI)., Results: During 362 728 person-years of follow-up (median 14 years), 995 cases of cholecystectomy were recorded. After adjustment for potential confounders, the HR of cholecystectomy was 1.52 (95% CI, 1.33-1.74) among ever users of HRT compared with never users. The risk did not differ by current or past use (p = 0.38) or duration of use (p = 0.65), but it did differ by indication of use (p = 0.006). Women who used HRT for systemic symptoms had a higher risk of cholecystectomy than those who used it for local symptoms (HR, 1.62; 95% CI, 1.41-1.87 vs HR, 1.21; 95% CI, 0.97-1.50)., Conclusions: This prospective study of postmenopausal women adds to the evidence that use of HRT may increase the risk of cholecystectomy.

Importance: Oral glucocorticoid use has been suggested to cause acute pancreatitis in several case reports. However, no epidemiological study has investigated this association., Objective: To conduct a nationwide population-based case-control study to investigate the potential association between oral glucocorticoid use and acute pancreatitis., Design: In this population-based case-control study, all individuals aged 40 to 84 years who developed a first episode of acute pancreatitis between 2006 and 2008 in Sweden were identified., Setting: Population-based, nationwide, register-based study., Participants: A total of 6161 cases with a first episode of acute pancreatitis and 61,637 controls were included in the final analyses. Cases were all patients diagnosed as having a first episode of acute pancreatitis during the study period, defined by the diagnosis code K85 in the International Statistical Classification of Diseases, 10th Revision (ICD-10). Controls were randomly selected from the source population at risk of developing acute pancreatitis. For each case, 10 controls, matched for age, sex, and calendar period, were randomly selected from the general population. Oral glucocorticoid use was assessed from the Swedish Prescribed Drug Register. Current, recent, and former users were defined as patients who collected their glucocorticoid prescription within 30, 31 to 180, and after 180 days before the index date, respectively., Main Outcome Measures: Unconditional logistic regression was performed to calculate the odds ratios (ORs) with 95% confidence intervals for the association between oral glucocorticoid use and acute pancreatitis. Multivariable adjustment was made for potential confounders including, among others, alcohol abuse, diabetes, and concomitant drug use., Results: The study included 6161 cases of acute pancreatitis and 61,637 controls. The risk of acute pancreatitis was increased among current users of oral glucocorticoids compared with nonusers (OR, 1.53; 95% CI, 1.27-1.84). This risk was highest 4 to 14 days after drug dispensation (OR, 1.73; 95% CI, 1.31-2.28) and attenuated thereafter. There was no association between oral glucocorticoid use and acute pancreatitis immediately after drug dispensation. There was no increased risk of acute pancreatitis among recent or former users of glucocorticoids compared with nonusers., Conclusions and Relevance: Current oral glucocorticoid use is associated with an increased risk of acute pancreatitis.

Purpose: The influence of hospital and surgeon volume on survival after esophageal cancer surgery deserves clarification, particularly the prognosis after the early postoperative period. The interaction between hospital and surgeon volume, and the influence of known prognostic factors need to be taken into account., Methods: A nationwide Swedish population-based cohort study of 1,335 patients with esophageal cancer who underwent esophageal resection in 1987 to 2005, with follow-up for survival until February 2011, was conducted. The associations between annual hospital volume, annual surgeon volume, and cumulative surgeon volume and risk of mortality were calculated with multivariable parametric survival analysis, providing hazard ratios (HRs) with 95% CIs. HRs were mutually adjusted for the surgery volume variables and further adjusted for the prognostic factors age, sex, comorbidity, calendar period, tumor stage, tumor histology, and neoadjuvant therapy., Results: There was no independent association between annual hospital volume and overall survival, and hospital volume was not associated with short-term mortality after adjustment for hospital clustering effects. A combination of higher annual and cumulative surgeon volume reduced the mortality occurring at least 3 months after surgery (P trend < .01); the HR was 0.78 (95% CI, 0.65 to 0.92) comparing surgeons with both annual and cumulative volume above the median with those below the median. These results remained when hospital and surgeon clustering were taken into account., Conclusion: Because surgeon volume rather than hospital volume independently influences the prognosis after esophageal cancer surgery, centralization of this surgery to fewer surgeons seems warranted.

Background & Aims: Little is known about how discontinuation of low-dose aspirin therapy after peptic ulcer bleeding affects patient mortality or acute cardiovascular events., Methods: We performed a retrospective cohort study by using data from patients who received low-dose aspirin therapy and were treated for bleeding peptic ulcers between 2007 and 2010 at Karolinska University Hospital, Stockholm, Sweden. We used a multivariable Cox regression model to adjust for potential confounders and analyze associations between discontinuation of low-dose aspirin therapy at discharge, death, and acute cardiovascular events., Results: Of the 118 patients who received low-dose aspirin therapy, the therapy was discontinued for 47 (40%). During a median follow-up period of 2 years after hospital discharge, 44 of the 118 patients (37%) either died or developed acute cardiovascular events. Adjusting for confounders, patients with cardiovascular comorbidities who discontinued low-dose aspirin therapy had an almost 7-fold increase in risk for death or acute cardiovascular events (hazard ratio, 6.9; 95% confidence interval, 1.4-34.8) compared with patients who continued this therapy during the first 6 months of the follow-up period. A corresponding association was not observed among patients without cardiovascular comorbidities when the study began., Conclusions: In patients with cardiovascular disease, discontinuation of low-dose aspirin therapy after peptic ulcer bleeding increases risk of death and acute cardiovascular events almost 7-fold., (Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Aims: We studied trends in first-time myocardial infarction (MI) incidence and case fatality after day 28 and to examine the role of sex, education as an indicator for socioeconomic position, and birth country on these events in Sweden., Methods and Results: Nationwide cohort including 6,752,655 individuals aged 35-89 years living in Sweden between January 1987 and December 2008, of which, 6,464,968 individuals and 366,085 nonfatal first-time MI patients were classified according to their sex, birth country, and education and followed over two decades., Main Outcome Measures: Incidence and case-fatality rate after day 28 of first-time MI and their trends. A decreasing trend for first-time MI incidence and case fatality after day 28 for both sexes regardless of birth country was observed (p-trend<0.0001). The trend was, however, less pronounced among female and foreign-born. Men had higher incidence than women (incidence rate ratio, IRR 2.09, 95% CI 2.08-2.11). Men born in Southern and Western Asia had 50% (95% CI 40-60%) higher risk than men born in Sweden. Incidence was 50-80% higher in the least educated irrespective of sex and birth country (p-trend<0.0001). This association was stronger for female and foreign-born. We observed a 15% higher case fatality after day 28 among men than women (hazard ratio, HR 1.15, 95% CI 1.13-1.17) and 20-40% lower case fatality after day 28 among patients with no diabetes. Low education was associated with 50% higher case fatality after day 28 regardless of sex and birth country (p-trend <0.0001)., Conclusion: Although incidence of, and fatality after, first-time MI continued to decrease, low socioeconomic position, independent of birth country and sex, remained an important risk indicator for both events.

Background & Aims: Patients with celiac disease have been reported to be at increased risk for pancreatitis and pancreatic insufficiency, but the risk might have been overestimated because of patient selection and limited numbers of patients for analysis. Furthermore, no distinction has been made between patients with gallstone-related and non-gallstone-related pancreatitis. We performed a nationwide study to determine the risk for any pancreatitis or subtype of pancreatitis among patients with biopsy-verified celiac disease., Methods: We analyzed data from patients in Sweden with celiac disease (n = 28,908) who were identified on the basis of small intestinal biopsy records from 28 pathology departments (those with villous atrophy, Marsh 3). Biopsies were performed from 1969 to 2008, and biopsy report data were collected from 2006 to 2008. Patients with pancreatitis were identified on the basis of diagnostic codes in the Swedish Patient Register and records of pancreatic enzyme use in the Swedish Prescribed Drug Register. Data were matched with those from 143,746 individuals in the general population; Cox regression was used to estimate hazard ratios (HRs) for pancreatitis., Results: We identified 406 patients with celiac disease who were later diagnosed with pancreatitis (and 143 with expected pancreatitis) (HR, 2.85; 95% confidence interval [CI], 2.53-3.21). The absolute risk of any pancreatitis among patients with celiac disease was 126/100,000 person-years, with an excess risk of 81/100,000 person-years. The HR for gallstone-related acute pancreatitis was 1.59 (95% CI, 1.06-2.40), for non-gallstone-related acute pancreatitis HR was 1.86 (95% CI, 1.52-2.26), for chronic pancreatitis HR was 3.33 (95% CI, 2.33-4.76), and for supplementation with pancreatic enzymes HR was 5.34 (95% CI, 2.99-9.53). The risk of any pancreatitis within 5 years of diagnosis was 2.76 (95% CI, 2.36-3.22)., Conclusions: Based on an analysis of medical records from Sweden, patients with celiac disease have an almost 3-fold increase in risk of developing pancreatitis, compared with the general population., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effect of major postoperative complications on health-related quality of life (HRQL) in 5-year survivors of esophageal cancer surgery., Patients and Methods: This study was based on the Swedish Esophageal and Cardia Cancer register with almost complete nationwide coverage and data on esophageal cancer surgery collected prospectively between 2001 and 2005. Patients who were alive 5 years after surgery were eligible. HRQL was assessed longitudinally until 5 years after surgery by using the validated European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and OES18. Linear mixed models were used to assess the mean score difference (MD) with 95% CIs of each aspect of HRQL in patients with or without major postoperative complications. Adjustment was made for several potential confounders., Results: Of 153 patients who survived 5 years, 141 patients (92%) answered the 5-year HRQL questionnaires. Of these individuals, 46 patients (33%) sustained a major postoperative complication. Dyspnea (MD, 15; 95% CI, 6 to 23), fatigue (MD, 13; 95% CI, 5 to 20), and eating restrictions (MD, 10; 95% CI, 2 to 17) were clinically and statistically significantly deteriorated throughout the follow-up in patients with major postoperative complications compared with patients without major complications. Although problems with choking declined to levels comparable with patients without major postoperative complications, sleep difficulties and gastroesophageal reflux progressively worsened during follow-up., Conclusion: The occurrence of postoperative complications exerts a long-lasting negative effect on HRQL in patients who survive 5 years after esophagectomy for cancer.

Background: The incidence of acute cardiovascular and cerebrovascular events in patients treated for complicated or uncomplicated peptic ulcer disease (PUD) has not been ascertained completely., Method: All patients with in-hospital treatment due to PUD between 1987 and 2007, who did not have any past history of acute or chronic cardiovascular or cerebrovascular disease, were identified through the Swedish Patient Register. Standardized incidence ratios were calculated to compare the subsequent incidence of acute myocardial infarction (AMI), ischemic, or hemorrhagic stroke after hospital admission in six different subgroups of PUD relative to the general population. To partly account for the impact of smoking, the incidence of lung cancer in those treated for PUD was compared with that of the general population., Results: A total of 84 156 patients with no past history of acute or chronic cardiovascular or cerebrovascular disease were discharged from hospital due to PUD. The risk of AMI, ischemic, or hemorrhagic stroke was increased from 2-fold to 4-fold within the first 60 days of hospitalization due to PUD compared with the general population. This risk remained 30-70% higher among all subgroups of PUD compared with the general population throughout the entire follow-up period., Conclusion: Patients treated in hospital for PUD have a higher risk of AMI and stroke compared with the general population. Careful surveillance of these patients seems to be indicated, particularly during the first 60 days after discharge.

Background: Testicular cancer is the most common cancer among young male adults in several populations. We compared subtype-specific risk of testicular cancer among migrants and their descendants to that of Swedish-born men to elucidate importance of genetic and environmental factors in testicular cancer etiology and the potential timing of exposures., Methods: We followed a nationwide cohort of 3.6 million men ages 15 to 54 years between 1960 and 2007 through linkage between Swedish National Registers. Incidence rate ratio (IRR) adjusted for age and calendar year with 95% confidence intervals (CI) was estimated using Poisson regression., Results: A total of 5,801 cases of testicular cancer occurred during 80 million person-years of follow-up. Compared with Swedish-born men, first-generation immigrants from low-risk countries had a lower risk (IRR, 0.43; 95% CI, 0.38-0.49) and first-generation immigrants from high-risk countries had a higher risk (IRR, 1.61; 95% CI, 1.42-1.83) of testicular cancer. The risk among first-generation immigrants varied remarkably by birthplace, reflecting the risk in their countries of birth. The risk of seminomas was statistically significantly modified by age at immigration and duration of residence among immigrants born in high-risk areas. We observed a statistically significantly convergence of risk among second-generation immigrants toward the risk in Sweden (IRR, 1.02; 95% CI, 0.93-1.12). The risk among second-generation immigrants was not affected by the duration of stay of their mothers in Sweden before pregnancy., Conclusions: Our study provides evidence that life-style and environmental factors play an important role in the etiology of testicular cancer.

To elucidate the importance of environmental and genetic factors in prostate cancer etiology, we compared the risk of prostate cancer among foreign-born men to that of Swedish-born men in Sweden and to that in the country of origin. We estimated rate ratios (RRs) with 95% confidence intervals (CIs) adjusted for age, calendar period of year and education using Poisson regression in a cohort of 3.8 million men aged 45 years and older between 1961 and 2004. During the 45 years of follow-up, 8,244 and 187,675 cases of prostate cancer occurred among foreign-born and Swedish-born men, respectively. Overall, foreign-born men had a significantly 40% decreased risk of prostate cancer compared to Swedish-born men (RR = 0.62, 95% CI = 0.61-0.63). Men born in Middle Africa and in the Caribbean had an increased risk (RR = 1.89, 95% CI = 0.95-3.78 and RR = 1.24, 95% CI = 0.71-2.19, respectively). The overall risk in both strata of duration of residence or age at immigration was lower among immigrants compared to Swedish-born men. After additional adjustment for birthplace and age at immigration, although the risk remained lower among immigrants compared to Swedish-born, but it was increased among immigrants who stayed 35 years and longer compared to those who stayed shorter (RR = 1.33, 95% CI = 1.21-1.46). Both environmental and genetic factors seem to be involved in the etiology of prostate cancer. Duration of residence was an important factor affecting the risk among immigrants. Studies focusing on the etiology of prostate cancer specifically in African immigrants and their descendants and increasing preventive and diagnostic activities on old immigrants are recommended.

Background and Purpose: Implant dislocation is one of the commonest complications following primary total hip replacement (THR). We investigated the effect of body mass index (BMI) and tobacco use on the risk of this complication., Subjects and Methods: Through linkage between the Swedish Construction Workers' cohort and the Swedish Inpatient Register, 2,106 male patients who had undergone primary THR between 1997 and 2004 were identified. We used Cox multivariable regression analysis to study the association between BMI and tobacco use and the risk of implant dislocation., Results: 53 patients (2.5%) developed implant dislocation during a mean of 2 (0-3) years of follow-up. We found overweight and obesity to be associated with increased risk of implant dislocation (HR = 2.5,95% CI: 1.1-5.5 and HR = 3.7, 95% CI: 1.5-9.3, respectively as compared to those of normal weight). There was no statistically significant association between tobacco use and the risk of dislocation., Interpretation: Greater attention should be given to high BMI as a risk factor for implant dislocation following THR.