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Early diagnosis is crucial to treatment success. This is especially relevant for Alzheimer's disease (AD), with its protracted preclinical phase. Most health care systems do not have the resources to conduct large-scale AD screenings in middle-aged individuals in need of novel AD treatment options and early, accurate diagnosis. Recent developments in blood-based biomarkers and remote cognitive testing offer novel, cost-effective, and scalable methods to detect cognitive and biomarker changes that may indicate early AD. In research cohorts, promising results have been reported, but these modalities have not been validated in population-based settings. The validation of a realistic screening approach for early Alzheimer's disease (REAL AD) study aims to validate the diagnostic and prognostic performance of the combined use of blood-based biomarkers and remote cognitive testing as a screening approach for early AD employing an existing health care infrastructure (the Swedish Västra Götaland Region Primary Healthcare). REAL AD aims to provide a concrete, individualized diagnostic framework, which could significantly improve AD prognosis. HIGHLIGHTS: In Sweden, most Alzheimer's disease (AD) diagnoses are made in primary care, where access to AD biomarkers is almost non-existent. Most health care systems have limited resources for the screening of middle-aged adults for early evidence of AD pathology. Blood-based biomarkers and remote cognitive testing offer novel, cost-effective, and scalable methods for detecting cognitive and biomarker changes that may indicate early AD. The REAL AD study aims to validate the diagnostic and prognostic performance of blood-based biomarkers and remote cognitive testing as a screening approach for early AD in an existing primary health care infrastructure in the Västra Götaland Region in Sweden. Studies such as REAL AD will play a vital role in helping to move the field toward concrete implementation of biomarkers in AD diagnostic workup at all care levels, eventually providing more comprehensive treatments options for the large and growing AD population, and for those at risk., (© 2024 The Author(s). Alzheimer's & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

Background: Previous research indicates that routine inquiry or screening conducted by healthcare providers may significantly increase the identification of interpersonal violence. There is a lack of comprehensive instruments to routinely assess patients about interpersonal violence and violence against children in the household. The purpose of this study was to assess the content validity, face validity and reliability of the Questions on Violence (FOV) tool, an instrument specifically designed for routine inquiries about interpersonal violence in healthcare settings within the Swedish context., Methods: The content validity, face validity and reliability of the FOV instrument was assessed through (1) a content validity index with six experts in the field of intimate partner violence, (2) cognitive interviews with nine patients recruited from a primary healthcare facility, and (3) an evaluation of the test-retest reliability based on responses from 37(50.0%) university students. The intraclass correlation coefficient, model 2.1, was calculated to assess the degree of correlation and agreement between the two measurements., Results: Calculations based on the content validity index indicated that five out of seven items had excellent content validity (≥ 0.78). The average content validity index of included items was 0.88, which is slightly below the recommended threshold for excellent content validity. The results based on the cognitive interviews revealed that participants found the seven items to be relevant and easy to understand. Overall, the participants agreed that the concept of 'close relationships' primarily encompassed intimate partners, family members, and close friends. The value of the intraclass correlation coefficient was 0.85 (0.77-0.91; CI 95%), indicating good reliability with an interval of good to excellent test-retest reliability., Conclusions: The results demonstrate that the seven-item FOV instrument has good content and face validity as well as good to excellent test-retest reliability. The current study provides healthcare professionals with a short yet comprehensive instrument for identifying patients who have experienced or perpetrated different forms of interpersonal violence., (© 2024. The Author(s).)

Middle-aged adults engaging in unhealthy lifestyle behaviors are at higher risk of chronic diseases. However, little is known about the co-occurrence of these behaviors and their determinants. This cohort study examined the co-occurrence of unhealthy lifestyle behaviors (alcohol consumption, diet, physical inactivity, and smoking) in 30,154 middle-aged adults and their associations with sociodemographic factors, social support, and disease history. Alcohol use was measured by the AUDIT, diet by the MiniMeal-Q, and physical inactivity and smoking by single questions. Participants had a mean age of 58 years, with 51% being female. Of them, 14% had no unhealthy behaviors, 38% had one, 36% had two, 10% had three, and 2% had all four. The most common co-occurrence was between physical inactivity and poor diet (38%). Higher education decreased the likelihood of having three or four unhealthy behaviors, while financial difficulties, having no one around who appreciated one's efforts, and suffering of a lung disease increased it. In conclusion, middle-aged adults exhibit varying levels of unhealthy lifestyle behaviors. Higher education is linked to reduced engagement in multiple unhealthy behaviors, whereas financial strain, lower quality of social support, and lung disease increase the risk., (© 2024. The Author(s).)

Background: Longitudinal studies on functional outcomes after colon resection are limited., Objective: To evaluate bowel dysfunction and related distress 1 and 3 years after colon resection using the low anterior resection syndrome score as well as specific validated items., Design: This study presents the long-term results of bowel dysfunction and related distress based on the Quality of Life in Colon Cancer study, an observational, prospective multicenter study of patients with newly diagnosed colon cancer., Settings: The study was conducted at 21 Swedish and Danish surgical centers between 2015 and 2019., Patients: All patients who underwent right-sided or left-sided colon resection were considered eligible. Exclusion criteria were age younger than 18 years, cognitive impairment, or inability to understand Swedish/Danish. Patients completed extensive questionnaires at diagnosis and after 1 and 3 years. Clinical data were supplemented by national quality registries., Main Outcome Measures: The low anterior resection syndrome score, specific bowel symptoms, and patient-reported distress were assessed., Results: Of 1221 patients (83% response rate), 17% reported major low anterior resection syndrome 1 year after either type of resection; this finding was consistent at 3 years (17% right, 16% left). In the long-term, the only significant difference between types of resections was a high occurrence of loose stools after right-sided resections. Overall, less than one-fifth of patients experienced distress, with women reporting more frequent symptoms and greater distress. In particular, incontinence and loose stools correlated strongly with distress., Limitations: Absence of prediagnosis bowel function data., Conclusions: Our study indicates that bowel function remains largely intact after colon resection, with only a minority reporting significant distress. Adverse outcomes were more common among women. The occurrence of loose stools after right-sided resection and the association between incontinence, loose stools, and distress highlights a need for postoperative evaluations and more thorough assessments beyond the low anterior resection syndrome score when evaluating patients with colon cancer. See the Video Abstract ., Disfuncionamiento Intestinal Despus De La Ciruga Por Cncer De Colon Estudio Prospectivo, Longitudinal Y Multicntrico: ANTECEDENTES:Los estudios longitudinales sobre el resultado funcional después de una resección cólica son limitados.OBJETIVO:Examinar la disfunción intestinal y el malestar relacionado uno y tres años después de la resección del colon utilizando la puntuación de referencia en el síndrome de resección anterior baja (LARS), así como otros ítems de validez específica.DISEÑO:Este estudio presenta los resultados a largo plazo de la disfunción intestinal y la angustia relacionada según el estudio QoLiCOL (Quality of Life in COLon cancer), un analisis observacional, prospectivo y multicéntrico de pacientes con cáncer de colon recién diagnosticado.AJUSTES:El presente estudio fué realizado en 21 centros quirúrgicos suecos y daneses entre 2015 y 2019.PACIENTES:Todos los pacientes sometidos a resección de colon, tanto del lado derecho como el izquierdo se consideraron elegibles. Los criterios de exclusión fueron tener menos de 18 años, deterioro cognitivo o incapacidad para entender sueco/danés. Los pacientes completaron extensos cuestionarios en el momento del diagnóstico y después de uno y tres años. Los datos clínicos se complementaron con los registros de calidad binacionales.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron los síntomas intestinales específicos, la puntuación LARS y la angustia manifestada por cada paciente.RESULTADOS:De 1221 pacientes (tasa de respuesta del 83%), el 17% informó LARS mayor un año después de cualquier tipo de resección, consistente a los tres años (17% derecha, 16% izquierda). A largo plazo, la única diferencia significativa entre los tipos de resección fue una alta incidencia de heces liquidas después de las resecciones del lado derecho. En general, menos de una quinta parte de los pacientes experimentaron angustia, y fué la poblacion femenina quién informó de síntomas más frecuentes y de mayor angustia. En particular, la incontinencia y las heces liquidas se correlacionaron fuertemente con la angustia.LIMITACIONES:Ausencia de datos de función intestinal previos al diagnóstico.CONCLUSIONES:Nuestro estudio indica que la función intestinal permanece en gran medida intacta después de la resección del colon, y sólo una minoría reporta malestar significativo. Los resultados adversos fueron más comunes en la población femenina. La aparición de heces liquidas después de la resección del lado derecho y la asociación entre incontinencia, heces liquidas y malestar resalta la necesidad de evaluaciones postoperatorias y valoraciones más exhaustivas más allá de la puntuación LARS al evaluar a los pacientes con cáncer de colon. (Traducción-Dr. Xavier Delgadillo )., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Colon and Rectal Surgeons.)

Objectives: To investigate whether intensified cooperation between general practitioner (GP), care manager and rehabilitation coordinator (RC) for patients sick-listed for stress-related mental disorder, combined with a person-centred dialogue meeting with employer, could reduce sick-leave days compared with usual care manager contact., Design: Pragmatic cluster-randomised controlled trial, randomisation at primary care centre (PCC) level., Setting: PCCs in Region Västra Götaland, Sweden, with care manager organisation., Participants: Of 30 invited PCCs, 28 (93%) accepted the invitation and recruited 258 patients newly sick-listed due to stress-related mental disorder ( n  = 142 intervention, n  = 116 control PCCs)., Intervention: Cooperation between GP, care manager and rehabilitation coordinator from start of illness notification plus a person-centred dialogue meeting between patient and employer within 3 months. Regular contact with care manager was continued at the control PCCs., Main Outcome Measures: 12-months net and gross number of sick-leave days. Secondary outcomes: Symptoms of stress, depression, anxiety; work ability and health related quality of life (EQ-5D) over 12 months., Results: There were no significant differences between intervention and control groups after 12 months: days on sick-leave (12-months net sick-leave days, intervention, mean = 110.7 days (95% confidence interval (CI) 82.6 - 138.8); control, mean = 99.1 days (95% CI 73.9 - 124.3)), stress, depression, or anxiety symptoms, work ability or EQ-5D. There were no significant differences between intervention and control groups concerning proportion on sick-leave after 3, 6, 12 months. At 3 months 64.8% were on sick-leave in intervention group vs 54.3% in control group; 6 months 38% vs 32.8%, and12 months 16.9% vs 15.5%., Conclusion: Increased cooperation at the PCC between GP, care manager and RC for stress-related mental disorder coupled with an early workplace contact in the form of a person-centred dialogue meeting does not reduce days of sick-leave or speed up rehabilitation. Trial registration: ClinicalTrials.gov Identifier: NCT03250026 https://clinicaltrials.gov/study/NCT03250026?tab=results#publicationsCO-WORK-CAREFirst Posted: August 15, 2017. Recruitment of PCCs: September 2017. Inclusion of patients from December 2017.

Introduction: Although breast reconstruction is an integral part of breast cancer treatment, there is little high-quality evidence to indicate which method is the most effective. Randomised controlled trials (RCTs) are generally thought to provide the most solid scientific evidence, but there are significant barriers to conducting RCTs in breast reconstruction, making both recruitment and achieving unbiased and generalisable results a challenge. The objective of this study is to compare implant-based and autologous breast reconstruction in non-irradiated patients. Moreover, the study aims to improve the evidence for trial decision-making in breast reconstruction., Methods and Analysis: The study design partially randomised patient preference trial might be a way to overcome the aforementioned challenges. In the present study, patients who consent to randomisation will be randomised to implant-based and autologous breast reconstruction, whereas patients with strong preferences will be able to choose the method. The study is designed as a superiority trial based on the patient-reported questionnaire BREAST-Q and 124 participants will be randomised. In the preference cohort, patients will be included until 62 participants have selected the least popular alternative. Follow-up will be 60 months. Embedded qualitative studies and within-trial economic evaluation will be performed. The primary outcome is patient-reported breast-specific quality of life/satisfaction, and the secondary outcomes are complications, factors affecting satisfaction and cost-effectiveness., Ethics and Dissemination: The study has been approved by the Swedish Ethical Review Authority (2023-04754-01). Results will be published in peer-reviewed scientific journals and presented at peer-reviewed scientific meetings., Trial Registration Number: NCT06195865., 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.)

Little is known about intimate partner homicide (IPH) perpetrator´s healthcare contacts and mental health problems before the killing. The aim was to compare male and female IPH perpetrators with matched controls from the general population by analysing differences in healthcare utilization and mental and behavioural disorders. This study includes 48 males and 10 females who perpetrated IPH between 2000 and 2016 in the Västra Götaland Region of Sweden. Controls (n = 458) were randomly selected from the general population and matched for sex, birth year and residential area. Data were retrieved from the Swedish National Patient Register and the Western Swedish Healthcare Register. Mental and behavioural disorders were classified according to ICD-10 (F00-F99). The Mann-Whitney U test was used to test for differences in health care utilization and mental and behavioural disorders. Compared to their controls, male perpetrators had more registered contacts with primary care ≤ 30 (p = < .001) and ≤ 365 days (p = .019), respectively, before the homicide; with specialist outpatient care ≤ 30 (p = < .001) and ≤ 365 days (p = < .001), respectively, before the homicide: and with inpatient care ≤ 30 (p = < .001) and ≤ 365 days (p = .024), respectively, before the homicide. Female perpetrators had more specialized outpatient care (p = .040) and inpatient care (p = .003) contacts ≤ 365 days before the homicide, compared to controls. Male perpetrators had at least one mental or behavioral disorder diagnosed in any studied healthcare setting except in inpatient care ≤ 30 days before homicide. Female perpetrators had more mental health disorders diagnosed in specialized outpatient care ≤ 365 days before the homicide (p < .001). Perpetrators had more healthcare contacts and mental disorders one year and one month prior to the homicide compared to their controls. Health care professionals should obtain necessary skills in routinely enquiring about intimate partner violence perpetration., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Lövestad et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To obtain a deeper understanding of the daily life experiences of working aged people during the year following hospitalization due to SARS-CoV-2 (COVID-19), with a focus on function-ing in daily life and return to work., Design: An explorative qualitative study using individual interviews., Subjects: A purposive sample was selected of persons who had received inpatient hospital care, had been discharged approximately 1 year previously and were of working age., Methods: Semi-structured interviews were conducted with 11 participants (9 men, 2 women). The interviews were transcribed and analysed with inductive thematic analysis., Results: Four themes were identified. Navigating health, with or without support from healthcare, was described as challenging when managing consequences of COVID-19. Participants struggled with a lack of energy that interfered with daily life. It was a trial-and-error process trying to use familiar strategies in new ways to manage. The return to work process was facilitated by own strategies and support., Conclusion: This study contributes increased knowledge of everyday life experiences of people 1 year following hospitalization due to COVID-19. The lack of energy and a struggle to manage health while navigating the healthcare system emphasize the importance of strengthening personal and organizational health literacy to facilitate the recovery process after severe COVID-19.

Aim: To analyse the associations between bullying victimisation, disability, and self-reported psychosomatic complaints in adolescents, and to investigate the role of support from parents and teachers in such associations., Methods: The study was based on Finnish and Swedish data from two waves (2013/2014 and 2017/2018) of the Health Behaviour in School-aged Children survey ( n =16,057). Descriptive statistics were produced for four groups of adolescents: (a) bullied with disabilities; (b) not bullied with disabilities; (c) bullied without disabilities; and (d) not bullied without disabilities (reference group). Two multilevel multinomial logistic regression models were performed for the Finnish and Swedish samples separately. The first model analysed associations between psychosomatic complaints and bullying victimisation, controlling for a range of confounders. The second model analysed associations between psychosomatic complaints and social support from parents and teachers., Results: Across both countries, bullied adolescents with disabilities were more likely to self-report psychosomatic complaints than the reference group, even after adjusting for other potential confounders. Teacher support was identified as a potential protective factor as the odds ratio for psychosomatic complaints decreased when including teacher support as a factor in the model. The association with parent support showed mixed findings in Finland and Sweden., Conclusions: Disability in combination with bullying victimisation generated the highest levels of self-reported psychosomatic complaints compared to adolescents that were not bullied nor had disabilities. High teacher support may be a protective factor against psychosomatic complaints for bullied and/or disabled adolescents., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/ or publication of this article.

Iodine deficiency may cause thyroid dysfunction. The iodine intake in a population is measured by urinary iodine concentration (UIC) in spot samples or 24-h urinary iodine excretion (24UIE). 24UIE is considered the gold standard and may be estimated using an equation including UIC, urinary creatinine concentration, sex and age (e24UIE). The aims of this study were to evaluate the preferable timing of UIC when using this equation and assess the variability of UIE. Sixty healthy non-smoking women ( n 31) and men ( n 29) were included in Gothenburg, Sweden. Twelve urine samples were collected at six fixed times on two separate days. Variability was calculated for UIC, 24UIE, e24UIE, iodine excretion per hour (iHr) and UIC adjusted for creatinine and specific gravity. Median 24UIE was 156 µg/24 h and the median UIC (all spot samples) was 104 µg/l. UIC ( P < 0·001), 24UIE ( P = 0·001) and e24UIE ( P < 0·001) were significantly higher in men. e24UIE was relatively similar to 24UIE. However, when e24UIE was calculated from UIC in the first void, it was about 15 % lower than 24UIE ( P < 0·001). iHr was lowest in the morning and highest in the afternoon. Median iHr was higher in men (7·4 v . 5·3 µg/h, P < 0·001). The variability of UIE was higher within individuals than between individuals. This study suggests that most time points for estimation of individual 24UIE are appropriate, but they should preferably not be collected in the first void.

Aim: Poor physical and mental health are common and increasing in Swedish children. The aim was to investigate significant changes in health and digital habits in fourth grade and ninth grade pupils in 2020 compared to 2011., Methods: A validated questionnaire was conducted in 2011 and 2020 among schoolchildren in fourth (10 years) and ninth grade (15 years) in Sweden. The study population consisted of 196 students in 2020 and 254 students in 2011., Results: A significant increase was seen in self-reported sleeping difficulties, tiredness, life dissatisfaction and dissatisfaction with academic abilities among fourth grade children and a sixfold increase in their refusal to go to school. Students in fourth grade also reported that they spent more time on social media and had a reduced interest in sports. Both students in fourth and ninth grade described an increase in attacks of anger and unhappiness, as well as decreased time with family., Conclusion: We conclude that fourth grade children have more physical and mental health symptoms in 2020 compared to 2011. The ninth grade students showed a high frequency of physical and mental symptoms in 2011, which remained high in 2020. One possible explanation may be that digital habits have increased., (© 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Background: Pain is common in children and its associations with various biopsychosocial factors is complex. Comprehensive pain assessments could contribute to a better understanding of pediatric pain, but these assessments are scarce in literature. The aim of this study was to examine differences in pain prevalence and pain patterns in 10-year-old boys and girls from a Swedish birth cohort and to study associations between pain, health-related quality of life and various lifestyle factors stratified by sex., Methods: 866 children (426 boys and 440 girls) and their parents from the "Halland Health and Growth Study" participated in this cross-sectional study. Children were categorized into two pain groups, "infrequent pain" (never-monthly pain) or "frequent pain" (weekly-almost daily pain), based on a pain mannequin. Univariate logistic regression analyses, stratified by sex, were performed to study associations between frequent pain and children's self-reports of disease and disability and health-related quality of life (Kidscreen-27, five domains), and parents' reports of their child's sleep (quality and duration), physical activity time, sedentary time, and participation in organized physical activities., Results: The prevalence of frequent pain was 36.5% with no difference between boys and girls (p = 0.442). Boys with a longstanding disease or disability had higher odds of being in the frequent pain group (OR 2.167, 95% CI 1.168-4.020). Higher scores on health-related quality of life in all five domains for girls, and in two domains for boys, was associated with lower odds of being categorized into the frequent pain group. Frequent pain was associated with poor sleep quality (boys OR 2.533, 95% CI 1.243-5.162; girls OR 2.803, 95% CI 1.276-6.158) and more sedentary time (boys weekends OR 1.131, 95% CI 1.022-1.253; girls weekdays OR 1.137, 95% CI 1.032-1.253), but not with physical activity., Conclusions: The high prevalence of frequent pain needs to be acknowledged and treated by school health-care services and the healthcare sector in order to prevent pain from influencing health and lifestyle factors negatively in children., (© 2023. The Author(s).)

Background Coronary heart disease remains the dominant cause of death worldwide. To improve cardiovascular disease prevention, knowledge of early key risk factors, especially those that are modifiable, is essential. The ongoing global obesity epidemic is of particular concern. We aimed to determine whether body mass index at conscription predicts early acute coronary events among men in Sweden. Methods and Results This was a population-based Swedish cohort study of conscripts (n=1 668 921; mean age, 18.3 years; 1968-2005), with follow-up through linkage to the nationwide Swedish patient and death registries. Risk of a first acute coronary event (hospitalization for acute myocardial infarction or coronary death) during follow-up (1-48 years) was calculated with generalized additive models. Objective baseline measures of fitness and cognition were included in the models in secondary analyses. During follow-up, there were 51 779 acute coronary events, of which 6457 (12.5%) were fatal within 30 days. Compared with men at the lowest end of the normal body mass index spectrum (body mass index, 18.5 kg/m 2 ), an increasing risk for a first acute coronary event was observed, with hazard ratios (HRs) peaking at 40 years of age. After multivariable adjustments, men with a body mass index of 35 kg/m 2 had an HR of 4.84 (95% CI, 4.29-5.46) for an event before the age of 40 years. Conclusions An increased risk of an early acute coronary event was detectable within normal levels of body weight at the age of 18 years, increasing to almost 5-fold in the highest weight category at 40 years of age. Given increasing levels of body weight and prevalence of overweight and obesity in young adults, the current decrease in coronary heart disease incidence in Sweden may flatten or even reverse in the near future.

Background: Community-acquired acute kidney injury (CA-AKI) is common among hospitalized patients and has a poor prognosis. Research is scarce on the impact of a CA-AKI episode among patients without preexisting kidney disease and has not previously been investigated in Sweden. The aim was to describe the outcomes of patients with normal pre-hospitalization kidney function, admitted with community-acquired AKI and to investigate the association between AKI severity with outcomes., Methods: A retrospective population-based study was applied including patients with CA-AKI according to KDIGO classification, admitted via emergency department (ED) 2017-2019 and with a 90-day follow-up period from the ED-admission, collecting data from the Regional Healthcare Informative Platform. Age, gender and AKI stages, mortality and follow-up regarding recovery and readmission was registered. Hazard ratio (HR) and 95% confidence Interval (CI) for mortality was analyzed using Cox regression adjusted for age, comorbidities, and medication., Results: There were 1646 patients included, mean age was 77.5 years. CA-AKI stage 3 occurred in 51% of patients < 65 years of age and 34% among those > 65 years. In this study, 578 (35%) patients died and 233 (22%) recovered their kidney function. Mortality rate peaked within the first two weeks and among those at AKI stage 3. Nephrology referral post discharge occurred in 3% and 29% were readmitted. HRs for mortality was 1.9 (CI 1.38-2.62) for those who are > 65 years, 1.56 (CI 1.30-1.88) for atherosclerotic-cardiovascular disease. Medication with RAASi related to a decreased HR 0.27 (95% CI 0.22-0.33)., Conclusions: CA-AKI is associated with high mortality within 90 days, increased risk for developing chronic kidney disease (CKD) and only one fifth recover their kidney function after hospitalization with an AKI. Nephrology referral was sparse. Patient follow-up after a hospitalization with AKI should be carefully planned during the first 90 days and focused on identifying those with a higher risk of developing CKD., (© 2023. The Author(s).)

Trial Registration: ClinicalTrials.gov Identifier NCT04714463, 19 January 2021 Patient and public contribution: All the data were generated directly from patients.

Objectives: To investigate mid-adolescent boys' and girls' experiences of school demands, teacher support, and classmate support, and explore the associations of these factors with mental wellbeing. Methods: Data were derived from the Swedish Health Behaviour in School-aged Children (HBSC) study of 2017/18, with information collected among 1,418 students in grade 9 (∼15-16 years). School demands, teacher support, and classmate support were measured by indices based on three items each. Mental wellbeing was measured by the Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS). Linear regression analyses were performed. Results: Higher demands were associated with lower mental wellbeing. Conversely, mental wellbeing increased with greater teacher support and classmate support. Interactions between demands and the support variables showed that at the lowest levels of teacher and of classmate support, mental wellbeing was low and not associated with school demands. With increasing levels of teacher and classmate support, the overall level of mental wellbeing increased and revealed an inverse association between school demands and mental wellbeing. Conclusion: The study contributes with knowledge about how psychosocial conditions in school may hinder or enhance wellbeing among students., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2023 Låftman, Modin, Granvik Saminathen, Östberg, Löfstedt and Rajaleid.)

Background: The Swedish National Diabetes Register (NDR) initiated registration of the FreeStyle Libre® system and other continuous glucose monitoring (CGM) systems in June 2016. We investigated change in HbA1c for people with type 2 diabetes (T2DM) using FreeStyle Libre in Sweden., Methods: We included adults with T2DM, registered in the NDR after January 1, 2014, and an index date for first use of FreeStyle Libre of June 2016 or later. Methodology was a before/after comparison of HbA1c within 6 months before the index date versus HbA1c around 6 and 12 months after the index date., Results: 711 adults with T2DM using FreeStyle Libre had HbA1c measurements within the study period . Mean HbA1c was significantly reduced at 6 months (-0.50%-unit) and at 12 months (-0.52%-unit) in this group. Degree of change was negatively correlated to baseline HbA1c. Reductions in HbA1c were observed in incident users of FreeStyle Libre with T2DM who were truly naïve to CGM or had unknown prior experience of CGM, and aged 25-74 years., Conclusions: This real-world study on the Swedish NDR shows that people with T2DM using FreeStyle Libre system for 6 and 12 months significantly reduced their HbA1c.

Context: Obesity is considered to have a detrimental impact on health-related quality of life (HRQoL)., Objective: To compare HRQoL in a well-defined group of people with obesity with a population-based control group from the general public., Design: Observational cross-sectional cohort study with a reference population., Setting: The Regional Obesity Center at the Department of Medicine at Sahlgrenska University Hospital, Gothenburg, Sweden., Participants: People with obesity (n = 1122) eligible for surgical and non-surgical obesity treatment in routine care were included consecutively between 2015 and 2017 into the BASUN study. Men and women from the WHO-MONICA-GOT project were used as a reference population (n = 414)., Main Outcome Measures: HRQoL was measured with the RAND-36/Short Form-36 questionnaire (SF-36) and a Visual Analogue Scale (VAS) for self-related health (SRH). Prescription drugs for hypertension, diabetes mellitus, depression, and anxiety were taken as a proxy for these conditions., Results: People with obesity rated their overall HRQoL lower than the reference population according to the SRH-VAS. Lower scores were reported on physical and social functioning, vitality, general and mental health after adjustment for age and use of prescription drugs (considered a proxy for burden of disease, or comorbidities) using the RAND-36/SF-36 questionnaire. Use of some psychopharmacological agents was more common in patients with obesity., Conclusion: People with obesity seeking help with weight reduction are more likely to have lower physical and mental self-reported HRQoL than the general population., Competing Interests: The authors have declared that no competing interests exist.

Objective: This study explored the considerations and experiences of Swedish General Practitioners (GPs) of hypertension treatment in patients 80 years and above., Design: Qualitative design with focus group interviews. Data were analysed by qualitative content analysis., Setting: Primary health care centres (PHCCs), both rural and urban, in the Region of Västra Götaland, Sweden., Subjects: GPs and GP trainees working at PHCCs in 2019 and 2020. Five focus group interviews with 24 physicians were performed., Main Outcome Measures: Considerations and experiences of hypertension treatment in the oldest-old., Results: Eighteen GPs and six GP trainees participated in the study. The latent content was formulated in a theme: 'The physician's decision-making in the treatment of hypertension in the oldest-old implies the inclusion of both medical and humanistic considerations.' The manifest content constituted three main categories: 'The patient characteristics' included medical condition, behavioural factors and daily life. 'The physician's role' described the GP as a professional and her/his experienced support. 'The treatment decision' considered these categories and involved risk-benefit balancing and communication. For the future, the participants proposed better guidelines for the oldest-old multimorbid patients, increased teamwork, continuous cooperation with nurses and better cooperation with hospital physicians., Conclusion: Hypertension care for the oldest-old was experienced as complicated by GPs, due to the need of balancing medical and humanistic considerations. The GP's clinical experience and the received support were of importance when making the treatment decision based on risk-benefit balancing and communication with the patient.Key pointsGPs experienced the task of caring for the oldest-old patients with hypertension as complicated.Patient factors like multimorbidity, polypharmacy, behavioural factors and the patient's condition of daily life were identified.Clinical experience and the experienced support at the PHCC were discussed as important for the GPs' treatment decision.Treatment decisions for the oldest-old patients with hypertension were based on risk-benefit balancing and communication with the patients.

Background: Pain is a common symptom in children receiving hospital care. Adequate pain management in paediatric patients is of the utmost importance. Few studies have investigated children's own experiences of pain during hospitalization., Aim: To describe the prevalence of pain, self-reported pain intensity at rest and during movement, pain management and compliance with pain treatment guidelines in children and adolescents receiving hospital care. Furthermore, to examine self-reported statements about pain relief and how often staff asked about pain., Methods: A quantitative, cross-sectional study with descriptive statistics as the data analysis method was conducted at a county hospital in western Sweden. Sixty-nine children/adolescents aged 6-18 years who had experienced pain during their hospital stay were included. A structured, verbally administered questionnaire was used to obtain pain reports. The participants were also asked what they considered alleviated pain and how often they told staff about pain. Patient demographics, prescribed analgesics and documentation of pain rating were obtained from medical records., Results: Fifty children/adolescents (72%) experienced moderate to severe pain in the previous 24 hours. At the time of the interview 36% reported moderate to severe pain at rest and 58% during movement. Seven participants (10%) reported severe pain both at rest and during movement. About one-third were on a regular multimodal analgesic regimen and 28% had used a validated pain rating scale. Thirty children/adolescents (43%) reported that they had experienced procedural pain in addition to their underlying pain condition. Most of the children/adolescents (74%) reported that analgesics provided pain relief. Forty (58%) stated that various non-pharmacological methods were helpful., Conclusions: Despite evidence-based guidelines, half of the children/adolescents experienced moderate to severe pain, highlighting the need for improvement. Pain levels should be assessed both at rest and during movement. Response to treatment should be evaluated to prevent undertreatment of pain. Compliance with guidelines and professional communication are of the utmost importance for pain management in children/adolescents. Non-pharmacological methods are a valuable part of a pain management strategy. This study shows that it is important to evaluate and improve pain care also outside specialised tertiary clinics., (© 2022. The Author(s).)

Aims: This study was performed to compare trends in home-time for patients with heart failure (HF) between those of working age and those of retirement age in Sweden from 1992 to 2012., Methods and Results: The National Inpatient Register (IPR) was used to identify all patients aged 18 to 84 years with a first hospitalization for HF in Sweden from 1992 to 2012. Information on date of death, comorbidities, and sociodemographic factors were collected from the Swedish National Register on Cause of Death, the IPR, and the longitudinal integration database for health insurance and labour market studies, respectively. The patients were divided into two groups according to their age: working age (<65 years) and retirement age (≥65 years). Follow-up was 4 years. In total, following exclusions, 388 775 patients aged 18 to 84 years who were alive 1 day after discharge from a first hospitalization for HF were included in the study. The working age group comprised 62 428 (16%) patients with a median age of 58 (interquartile range, 53-62) years and 31.2% women, and the retirement age group comprised 326 347 (84%) patients with a median age of 77 (interquartile range, 73-81) years and 47.4% women. Patients of working age had more home-time than patients of retirement age (83.8% vs. 68.2%, respectively), mainly because of their lower 4 year mortality rate (14.2% vs. 29.7%, respectively). Home-time increased over the study period for both age groups, but the increase levelled off for older women after 2007, most likely because of less reduction in mortality in older women than in the other groups., Conclusions: This nationwide study showed increasing home-time over the study period except for women of retirement age and older for whom the increase stalled after 2007, mainly because of a lower mortality reduction in this group. Efforts to improve patient-related outcome measures specifically targeted to this group may be warranted., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: HbA1c variability has emerged as risk factor for cardiovascular diseases in diabetes. However, the impact of HbA1c variability on cardiovascular diseases in subjects within the recommended HbA1c target has been relatively unexplored., Methods: Using data from a large database, we studied 101,533 people with type 2 diabetes without cardiovascular diseases. HbA1c variability was expressed as quartiles of the standard deviation of HbA1c during three years (exposure phase). The primary composite outcome included non-fatal myocardial infarction, non-fatal stroke, all-cause mortality and was assessed during five years following the first three years of exposure to HbA1c variability (longitudinal phase). An expanded composite outcome including non-fatal myocardial infarction, non-fatal stroke, coronary revascularization/reperfusion procedures, peripheral revascularization procedures, and all-cause mortality was also considered, as well as a series of specific cardiovascular complications. Cox models were adjusted for a large range of risk factors and results were expressed as adjusted hazard ratios., Results: An association between HbA1c variability and all the outcomes considered was found. The correlation between HbA1c variability and cardiovascular complications development was confirmed in both the subgroups of subjects with a mean HbA1c ≤ 53 mmol/mol (recommended HbA1c target) or > 53 mmol/mol during the exposure phase. The risk related to HbA1c variability was higher in people with mean HbA1c ≤ 53 mmol/mol for the primary outcome (p for interaction 0.004), for the expanded secondary outcome (p for interaction 0.001) and for the stroke (p for interaction 0.001), even though HbA1c remained at the target during the follow-up., Conclusions: These findings suggest that HbA1c variability may provide additional information for an optimized management of diabetes, particularly in people within the target of HbA1c., (© 2022. The Author(s).)

Background: Depression is a common cause of sickness absence (SA) and also highly associated with stigma. Few studies have addressed the role of stigma in relation to SA., Objective: To investigate if attitudes to depression were associated with the public's opinion of depression as a valid reason of SA., Methods: The study population (n = 2413) originated from a web-based panel of citizens. The survey included a short vignette describing a person with symptoms of depression and the person's work tasks, followed by a question on recommendation of SA. Negative attitudes were measured by the Depression Stigma Scale. Logistic regressions were used to estimate the odds ratios (OR) for the likelihood of not recommending SA, controlling for individual and work-related co-variates., Results: The crude association between negative attitudes and not recommending SA was OR 2.15 (95% CI, 1.76-2.62). In the fully adjusted model the OR was 1.76 (95% CI, 1.40 -2.21) for not recommending SA., Conclusions: Participants with negative attitudes to depression were more likely to not consider depression as a valid reason of sickness absence. The study supports theories on layered stigma; attitudes from one arena are related to other arenas. Future studies are needed to confirm our findings.

Aims: Atrial fibrillation (AF) is associated with arterial thromboembolism, mainly ischaemic stroke, while venous thromboembolism (VTE) in AF is less well studied. The aim of this study, therefore, was to examine the relationship between AF and VTE, including pulmonary embolism (PE) and deep venous thrombosis (DVT)., Methods and Results: AF cases without previous VTE, ischaemic stroke or pulmonary arterial hypertension were identified from the Swedish Inpatient Registry between 1987 and 2013 and compared to two population controls per case without AF matched for age, sex, and county with respect to the incidence of VTE, PE, and DVT. In total, 463 244 AF cases were compared to 887 336 population controls. In both men and women, VTE rates were higher among AF patients the first 30 days after an AF diagnosis [40.2 vs. 5.7 in men and 55.7 vs. 6.6 in women per 1000 person-years at risk, respectively; hazard ratios 6.64 (95% confidence interval, 5.74-7.69) and 7.56 (6.47-8.83)]; and then decreasing, simultaneously with an increasing number of AF patients being treated with oral anticoagulation. VTE risk was similar to controls after 9 months in men but remained slightly elevated in women., Conclusion: AF is strongly associated with an increased risk of VTE during the first months after diagnosis. Introduction of anticoagulant therapy soon after AF diagnosis might reduce the risk of VTE as well as of ischaemic stroke., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Background: The vasoconstricting peptide endothelin-1 (ET-1) is associated with endothelial dysfunction. The aim of this paper was to investigate whether circulating ET-1 levels predicts chronic kidney disease (CKD) in a prospective population study., Methods: In 2002-2005, 2816 participants (30-74 years) were randomly selected from two municipalities in South-Western Sweden and followed up in a representative sample of 1327 individuals after 10 years. Endothelin-1 levels were assessed at baseline. Outcome was defined as CKD stage 3 or above based on eGFR < 60 mL/min/1.73m 2 . Those 1314 participants with successful analysis of ET-1 were further analyzed using binary logistic regression., Results: At follow-up, 51 (8%) men and 47 (7,8%) women had CKD stage 3 and above. Based on levels of ET-1 the population was divided into quintiles showing that women in the highest quintile (n = 132) had a significantly increased risk of developing CKD during the follow up period (OR = 2.54, 95% CI:1.19-5.45, p = 0.02) compared with the other quintiles (1-4). The association was borderline significant after adjusted for age, current smoking, alcohol consumption, hypertension, diabetes, BMI, high- sensitive CRP and LDL-cholesterol (OR = 2.25, 95% CI:0.97-5.24, p = 0.06). No significant differences were observed between quintiles of ET-1 and development of CKD in men (NS)., Conclusions: High levels of ET-1 are associated with development of CKD in women., (© 2021. The Author(s).)

Background: The vast availability of and demand for evidence in modern primary healthcare force clinical decisions to be made based on condensed evidence in the form of policies and guidelines. Primary healthcare managers play a key role in implementing these governing documents. Thus, the aim of this article is to investigate the use and availability of evidence-based practice resources from the perspective of first-line primary healthcare managers., Methods: The study is based on a national survey of primary healthcare managers, consisting of 186 respondents, recruited nationally from Sweden. The data was analysed using empirically constructed concepts and validated using factor analysis. A chi-square test was utilized to determine the statistical significance of comparisons. Associations between variables were calculated using Spearman's correlation coefficients. All tests were two-sided, and the significance level was set to 0.05., Results: A majority (97 %) of managers stated that guidelines and policy documents impacted primary healthcare; 84 % of managers observed a direct effect on daily practices. Most of the managers (70 %) stated that some adaptation was needed when new evidence was introduced. The managers emphasized the importance of keeping themselves updated and open to new information about work routines (96 %)., Conclusions: The study illustrates a nearly unanimous response about the influence of clinical evidence on daily practice. The emphasis on the importance of all staff members keeping their professional knowledge up to date is viewed as a direct result of this effect on daily practice. An information-dense organization such as a primary healthcare organization would have much to gain from increased cooperation with regional information resources such as clinical libraries., (© 2021. The Author(s).)

Background: The development of obesity is most likely due to a combination of biological and environmental factors some of which might still be unidentified. We used a machine learning technique to examine the relative importance of more than 100 clinical variables as predictors for BMI., Methods: BASUN is a prospective non-randomized cohort study of 971 individuals that received medical or surgical treatment (treatment choice was based on patient's preferences and clinical criteria, not randomization) for obesity in the Västra Götaland county in Sweden between 2015 and 2017 with planned follow-up for 10 years. This study includes demographic data, BMI, blood tests, and questionnaires before obesity treatment that cover three main areas: gastrointestinal symptoms and eating habits, physical activity and quality of life, and psychological health. We used random forest, with conditional variable importance, to study the relative importance of roughly 100 predictors of BMI, covering 15 domains. We quantified the predictive value of each individual predictor, as well as each domain., Results: The participants received medical (n = 382) or surgical treatment for obesity (Roux-en-Y gastric bypass, n = 388; sleeve gastrectomy, n = 201). There were minor differences between these groups before treatment with regard to anthropometrics, laboratory measures and results from questionnaires. The 10 individual variables with the strongest predictive value, in order of decreasing strength, were country of birth, marital status, sex, calcium levels, age, levels of TSH and HbA1c, AUDIT score, BE tendencies according to QEWPR, and TG levels. The strongest domains predicting BMI were: Socioeconomic status, Demographics, Biomarkers (notably TSH), Lifestyle/habits, Biomarkers for cardiovascular disease and diabetes, and Potential anxiety and depression., Conclusions: Lifestyle, habits, age, sex and socioeconomic status are some of the strongest predictors for BMI levels. Potential anxiety and / or depression and other characteristics captured using questionnaires have strong predictive value. These results confirm previously suggested associations and advocate prospective studies to examine the value of better characterization of patients eligible for obesity treatment, and consequently to evaluate the treatment effects in groups of patients., Trial Registration: March 03, 2015; NCT03152617 ., (© 2021. The Author(s).)

Objectives: To estimate concentration-response relationships for particulate matter (PM) and black carbon (BC) in relation to mortality in cohorts from three Swedish cities with comparatively low pollutant levels., Setting: Cohorts from Gothenburg, Stockholm and Umeå, Sweden., Design: High-resolution dispersion models were used to estimate annual mean concentrations of PM with aerodynamic diameter ≤10 µm (PM10) and ≤2.5 µm (PM2.5), and BC, at individual addresses during each year of follow-up, 1990-2011. Moving averages were calculated for the time windows 1-5 years (lag1-5) and 6-10 years (lag6-10) preceding the outcome. Cause-specific mortality data were obtained from the national cause of death registry. Cohort-specific HRs were estimated using Cox regression models and then meta-analysed including a random effect of cohort., Participants: During the study period, 7 340 cases of natural mortality, 2 755 cases of cardiovascular disease (CVD) mortality and 817 cases of respiratory and lung cancer mortality were observed among in total 68 679 individuals and 689 813 person-years of follow-up., Results: Both PM10 (range: 6.3-41.9 µg/m 3 ) and BC (range: 0.2-6.8 µg/m 3 ) were associated with natural mortality showing 17% (95% CI 6% to 31%) and 9% (95% CI 0% to 18%) increased risks per 10 µg/m 3 and 1 µg/m 3 of lag1-5 exposure, respectively. For PM2.5 (range: 4.0-22.4 µg/m 3 ), the estimated increase was 13% per 5 µg/m 3 , but less precise (95% CI -9% to 40%). Estimates for CVD mortality appeared higher for both PM10 and PM2.5. No association was observed with respiratory mortality., Conclusion: The results support an effect of long-term air pollution on natural mortality and mortality in CVD with high relative risks also at low exposure levels. These findings are relevant for future decisions concerning air quality policies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: There is a high incidence of cardiovascular disease in diabetes. Weight variability has been reported as independent risk factor for cardiovascular disease in the general population and preliminarily also in people with type 2 diabetes., Methods: Using data from the Swedish National Diabetes Register the possible link between visit-to-visit body weight variability and the risk of cardiovascular complications among people with type 2 diabetes and without prevalent cardiovascular diseases at baseline has been evaluated. Overall, 100,576 people with type 2 diabetes, with at least five measurements of body weight taken over three consecutive years, were included. Variability was expressed as quartiles of the standard deviation of the measures during the three years. The primary composite outcome included non-fatal myocardial infarction, non-fatal stroke, and all-cause mortality and was assessed during five years following the first 3 years of exposure to weight variability., Results: After adjusting for known cardiovascular risk factors, the risk of the primary composite outcome significantly increased with increasing body weight variability [upper quartile HR = 1.45; 95% confidence interval 1.39-1.52]. Furthermore, elevated body weight variability was associated with almost all the other cardiovascular complications considered (non-fatal myocardial infarction, non-fatal stroke, all-cause mortality, peripheral arterial disease, peripheral vascular angioplasty, hospitalization for heart failure, foot ulcer, and all-cause mortality)., Conclusions: High body weight variability predicts the development of cardiovascular complications in type 2 diabetes. These data suggest that any strategy to reduce the body weight in these subjects should be aimed at maintaining the reduction in the long-term, avoiding oscillations., (© 2021. The Author(s).)

Background: As opposed to the decreasing overall rates of coronary heart disease (CHD) incidence and overall cardiovascular disease (CVD) mortality, heart failure (HF) and stroke incidence are increasing in young people, potentially due to rising rates of obesity and reduced cardiorespiratory fitness (CRF)., Objectives: We investigated trends in early major CVD outcomes in a large cohort of young men., Methods: Successive cohorts of Swedish military conscripts from 1971 to 1995 (N = 1,258,432; mean age, 18.3 years) were followed, using data from the National Inpatient and Cause of Death registries. Cox proportional hazard models were used to analyse changes in 21-year CVD event rates., Results: 21-year CVD and all-cause mortality and incidence of acute myocardial infarction (AMI) decreased progressively. Compared with the cohort conscripted in 1971-1975 (reference), the hazard ratios (HRs) for the last 1991-1995 cohort were 0.50 [95% confidence interval (CI) 0.42-0.59] for CVD mortality; 0.57 (95% CI 0.54-0.60) for all-cause mortality; and 0.63 (95% CI 0.53-0.75) for AMI. In contrast, the incidence of ischaemic stroke, intracerebral haemorrhage and HF increased with HRs of 1.43 (95% CI 1.17-1.75), 1.30 (95% CI 1.01-1.68) and 1.84 (95% CI 1.47-2.30), respectively. During the period, rates of obesity increased from 1.04% to 2.61%, whilst CRF scores decreased slightly. Adjustment for these factors influenced these secular trends only moderately., Conclusion: Secular trends of young-onset CVD events demonstrated a marked shift from AMI and CVD mortality to HF and stroke incidence. Trends were significantly, though moderately, influenced by changing baseline BMI and CRF., (© 2021 The Authors. Journal of Internal Medicine published by John Wiley & Sons Ltd on behalf of Association for Publication of The Journal of Internal Medicine.)

Objective: In a previous study we demonstrated that the occurrence of sexual jokes in the class was associated with higher levels of psychological health complaints. Building on and extending these findings, the aim of the current study was to examine if exposure to sexual jokes at the student and at the class level was inversely associated with students' life satisfaction. Data were derived from the 2017/18 Swedish Health Behaviour in School-aged Children (HBSC) study, with students aged 11, 13 and 15 years (n = 3710 distributed across 209 classes). Exposure to sexual jokes at the student level was captured by one item. Exposure to sexual jokes at the class level was calculated by aggregating this measure. The Cantril ladder was used to operationalise life satisfaction. Two-level logistic regression analyses were performed., Results: Students who were exposed to sexual jokes at school were less likely to report high life satisfaction (OR 0.38, 95% CI 0.27-0.53). An inverse association was found between the class proportion of students who were exposed to sexual jokes and students' likelihood of reporting high life satisfaction, whilst adjusting for exposure to sexual jokes at the student level (OR 0.98, 95% CI 0.97-0.9994). The findings highlight the importance of promoting a school climate without sexual harassment., (© 2021. The Author(s).)

Objectives: Group-level characteristics in shared contexts such as schools may affect adolescent psychological health. This study examined if the immigrant density in the classroom was associated with the level of self-reported psychological complaints among students with an immigration background. Methods: Cross-sectional data were derived from 2,619 lower secondary school students (aged 13-15) in the 2017/18 wave of the Swedish Health Behaviour in School-aged Children (HBSC) survey. Using multilevel analysis estimating two-level random intercept linear regression models, classroom immigrant density was considered as a potential predictor of immigrant students' psychological complaints. Results: Students with an immigration background reported significantly fewer psychological complaints, on average, than students without such a background, even when adjusting for other sociodemographic characteristics. A cross-level interaction indicated that both first- and second-generation immigrant students experienced fewer psychological complaints in immigrant-dense classes compared to when the proportion of immigrant students was lower. Conclusion: Students with an immigration background fare better psychologically in classes with a higher proportion of immigrant students. Such compositional effects could be alleviated by strengthening all schools' capacities to provide a more inclusive classroom climate., 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 © 2021 Granvik Saminathen, Löfstedt and Låftman.)

Aim: To evaluate the economic and clinical burden associated with poor glycaemic control in Sweden, in people with type 2 diabetes (T2D) initiating first-line glucose-lowering therapy., Materials and Methods: Population data were obtained from Swedish national registers. Immediate glycaemic control was compared with delays in achieving control of 1 and 3 years, with outcomes projected over 3, 10 and 50 years in the validated IQVIA CORE Diabetes Model. Glycaemic control was defined as glycated haemoglobin (HbA1c) targets of 52, 48 and 42 mmol/mol, as recommended in Swedish guidelines, according to age and disease duration. Costs (expressed in 2019 Swedish krona [SEK]) were accounted from a Swedish societal perspective., Results: Immediate glycaemic control was associated with population-level cost savings of up to SEK 279 million and SEK 673 million versus delays of 1 and 3 years, respectively, as well as small population-level life expectancy benefits of up to 1305 and 2590 life years gained. Reduced levels of burden were a result of lower incidence and delayed time to onset of diabetes-related complications., Conclusions: Even in people with T2D initiating first-line glucose-lowering therapy, the economic burden of poor glycaemic control in Sweden is substantial, but could be reduced by early and effective treatment to achieve glycaemic targets., (© 2021 Ossian Health Economics and Communications GmbH. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Aims/hypothesis: The aim of this work was to evaluate changes in glycaemic control (HbA 1c ) and rates of severe hypoglycaemia over a 2 year period after initiation of flash glucose monitoring (FM) in type 1 diabetes., Methods: Using data from the Swedish National Diabetes Registry, 14,372 adults with type 1 diabetes with a new registration of FM during 2016-2017 and with continued FM for two consecutive years thereafter, and 7691 control individuals using conventional self-monitoring of blood glucose (SMBG) during the same observation period, were included in a cohort study. Propensity sores and inverse probability of treatment weighting (IPTW) were used to balance FM users with SMBG users. Changes in HbA 1c and events of severe hypoglycaemia were compared., Results: After the start of FM, the difference in IPTW change in HbA 1c was slightly greater in FM users compared with the control group during the follow-up period, with an estimated mean absolute difference of -1.2 mmol/mol (-0.11%) (95% CI -1.64 [-0.15], -0.75 [-0.07]; p < 0.0001) after 15-24 months. The change in HbA 1c was greatest in those with baseline HbA 1c ≥70 mmol/mol (8.5%), with the estimated mean absolute difference being -2.5 mmol/mol (-0.23%) (95% CI -3.84 [-0.35], -1.18 [-0.11]; p = 0.0002) 15-24 months post index. The change was also significant in the subgroups with initial HbA 1c ≤52 mmol/mol (6.9%) and 53-69 mmol/mol (7.0-8.5%). Risk of severe hypoglycaemic episodes was reduced by 21% for FM users compared with control individuals using SMBG (OR 0.79 [95% CI 0.69, 0.91]; p = 0.0014)]., Conclusions/interpretation: In this large cohort, the use of FM was associated with a small and sustained improvement in HbA 1c , most evident in those with higher baseline HbA 1c levels. In addition, FM users experienced lower rates of severe hypoglycaemic events compared with control individuals using SMBG for self-management of glucose control.

Aims: We aimed to investigate (a) the association between body mass index (BMI) and self-rated health (SRH) and (b) BMI's predicted value for SRH within a representative population in the Skaraborg Project. Methods: This was a longitudinal observational study. A random population of 2816 individuals were included in the study between 2002 and 2005, and a representative sample of these individuals were invited consecutively for a follow-up visit between 2012 and 2014. At follow-up, data from 1327 participants were collected concerning anthropometric variables, blood samples and validated questionnaires regarding lifestyle factors. Results: A significant inverse association was observed between BMI and SRH both at baseline and at follow-up, with all p -values for trend being ⩽0.001 in both men and women. This association was observed even after adjusting for confounders such as co-morbidity, age, sex, education, marital status and lifestyle factors. In addition, the longitudinal analyses showed that BMI at baseline was inversely associated with SRH at follow-up in both sexes (odds ratio (OR)=1.1, confidence interval (CI) 1.02-1.16, p =0.017 in men; and OR=1.1, CI 1.04-1.14, p =0.001 in women). These findings remained in participants whose weight increased ( p =0.022) or was stable ( p =0.004), while it was not seen in individuals who lost weight over the years ( p =0.340). SRH is inversely associated with BMI in Swedish men and women. High BMI predicted low SRH from a longitudinal perspective, independent of co-morbidities, except for individuals who lost weight over the years. This knowledge emphasises the importance of an understanding and empathetic attitude towards these individuals.Conclusions: SRH is inversely associated with BMI in Swedish men and women. High BMI predicted low SRH from a longitudinal perspective, independent of co-morbidities, except for individuals who lost weight over the years. This knowledge emphasises the importance of an understanding and empathetic attitude towards these individuals.

Background: The general population is ubiquitously exposed to the toxic metal cadmium through the diet and smoking. Cadmium exposure is associated with increased morbidity and mortality in myocardial infarction and stroke. Atherosclerosis is the main underlying mechanism of myocardial infarction. However, associations between cadmium and coronary artery atherosclerosis have not been examined., Objectives: Our study sought to examine the hypothesis that blood cadmium (B-Cd) is positively associated with coronary artery calcification, as a measure of coronary artery atherosclerosis in the population-based Swedish SCAPIS study., Methods: Our analysis included 5,627 individuals (51% women), age 50-64 y, enrolled from 2013 to 2018. The coronary artery calcium score (CACS) was obtained from computed tomography. Blood cadmium was determined by inductively coupled plasma mass spectrometry (ICP-MS). Associations between B-Cd and coronary artery calcium score (CACS Agatston score) were evaluated using prevalence ratios (PRs) in models adjusted for sex, age, smoking, hypertension, diabetes, low-density cholesterol/high-density cholesterol ratio, and family history., Results: The median B-Cd concentration was 0.24 μ g / L . The prevalence of positive coronary artery calcium ( CACS > 0 ) was 41% and the prevalence of CACS ≥ 100 was 13%. Relative to the lowest quartile (Q) of B-Cd ( < 0.16 μ g / L ), the highest quartile (median 0.63 μ g / L ) was associated with a small but significant increase in CACS > 0 (PR 1.1; 95% CI: 1.0, 1.3), and a greater relative increase in CACS ≥ 100 (PR 1.6; 95% CI: 1.3, 2.0). When restricted to 2,446 never-smokers, corresponding PRs were 1.1 (95% CI 0.9, 1.3) for CACS > 0 (63 cases in Q4) and 1.7 (95% CI 1.1, 2.7) for CACS ≥ 100 (17 cases in Q4)., Discussion: Blood cadmium in the highest quartile was associated with CACS in a general population sample with low to moderate cadmium exposure. This supports the hypothesis that atherosclerosis is an important mechanism underlying the associations between cadmium and incident cardiovascular disease. The findings suggest that public health measures to reduce cadmium exposure are warranted. https://doi.org/10.1289/EHP8523.

Poor psychosocial working conditions in school have consistently been shown to be associated with adverse health among adolescents. However, the relationships between school demands, teacher support, and classmate support and positive aspects of health have not been explored to the same extent. The aim of this study was to examine differences in psychosocial working conditions in school and in life satisfaction by gender and by grade, and to investigate the association between psychosocial working conditions in school and life satisfaction among boys and girls, and among students in different grades. Data from the Swedish Health Behavior in School-Aged Children (HBSC) study of 2017/18 were used, consisting of 3614 students in Grades 5, 7, and 9 (~11, 13, and 15 years). Psychosocial working conditions in school were captured by indices of perceived school demands, teacher support, and classmate support. Life satisfaction was measured by the 11-step Cantril's ladder (using cutoffs at >5 and >8, respectively). Whereas girls reported higher school demands than boys, higher levels of teacher and classmate support were reported by boys. Students in lower grades reported lower school demands but higher levels of teacher and classmate support compared with students in higher grades. Boys and students in lower grades were more likely to report high life satisfaction compared with girls and students in higher grades. Results from binary logistic regression analyzes showed that school demands were inversely associated with life satisfaction, and that higher levels of teacher support and classmate support were associated with high life satisfaction. These results were found for both boys and girls, and for students in all grades. The findings indicate that schools have the potential to promote positive health among students.

Background: Students who are subjected to sexual harassment at school report lower psychological well-being than those who are not exposed. Yet, it is possible that the occurrence of sexual harassment in the school class is also stressful for those who are not directly targeted, with potential negative effects on well-being for all students. Aim: The aim was to examine whether exposure to sexual jokes at the student level and at the class level was associated with students' psychological complaints, and if these associations differed by gender. Method: Data from the Swedish Health Behaviour in School-aged Children (HBSC) of 2017/18 was used, with information from students aged 11, 13 and 15 years ( N =3720 distributed across 209 classes). Psychological health complaints were constructed as an index based on four items. Exposure to sexual jokes at the student level was measured by one item, and at the class level as the class proportion of students exposed to sexual jokes, in per cent. Two-level linear regression analyses were performed. Results: Students who had been exposed to sexual jokes at school reported higher levels of psychological complaints, especially boys. Furthermore, the class proportion of students who had been exposed to sexual jokes was also associated with psychological complaints, even when adjusting for student-level exposure to sexual jokes, gender, grade and class size. Conclusions: Sexual jokes seem to be harmful for those who are directly exposed, but may also affect indirectly exposed students negatively. Thus, a school climate free from sexual jokes may profit all students .

Objectives: Sense of unity refers to the positive feeling of being part of a larger social structure. This study aimed to investigate to what extent adolescents report sense of unity and if this differs across groups, and to assess the associations between sense of unity and self-reported health while taking into account sociodemographic characteristics and tangible social relationships. Methods: Data were obtained from the 2017/18 Swedish Health Behavior in School-aged Children study, using information collected among 15-year-old students ( n = 1,392). Linear and binary logistic regression analyses were performed. Results: The participants reported overall high levels of sense of unity. Sense of unity did not differ by gender, but adolescents without an immigrant background and those with higher family affluence reported higher levels. Sense of unity was inversely associated with psychological complaints, somatic complaints, and less than good self-rated health, even when adjusting for sociodemographic characteristics and family, classmate, and teacher relationships. Conclusion: This study suggests that sense of unity may be an important social determinant for adolescent health. More research is needed on the origins and implications of sense of unity., 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 © 2021 Wahlström, Modin, Svensson, Löfstedt and Brolin Låftman.)

Background: Urine is often used for biomonitoring the exposure to elements. However, most studies report concentrations in spot urine samples, which may not accurately mirror the "gold standard" of complete 24-h (24 h) urine samples. There are relatively few data published for 24 h samples, and little information on the within- and between person variability., Objectives: The present study aimed at assessing variability within and between individuals in 24 h excretion for a number of elements in adults from the general population and the typical 24 h excretion of these elements. In addition, we assessed concentrations adjusted for creatinine and specific gravity (SG), and associations between elements., Methods: 60 healthy non-smokers (31 women and 29 men) from Sweden, aged 21-64 years, collected all urine during 24 h (split into six separate samples) on two occasions, about one week apart. Concentrations of As, Br, Cd, Co, Cr, Cu, Fe, Hg, Li, Mn, Mo, Ni, P, Pb, S, Sb, Se, Sn, U, V, W, and Zn in urine were analyzed by inductively coupled plasma sector-field mass spectrometry (ICP-SF-MS) and 24 h excretion rates were calculated for each day. The ratio of between-individual variance and the total variance, the intra-class correlation (ICC) was calculated based on natural log-transformed 24 h excretion. Correlation coefficients were calculated between excretion rates (mass/24 h), and concentrations adjusted for creatinine and SG., Results: Geometric means (GM), and 90-percentiles are presented for each element. The 24 h excretion was higher in men than in women for most elements, and the difference was statistically significant for Cr, Cu, Fe, Li, P, Pb, S, Se, U, V, and Zn. However, for Cd and Co, the excretion was higher in women. Variability between days was low for Cd, Co, Hg, Pb, Sn, Se, V, and Zn (ICC 0.75-0.90), highest for Cr (ICC = 0.3) and Sb (ICC = 0.18), and moderate for the other elements. Spearman's rank correlation coefficients were about 0.8-0.9 for 17 elements, and 0.3-0.7 for Br, Cu, P, S, Se. Excretion of P and S were highly correlated, and also associated with excretion of most of the other elements, especially Cu, Se, V, and Zn. A high correlation was also found between As and Hg, between Mo and W, as well as between Cr, Fe and Mn., Conclusions: These data present normal variability of 24 h excretion of a number of elements, and can also be used as updated reference levels for elements with no or limited previous literature available. Information on variability within- and between individuals is important to know when designing studies with urine levels of elements used as exposure biomarker in studies of associations with health outcomes., (Copyright © 2021 The Author(s). Published by Elsevier GmbH.. All rights reserved.)

The aim of this study was to investigate the extent to which school demands, teacher support, and classmate support were associated with excellent self-rated health among students, and to examine if any such statistical predictions differed by gender. Data were drawn from the Swedish Health Behaviour in School-aged Children (HBSC) study of 2017/18, performed among adolescents in grades five, seven, and nine (n = 3701). Linear probability models showed that school demands were negatively associated with excellent self-rated health, whereas teacher and classmate support showed positive associations. The link with school demands was stronger for girls than boys, driven by the finding that in grades five and nine, school demands were associated with excellent self-rated health only among girls. In conclusion, the study suggests that working conditions in school in terms of manageable school demands and strong teacher and classmate support may benefit adolescents' positive health. The finding that the link between school demands and excellent self-rated health was more evident among girls than among boys may be interpreted in light of girls' on average stronger focus on schoolwork and academic success. The study contributes to knowledge about how working conditions in school may impede or promote students' positive health.

Background: The associations between cannabis use and anxiety or depression remain unclear. If cannabis affects these conditions, it is of interest to examine possible changes in cannabis use over time, in relation to anxiety and depression, as cannabis potency has increased in recent decades., Methods: Cohorts from the Women and Alcohol in Gothenburg study (n = 1 100), from three time periods were used to examine associations over time between cannabis use and anxiety and depression. Logistic regression analyses were used and relative excess risk due to interaction (RERI) was calculated to examine potential additive interactions between period of cannabis use, cannabis use, and anxiety or depression., Findings: Cannabis use was associated with anxiety in the oldest cohort (examined 1986-1992, born 1955/65), OR = 5.14 (1.67-15.80, 95 % CI), and with both anxiety and depression in the youngest cohort (examined 2000-2015, born 1980/93), OR = 1.66 (1.00-2.74, 95 % CI) and 2.37 (1.45-3.86, 95 % CI), respectively. RERI was significant between cannabis use and depression in the youngest cohort when compared with older cohorts (1.68 (0.45-2.92, 95 % CI))., Limitations: Cross-sectional data prevent statements on causality, though between-cohort comparisons are possible., Conclusion: The association between cannabis use and depression becomes more pronounced when adding the effect of period of use rather than looking at the effect of cannabis use itself. This study provides clinicians and public health workers with scientifically underpinned knowledge regarding the link between cannabis use and depression, of particular importance given increasing cannabis potency., (Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Providing support to others has been shown to be beneficial to older adults. As people age, their health and social relationships change. These changes may also relate to changes in social support provision. We examined the trajectory of instrumental support provision by older people in three European regions throughout 11 years of follow-up. We then examined the extent to which age at baseline, sex, and region (representing welfare state regime) influenced the variations in the trajectory., Methods: Data collected from 8354 respondents who had completed at least waves 1 and 6 of the Survey of Health, Ageing and Retirement in Europe (SHARE) was analysed. Instrumental support provision was determined from asking a single question regarding whether the respondent provided help personally for people outside their household. Region, sex, and age at baseline were the main predictors tested. We used growth modelling to address the aims of this study., Results: The northern European region (Sweden and Denmark) had the highest odds ratio of instrumental support provision. The likelihood of being involved in providing instrumental support decreased by 8% annually (OR: 0.916, 95%CI: 0.893,0.940) over the 11 years of follow-up. Older respondents were less likely to provide instrumental support and their trajectories declined faster than those of the younger respondents. Sex difference in instrumental support provision was more apparent among younger-older people in the southern European region., Conclusions: Older European adults are an important source of instrumental support, especially for their families. The probability of instrumental support provision by European older adults declines over time. Age, sex, and welfare state regime predict this trajectory.

Background: The treatment of depression is a main strategy for suicide prevention in older adults. Our aim was to examine factors related to suicide in older adults (75+) with and without antidepressant (AD) therapy., Methods: A national population-based register study, including all Swedish residents aged ≥75 years between 2006 and 2014 (N = 1 413 806). A nested case-control design was used to investigate sociodemographic factors associated with suicide among users and non-users of ADs. Risk estimates were calculated in adjusted conditional logistic regression models for the entire cohort and by gender., Results: In all, 1305 individuals died by suicide (70% men). The suicide rate in men who used ADs was over four times higher than women with such treatment. Being unmarried was a risk factor for suicide in men but not in women. Being born outside of Nordic countries was associated with increased suicide risk; a 3-fold risk increase was observed in non-Nordic women without AD treatment. Lower suicide risk was observed in blue-collar women who used ADs, whereas a higher risk was found in blue-collar men who did not., Conclusions: Our differential findings on factors associated with suicide can offer clues for gender-specific preventive strategies that go beyond the healthcare sphere., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association.)

Background: Rational antibiotic prescribing is crucial to combat antibiotic resistance. Optimal strategies to improve antibiotic use are not known. Strama, the Swedish strategic program against antibiotic resistance, has been successful in reducing antibiotic prescription rates. This study investigates whether two specific interventions directed toward healthcare centers, an informational visit and a self-evaluation meeting, played a role in observed reduction in rates of antibiotic prescriptions in primary healthcare., Methods: The study was a retrospective, observational, empirical analysis exploiting the variation in the timing of the interventions and considering past prescriptions through use of estimations from dynamic panel data models. Primary healthcare data from 2011 to 2014 were examined. Data were from public and private primary healthcare centers in western Sweden. The key variables were prescription of antibiotics and indicator variables for the two interventions., Results: The first intervention, an educational information intervention, decreased the number of prescriptions among public healthcare centers, but this effect was only temporary. We found no proof that the second intervention, a self-evaluation meeting at the healthcare center, had an impact on the reduction of prescriptions., Conclusions: Single educational interventions aimed at influencing rates of antibiotic prescriptions have limited impact. A multifaceted approach is needed in efforts to reduce the use of antibiotics in primary health care.

Purpose: The prevalence of cancer pain is too high. There is a need for improvement of pain management in cancer care. The aim of this study was to explore whether the use of the multidimensional pain assessment questionnaire Brief Pain Inventory (BPI) could improve pain relief in hospitalized patients with cancer., Methods: A controlled intervention study was performed at two hospitals in western Sweden, 264 patients were included, 132 formed a control group and 132 an intervention group. All participants completed the BPI and the Edmonton Symptom Assessment Scale (ESAS) at baseline. Only the researcher had access to questionnaires from the control group. The completed forms from the intervention group were presented to the patients' care team. A follow-up took place after 2-5 days when patients in both groups rated the scales a second time., Results: In the intervention group, significant differences in all measured items of the BPI were found at follow-up compared with baseline. Symptoms rated with the ESAS also decreased significantly, except shortness of breath. At follow-up, a significant increase in regular use of paracetamol, anti-neuropathic pain drugs and opioids was found, as well as elevated doses of fixed-schedule opioids. In the control group, differences between baseline and follow-up were significant regarding average pain and worst pain over the past 24 h., Conclusion: Presenting the patient-reported BPI to the care team helped them to focus on patients' pain, identify pain mechanisms and adjust analgesics accordingly. A possible explanation for the results is changes in the medication prescribed.

Aim: To describe the personality and social characteristics associated with regular and episodic alcohol consumption in a Swedish cohort of women., Methods: 406 women aged 38 and 50 who participated in the Population Study of Women in Gothenburg in 2004-2005 with complete data on the key variables are included. Regular alcohol use was based on frequencies of alcoholic beverage consumption, reported to examining physicians. Regular drinking was defined as those consuming wine, beer, or spirits at least twice weekly. Episodic drinking was defined as consumption of six drinks or more on a single occasion at least once during the last year. Personality traits were studied using the self-administered 57-item Eysenck Personality Inventory, which includes a 'lie scale' measuring the tendency toward social desirability, a 'neuroticism scale', and an 'extraversion scale'. Logistic regression was used to estimate odds ratios (OR) for regular and episodic drinking, respectively, in relation to standardized (SD) personality scores and selected social characteristics., Results: 49% of the women reported episodic drinking, while 58% reported regular drinking, and 34% reported both. Women with a higher tendency toward socially desirable responses were less likely to report episodic drinking (odds ratio [OR] = 0.67, 95% confidence interval [CI] = 0.53-0.84) per standard deviation (SD), a trait that was not associated with regular drinking., Conclusions: The strong inverse association between the propensity to lie scale with episodic but not regular drinking suggests that episodic drinking is subject to greater social desirability and under-reporting biases than regular drinking. Our findings indicate that this type of problem drinking may be missed in medical examinations, which limits the ability of health professionals to intervene., Competing Interests: Declaration of competing interest The author(s) declare that there is no conflict of interest., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background and aims Few studies have reported the long-term impact of chronic pain on health care utilization. The primary aim of this study was to investigate if chronic musculoskeletal pain was associated with health care utilization in the general population in a 21-year follow-up of a longitudinal cohort. The secondary aim was to identify and describe factors that characterize different long-term trajectories of health care utilization. Methods A prospective cohort design with a baseline sample of 2,425 subjects (aged 20-74). Data were collected by self-reported questionnaires, and three time points (1995, 2007, and 2016) were included in the present 21-year follow up study. Data on health care utilization were dichotomized at each time point to either high or low health care utilization. High utilization was defined as >5 consultations with at least one health care provider, or ≥1 consultation with at least 3 different health care providers during the last 12 months. Low health care utilization was defined as ≤5 consultations with one health care provider and <3 consultations with different health care providers. The associations between baseline variables and health care utilization in 2016 were analyzed by multiple logistic regression. Five different trajectories for health care utilization were identified by visual analysis, whereof four of clinical relevance were included in the analyses. Results Baseline predictors for high health care utilization at the 21-year follow-up in 2016 were chronic widespread pain (OR: 3.2, CI: 1.9-5.1), chronic regional pain (OR:1.8, CI: 1.2-2.6), female gender (OR: 2.0, CI: 1.4-3.0), and high age (OR: 1.6, CI:0.9-2.9). A stable high health care utilization trajectory group was characterized by high levels of health care utilization, and a high prevalence of chronic pain at baseline and female gender (n = 23). A stable low health care utilization trajectory group (n = 744) was characterized by low health care utilization, and low prevalence of chronic pain at baseline. The two remaining trajectories were: increasing trajectory group (n = 108), characterized by increasing health care utilization, chronic pain at baseline and female gender, and decreasing trajectory group (n = 107) characterized by decreasing health care utilization despite a stable high prevalence of chronic pain over time. Conclusions The results suggest that chronic pain is related to long-term health care utilization in the general population. Stable high health care utilization was identified among a group characterized by female gender and a report of chronic widespread pain. Implications This cohort study revealed that chronic widespread pain predicted high health care utilization over a 21-year follow-up period. The results indicate the importance of early identification of musculoskeletal pain to improve the management of pain in the long run.

Despite the rapid growth in research and R&D expenditures, the translation of research into practice is limited. One approach to increase the translation and utilization of research is practice based research networks. With the aim of strengthening evidence-based practice (EBP) within occupational health services in Sweden (OH-Services), a practice-based research network (PBRN-OSH) was developed. The PBRN-OSH includes researchers and representatives from end-users. This paper reports on the development, outputs and lessons learned in the PBRN-OSH. The PBRN-OSH resulted in several practice-based research projects as well as different measures to ensure EBP in OSH such as the governmentally sanctioned national guidelines for the OH-services. Moreover, results show that the competence in EBP increased among practitioners at the OH-services. Conducting research in a PBRN is more resource demanding; however, this does not imply that it is less cost effective. To succeed in increasing the utility of research findings via PBRN, resources must be invested into an infrastructure that supports collaboration in the PBRN, including costs for a variety of means of dissemination. Further, translation activities need to be included in academic career paths and reward systems if a major improvement in the impact and return of investments from research is to be expected.

Background: Extensive exposure to per- and polyfluoroalkyl substances (PFAS) have been observed in many countries. Current deterministic frameworks for risk assessment lack the ability to predict the likelihood of effects and to assess uncertainty. When exposure exceeds tolerable intake levels, these shortcomings hamper risk management and communication., Objective: The integrated probabilistic risk assessment (IPRA) combines dose-response and exposure data to estimate the likelihood of adverse effects. We evaluated the usefulness of the IPRA for risk characterization related to decreased levels of total triiodothyronine ( T 3 ) in humans following a real case of high exposure to PFAS via drinking water., Methods: PFAS exposure was defined as serum levels from residents of a contaminated area in Ronneby, Sweden. Median levels were 270  ng / mL [perfluorooctane sulfonic acid (PFOS)] and 229  ng / mL [perfluorohexane sulfonic acid (PFHxS)] for individuals who resided in Ronneby 1 y before the exposure termination. This data was integrated with data from a subchronic toxicity study in monkeys exposed daily to PFOS. Benchmark dose modeling was employed to describe separate dose-effect relationship for males and females, and extrapolation factor distributions were used to estimate the corresponding human benchmark dose. The critical effect level was defined as a 10% decrease in total T 3 ., Results: The median probability of critical exposure, following a combined exposure to PFOS and PFHxS, was estimated to be [2.1% (90% CI: 0.4 % - 13.1 % )]. Gender-based analysis showed that this risk was almost entirely distributed among women, namely [3.9% (90% CI: 0.8 % - 21.6 % )]., Discussion: The IPRA was compared with the traditional deterministic Margin of Exposure (MoE) approach. We conclude that probabilistic risk characterization represents an important step forward in the ability to adequately analyze group-specific health risks. Moreover, quantifying the sources of uncertainty is desirable, as it improves the awareness among stakeholders and will guide future efforts to improve accuracy. https://doi.org/10.1289/EHP6654.