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Background: Elevated troponin levels are a sensitive biomarker for cardiac injury. The quick and reliable prediction of troponin elevation for patients with chest pain from readily available ECGs may pose a valuable time-saving diagnostic tool during decision-making concerning this patient population., Methods and Results: The data used included 15 856 ECGs from patients presenting to the emergency rooms with chest pain or dyspnoea at two centres in Sweden from 2015 to June 2023. All patients had high-sensitivity troponin test results within 6 hours after 12-lead ECG. Both troponin I (TnI) and TnT were used, with biomarker-specific cut-offs and sex-specific cut-offs for TnI. On this dataset, a residual convolutional neural network (ResNet) was trained 10 times, each on a unique split of the data. The final model achieved an average area under the curve for the receiver operating characteristic curve of 0.7717 (95% CI±0.0052), calibration curve analysis revealed a mean slope of 1.243 (95% CI±0.075) and intercept of -0.073 (95% CI±0.034), indicating a good correlation between prediction and ground truth. Post-classification, tuned for F1 score, accuracy was 71.43% (95% CI±1.28), with an F1 score of 0.5642 (95% CI±0.0052) and a negative predictive value of 0.8660 (95% CI±0.0048), respectively. The ResNet displayed comparable or surpassing metrics to prior presented models., Conclusion: The model exhibited clinically meaningful performance, notably its high negative predictive accuracy. Therefore, clinical use of comparable neural networks in first-line, quick-response triage of patients with chest pain or dyspnoea appears as a valuable option in future medical practice., 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: As the survival of preterm infants has increased, the management of long-term complications, especially neurodevelopmental impairment, becomes increasingly important. The aim of this study was to investigate the risk of neurodevelopmental disorders in preterm babies receiving medical or surgical treatment for necrotizing enterocolitis, compared with other preterm babies and preterm babies who received abdominal surgery for other indications., Methods: In this nationwide Swedish cohort study, including all liveborn preterm babies born between 1998 and 2019, the risk of attention deficit (and hyperactivity) disorder, autism spectrum disorders, cerebral palsy and intellectual disability was assessed by multivariable Cox regression, expressed as hazard ratios and 95% confidence intervals (c.i.)., Results: Of the surgically (n = 384) and medically (n = 709) treated preterm infants with necrotizing enterocolitis, neurodevelopmental disorders were present in 32% (HR 2.24, 95% c.i. 1.86 to 2.69) and 22% respectively (HR 1.40, 95% c.i. 1.19 to 1.65), compared with 21% (HR 1.63, 95% c.i. 1.40 to 1.91) in the abdominal surgery group (n = 844) and 13% (reference) among other preterm infants (n = 78 972). The highest relative increases were for intellectual disability (HR 3.60, 95% c.i. 2.65 to 4.89) in the surgical necrotizing enterocolitis group and abdominal surgery group (HR 2.84, 95% c.i. 2.12 to 3.80) compared with the control preterm group, and for cerebral palsy (respectively HR 2.74, 95% c.i. 2.04 to 3.68 and HR 2.54, 95% c.i. 1.87 to 3.44). Medically treated necrotizing enterocolitis was associated with autism (HR 1.67, 95% c.i. 1.34 to 2.08), without significant increases for the other specific outcomes. Both surgically treated groups were also strongly associated with both attention deficit (and hyperactivity) disorder and autism., Conclusion: Surgically treated necrotizing enterocolitis, medically treated necrotizing enterocolitis and abdominal surgery for other indications in preterm infants were all associated with an increased risk of impaired neurodevelopmental outcomes, compared with other preterm infants., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.)

Background: An increased number of revisits may signal that the immediate medical needs of patients seeking care at Emergency Departments (EDs) are not being met. The prevalence and characteristics of revisits to the EDs in Sweden among older patients, and its association to frailty, are unknown. We aimed to investigate the prevalence of ED revisits among patients over 65 years of age, living with or without frailty, and its association with rate of admission, and mortality; in the Swedish ED setting., Methods: This was a prospective, multicentre study of patients over 65 years of age with an index visit to one of three Swedish EDs during May-Nov 2021. Frailty was assessed in conjunction with standard triage, using the 9-level Clinical Frailty Scale (CFS) with a CFS score of 5 to 8 as cut-off for identifying frailty. For all patients who made a revisit within 90 days of their index visit, we collected information about the revisit, admission, and mortality., Results: A total of 1835 patients made an index visit which were included, and out of those, 595 patients made a revisit within 90 days of the index visit. Patients living with frailty (CFS 5 to 8) were more likely to make a revisit to the ED at 8 to 30 days (17% vs. 11%, diff 6%, 95% CI 2-10%, p < 0.001) and at 31 to 90 days (19% vs. 12%, diff 7%, 95% CI 3-10%, p < 0.001) and be admitted to in-hospital care during their revisit (57% vs. 47%, diff 10%, 95% CI, 1-18%, p < 0.05), compared to patients living without frailty. Results also show that patients living with frailty had a higher overall mortality rate (17% vs. 5%, diff 12%, 95% CI 7-18%, p < 0.001). However, among patients living without frailty, making a revisit slightly increased the mortality rate compared to those who did not (5% vs. 2%, diff 3%, 95% CI 1-10%, p < 0.05)., Conclusions: Patients living with frailty make more revisits, are more often admitted to in-hospital care, and have a higher overall mortality rate than patients not living with frailty. Frailty, assessed with the CFS may be a simple and useful indicator of increased risk of adverse events, including revisits, in the ED., (© 2024. The Author(s).)

Background: Few studies describe the use of the Post-Stroke Checklist (PSC) as a tool for longitudinal stroke follow-up in clinical practice. We mapped the prevalence of stroke-related health problems and targeted interventions at 3 and 12 months post-stroke by using the PSC., Methods: Patients with acute stroke discharged home in 2018-2019 at Skåne University Hospital, Sweden, were invited to participate in a comprehensive nurse-led follow-up based on a 14-item PSC 3 and 12 months post-stroke. We measured time consumption, screened for stroke-related health problems, compared the findings, and recorded targeted healthcare interventions. Problems at 12 months were grouped into new, persistent, or none compared to the 3-month evaluation., Results: Of 200 consecutively included patients, 146 (77%) completed both the 3- and 12-month follow-ups. At 12-month follow-up, 36% of patients reported no stroke-related health problems, 24% reported persistent problems, and 40% reported new problems since the 3-month evaluation. New problems at 12 months were most common within the domains: secondary prevention (23%) and life after stroke (10%). Stroke recurrence rate was 7.5%, 43% had high blood pressure, and few smokers had quit smoking. At 12 months, 53% received at least one new healthcare intervention, compared to 84% at 3 months., Conclusions: Stroke-related health problems decreased beyond 3 months but were still present in two-thirds of patients at 1 year. This emphasizes the relevance of continuous structured follow-up using the PCS. However, the follow-up alone was insufficient to adequately achieve treatment targets for secondary prevention, which require intensified focus., Trial Registration: ClinicalTrials.gov ID NCT04295226, (04/03/2020)., (© 2024. The Author(s).)

Background: Open-angle glaucoma (OAG) is a leading cause of irreversible blindness. There are no prospective studies on the risk of developing blindness in both eyes in individuals with definite OAG., Methods: A total of 354 patients with newly diagnosed OAG, who had participated in four studies conducted at the Eye Department in Tierp, Sweden, from 1979 to 2006, were included in the investigation. Using the World Health Organization's criteria for blindness, medical records, glaucoma case records, and visual fields were reviewed to identify patients who developed bilateral blindness. Incidence proportions and incidence rates were estimated. To assess potential risk factors for blindness, standardised morbidity ratios (SMRs) were calculated. The effects of age and sex were also analysed using Cox proportional hazard models., Results: By the end of the study in August 2023, 33 cases of blindness caused by OAG had been found, corresponding to an incidence proportion of 9.3% (95% confidence interval [CI]: 6.5-12.8%). Within the first 20 years, 29 cases were detected, yielding a proportion of 8.2% (95% CI: 5.5-11.6%). The incidence rate was estimated to be 8.6 per 1,000 person-years (95% CI: 5.9-12.6 per 1,000 person-years). Glaucoma-related blindness was associated with male sex (SMR 2.33; 95% CI: 1.13-4.80). The hazard ratio was doubled for every 5 year of increasing age (2.21; 95% CI: 1.60-3.05)., Conclusion: In this study of blindness in newly diagnosed OAG in a Swedish population, approximately one in 10 patients progressed to bilateral blindness caused by the disease. Old age and male sex were identified as significant risk factors., Competing Interests: The authors report no conflicts of interest., (© 2024 The Author(s). Published by Upsala Medical Society.)

Background: This study aimed to examine the social gradient in self-reported alcohol-related harm (ARH) among young alcohol consumers by including a largely overlooked group of adolescents. We also explored the extent to which such a gradient could be attributed to differential exposure or differential vulnerability to risk factors., Method: Cross-sectional survey of upper-secondary students (n = 2996) in Sweden. Negative binomial regressions estimated the relationship between academic orientation (higher education preparatory; HEP, vocational; VP and introductory; IP) and ARH. To assess the contribution of explanatory factors, we estimated models that included risk factors such as heavy episodic drinking (HED)., Results: A graded association was observed between academic orientation and ARH, with more ARH among students in IP (IRR = 1.79) and VP (IRR = 1.43) than in HEP. Adjustments for risk factors attenuated the estimates by approximately half, but there was still 14% more ARH in VP and 50% more in IP than in HEP. The additive interaction test indicated a positive and significant interaction for students in VP who engaged in HED, versus students in HEP, who did not., Conclusion: The findings suggest a negative gradient in the association between academic orientation and ARH, where the students in IP experienced the highest levels of ARH. While differential exposure and vulnerability to HED account for a significant proportion of the excess risk among VP students, HED seems to be less important relative to other risk factors among IP students. More research is needed to identify the mechanisms underlying the elevated levels of ARH among the most disadvantaged group-students enrolled in IP., (© 2024. The Author(s).)

Background: Percutaneous coronary intervention (PCI) is frequently used for patients with chronic coronary syndrome (CCS). However, the role of PCI beyond symptom relief in CCS remains controversial. The objective of this study was to determine whether PCI is associated with better outcomes, compared with medical therapy (MT) alone., Methods: We conducted a retrospective cohort study. Using the Swedish Coronary Angiography and Angioplasty Registry, we included all patients with CCS undergoing coronary angiography in Sweden between 2010 and 2020. Two groups were formed based on treatment strategy: PCI+MT versus MT alone. One-to-one propensity score (PS) matching was used to address confounding. Outcome was assessed using matched win ratio analysis, a statistical method that ranks the components of the composite by clinical importance. The primary outcome was net adverse clinical event (NACE) within 5 years. In the win ratio analysis, the components of NACE were ranked as follows: (1) all-cause mortality, (2) myocardial infarction (MI), (3) bleeding and (4) urgent revascularisation. Secondary outcomes were the individual components of NACE, major adverse cardiovascular events (MACE) and cardiovascular mortality., Results: After PS matching, two groups of 7220 patients each were formed. The hierarchical outcome analysis of NACE and MACE showed that PCI was associated with improved outcome (matched win ratio: 1.28 (95% CI 1.20 to 1.36, p<0.001) and matched win ratio: 1.38 (95% CI 1.29 to 1.48, p<0.001), respectively). The use of PCI was associated with higher win ratio of MI (matched win ratio: 1.15, 95% CI 1.04 to 1.28, p=0.008), urgent revascularisation (matched win ratio: 1.85, 95% CI 1.69 to 2.03, p<0.001) and cardiovascular mortality (matched win ratio: 1.15, 95% CI 1.00 to 1.34, p=0.044). No difference in win ratio was observed for all-cause mortality or bleeding., Conclusions: In this study, which sought to evaluate the outcomes of patients with CCS using a hierarchical approach, patients selected for revascularisation with PCI experienced better outcome compared with MT alone., 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.)

The association of socioeconomic status with cardiovascular morbidity and mortality is well known, but data on the influence of education level on mortality in individuals with atrial fibrillation (AF) are scarce. We investigated education level as a predictor of all-cause mortality in patients diagnosed with AF. This retrospective cohort study used a database created from several Swedish nationwide registries to identify all patients hospitalized with a diagnosis of AF hospitalized from 1995 to 2008. Education level was categorized as primary, secondary, and academic. All-cause mortality risk was estimated in subpopulations defined by the Charlson Comorbidity Index and several comorbidities. A total of 272,182 patients (56% male; mean age 72 ± 10 years) were followed for five years. Cox regression models showed a reduction in all-cause mortality risk with increased education level. Hazard ratios (HR) relative to primary education remained significant after stratification and adjustment for several confounders: secondary education HR = 0.88; 95% CI: 0.86-0.89; P < 0.001; academic education HR = 0.70; 95% CI: 0.67-0.72; P < 0.001. Subpopulation analyses confirmed a significant reduction in relative risk with higher education level. Targeted screening and education programs could be effective in reducing mortality in AF patients with fewer years of formal education., (© 2024. The Author(s).)

Background: Hospitalization indicates the presence of severe disease and constitutes a leading cost in health care. We aimed to prospectively assess if prevalent diabetes mellitus contributes to excess all-cause and cause-specific hospital admissions and mortality at the population level., Methods: We used a Swedish prospective population-based cohort, including 25,642 individuals of whom 4.2% had prevalent diabetes at baseline (mean age 61.2 ± 6.8 years, age range 44.8-73.4 years). We compared the number of hospitalizations and mortality classified according to the main chapters of the 10th revision of the International Classification of Diseases (ICD-10) during follow-up using nationwide inpatient registries, comparing individuals with and without prevalent diabetes, using multivariate adjusted negative binomial regression (incidence rate ratio, IRR) and Cox regression, respectively., Results: During a median follow-up of 19 years, 18,904 subjects were hospitalized at least once [median 3 (IQR 2-6)] and 6767 (26.4%) individuals died. Overall, subjects with diabetes were hospitalized (IRR 1.83, p < 0.001) more often, and had a higher incidence rate of hospital admissions due to endocrine diseases (IRR 14.6, p < 0.001), dermatological diseases (IRR 3.7, p < 0.001), injuries and poisoning (IRR 2.7, p < 0.001), infectious diseases (IRR 2.5, p < 0.001), psychiatric diseases (IRR 2.0, p < 0.001), but also cardiovascular, hematological, genitourinary, neurologic and respiratory diseases compared with non-diabetic individuals. No difference was observed for hospital admissions due to cancer or musculoskeletal disorders. All-cause mortality was higher (HR 1.77, p < 0.001) in individuals with diabetes, with disease-specific mortality being significant only for cardiovascular and endocrine disease-related death., Conclusions: At the population level, prevalent diabetes increased the hospitalization burden longitudinally due to diseases of most of the ICD-10 main chapters, except for cancer and musculoskeletal disorders. These novel findings challenge the current view on the spectrum of prevalent diabetes-related conditions and may have implications for screening and treatment strategies in diabetes., Permission of Graphical Illustrations: Source: Pixabay.com. No permission or acknowledgement is required., (© 2024. The Author(s).)

Aims: To examine the number and types of urological surgical procedures carried out in a regional prevalence population of patients with traumatic spinal cord injury (SCI) during five decades, evaluate objective and patient-reported outcomes and to consider lessons learned for further improvement of surgical treatment in this patient group., Methods: In a cross-sectional study of 412 patients with traumatic SCI, one-third had undergone urological surgery through a period of up to 50 years. Data on types of surgery, complications, follow-up and outcomes were collected in a retrospective review of patient files. S-creatinine, S-cystatin-C, renal ultrasound and a questionnaire regarding complications during the preceding year were assembled as part of a yearly follow-up. Descriptive statistics were calculated. Logistic regression was used to determine risk profiles for the incidence of urological surgery., Results: A total of 137 patients had undergone 262 urological surgical interventions. The incidence was highest amongst persons with a cervical-thoracic neurological level of spinal cord lesion and during the first 2 years after SCI. Surgery for urinary stones constituted 29% of all procedures. One-fourth of the patients had undergone 47% of all procedures, notably urinary diversion and ensuing complications, implants and revisions, repeated stone interventions or bladder outlet procedures. After reconstructive surgery functional outcomes and patient-reported satisfaction were generally favourable, but long-term signs of renal complications were frequent., Conclusions: Urological surgery after SCI involves imperative as well as reconstructive procedures, some of which are challenging and call for centralisation to devoted teams. Prospective studies of reconstructive urology are warranted, including more extensive patient-reported outcomes.

Background: It is a challenge for the ambulance service to identify which patients to convey to the emergency department (ED). Ideally this would be the patients with serious conditions requiring further care in the ED. However, patients presenting with non-specific chief complaints are difficult to prioritize and typically have normal or near normal vital signs despite up to one third having underlying serious conditions. The proportion of patients with serious conditions among non-conveyed patients with non-specific chief complaints (NSC) as assessed by ambulance clinicians is not known. Therefore, the primary aim was to study the proportion of serious conditions among conveyed and non-conveyed patients presenting to the ambulance service with NSCs. The secondary aim was to study the mortality rate among patients with NSCs in relation to conveyance and serious and nonserious conditions., Method: A retrospective cohort study of patients ≥ 18 years of age presenting with NSCs to the ambulance service in Stockholm Region between January 1st, 2013 and December 31st, 2013. Patients were identified via the ambulance service electronic health record and followed via records from the the National Patient Register and Causes of Death Registry at Sweden's National Board for Health and Welfare. Descriptive statistics as well as regression analyses were used., Results: A total of 4744 patients were included with a median age of 76 years. A serious condition was present in 1398 (29.5%) of the patients. After index assessment by the ambulance service, 3780 (79.7%) were conveyed of which 1334 (35.3%) had serious conditions, compared to 964 (20.3%) who were non-conveyed of which 64 (6.6%) had serious conditions. 30-day mortality was 372 (9.8%) in the conveyance group compared to 32 (3.3%) in the non-conveyance group. If serious conditions were present, the mortality rates were 269 (20.2%) in the conveyance group compared to 11 (17.2%) in the non-conveyance group., Conclusion: The results show that serious conditions were more than five times more common among conveyed as compared to non-conveyed patients. Mortality rates were three times higher in the conveyance group as compared to the non-conveyance group. Our results suggest that the ambulance personnel play an important role in identifying patients with serious conditions, hence, likely to be in need of treatment in the ED., Trial Registration: N/A., (© 2024. The Author(s).)

Background: Recent studies have suggested an increasing prevalence of intellectual disability diagnoses in some countries. Our aim was to describe the trend in the prevalence of intellectual disability diagnoses in Sweden and explore whether associated sociodemographic and perinatal factors can explain changes in the prevalence., Methods: We used a register-based nationwide cohort of residents in Sweden born between 2001 and 2011. We calculated the prevalence of intellectual disability diagnoses by age 10 for each birth cohort and the prevalence ratios in relation to the baseline year 2011, overall and by severity of intellectual disability, and comorbidity of autism and attention-deficit/hyperactivity disorder. The prevalence ratios were stratified and adjusted for associated sociodemographic and perinatal factors., Results: Among 1,096,800 individuals, 8,577 were diagnosed with intellectual disability by age 10. Among these, 3,949 (46%) and 2,768 (32%) were also diagnosed with autism and attention-deficit/hyperactivity disorder, respectively, and 4% were diagnosed with profound, 8% severe, 20% moderate, 52% mild, and 16% other/unspecific intellectual disability. The recorded age-10 prevalence of intellectual disability diagnoses increased from 0.64% (95% confidence interval 0.59-0.69%) in 2011 to 1.00% (0.94-1.06%) in 2021, corresponding to an annual prevalence ratio of 1.04 (1.04-1.05). The increase was, however, restricted to mild, moderate, and other/unspecific intellectual disability diagnoses, while the trends for profound and severe intellectual disability diagnoses were stable. The increasing trend was perhaps less pronounced among females and children with diagnosed attention-deficit/hyperactivity disorder, but independent of the co-occurrence of autism. The prevalence ratios did not change with stratification or adjustment for other associated demographic and perinatal factors., Conclusion: The recorded prevalence of diagnosed mild and moderate intellectual disability among 10-year-olds in Sweden has increased over the recent decade. This increase could not be explained by changes in associated sociodemographic or perinatal factors, including birth weight, gestational age, and parental age, migration status, and education at the child's birth. The increase instead may be due to changes in diagnostic practices in Sweden over time., (© 2024. The Author(s).)

Background: Uric acid closely relates to both kidney disease and atrial fibrillation (AF), yet the extent to which it influences the kidney-AF association remains uncertain. We examined the relationship between kidney function and risk of AF, accounting for uric acid levels., Methods: A total of 308,509 individuals in the Swedish Apolipoprotein-Related Mortality Risk (AMORIS) cohort were included and their serum creatinine and uric acid were measured during 1985-1996. Ten-year incident AF was identified via linkage with the national registers. Glomerular filtration rate (eGFR) (ml/min/1.73 m 2 ) was calculated with the 2009 Chronic Kidney Disease Epidemiology Collaboration equation. Hyperuricemia was defined as > 420 µmol/L for men and > 360 µmol/L for women., Results: Over a mean follow-up of 9.4 years, 10,007 (3.2%) incident AF cases occurred. After adjusting for age, sex, cardiovascular diseases, total cholesterol, triglycerides, and glucose, individuals with low eGFR (< 30 and 30-59 ml/min/1.73 m 2 ) had a higher risk of AF compared to those with normal eGFR (60-89) (hazard ratio (HR) = 1.72, 95% confidence interval (CI):1.29-2.30; HR = 1.10, 95% CI: 1.03-1.18, respectively). After further adjusting for uric acid levels, the association disappeared (HR = 0.97, 95% CI: 0.72-1.30; HR = 0.93, 95% CI: 0.86-1.00, respectively). When stratifying by hyperuricemia yes/no, eGFR < 30 ml/min/1.73 m 2 was associated with higher AF risk in a small group of individuals without hyperuricemia (HR = 2.58, 95% CI: 1.64-4.07)., Conclusion: Uric acid largely accounted for the relationship between eGFR and AF in this study. However, in individuals without hyperuricemia, eGFR in the lowest range (< 30 ml/min/1.73 m 2 ) was still associated with increased risk of AF., (© 2024. The Author(s).)

Background and Objectives: Muscular dystrophies and myotonic disorders are genetic disorders characterized by progressive skeletal muscle degeneration and weakness. Epidemiologic studies have found an increased cancer risk in myotonic dystrophy, although the cancer risk spectrum is poorly characterized. In patients with muscular dystrophy, the cancer risk is uncertain. We aimed to determine the overall cancer risk and cancer risk spectrum in patients with muscular dystrophy and myotonic dystrophy using data from the Swedish National registers., Methods: We performed a matched cohort study in all patients with muscular dystrophy or myotonic dystrophy born in Sweden 1950-2017 and 50 matched comparisons by sex, year of birth, and birth county per individual. The association with cancer overall and specific malignancies was estimated using stratified Cox proportional hazard models., Results: We identified 2,355 and 1,968 individuals with muscular dystrophy and myotonic dystrophy, respectively. No increased overall cancer risk was found in muscular dystrophy. However, we observed an increased risk of astrocytomas and other gliomas during childhood (hazard ratio [HR] 8.70, 95% CI 3.57-21.20) and nonthyroid endocrine cancer (HR 2.35, 95% CI 1.03-5.34) and pancreatic cancer (HR 4.33, 95% CI 1.55-12.11) in adulthood. In myotonic dystrophy, we found an increased risk of pediatric brain tumors (HR 3.23, 95% CI 1.16-9.01) and an increased overall cancer risk in adults (HR 2.26, CI 1.92.2.66), specifically brain tumors (HR 10.44, 95% CI 7.30-14.95), thyroid (HR 3.92, 95% CI 1.70-9.03), and nonthyroid endocrine cancer (HR 7.49, 95% CI 4.47-12.56), endometrial (HR 8.32, 95% CI 4.22-16.40), ovarian (HR 4.00, 95% CI 1.60-10.01), and nonmelanoma skin cancer (HR 3.27, 95% CI 1.32-8.13)., Discussion: Here, we analyze the cancer risk spectrum of patients with muscular dystrophy and myotonic dystrophy. To the best of our knowledge, this is the first report of an increased risk for CNS tumors in childhood and adult nonthyroid endocrine and pancreatic cancer in muscular dystrophy. Furthermore, for myotonic dystrophy, we confirmed previously reported associations with cancer and expanded the cancer spectrum, finding an unreported increased risk for nonthyroid endocrine cancer. Additional studies confirming the cancer risk and delineating the cancer spectrum in different genetic subtypes of muscular dystrophies are warranted before considering altered cancer screening recommendations than for the general population.

Background: We aimed to use open source data to understand the incidence, trends, and regional differences of finger and partial hand amputations on a national level in individuals aged 15 or older in Sweden., Methods: We analyzed 6,918 patients aged 15 and older who had experienced finger and partial hand amputations. Incidence rates, trends, and regional disparities were assessed using negative binomial regression models and Student's t-tests. Future trend prediction was performed using Poisson regression., Results: Finger amputations declined most, followed by partial hand and thumb amputations. Regional variations existed, with Stockholm having the lowest and Gotland highest incidence respectively. Overall, the incidence of finger, thumb and partial hand amputations in Sweden decreased slightly. Future trend analysis indicated decreasing incidence., Conclusion: Although, lacking in definition, publicly available data can be used for monitoring of finger, thumb, and partial hand amputation incidence on a national level. Sex, age, and regional differences were observed, suggesting the need for targeted interventions to address disparities and mitigate the burden of finger and partial hand amputations on affected individuals., (© 2024. The Author(s).)

Background: There is no consensus or clinical guidelines for screening routines of autoimmune disease in individuals with juvenile idiopathic arthritis (JIA), since results are conflicting whether the risk for such conditions is increased or not among individuals with JIA. The aim of this study was to investigate if the frequency of comorbid autoimmune conditions is increased after JIA diagnosis in a validated population-based JIA cohort in southern Sweden., Methods: Autoimmune comorbidities were evaluated in a pre-existing population-based JIA cohort of 302 participants, constituting of individuals diagnosed with a validated JIA diagnosis 2000-2010 in southern Sweden. The comorbidities were determined through analysis of diagnosis codes registered after the JIA diagnosis and until 2019. With the use of a reference population of 1510 age- and sex matched individuals, hazard ratios (HR) were calculated with Cox proportional models., Results: During the study period, 7.7% of the JIA cohort received an autoimmune diagnosis after their JIA diagnosis. Individuals with JIA had an increased risk of autoimmune diseases in general (HR 4.11, 95% CI 2.13-7.91) within the first 7 years of disease, as well as separately for coeliac disease (HR 5.24, 95% CI 1.76-15.65) and hypothyroidism (HR 3.74, 95% CI 1.14-12.30) compared to the reference population. Antinuclear antibody (ANA) positivity was associated with a significantly increased risk of comorbid autoimmune disease in the JIA cohort, with HR 6.21 (95% CI 1.64-23.55) for ANA positive individuals., Conclusions: Individuals with JIA have a significantly increased risk of being diagnosed with an autoimmune condition after receiving their JIA diagnosis compared to matched references. ANA positivity is associated with a further increased risk. Our results emphasize awareness in physicians of additional autoimmune disorders in individuals with JIA and advocate serological screening of autoimmune conditions during follow-up., (© 2024. The Author(s).)

Background: Associations between violent victimisation and psychiatric disorders are hypothesised to be bidirectional, but the role of violent victimisation in the aetiologies of psychiatric disorders and other adverse outcomes remains unclear. We aimed to estimate associations between violent victimisation and subsequent common psychiatric disorders, suicidal behaviours, and premature mortality while accounting for unmeasured familial confounders., Methods and Findings: Using nationwide registers, we identified a total of 127,628 individuals born in Finland (1987 to 2004) and Sweden (1973 to 2004) who had experienced violent victimisation, defined as either hospital admissions or secondary care outpatient visits for assault-related injuries. These were age- and sex-matched with up to 10 individuals in the general population (n = 1,276,215). Additionally, we matched those who had experienced violent victimisation with their unaffected siblings (n = 132,408). Outcomes included depression, anxiety, personality disorders, alcohol use disorders, drug use disorders, suicidal behaviours, and premature mortality. Participants were followed from the victimisation date until the date of the outcome, emigration, death, or December 31, 2020, whichever occurred first. Country-specific associations were estimated using stratified Cox regression models, which also accounted for unmeasured familial confounders via sibling comparisons. The country-specific associations were then pooled using meta-analytic models. Among 127,628 patients (69.0% male) who had experienced violent victimisation, the median age at first violent victimisation was 21 (interquartile range: 18 to 26) years. Incidence of all outcomes was larger in those who were exposed to violent victimisation compared to population controls, ranging from 2.3 (95% confidence interval (CI) [2.2; 2.4]) per 1,000 person-years for premature mortality (compared with 0.6, 95% CI [0.6; 0.6], in controls) to 22.5 (95% CI [22.3; 22.8]) per 1,000 person-years for anxiety (compared with 7.3, 95% CI [7.3; 7.4], in controls). In adjusted models, people who had experienced violent victimisation were between 2 to 3 times as likely as their siblings to develop any of the outcomes, ranging from adjusted hazard ratio [aHR] 1.7 (95% CI [1.7; 1.8]) for depression to 3.0 (95% CI [2.9; 3.1]) for drug use disorders. Risks remained elevated 2 years post-victimisation, ranging from aHR 1.4 (95% CI [1.3; 1.5]) for depression to 2.3 (95% CI [2.2; 2.4]) for drug use disorders. Our reliance on secondary care data likely excluded individuals with milder assault-related injuries and less severe psychiatric symptoms, thus suggesting that our estimates may be conservative. Another limitation is the possibility of residual genetic confounding, as full siblings share on average about half of their co-segregating genes. However, the associations remained robust even after adjusting for both measured and unmeasured familial confounders., Conclusions: In this longitudinal cross-national cohort study, we observed that those who had experienced violent victimisation were at least twice as likely as their unaffected siblings to develop common psychiatric disorders (i.e., depression, anxiety, personality disorder, and alcohol and drug use disorders), engage in suicidal behaviours, and to die prematurely. Importantly, these risk elevations remained 2 years after the first victimisation event. Improving clinical assessment, management, and aftercare psychosocial support could therefore potentially reduce rates of common psychiatric disorders, suicidality, and premature mortality in individuals experiencing violent victimisation., Competing Interests: SF is an Academic Editor on PLOS Medicine’s editorial board. HL reports receiving grants from Shire Pharmaceuticals; personal fees from and serving as a speaker for Medice, Shire/Takeda Pharmaceuticals and Evolan Pharma AB; all outside the submitted work. HL is the editor-in-chief of JCPP Advances. Shire/Takeda and Evolan were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review or approval of the manuscript., (Copyright: © 2024 Sariaslan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Understanding the heterogeneity of opioid overdose fatalities is critical to developing effective preventive interventions. This study examines patterns of care contacts among people who subsequently died from opioid overdose. The aim was to identify distinct groups of deceased individuals, based on their contacts with different care agencies in their last year of life., Methods: A retrospective registry study was conducted in Skåne, Southern Sweden. All recorded opioid overdose fatalities during the study period were included, n = 191. Latent class analysis was used to identify patterns of care contacts in the last year of life., Results: Three distinct classes were identified: "Few care contacts," with limited interaction with any services; "Social service contacts," comprising individuals who predominantly had contacts with the social services and, to a lesser extent, with prison and probation services; and "Numerous care contacts," with extensive contacts with both healthcare and social services. The "few care contacts" class comprises about half of the population. This is an important finding, since this group has not been clearly visible in previous research. The analysis indicates significant gaps in service provision, particularly regarding substance use treatment and mental health support., Conclusions: Using a person-centred approach, this article offers a novel way of analysing care contacts among people who subsequently died from opioid overdose. The identification of distinct groups, particularly a large group of people with minimal contact with the community care system, highlights the need for more targeted outreach and support work. Developing targeted interventions in emergency and inpatient care settings may provide an opportunity to reach the group with few care contacts., (© 2024. The Author(s).)

Objectives: While Mycoplasma genitalium is reported as a common rectal infection among men who have sex with men (MSM), published data refer predominantly to urethral infections. Currently, most guidelines recommend M. genitalium testing from urine in men with symptomatic, non-gonococcal urethritis. Macrolide resistance-associated mutations (MRMs) among M. genitalium have increased during the last decade especially among MSM. We aim to demonstrate the prevalence and anatomical distribution of M. genitalium infection and MRM in urine and rectal specimens among MSM in Sweden., Methods: In this cross-sectional study in 2019, paired urine and rectal samples from symptomatic and asymptomatic MSM attending a sexually transmitted infection clinic in the south of Sweden were screened for M. genitalium , presence of MRM, Neisseria gonorrhoeae , Chlamydia trachomatis , HIV and syphilis., Results: The overall prevalence of M. genitalium was 10.5% (64 of 609), rectal samples 7.6% (46 of 609) and urine samples 3.9% (24 of 609) (p=0.007). Among M. genitalium -positive cases, single rectal and single urethral infection was detected in 62.5% (40 of 64) and 28.1% (18 of 64), respectively (p<0.0001). Infection at both sites was seen in 9.4% (6 of 64). The prevalence of MRM was 67.9% (19 of 28). M. genitalium was significantly associated with HIV (OR 2.60, 95% CI 1.14 to 5.88, p=0.02). Among the MSM, 7.4% (45 of 609) were infected with N. gonorrhoeae, 6.7% (41 of 609) with C. trachomatis , 7.1% (43 of 609) with HIV and 0.7% (4 of 609) with syphilis., Conclusions: In this study, among MSM, most infections with M. genitalium were detected as rectal mono infections. The prevalence of M. genitalium among MSM was almost twofold higher in rectal samples (7.6%) compared with urine samples (3.9%). The prevalence of macrolide resistance was high with no difference between urine and rectal samples., 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: There is a difference in the incidence of spontaneous subarachnoid hemorrhage (SAH) between sexes, with the majority of cases occurring in female patients. Although this phenomenon has been studied from a medical perspective, the reasons for the predominance of female cases are still unclear. Non-medical factors, such as a patient's socioeconomic situation, can differ between female and male patients, with health implications. The aim of the study was to identify socioeconomic profiles for both sexes that may be vulnerable to developing SAH. This information could potentially be used for active preventive health efforts., Methods: This study was based on a 7-year consecutive cohort of 890 patients with SAH treated at Uppsala University Hospital, along with a sex- and age-matched 5:1 control group from Statistics Sweden. The collected information included demographic data, income that was analyzed through "earnings" (EAs), which is defined as the sum of income and other economic compensations related to work, and "disposable income" (DI), which is the net amount that an individual can use. Pension and sickness-related absence from work were measured using early pension (EP), old age pension (OAP), sickness absence (SA), and disability pension (DP). Univariate and multivariate analyses were used., Results: Among the women, the socioeconomic risk profile for SAH included lower education, unemployment, being registered as living single, residing in a sparsely populated municipality, and increased age. For the men, the risk profile included residing in a sparsely populated municipality and changes in civil status. Both women and men with SAH had lower EAs and DI compared to the controls. Notably, a significantly higher proportion of the women with SAH received DP compared to the controls., Conclusion: Residing in a sparsely populated area was associated with an increased risk for SAH for both women and men. The women with SAH were more economically vulnerable, whereas the men faced a different type of vulnerability related to changes in civil status. We suggest that healthcare organizations use this information to identify individuals at risk and actively implement preventive measures according to stroke guidelines for both groups., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Ronne-Engström and Friberg.)

Objectives: Antihypertensives reduce the risk of myocardial infarction and stroke. Restrictions during the COVID-19 pandemic limited access to healthcare, which may have had a negative impact on drug prescribing. This study aimed to assess the effect of the COVID-19 pandemic on the initiation of antihypertensive drugs., Design: Interrupted time series study using a segmented linear regression model., Setting: Swedish population assessed through linked national healthcare registers., Participants: 720 300 new users of antihypertensives., Intervention: March 2020, COVID-19 pandemic onset., Main Outcomes Measures: The change in the initiation of antihypertensives expressed as monthly cumulative incidence, stratified by age and sex. Data on dispensed prescriptions of diuretics, beta-blockers, calcium channel blockers, ACE inhibitors (ACEi) and angiotensin receptor blockers were extracted from the Swedish Prescribed Drug Register, from March 2018 to November 2021. Initiation (new use) was defined as having no previous dispensations before March 2019. Monthly cumulative incidence in March 2019-November 2021 was calculated as the number of patients initiating each drug class in each month divided by the population., Results: The start of the pandemic was associated with an immediate drop in the initiation of any antihypertensive, but no sustained effects were observed, as the incidence continued to increase in the postinterruption period by +0.02% each month in both sexes. The immediate drop was statistically significant for ACEi in both sexes and all antihypertensive classes except diuretics in patients >65 years. А significant postintervention trend change was observed for initiation of diuretics (+0.013% overall), driven mainly by a significant increase in patients >65 years. Similar findings were also observed for diuretics in females (+0.02%) and ACEi (+0.03%) in patients >65 years., Conclusions: The pandemic had an immediate negative short-term effect, but we found no major long-term negative influence of the COVID-19 pandemic on initiation of any type of antihypertensive drugs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Cesarean section for breech presentation is often recommended. However, cesarean section affects future reproduction. The aim of this study was to assess the effect of mode of the first birth in breech on outcomes of the second birth and the two births together. This is a register-based nationwide cohort study including 23 062 women with a first singleton birth in breech ≥ 34 gestational weeks and a subsequent singleton birth in Sweden 2000-2019. Exposure was mode of first delivery. Main maternal outcome was a composite of fourth-degree perineal injury, postpartum hemorrhage requiring blood transfusion, hysterectomy, or death. Main infant outcome was a composite of stillbirth, extremely preterm birth (< 28 weeks), moderate to severe hypoxic ischemic encephalopathy, therapeutic hypothermia, or death. Outcomes were analyzed using multivariable logistic regression. In the first birth, the infant composite outcome affected < 1% in both groups but the risk was higher in the vaginal breech group (13/1525), compared with the breech CS group (27/21 537), aOR 7.06, 95% CI 2.91-17.1. In the second birth, the infant composite outcome affected < 1% in both groups but the risk was lower for the first vaginal breech group (3/1525) compared with the first breech CS group (152/21 537), aOR 0.26, 95% CI 0.08-0.84. There was no significant difference between the groups in risk of composite infant outcome in the two births assessed together, or in risk of composite maternal outcome. In total, the chance of a two-children family without maternal or infant severe adverse composite outcome was high and similar regardless mode of the breech first birth., (© 2024. The Author(s).)

Timing of human immunodeficiency virus-1 (HIV-1) reservoir formation is important for informing HIV cure efforts. It is unclear how much of the variability seen in dating reservoir formation is due to sampling and gene-specific differences. We used a Bayesian extension of root to tip regression (bayroot) to reestimate formation date distributions in participants from Swedish and South African cohorts, and assessed the impact of variable timing, frequency, and depth of sampling on these estimates. Significant shifts in formation date distributions were only observed with use of faster-evolving genes, while timing, frequency, and depth of sampling had minor or no significant effect on estimates., Competing Interests: Potential conflicts of interest . All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (Published by Oxford University Press on behalf of Infectious Diseases Society of America 2024.)

Background: A self-harm episode is a major risk factor for repeat self-harm. Existing tools to assess and predict repeat self-harm have major methodological limitations, and few are externally validated., Objective: To develop and validate a risk assessment model of repeat self-harm up to 6 months after an episode of non-fatal self-harm that resulted in an emergency visit to hospital or specialised care., Methods: Using Swedish national registers, we identified 53 172 people aged≥10 years who self-harmed during 2008-2012. We allocated 37 523 individuals to development (2820 or 7.5% repeat self-harm incidents within 6 months) and 15 649 to geographic validation (1373 repeat episodes) samples, based on region of residence. In a temporal validation of people who self-harmed during 2018-2019, we identified 25 036 individuals (2886 repeat episodes). We fitted a multivariable accelerated failure time model to predict risk of repeat self-harm., Findings: In the external validations (n=40 685), rates of repeat self-harm were 8.8%-11.5% over 6 months. The final model retained 17 factors. Calibration and discrimination were similar in both validation samples, with observed-to-expected ratio=1.15 (95% CI=1.09 to 1.21) and c-statistic=0.72 (95% CI=0.70 to 0.73) in the geographical validation. At 6 months and a 10% risk cut-off, sensitivity was 51.5% (95% CI=48.8% to 54.2%) and specificity was 80.7% (95% CI=80.1% to 81.4%) in geographic validation; corresponding values were 56.9% (95% CI=55.1% to 58.7%) and 76.0% (95% CI=75.5% to 76.6%) in temporal validation. Discrimination was slightly worse at the 1-month prediction horizon (c-statistics of 0.66-0.68)., Conclusions: Using mostly routinely collected data, simple risk assessment models and tools can provide acceptable levels of accuracy for repeat of self-harm., Clinical Implications: This risk model (OXford SElf-harm repeat tool) may assist clinical decision-making., Competing Interests: Competing interests: HL reports receiving grants from Shire Pharmaceuticals; personal fees from and serving as a speaker for Medice, Shire/Takeda Pharmaceuticals and Evolan Pharma AB; all outside the submitted work. HL is editor-in-chief of JCPP Advances., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Self-rated health is a common assessment used in epidemiological research and an independent predictor of morbidity and mortality. We investigate if a single measure of self-rated health in late adolescence predict mortality between 46 and 70 years of age. This study was based on 47 286 Swedish men that conscribed 1969-1970 at age 18-20 and that were still alive in 1997. Self-rated health and data on potential explanatory factors (psychological factors, health status markers and health behaviors) were collected at conscription. Adult socioeconomic position in 1990 was derived from registries. Death and cause of death (cancer, cardiovascular disease, violent and alcohol abuse related disorders) were derived from the Causes of Death Register between 1997 and 2019. Conscripts that rated their health as fair or poor/very poor had significantly higher hazard of all-cause mortality than conscript that rated their health as very good (HR fair  = 1.27, 95%CI:1.18-1.37 and HR poor  = 1.25, 95%CI:1.11-1.41) and disease-specific mortality. Adjusting for all explanatory factors attenuated the risk estimates by 9-100%. In conclusion, poor self-rated health reported in late adolescence predicts all-cause and disease-specific mortality between the ages of 46 and 70 years. Psychological factors and health behaviors measured at conscription may serve as potential explanatory factors underlying the predictive ability of self-rated health in late adolescence., (© 2024. The Author(s).)

Background: Malaria remains a significant public health concern, especially for the deadliest parasite, Plasmodium falciparum. During acute malaria, various cytokines, including osteopontin (OPN), regulate the immune response. OPN has been shown to be protective against malaria in mice. Nonetheless, its precise function and potential ability to control parasites during acute malaria in humans remain poorly understood., Results: Blood samples were collected from Swedish adults with imported malaria, Ugandan children and adults with symptomatic malaria (including follow-up after 42 days), Ugandans with non-malarial fever and healthy individuals from both Uganda and Sweden. Parasitemia was determined by microscopy. Malaria-negative samples were verified by LAMP. OPN and interferon-γ (IFN- γ) levels were measured using ELISA. In children, OPN levels were significantly higher during acute infection compared to levels after 42 days, whereas Ugandan adults showed no difference. Swedish adults with imported malaria had elevated OPN levels compared to both Swedish controls and Ugandan adults with malaria. Parasitemia was significantly correlated with both OPN and IFN-γ levels across the entire cohort. While a significant correlation between OPN and IFN-γ was evident overall, it remained statistically significant only in Ugandan adults when analyzed by subgroups. This suggests that OPN is not just a general marker of inflammation but may be regulated differently during the development of malaria immunity., Conclusions: In acute malaria, elevated OPN levels showed a stronger correlation with lack of immunity than age. These findings underscore the potential importance of OPN in malaria, particularly in non-immune individuals., (© 2024. The Author(s).)

Background: Overweight and obesity are increasing globally with aging, as are life expectancy and aging-associated disorders, including calcific aortic stenosis (AS). Studies investigating the correlation between high body mass index (BMI) and AS are contradictory and inconclusive. This study examines a potential association between BMI and AS in women., Methods and Results: By linking the Swedish Medical Birth Register and the Swedish National Patient Register, we included women aged 18 to 55 years with a first childbirth from 1981 to 2020. Diagnosis of AS and comorbidities were defined according to the International Classification of Diseases ( ICD ) codes. The women were divided into groups on the basis of BMI. Cox proportional hazards regression models were used to investigate the difference in the risk of being diagnosed with AS, with reference BMI 20 to <22.5 kg/m 2 . Among the 1 722 625 included women, the mean age was 28 years, and mean BMI was 24 kg/m 2 , with 21% being overweight (BMI 25 to <30 kg/m 2 ) and 8.5% obese (BMI ≥30 kg/m 2 ). During median follow-up of 19.5 years, 2488 women (0.14%) were diagnosed with AS. The age-adjusted risk of being diagnosed with AS increased with higher BMI to 2.82 (95% CI, 2.44-3.25) times higher in women with BMI 30 to <35 kg/m 2 , and to 3.72 (95% CI, 2.95-4.70) times higher in those with BMI ≥35 kg/m 2 . Similar results were found after excluding AS of rheumatic pathogenesis., Conclusions: An increase in BMI from its upper normal range was consistently and independently associated with the risk of developing AS in women.

Background: In-center hemodialysis (IHD) is the most common dialysis modality. Assisted peritoneal dialysis (assPD) is an option for frail and/or incapacitated patients. Both modalities can be used to alleviate uremic symptoms towards the end of life. There are few studies comparing these modalities. The primary aim is to compare hospital admissions between assPD and IHD. The secondary aim is to compare continuation of the dialysis modality and patient survival., Methods: Patients > 65 years, registered in the Swedish Renal Registry (SRR) and starting dialysis 2010-2017 were eligible for inclusion. Patients starting on assPD were matched with patients starting on IHD according to sex, Charlson Index, age and date for start of dialysis. Data were collected from SRR and other registries., Results: During the first year, patients on assPD and IHD had in median one (IQR 0-5.0; 0-4.0) hospitalization (p = 0.412). There was no significant difference after two years, in the annual number of days admitted to hospital, in hospitalizations with cardiovascular or infectious disease diagnoses or continuation of the dialysis modality, respectively. However, patients on assPD had a worse median survival (1.1 years IQR 0.6-2.1; IHD 3.1 years IQR 0.2-5.8; p < 0.001)., Conclusion: In this study patients starting assPD, often as a palliative treatment, showed no difference compared to IHD concerning the number of hospitalizations, number of days in hospital/year or continuation of the dialysis modality. Patients on assPD had a worse survival, which is likely due to residual confounding. Without that, patients on assPD would probably have lower number of hospitalizations. Despite limitations due to the retrospective observational design of the study, the results indicate that assPD is a feasible alternative to IHD when self-care dialysis is not possible and/or IHD too arduous., (© 2024. The Author(s).)

Background: To investigate the association between surgical removal of tonsils and risk of COVID-19 with different severity., Methods: Through a nested case-control study during January 31st to December 31st 2020, including 58,888 participants of the UK Biobank, we investigated the association of tonsillectomy with the future risk of mild and severe COVID-19, using binomial logistic regression. We further examined the associations of such surgery with blood inflammatory, lipid and metabolic biomarkers to understand potential mechanisms. Finally, we replicated the analysis of severe COVID-19 in the Swedish AMORIS Cohort (n = 451,960)., Results: Tonsillectomy was associated with a lower risk of mild (odds ratio [95% confidence interval]: 0.80 [0.75-0.86]) and severe (0.87 [0.77-0.98]) COVID-19 in the UK Biobank. The associations did not differ substantially by sex, age, Townsend deprivation index, or polygenic risk score for critically ill COVID-19. Levels of blood inflammatory, lipid and metabolic biomarkers did, however, not differ greatly by history of surgical removal of tonsils. An inverse association between tonsillectomy and severe COVID-19 was also observed in the AMORIS Cohort, primarily among older individuals (> 70 years) and those with ≤ 12 years of education., Conclusions: Surgical removal of tonsils may be associated with a lower risk of COVID-19. This association is unlikely attributed to alterations in common blood inflammatory, lipid and metabolic biomarkers., (© 2024. The Author(s).)

Background and Aims: Non-HDL-C provides an estimate of lipid-associated risk and is a secondary treatment target after myocardial infarction (MI). The aim was to study the relationship between non-HDL-C levels after MI and risk of adverse outcomes., Methods: From the SWEDEHEART registry, 56 262 patients with MI were included. Outcomes were major adverse cardiovascular event (MACE: death, MI, and ischaemic stroke), death, and non-fatal MI. Non-HDL-C was assessed at admission, 2 months, and 1 year. Target achievement (<2.2 mmol/L) of non-HDL-C, timing thereof, and outcomes were assessed., Results: During median follow-up of 5.4 years, 9549 had MACE, 5427 died, and 3946 had MI. Long-term hazard ratio (HR) for MACE in the lowest vs. the highest quartile of achieved non-HDL-C at 1 year was 0.76 [95% confidence interval (CI) 0.71-0.81]. Short-term results were consistent also when assessing non-HDL-C levels at 2 months, including early events up to 1 year (HR 0.80, 95% CI 0.68-0.92). Similar results were observed for all outcomes. Patients achieving both early and sustained targets had lowest risk of outcomes (HR 0.80, 95% CI 0.74-0.86) vs. patients achieving target early or late (HR for both 0.86, 95% CI 0.79-0.93)., Conclusions: The lowest achieved levels both at 2 months and at 1 year of non-HDL-C were associated with better outcome. The lowest risk was observed when target was achieved within 2 months of MI and sustained thereafter. These findings challenge the current stepwise approach for cholesterol lowering after MI, which inevitably results in delaying goal attainment and possible harm., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Intracranial hemorrhage (ICH) is a potentially severe complication of endovascular thrombectomy (EVT). However, the relationship between the incidence and severity of ICH and vascular occlusion location is not well described., Objective: To present a comprehensive analysis of subtypes of ICHs and their relationship to the occlusion site following EVT in the anterior circulation., Methods: All patients with anterior circulation vessel occlusion stroke (internal carotid (ICA) and middle cerebral artery's first (M1) and later segments (M2 and beyond)) registered in the two Swedish national quality registers for stroke care and endovascular therapy during 2015-2020 were included. Hemorrhagic complications identified on imaging within 36 hours post-EVT were classified according to Heidelberg Bleeding Classification and further divided into symptomatic (sICH) or non-symptomatic (non-sICH)., Results: Of the 3077 patients, ICH frequency was 24.2%, which included 4.5% sICH. Subarachnoid hemorrhage (SAH) was the most frequent subtype of hemorrhage (10.9%). The hemorrhagic subtypes differed significantly by occlusion site, but the frequency of any bleed did not. EVT performed in and beyond the M2 more often resulted in SAH, frequently classified as non-sICH. EVT performed in the ICA was associated with more severe hemorrhages, such as intraventricular and large parenchymal hematomas, that were more often classified as sICH., Conclusion: In this nationwide unselected EVT cohort we found that ICH severity significantly differed between different vessel occlusion sites., Competing Interests: Competing interests: EH received funding from the Swedish Stroke Federation. JW is a founder and shareholder of Uman Sense AB and has received speaker honoraria from Siemens Healthineers, BALT group, and Medtronic Inc. TU received speaker honoraria from AstraZeneca and Siemens Healthineers and is a steering committee member of Riksstroke., (© 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: Meta-analyses of randomized trials suggest that health checks and health promotion interventions targeting behavior change in primary care do not prevent cardiovascular morbidity and mortality in the general population. However, whether such interventions are more effective in high-risk populations, such as people living in low socioeconomic settings, remains unclear, as they have been poorly represented in previous trials. Therefore, we aim to evaluate the effectiveness, cost-effectiveness, and implementation of systematic screening followed by an individually oriented, lifestyle-focused, health dialogue intervention for prevention of type 2 diabetes and cardiovascular disease, as compared to opportunistic screening, in primary care in socioeconomically disadvantaged areas., Methods: Using an overall pragmatic approach and a cluster-randomized design with two arms, we aim to enroll 3000 participants aged 50-59 years from 30 primary care centers (PCCs) with an above-average level of Care Need Index in Stockholm Region, Sweden. PCCs will be randomized (1:1) either to a health dialogue intervention, which includes inviting enlisted patients to a systematic screening of risk factors followed by an individually oriented lifestyle-focused health dialogue, or to opportunistic screening, which includes screening patients for a smaller set of risk factors during an appointment at their PCC taking place for other reasons. The main outcome will be change in systolic blood pressure during 6- and 12-month follow-ups. Additional short-term outcomes will be changes in other biological risk factors, health-related quality-of-life, and lifestyle habits, as well as process and implementation outcomes, and unintended side effects. The long-term effect on type 2 diabetes and cardiovascular disease incidence and mortality will be examined using regional and nationwide registers. Changes in systolic blood pressure and other health outcomes will be analyzed using mixed-effect generalized linear modeling and mixed-effect Cox regression to capture variability between and within PCCs. A health economic evaluation will assess resource use and costs in the short- and long-term., Discussion: This trial of lifestyle-focused health dialogues and opportunistic screening in primary care in socioeconomically disadvantaged areas in the largest region of Sweden has the potential to yield valuable insights that could support evidence-based policymaking., Trial Registration: ClinicalTrials.gov (NCT06067178). Prospectively registered September 27, 2023., (© 2024. The Author(s).)

COVID-19 is a severe respiratory disease affecting millions worldwide, causing significant morbidity and mortality. Adrenomedullin (bio-ADM) is a vasoactive hormone regulating the endothelial barrier and has been associated with COVID-19 mortality and other adverse events. This prospective cohort pilot study included 119 consecutive patients with verified SARS-CoV-2 infection admitted to two intensive care units (ICUs) in Southern Sweden. Bio-ADM was retrospectively analysed from plasma on ICU admission, and days 2 and 7. Information on comorbidities, adverse events and mortality was collected. The primary outcome was 90-day mortality, and secondary outcomes were markers of disease severity. The association between bio-ADM and outcomes was analysed using survival analysis and logistic regression. Bio-ADM on admission, day 2, and day 7 only moderately predicted 90-day mortality in univariate and multivariate Cox regression. The relative change in bio-ADM between sample times predicted 90-day mortality better even when adjusting for the SAPS3 score, with an HR of 1.09 (95% CI 1.04-1.15) and a C-index of 0.82 (95% CI 0.72-0.92) for relative change between day 2 and day 7. Bio-ADM had a good prediction of the need for renal replacement therapy in multivariate Cox regression adjusting for creatinine, where day 2 bio-ADM had an HR of 3.18 (95% CI 1.21-8.36) and C-index of 0.91 (95% CI 0.87-0.96). Relative changes did not perform better, possibly due to a small sample size. Admission and day 2 bio-ADM was associated with early acute kidney injury (AKI). Bio-ADM on ICU admission, day 2 and day 7 predicted 90-day mortality and dialysis needs, highlighting bio-ADM's importance in COVID-19 pathophysiology. Bio-ADM could be used to triage patients with a risk of adverse outcomes and as a potential target for clinical interventions., (© 2024. The Author(s).)

Study Objectives: Shift work, insufficient sleep, and poor sleep quality at young age have been associated with increased risk of multiple sclerosis (MS). This study aimed to investigate the potential interaction between aspects of inadequate sleep (short sleep, phase shift, and poor sleep quality) during adolescence and HLA-DRB1*15:01 in relation to MS risk., Methods: We used a Swedish population-based case-control study (1253 cases and 1766 controls). Participants with different sleep patterns during adolescence and HLA-DRB1*15:01 status were compared regarding MS risk by calculating odds ratios with 95% confidence intervals (CI) using logistic regression models. Additive interaction between aspects of inadequate sleep and HLA-DRB1*15:01 status was assessed by calculating the attributable proportion due to interaction (AP) with 95% CI., Results: Short sleep duration (<7 hours/night) during adolescence acted synergistically with HLA-DRB1*15:01, increasing the risk of MS (AP 0.38, 95% CI: 0.01 to 0.75, p = .04). Similarly, subjective low sleep quality during adolescence interacted with HLA-DRB1*15:01 regarding risk of MS (AP 0.30, 95% CI: 0.06 to 0.56, p = .03), whereas phase shift did not significantly influence the risk of the disease, irrespective of HLA-DRB1*15:01 status., Conclusions: Our findings underscore the importance of addressing inadequate sleep during adolescence, particularly in the context of the HLA-DRB1*15:01 allele, as it appears to amplify the risk of subsequently developing MS., (© The Author(s) 2024. Published by Oxford University Press on behalf of Sleep Research Society.)

Background: The objective of this study is to estimate the prevalence of self-reported hearing difficulties, vision difficulties and combined vision and hearing difficulties in a Swedish adult population that varies according to migration status, sex, age, disability measured by ADL and IADL and educational attainment level., Methods: The study utilised data from the Survey of Health, Ageing and Retirement in Europe, which consisted of 2257 individuals aged 60 and above that were interviewed in Sweden in the 2019/2020, SHARE wave 8. To determine the prevalence of sensory difficulties (hearing, vision and dual-sensory difficulties) among various subgroups of the population, a multinomial logistic regression was used. The results of these analyses are presented in terms of predicted probabilities., Results: The study findings indicate that foreign-born older adults experience a lower prevalence of visual difficulties (6.2% [3.3-11.5] in comparison to their Swedish-born counterparts. Moreover, older adults with higher levels of education tend to report a lower prevalence of sensory difficulties overall. Furthermore, sex differences are apparent, with males reporting a higher prevalence of hearing difficulties (18.9% [15.5-22.8] vs. 12.8% [10.7-15.3]) and females reporting a higher prevalence of vision difficulties (12.7% [10.7-15.1] vs. 8.5%[6.8-10.5])., Conclusion: The findings highlight disparities in the prevalence and type of perceived sensory difficulties experienced by older adults, by factors such as age, sex, education and migration status. It is important to consider these demographic factors in healthcare planning and interventions aimed at mitigating sensory difficulties in the older population., (© 2024. The Author(s).)

Introduction: Traumatic peripheral nerve injuries pose significant challenges to healthcare systems and individuals, affecting sensory function, causing neuropathic pain, and impairing quality of life. Despite their impact, comprehensive studies on the epidemiology and regional variance of these injuries are scarce. Understanding the incidence, trends, and anatomical distribution of such injuries is essential for targeted interventions and resource allocation., Methods: This observational study utilized register-based data from the Swedish National Patient Register covering the period from 2008 to 2022. Incidence rates, trends, and anatomical distribution of traumatic peripheral nerve injuries were analyzed using descriptive statistics, Poisson regression modeling, and regional comparisons., Results: Higher incidences of peripheral nerve injuries were observed among men compared to women across all age groups. The hand and wrist were the most commonly affected sites. Regional variations in incidence rates were evident, with some regions consistently exhibiting higher rates compared to others. Notably, a decreasing trend in injuries was observed over the study period., Conclusion: This study underscores the importance of targeted interventions and preventive strategies, considering sex, age, and regional disparities. Further research incorporating individual patient-level data is warranted to enhance our understanding and inform tailored interventions to reduce the burden of these injuries., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Magnéli, Axenhus. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Bradycardia is more common among well-trained athletes than in the general population, but the association with pacemaker implantations is less known. We investigated associations of endurance training with incidence of bradycardia and pacemaker implantations, including sex differences and long-term outcome, in a cohort of endurance trained individuals., Methods: All Swedish skiers who completed >1 race in the cross-country skiing event Vasaloppet between 1989 and 2011 (n=209 108) and a sample of 532 290 nonskiers were followed until first event of bradycardia, pacemaker implantation, or death, depending on end point. The Swedish National Patient Register was used to obtain diagnoses. Cox regression was used to investigate associations of number of completed races and finishing time in Vasaloppet with incidence of bradycardia and pacemaker implantations. In addition, Cox regression was used to investigate associations of pacemaker implantations with death in skiers and nonskiers., Results: Male skiers had a higher incidence of bradycardia (adjusted hazard ratio [aHR], 1.19 [95% CI, 1.05-1.34]) and pacemaker implantations (aHR, 1.17 [95% CI, 1.04-1.31]) compared with male nonskiers. Those who completed the most races and had the best performances exhibited the highest incidence. For female skiers in Vasaloppet, the incidence of bradycardia (aHR, 0.98 [95% CI, 0.75-1.30]) and pacemaker implantations (aHR, 0.98 [95% CI, 0.75-1.29]) was not different from that of female nonskiers. The indication for pacemaker differed between skiers and nonskiers, with sick sinus syndrome more common in the former and third-degree atrioventricular block in the latter. Skiers had lower overall mortality rates than nonskiers (aHR, 0.16 [95% CI, 0.15-0.17]). There were no differences in mortality rates by pacemaker status among skiers., Conclusions: In this study, male endurance skiers had a higher incidence of bradycardia and pacemaker implantations compared with nonskiers, a pattern not seen in women. Among male skiers, those who completed the most races and had the fastest finishing times had the highest incidence of bradycardia and pacemaker implantations. Within each group, mortality rates did not differ in relation to pacemaker status. These findings suggest that bradycardia associated with training leads to a higher risk for pacemaker implantation without a detrimental effect on mortality risk., Competing Interests: None.

Background and Aims: A variety of maternal heart conditions are associated with abnormal placentation and reduced foetal growth. However, their impact on offspring's long-term cardiovascular health is poorly studied. This study aims to investigate the association between intrauterine exposure to pre-existing maternal cardiovascular disease (CVD) and offspring CVD occurring from infancy to early adulthood, using paternal CVD as a negative control., Methods: This nationwide cohort study used register data of live singletons without major malformations or congenital heart disease born between 1992 and 2019 in Sweden. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models, adjusted for essential maternal characteristics. Paternal CVD served as a negative control for assessment of unmeasured genetic and environmental confounding., Results: Of the 2 597 786 offspring analysed (49.1% female), 26 471 (1.0%) were born to mothers with pre-existing CVD. During a median follow-up of 14 years (range 1-29 years), 17 382 offspring were diagnosed with CVD. Offspring of mothers with CVD had 2.09 times higher adjusted HR of CVD (95% CI 1.83, 2.39) compared with offspring of mothers without CVD. Compared with maternal CVD, paternal CVD showed an association of smaller magnitude (HR 1.49, 95% CI 1.32, 1.68). Increased hazards of offspring CVD were also found when stratifying maternal CVD into maternal arrhythmia (HR 2.94, 95% CI 2.41, 3.58), vascular (HR 1.59, 95% CI 1.21, 2.10), and structural heart diseases (HR 1.48, 95% CI 1.08, 2.02)., Conclusions: Maternal CVD was associated with an increased risk of CVD in offspring during childhood and young adulthood. Paternal comparison suggests that genetic or shared familial factors may not fully explain this association., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objectives: The aim of this cross-sectional survey was to assess oral health, including prevalence of periodontitis and rate of tooth loss, in a Swedish cohort of patients with inflammatory bowel disease (IBD)., Methods: A questionnaire on general anamnestic and socio-economic aspects, IBD diagnosis, and various oral health aspects was distributed online. The analyses focused on the comparison between patients diagnosed with ulcerative colitis (UC) or Crohn's disease (CD) as well as on factors associated with self-reported severe periodontitis and tooth loss., Results: Analyses were based on answers from 786 patients; 415 with UC, 371 with CD, 74% female. In both disease entities, high prevalence of severe periodontitis (i.e., 38.5%) was reported, and about 19% of the population had less than 20 remaining teeth and 6.5% a poor oral health-related quality of life. CD patients tended to be more severely affected than UC patients (p > 0.05 in the adjusted analysis). Almost 90% of CD patients were aware of being entitled to a bi-annual governmental financial support for dental care due to IBD; however, 1 out of 4 UC patients did not. Furthermore, IBD patients largely believe that the interest of their physicians in any oral lesions due to IBD diagnosis is low., Conclusions: Severe periodontitis and high rate of tooth loss are frequent in Swedish IBD patients., Clinical Relevance: Even though IBD patients receive bi-annually some special financial support for dental care, it seems this is still not sufficient and more preventive measures appear necessary., (© 2024. The Author(s).)

Background: Stress is today a common feature of patients seeking medical care and a growing public health issue in society. A method has been developed to measure biological chronic stress by Hair Cortisol Concentrations (HCC). This biomarker, for chronic stress, captures information about cumulative cortisol levels over the course of several months. Long-term stress might be one of the factors contributing to the onset of cardiovascular conditions and also affecting different risk factors. The aim of this study was to analyse the association between Hair Cortisol Concentrations and previous cardiovascular diseases and cardiovascular risk factors., Methods: The method of measuring chronic stress by Hair Cortisol Concentration was applied in a large Swedish national observational cross-sectional study. A population-based random sample of N = 4,821 Swedish middle-aged men and women was analysed for hair cortisol levels in relation to diagnosed previous cardiovascular diseases and biologically measured cardiovascular risk factors., Results: Long-term stress, measured by hair cortisol, was significantly associated with the classical cardiovascular risk factors hypertension and high cholesterol, but not smoking. Those with elevated HCC levels also had a significantly increased pre-history of myocardial infarction, type 2 diabetes, atrial fibrillation and by-pass surgery, but not regarding stroke, angina pectoris or sleep apnoea. Higher HCC was significantly associated (p < 0.001) with Body mass index and waist circumference, but only for females. HCC was also associated with the risk markers leukocytes, and high-sensitivity CRP, indicating a possible linkage between HCC and inflammation and hypothetically also the bodily immune defense. No association was found between perceived stress and HCC., Conclusions: An overall conclusion of our results is that health care should put more emphasis on patients reporting that they have been exposed to long term stress. Altogether, these analyses of Hair cortisol levels in a large middle-aged population show that chronically elevated cortisol levels represent a relevant and significant factor associated with cardiovascular diseases and classical cardiovascular risk factors., (© 2024. The Author(s).)

Background: We aimed to investigate whether early-life hygiene-related factors influenced the risk of inflammatory bowel disease (IBD) in a Scandinavian population and test the association's consistency across cohorts., Methods: This study followed 117 493 participants in the All Babies in Southeast Sweden study and the Norwegian Mother, Father, and Child Cohort Study. IBD diagnoses were defined by national registers. Comprehensive data on hygiene-related exposures, such as having pets, rural living, daycare attendance, and siblings, were retrieved from questionnaires administered from pregnancy until child's age of 36 months. A multivariable Cox regression model yielded adjusted hazard ratios (aHRs) for IBD accounting for socioeconomic status and perinatal factors. Cohort-specific estimates were pooled using a random-effects model., Results: In over 2 024 299 person-years of follow-up 451 participants developed IBD. In pooled estimates children attending daycare up to 36 months of life vs not attending daycare were less likely to develop Crohn's disease (aHR, 0.60; 95% confidence interval [CI], 0.37- 0.98). Children having 1 or more siblings had a modestly increased risk of IBD (aHR, 1.17; 95% CI, 0.96-1.42; aHR for each sibling, 1.12; 95% CI, 1.01-1.24). The other hygiene factors were not significantly linked to later IBD. In the Norwegian Mother, Father, and Child Cohort Study cohort, bed sharing was associated with an increased risk of IBD, most notably for ulcerative colitis (aHR, 1.67; 95% CI, 1.01-2.78)., Conclusions: In this birth cohort study from 2 high-income Scandinavian countries, some early-life hygiene-related exposures were associated with IBD risk. The generalizability of these results to countries of other socioeconomic level is unknown., (© 2023 Crohn’s & Colitis Foundation. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation.)

Background: Ecological observations suggest a negative relationship between childhood socioeconomic status (SES) and inflammatory bowel disease (IBD) risk. Individual-level analyses have been inconsistent and mostly lacked refined assessments of SES. We aimed to comprehensively study the association between early-life SES and later IBD., Methods: This study included 117 493 participants from the Norwegian Mother, Father and Child cohort and Swedish All Babies in Southeast Sweden cohorts. Participants were followed from birth (1997-2009) through 2021. IBD was identified through national patient registers. Questionnaire and register data were used to define parental educational level, employment, and household income level. Cox regression estimated adjusted hazard ratios (aHRs), accounting for other SES exposures and covariates (eg, parental IBD). Cohort-specific estimates were pooled using a random-effects model., Results: During 2 024 299 person-years of follow-up, 451 participants were diagnosed with IBD (All Babies in Southeast Sweden cohort, n = 113 and Norwegian Mother, Father and Child cohort, n = 338). Early-life maternal, but not paternal, educational level was associated with later IBD (low vs high educational level; pooled aHR, 1.81; 95% confidence interval [CI], 1.16-2.82; and pooled aHR, 1.20; 95% CI, 0.80-1.80; respectively). Having a nonworking mother or father was not significantly associated with IBD (pooled aHR, 0.69; 95% CI, 0.47-1.02; pooled aHR, 0.79; 95% CI, 0.45-1.37). High vs low household income level yielded a pooled aHR of 1.33 (95% CI, 0.94-1.89). Overall, results were largely consistent across cohorts., Conclusions: In this prospective Scandinavian cohort study, low maternal educational level was, independent of other SES and covariates, significantly associated with later IBD in her child. Further research is needed to elucidate factors that may mediate this relationship., (© 2023 Crohn’s & Colitis Foundation. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation.)

In January 2023, a Swedish piglet-producing farm with 2800 sows in production (SIP) was diagnosed with IAV (Influenza A virus) and the isolates were shown to cluster with the human seasonal influenza (2022/2023). In December 2022, employees with flu like symptoms tended to the pigs and a few weeks later, respiratory signs appeared in different age groups; sows in farrowing units were anorectic and pyrectic. Lung and nasal swabs were tested positive for IAV and other respiratory infectious agents. Blanket vaccination against H1N1pdm09 of sows and gilts was initiated but discontinued for sows after 2 treatments. Biosecurity measures aiming to reduce the spread of virus were implemented. However, the compliance to follow the protocol was moderate.Combining immunity and strict sanitary measures is crucial to control virus circulation. As the farmer discontinued sow vaccination and just partly increased biosecurity, this may have contributed to ongoing virus circulation and clinical signs in pigs, even 5 months post-diagnosis. Although H1N1pdm09 already had been found in the herd in 2017, there were no clinical signs or diagnostic results indicating continuous circulation of this or other IAV strains afterwards. However, this cannot be entirely excluded. Swine IAVs pose a risk of reintroduction into the human population, highlighting the importance of vaccination of farm workers against seasonal influenza., Competing Interests: The authors declare that they have no competing interests., (Thieme. All rights reserved.)

Background: Depression and dementia are known to be associated. The identification of characteristics distinguishing depression prodromal to dementia from other depressive symptoms would be of value for early identification of dementia. The study of risk factors for depressive symptoms prodromal to dementia could improve preventive care and provide clues to the causes of dementia., Method: Dementia-free 82-year-old participants were stratified into groups that did (n = 126) and did not (n = 378) subsequently develop dementia. Examinations took place from 2003 to 2005 and follow-up ended 1 January 2015. Their baseline characteristics and depressive symptoms, measured using the 15-item Geriatric Depression Scale (GDS-15), were compared. Multivariate regression analyses were performed for the two groups separately, with the total GDS-15 score as the dependent variable., Results: The groups did not differ significantly in answers to any of the GDS-15 questions, or mean ± SD score, which was 2.4 ± 2.5 among those who developed dementia and 2.1 ± 2.3 among those who did not. (p = 0.33). Stroke before the age of 82 years and the inability to use stairs had significant impacts on the GDS-15 scores in both groups. For those who did not develop dementia, age, dependence in activities of daily living, and cancer also had significant impacts. Cancer had opposite associations with depressive symptoms in the two groups., Conclusions: No difference was found in depressive symptoms preceding and not preceding dementia using the GDS-15. The results suggest that risk factors for depressive symptoms may differ depending on whether they precede dementia., (© 2024 The Author(s). International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.)

BackgroundSweden reached the UNAIDS 90-90-90 target in 2015. It is important to reassess the HIV epidemiological situation due to ever-changing migration patterns, the roll-out of PrEP and the impact of the COVID-19 pandemic.AimWe aimed to assess the progress towards the UNAIDS 95-95-95 targets in Sweden by estimating the proportion of undiagnosed people with HIV (PWHIV) and HIV incidence trends.MethodsWe used routine laboratory data to inform a biomarker model of time since infection. When available, we used previous negative test dates, arrival dates for PWHIV from abroad and transmission modes to inform our incidence model. We also used data collected from the Swedish InfCareHIV register on antiretroviral therapy (ART).ResultsThe yearly incidence of HIV in Sweden decreased after 2014. In part, this was because the fraction of undiagnosed PWHIV had decreased almost twofold since 2006. After 2015, three of four PWHIV in Sweden were diagnosed within 1.9 and 3.2 years after infection among men who have sex with men and in heterosexual groups, respectively. While 80% of new PWHIV in Sweden acquired HIV before immigration, they make up 50% of the current PWHIV in Sweden. By 2022, 96% of all PWHIV in Sweden had been diagnosed, and 99% of them were on ART, with 98% virally suppressed.ConclusionsBy 2022, about half of all PWHIV in Sweden acquired HIV abroad. Using our new biomarker model, we assess that Sweden has reached the UNAIDS goal at 96-99-98.

Importance: Brain injury is the leading cause of death following cardiac arrest and is associated with severe neurologic disabilities among survivors, with profound implications for patients and their families, as well as broader societal impacts. How these disabilities affect long-term survival is largely unknown., Objective: To investigate whether complete neurologic recovery at hospital discharge after cardiac arrest is associated with better long-term survival compared with moderate or severe neurologic disabilities., Design, Setting, and Participants: This cohort study used data from 4 mandatory national registers with structured and predefined data collection and nationwide coverage during a 10-year period in Sweden. Participants included adults who survived in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) beyond 30 days and who underwent predefined neurologic assessment conducted by health care professionals at hospital discharge using the Cerebral Performance Category (CPC) scale between January 2010 and December 2019. Patients were divided into 3 categories: complete recovery (CPC 1), moderate disabilities (CPC 2), and severe disabilities (CPC 3-4). Statistical analyses were performed in December 2023., Exposure: CPC score at hospital discharge., Main Outcomes and Measures: The primary outcome was long-term survival among patients with CPC 1 compared with those with CPC 2 or CPC 3 or 4., Results: A total of 9390 cardiac arrest survivors (median [IQR] age, 69 .0 [58.0-77.0] years; 6544 [69.7%] male) were included. The distribution of functional neurologic outcomes at discharge was 7374 patients (78.5%) with CPC 1, 1358 patients (14.5%) with CPC 2, and 658 patients (7.0%) with CPC 3 or 4. Survival proportions at 5 years were 73.8% (95% CI, 72.5%-75.0%) for patients with CPC 1, compared with 64.7% (95% CI, 62.4%-67.0%) for patients with CPC 2 and 54.2% (95% CI, 50.6%-57.8%) for patients with CPC 3 or 4. Compared with patients with CPC 1, there was significantly higher hazard of death for patients with CPC 2 (adjusted hazard ratio [aHR], 1.57 [95% CI, 1.40-1.75]) or CPC 3 or 4 (aHR, 2.46 [95% CI, 2.13-2.85]). Similar associations were seen in the OHCA and IHCA groups., Conclusions and Relevance: In this cohort study of patients with cardiac arrest who survived beyond 30 days, complete neurologic recovery, defined as CPC 1 at discharge, was associated with better long-term survival compared with neurologic disabilities at the same time point.

BackgroundDespite the unprecedented measures implemented globally in early 2020 to prevent the spread of SARS-CoV-2, Sweden, as many other countries, experienced a severe first wave during the COVID-19 pandemic.AimWe investigated the introduction and spread of SARS-CoV-2 into Sweden.MethodsWe analysed stored respiratory specimens (n = 1,979), sampled 7 February-2 April 2020, by PCR for SARS-CoV-2 and sequenced PCR-positive specimens. Sequences generated from newly detected cases and stored positive specimens February-June 2020 (n = 954) were combined with sequences (Sweden: n = 730; other countries: n = 129,913) retrieved from other sources for Nextstrain clade assignment and phylogenetic analyses.ResultsTwelve previously unrecognised SARS-CoV-2 cases were identified: the earliest was sampled on 3 March, 1 week before recognised community transmission. We showed an early influx of clades 20A and 20B from Italy (201/328, 61% of cases exposed abroad) and clades 19A and 20C from Austria (61/328, 19%). Clade 20C dominated the first wave (20C: 908/1,684, 54%; 20B: 438/1,684, 26%; 20A: 263/1,684, 16%), and 800 of 1,684 (48%) Swedish sequences formed a country-specific 20C cluster defined by a spike mutation (G24368T). At the regional level, the proportion of clade 20C sequences correlated with an earlier weighted mean date of COVID-19 deaths.ConclusionCommunity transmission in Sweden started when mitigation efforts still focused on preventing influx. This created a transmission advantage for clade 20C, likely introduced from ongoing cryptic spread in Austria. Therefore, pandemic preparedness should have a comprehensive approach, including capacity for large-scale diagnostics to allow early detection of travel-related cases and community transmission.

Importance: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are consistently reported to be discontinued by approximately half of pregnant women. Little is known about how this may be associated with postpartum psychiatric health., Objective: To investigate associations of SSRI or SNRI discontinuation in pregnant women with depression or anxiety and psychiatric health and sick leave absence after childbirth., Design, Setting, and Participants: This population-based cohort study was conducted between 2006 and 2019 using data from Swedish population-based registers. Pregnant women with a filled prescription of an SSRI or SNRI in the 90 days before pregnancy without recorded comorbid or severe psychiatric conditions were included. Analyses were performed in November 2023., Exposures: K-means for longitudinal data was used to cluster trajectories of SSRI and SNRI use during pregnancy, resulting in 2 trajectory groups based on the number of days covered, defined as continued and discontinued use groups., Main Outcomes and Measures: The primary outcome was psychiatric-related hospitalizations by 90 days after childbirth. Secondary outcomes included psychiatric-related outpatient visits, self-harm and suicide, and any-cause mortality by 90 days after childbirth and all outcomes plus sick leave absence by 1.5 years after childbirth., Results: Among 27 773 pregnant women (17 241 aged ≥30 years [62.1%] at childbirth), 13 184 women (47.5%) had discontinued SSRI or SNRI use and 14 589 individuals (52.5%) had continued use. Individuals in the discontinued compared with continued use group were younger (5588 women [42.4%] vs 4944 women [33.9%] aged <30 years), less educated (4281 women [32.5%] vs 5821 women [39.9%] who completed postsecondary education or above), and more likely to have smoked in early pregnancy (1445 individuals [11.0%] vs 1180 individuals [8.1%]), been born in a non-Nordic country (1641 individuals [12.4%] vs 975 individuals [6.7%]), and used anxiolytics (1301 individuals [9.9%] vs 1119 individuals [7.7%]) and hypnotics and sedatives (1609 individuals [12.2%] vs 1510 individuals [10.4%]). Psychiatric-related hospitalizations occurred in 49 individuals (0.4%) in the discontinued vs 59 individuals (0.5%) in the continued use group in the 90 days after childbirth, with an adjusted hazard ratio (aHR) of 1.28 (95% CI, 0.85-1.91), while at 1.5 years after childbirth, the aHR was 0.81 (95% CI, 0.66-1.00). Lower hazard rates for psychiatric-related outpatient visits in the discontinued vs continued use group at 90 days (aHR, 0.59; 95% CI, 0.53-0.66) and 1.5 years (aHR, 0.60; 95% CI, 0.57-0.64) after childbirth were found. No difference in sick leave absence was found; however, individuals who discontinued had fewer days of sick leave by 1.5 years after childbirth than those who continued (mean [SD], 44.6 [70.6] days vs 53.1 [82.3] days)., Conclusions and Relevance: In this study, approximately half of pregnant women discontinued SSRIs or SNRIs, and discontinuation during pregnancy was not associated with adverse psychiatric-related outcomes, including hospitalizations, outpatient visits, suicidal behavior, or sick leave absence in the 90 days or 1.5 years after childbirth.

Objectives: Previous reports suggest that betablockers appear non-beneficial after surgical aortic valve replacement (SAVR). This study aims to clarify the associations between betablockers and long-term outcome after SAVR., Methods: All patients with isolated SAVR due to aortic stenosis in Sweden between 2006 and 2020, alive at 6 months after surgery, were included. Patients were identified in the SWEDEHEART registry, and records were merged with data from 3 other mandatory national registries. Association between dispensed betablockers and major adverse cardiovascular events (MACE) (all-cause mortality, myocardial infarction and stroke) was analyzed using Cox proportional hazards models, with time-updated data on medication and adjusted for age, sex and comorbidities at baseline., Results: In total, 11 849 patients were included [median follow-up 5.4 years (range 0-13.5)]. Betablockers were prescribed to 79.7% of patients at baseline, decreasing to 62.2% after 5 years. Continuing treatment was associated with higher risk of MACE [adjusted hazard ratio 1.14 (95% confidence interval, CI 1.05-1.23)]. The association was consistent over subgroups based on age, sex and comorbidities except atrial fibrillation [hazard ratio (HR) 1.05 (95% CI 0.93-1.19)]. A sensitivity analysis including time-updated data on comorbidites attenuated the difference between the groups [HR 1.04 (95% CI 0.95-1.14, P = 0.33)]., Conclusions: Treatment with betablockers did not appear to be associated with inferior long-term outcome after SAVR, when adjusting for new concomitant diseases. Thus, it is likely that it is the underlying cardiac diseases that are associated with MACE rather than betablocker treatment., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Trajectories of asthma and allergy in children are heterogeneous and commonly derived from parental report of disease or clinical records. This study combined parental-reported and register-based dispensed medication data to characterize childhood trajectories of co-existing asthma, allergic rhinitis, and eczema., Methods: From a Swedish population-based birth cohort (N = 5654), survey responses collected at the age of 1, 4.5, 8, and 12 years were linked to dispensed medication register data for the period of 2-13 years. Trajectories were identified with latent class analysis. Statistical metrics and clinical interpretability guided the model selection., Results: Nine distinct trajectories were identified: three asthma-dominated (early-onset remitting [n = 189, 3.3%], late-onset [n = 117, 2.1%], and persistent [n = 149, 2.6%]), two eczema-dominated (persistent [n = 190, 3.4%] and remitting [n = 432, 7.6%]), one allergic rhinitis-dominated (late-onset [n = 259, 4.6%]), two multimorbidity (mid-childhood asthma and late-onset allergic rhinitis [n = 144, 2.5%], and persistent eczema and late-onset allergic rhinitis [n = 90, 1.6%]), and one low-disease burden trajectory (n = 4084, 72.2%). Differences were seen across the trajectories in the proportion of parental report of disease and dispensed medication as well as by class and quantity of medication dispensed., Conclusion: Combined parental-reported and dispensed medication data enriches characterization of longitudinal trajectories of asthma and allergy in children by merging subjective experience of disease with healthcare utilization. The identified trajectories were characterized by distinct disease development and prescription patterns suggesting clinically differential morbidity burden., (© 2024 The Author(s). Pediatric Allergy and Immunology published by European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)