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Summary: We studied the risk for hip fracture before and after total knee replacement (TKR) in the entire population in Sweden. Women and men had a low risk for hip fracture before TKR but an increased risk the first year after TKR. Purpose: It is known that osteoarthritis is associated with high bone mass. We therefore studied the risk of hip fracture before and after total knee replacement (TKR), risk of different hip fracture types, and risk subdivided in genders and age groups. Methods: We followed the total Swedish population born between 1902 and 1952 (n = 4,258,934) during the period 1987–2002 and identified all patients with TKR due to primary OA (n = 39,291), and all patients with hip fracture (n = 195,860) in the Swedish National Inpatient Register. The risk time analyses were based on Poisson regression models. Results: The hazard ratio (HR) for hip fracture the last year before TKR was 0.86 (95% CI 0.74 to 1.00) and the first year after 1.26 (95% CI 1.11 to 1.42) compared to individuals without TKR. The HR for femoral neck fracture 0–10 years after TKR was 0.95 (95% CI 0.89 to 1.01) and for trochanteric fracture was 1.13 (95% CI 1.06 to 1.21). The HR for hip fracture in the age group 50–74 was 1.28 (95% CI 1.14 to 1.43) and in the age group 75–90 years was 0.99 (95% CI 0.94 to 1.04) 0–10 years after TKR, compared to individuals without TKR. Conclusion: Individuals had a low risk for hip fracture before TKR but an increased risk the first year after TKR. The risk in individuals below age 75 years and for trochanteric fractures was increased after TKR. Possible explanations include changed knee kinematics after a TKR, physical activity level, fall risk, and other unknown factors. [ABSTRACT FROM AUTHOR]

Summary: Death of a spouse is associated with poorer physical and mental health. We followed all married individuals, born from 1902 to 1942, during the period from 1987 to 2002, and found that widows and widowers had higher risk for hip fracture, compared with still married women and men. Introduction: Spousal bereavement can lead to poorer physical and mental health. We aimed to determine whether married women and men had an elevated risk of hip fracture after death of a spouse. Methods: In a retrospective cohort study, we followed all Swedish married individuals aged 60 to 100 years (n = 1,783,035), from 1987 to 2002. Data are presented as mean with 95% confidence interval (CI). Results: During the follow-up period, 21,305 hip fractures among widows and 6538 hip fractures among widowers were noted. The hazard ratio (HR) for hip fracture in widows compared with married women was 1.34 (95% CI 1.31 to 1.37) and for widowers compared with married men 1.32 (95% CI 1.29 to 1.35). The HR for hip fracture in the first 6 months after death of a spouse was in widows compared with married women 1.62 (95% CI 1.53 to 1.71) and in widowers compared with married men 1.84 (95% CI 1.68 to 2.03). The elevated risk was especially prominent in young widowers in the age range 60–69 years. During the first 6 months they showed a HR of 2.76 (95% CI 1.66 to 4.58) for a hip fractvure compared with age matched married men. Widows aged 60–69 years showed a HR of 1.59 (95% CI 1.26 to 1.99) compared with age matched married women. Conclusion: Our observation of a higher hip fracture risk in both genders in connection with the death of a spouse indicates a possible effect of bereavement on frailty. [ABSTRACT FROM AUTHOR]

Purpose: To study the association between the use of drugs for hypertension or heart failure, particularly diuretics, and risk of death in COVID-19., Methods: We conducted a cohort study, based on record linked individual-based data from national registers, of all Swedish inhabitants 50 years and older (n = 3,909,321) at the start of the first SARS-CoV-2 wave in Sweden. The association between use of angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), thiazides, loop diuretics, aldosterone antagonists, beta blocking agents and calcium channel blockers at the index date 6 March 2020, and death in COVID-19 during 7 March to 31 July 2020, was analysed using Cox-proportional hazards regression, adjusted for a wide range of possible confounders., Results: Use of loop diuretics was associated with higher risk [adjusted hazard ratio (HR) 1.26; 95% confidence interval (95% CI) 1.17-1.35] and thiazides with reduced risk (0.78; 0.69-0.88) of death in COVID-19. In addition, lower risk was observed for ACEI and higher risk for beta-blocking agents, although both associations were weak. For ARB, aldosterone antagonists and calcium channel blockers no significant associations were found., Conclusion: In this nationwide cohort of nearly 4 million persons 50 years and older, the use of loop diuretics was associated with increased risk of death in COVID-19 during the first SARS-CoV-2 wave in Sweden. This contrasted to the decreased risk observed for thiazides. As treatment with loop diuretics is common, particularly in the elderly, the group most affected by severe COVID-19, this finding merit further investigation., (© 2024. The Author(s).)

Background: The COVID-19 pandemic has had several phases with varying characteristics. We aimed to compare severity outcomes in different phases in a population with limited bias from risk factors., Methods: In a nationwide observational study of all unvaccinated first-time COVID-19 test positive individuals in Sweden aged 18-64 years without comorbidity, from week 45 of 2020 to week 5 of 2022, variant periods with certain variants constituting ≥ 92 % of all whole genome-sequenced cases nationwide, were compared regarding hospitalisation (with main discharge code of COVID-19), severe illness (use of high-flow nasal oxygen or admission to intensive care unit), and death due to COVID-19. Logistic regression was used to estimate odds ratios (ORs) for comparison of these outcomes between variant periods, using adjustments for variant period, age, sex, country of birth, place of residence, income, and education., Findings: The study included 789,133 individuals, including 15,145 hospitalised individuals. Among all individuals, the adjusted ORs for hospitalisation were 1.7 for the Alpha period vs the Pre-variant period (week 45-52 2020), 1.8 for the Delta period vs the Alpha period, and 0.1 for the Omicron period vs the Delta period (all comparisons significant). Among hospitalised individuals, the adjusted ORs for severe illness were 1.4 for the Alpha period vs the Pre-variant period, 1.7 for the Delta period vs the Alpha period, and 0.5 for the Omicron period vs the Delta period (all comparisons significant), and the adjusted ORs for death were 1.1 for the Alpha period vs the Pre-variant period (non-significant), 1.8 for the Delta period vs the Alpha period (significant), and 0.1 for the Omicron period vs the Delta period (non-significant)., Interpretation: In this population with limited bias from risk factors, vaccination, and previous infection, disease severity increased from the pre-variant to the Delta period and then decreased with the Omicron period, among all individuals and among hospitalised individuals. These severity outcome differences should be considered when the pandemic is evaluated., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

In Sweden 1600 patients/year survive cardiac arrest (30-day survival). Post-resuscitation care is complex and aims to stabilize organ function with focus on preventing secondary brain injury. In 2021 The European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) published joint guidelines on post-resuscitation care. In this article the Swedish Resuscitation Council summarizes the new guidelines with addition of more recent evidence to guide post-resuscitation care.

Objectives: To investigate the cumulative incidence proportion of disseminated or local Bacillus Calmette-Guérin (BCG) infections after adjuvant BCG instillations in patients with non-muscle-invasive bladder cancer (NMIBC)., Patients and Methods: We analysed the timing and occurrence of BCG infections and absolute and relative risk in relation to patient characteristics available in the Swedish nationwide database 'BladderBaSe 2.0'. The cumulative incidence proportion of a BCG infection was indicated by a reported diagnosis of tuberculosis (TB) in the patient registry or filing a prescription for tuberculostatic drugs., Results: The cumulative incidence proportion was 1.1% at the 5-year follow-up in 5033 patients exposed to adjuvant BCG instillations. The incidence rate was highest during the first 2 years after start of BCG instillations. Women had a lower risk than men (hazard ratio 0.23, 95% confidence interval 0.07-0.74). Age and calendar time at diagnosis, comorbidity, tumour risk group, previous medication with corticosteroids, immunosuppressive drugs, or time between transurethral resection of the bladder tumour and commencing the adjuvant BCG instillation were not associated with risk., Conclusions: These data further supports that the overall risk of a BCG infection after BCG-instillation treatment for NMIBC is low. The great majority of infections occur in the first 2 years, calling for an awareness of the diverse symptoms of BCG infection during this period. We provide evidence for male sex as a risk factor; however, the statistical precision is low and with a risk of selection bias, making it difficult to rule out the other suggested risk factors without further studies with different approaches., (© 2024 The Authors. BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Background: While well-established associations exist between socioeconomic conditions and smoking during pregnancy (SDP), less is known about social disparities in the risk of continuous SDP. Intersectional analyses that consider multiple social factors simultaneously can offer valuable insight for planning smoking cessation interventions., Methods: We include all 146,222 pregnancies in Sweden between 2006 and 2016 where the mother smoked at three months before pregnancy. The outcome was continuous SDP defined as self-reported smoking in the third trimester. Exposures were age, education, migration status and civil status. We examined all exposures in a mutually adjusted unidimensional analysis and in an intersectional model including 36 possible combinations. We present ORs with 95% Confidence Intervals, and the Area Under the Curve (AUC) as a measure of discriminatory accuracy (DA)., Results: In our study, education status was the factor most strongly associated to continuous SDP among women who smoked at three months before pregnancy. In the unidimensional analysis women with low and middle education had ORs for continuous SDP of 6.92 (95%CI 6.63-7.22) and 3.06 (95%CI 2.94-3.18) respectively compared to women with high education. In the intersectional analysis, odds of continuous SDP were 17.50 (95%CI 14.56-21.03) for married women born in Sweden aged ≥ 35 years with low education, compared to the reference group of married women born in Sweden aged 25-34 with high education. AUC-values were 0.658 and 0.660 for the unidimensional and intersectional models, respectively., Conclusion: The unidimensional and intersectional analyses showed that low education status increases odds of continuous SDP but that in isolation education status is insufficient to identify the women at highest odds of continuous SDP. Interventions targeted to social groups should be preceded by intersectional analyses but further research is needed before recommending intensified smoking cessation to specific social groups., (© 2024. The Author(s).)

Purpose: The aim of this study was to examine relationships between education, income, and employment (socioeconomic status, SES) and intensive care unit (ICU) survival and survival 1 year after discharge from ICU (Post-ICU survival)., Methods: Individual data from ICU patients were linked to register data of education level, disposable income, employment status, civil status, foreign background, comorbidities, and vital status. Associations between SES, ICU survival and 1-year post-ICU survival was analysed using Cox's regression., Results: We included 58,279 adults (59% men, median length of stay in ICU 4.0 days, median SAPS3 score 61). Survival rates at discharge from ICU and one year after discharge were 88% and 63%, respectively. Risk of ICU death (Hazard ratios, HR) was significantly higher in unemployed and retired compared to patients who worked prior to admission (1.20; 95% CI: 1.10-1.30 and 1.15; (1.07-1.24), respectively. There was no consistent association between education, income and ICU death. Risk of post-ICU death decreased with greater income and was roughly 16% lower in the highest compared to lowest income quintile (HR 0.84; 0.79-0.88). Higher education levels appeared to be associated with reduced risk of death during the first year after ICU discharge., Conclusions: Significant relationships between low SES in the critically ill and increased risk of death indicate that it is important to identify and support patients with low SES to improve survival after intensive care. Studies of survival after critical illness need to account for participants SES., Competing Interests: Declaration of Competing Interest None of the co-authors have any financial interests to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The ongoing TANGO2 (Telephone Assisted CPR. AN evaluation of efficacy amonGst cOmpression only and standard CPR) trial is designed to evaluate whether compression-only cardiopulmonary resuscitation (CPR) by trained laypersons is noninferior to standard CPR in adult out-of-hospital cardiac arrest. This pilot study assesses feasibility, safety, and intermediate clinical outcomes as part of the larger TANGO2 survival trial., Methods: Emergency medical dispatch calls of suspected out-of-hospital cardiac arrest were screened for inclusion at 18 dispatch centers in Sweden between January 1, 2017, and March 12, 2020. Inclusion criteria were witnessed event, bystander on the scene with previous CPR training, age above 18 years of age, and no signs of trauma, pregnancy, or intoxication. Cases were randomized 1:1 at the dispatch center to either instructions to perform compression-only CPR (intervention) or instructions to perform standard CPR (control). Feasibility included evaluation of inclusion, randomization, and adherence to protocol. Safety measures were time to emergency medical service dispatch CPR instructions, and to start of CPR, intermediate clinical outcome was defined as 1-day survival., Results: Of 11 838 calls of suspected out-of-hospital cardiac arrest screened for inclusion, 2168 were randomized and 1250 (57.7%) were out-of-hospital cardiac arrests treated by the emergency medical service. Of these, 640 were assigned to intervention and 610 to control. Crossover from intervention to control occurred in 16.3% and from control to intervention in 18.5%. The median time from emergency call to ambulance dispatch was 1 minute and 36 s (interquartile range, 1.1-2.2) in the intervention group and 1 minute and 30 s (interquartile range, 1.1-2.2) in the control group. Survival to 1 day was 28.6% versus 28.4% ( P =0.984) for intervention and control, respectively., Conclusions: In this national randomized pilot trial, compression-only CPR versus standard CPR by trained laypersons was feasible. No differences in safety measures or short-term survival were found between the 2 strategies. Efforts to reduce crossover are important and may strengthen the ongoing main trial that will assess differences in long-term survival., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02401633., Competing Interests: Disclosures None.

Background: Well-established associations exist between the risk of small for gestational age (SGA) and unidimensional sociodemographic factors. We investigated social inequalities in SGA risk and adopted an intersectional approach that simultaneously considers different social categories. By doing so, we could assess heterogeneities in SGA risk within unidimensional sociodemographic categories., Methods: We included all live 679 694 singleton births in Sweden between 2010 and 2016. The outcome was SGA, and the exposures were age, maternal educational level, dichotomous migration status and civil status. Thirty-six possible combinations of these factors constituted the exposure in an intersectional model. We present odds ratios (ORs) with 95% confidence intervals (95% CIs) and the area under the receiver operating characteristic curve (AUC)-a measurement of discriminatory accuracy (i.e. the ability to discriminate the babies born SGA from those who are not)., Results: Women with low education and women born outside Sweden had ORs of 1.46 (95% CI 1.38-1.54) and 1.50 (95% CI 1.43-1.56) in unidimensional analyses, respectively. Among women aged under 25 with low education who were born outside Sweden and unmarried, the highest OR was 3.06 (2.59-3.63). The discriminatory accuracy was low for both the unidimensional model that included all sociodemographic factors (AUC 0. 563) and the intersectional model (AUC 0.571)., Conclusions: The intersectional approach revealed a complex sociodemographic pattern of SGA risk. Sociodemographic factors have a low accuracy in identifying SGA at the individual level, even when quantifying their multi-dimensional intersections. This cautions against interventions targeted to individuals belonging to socially defined groups to reduce social inequalities in SGA risk., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Public Health Association.)

Aim: Previous studies have reported an association between month of birth and incidence of type 1 diabetes. Using population-based data, including almost all newly diagnosed children with type 1 diabetes in Sweden, we tested whether month of birth influences the risk of type 1 diabetes., Methods: For 8761 children diagnosed with type 1 diabetes between May 2005 and December 2016 in the Better Diabetes Diagnosis study, month of birth, sex and age were compared. Human leucocyte antigen (HLA) genotype and autoantibodies at diagnosis were analysed for a subset of the cohort (n = 3647). Comparisons with the general population used data from Statistics Sweden., Results: We found no association between month of birth or season and the incidence of type 1 diabetes in the cohort as a whole. However, boys diagnosed before 5 years were more often born in May (p = 0.004). We found no correlation between month of birth and HLA or antibodies., Conclusion: In this large nationwide study, the impact of month of birth on type 1 diabetes diagnosis was weak, except for boys diagnosed before 5 years of age, who were more likely born in May. This may suggest different triggers for different subgroups of patients with type 1 diabetes., (© 2022 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Background: Around 70% of all ICU patients are treated with antibiotics whereas up to 30% are suggested as unnecessary. Measuring antibiotic consumption is a prerequisite to improving its use and the purpose of the present investigation was to explore the use of antibiotics in Swedish ICUs., Material and Methods: Daily Defined Doses (DDDs) of antimicrobials delivered to Swedish ICUs, 2016-2018, were retrieved from Swedish pharmacies. From the Swedish Intensive Care Registry, we extracted data on a number of patient admissions, occupied bed days and Simplified Acute Physiology Score (SAPS)3., Results: There was a similar annual rate of total DDDs per admission of 3.7, 3.5, 3.8 and total DDDs per 100 occupied bed days of 111, 111, and 115 but with an approximately 6-fold difference of DDDs per occupied bed days (61-366) between the ICUs. The most frequently used antibiotics were isoxazolyl penicillins (J01CF), penicillins with betalactamase-inhibitors, mainly piperacillin/tazobactam (J01CR), 3rd and 4th generation cephalosporins (J01DD + DE) and carbapenems (J01DH). Together these four classes accounted for a median of 52% of all antibiotic use. The use of carbapenems had a moderate positive correlation with the mean SAPS3 score ( r  = 0.6, p  = .01). The use of other broad-spectrum antibiotics showed no such correlation., Conclusion: Overall antibiotic use remained similar in Swedish ICUs during the years 2016-2018. Broad-spectrum antibiotics accounted for 50% of all DDDs but with a large inter-ICU variation which only partly can be explained by differences in patient case mix and microbial resistance. Presumably, it also reflects varying local prescribing practices.

Aims: To study incident narcolepsy in first- and second-generation immigrant groups using Swedish-born individuals and native Swedes as referents., Methods: The study population included all individuals registered and alive in Sweden at baseline. Narcolepsy was defined as having at least one registered diagnosis of narcolepsy in the Swedish National Patient Register. The incidence of narcolepsy in different immigrant groups was assessed by Cox regression, with hazard ratios (HRs) and 95% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, co-morbidities, and neighbourhood socioeconomic status., Results: In the first-generation study, 1225 narcolepsy cases were found; 465 males and 760 females, and in the second-generation study, 1710 cases, 702 males and 1008 females. Fully adjusted HRs (95% CI) in the first-generation study was for males 0.83 (0.61-1.13) and females 0.83 (0.64-1.07), and in the second-generation study for males 0.76 (0.60-0.95) and females 0.91 (95% CI 0.76-1.09). Statistically significant excess risks of narcolepsy were found in first-generation males from North America, and second-generation males with parents from North America, and second-generation females with parents from Latin America., Conclusions: There were only significant differences in incident narcolepsy between native Swedes and second-generation male immigrants. The observed differences can partly be explained by differences in Pandemrix® vaccinations and are probably not attributable to genetic differences between immigrants and natives., (© 2022 The Authors. Acta Neurologica Scandinavica published by John Wiley & Sons Ltd.)

While social vulnerability in the face of disasters has received increasing academic attention, relatively little is known about the extent to which that knowledge is reflected in practice by institutions involved in disaster management. This study charts the practitioners' approaches to disaster vulnerability in eight European countries: Belgium; Estonia; Finland; Germany; Hungary; Italy; Norway; and Sweden. It draws on a comparative document analysis and 95 interviews with disaster managers and reveals significant differences across countries in terms of the ontology of vulnerability, its sources, reduction strategies, and the allocation of related duties. To advance the debate and provide conceptual clarity, we put forward a heuristic model to facilitate different understandings of vulnerability along the dimensions of human agency and technological structures as well as social support through private relations and state actors. This could guide risk analysis of and planning for major hazards and could be adapted further to particular types of disasters., (© 2021 The Authors Disasters © 2021 ODI.)

Background: There is a lack of studies of amyotrophic lateral sclerosis (ALS) in immigrants., Objective: The objective is to study the association between country of birth and incident ALS in first-generation immigrants versus Swedish-born individuals, and in second-generation immigrants versus native Swedes., Methods: Study populations included all adults aged 18 years and older in Sweden, in the first-generation study 6,128,698 individuals (2,975,141 men, 3,153,557 women) with 5,344 ALS cases (3017 men, 2327 women), and in the second-generation study 4,588,845 individuals (2,346,855 men and 2,241,990 women) with 3,420 cases (2027 men and 1393 women). ALS was defined as having at least one registered diagnosis of ALS in the National Patient Register 1998-2017. The incidence of ALS in different first-generation immigrant groups versus Swedish-born individuals was assessed by Cox regression, expressed as hazard ratios (HRs) with 95% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, and neighbourhood socioeconomic status., Results: After adjusting for potential confounders, the HRs were lower in foreign-born men, 0.71 (95% CI 0.63-0.81), and women, 0.80 (95% CI 0.70-0.92). The ALS risk was lower among men and women from most Western countries (Europe outside Nordic countries, and North America), and from other regions of the world (Africa, Asia, and Latin America). Among men and women with foreign-born parents, the risk of ALS did not differ significantly from native Swedes., Significance: In general, the risk of ALS was lower in first-generation men and women but did not differ in second-generation individuals., (© 2021. The Author(s).)

Introduction: Studies from the first pandemic wave found associations between COVID-19 hospital load and mortality. Here, we aimed to study if mortality of hospitalized COVID-19 patients was associated with the COVID-19 admission rate during a full year of the pandemic in Sweden., Method: Observational review of all patients admitted to hospital with COVID-19 in Sweden between March 2020 and February 2021 ( n  = 42,017). Primary outcome was 60-day all-cause mortality related to number of COVID-19 hospital admissions per month/100,000 inhabitants. Poisson regression was used to estimate the relative risk for death by month of admission, adjusting for pre-existing factors., Results: The overall mortality was 17.4%. Excluding March 2020, mortality was clearly correlated to the number of COVID-19 admissions per month (coefficient of correlation ρ=.96; p <.0001). After adjustment for pre-existing factors, the correlation remained significant (ρ=.75, p =.02). Patients admitted in December (high admission rate and high mortality) had more comorbidities and longer hospital stays, and patients treated in intensive care units (ICU) had longer pre-ICU hospital stays and worse respiratory status on ICU admission than those admitted in July to September (low admission rate and low mortality)., Conclusion: Mortality in hospitalized COVID-19 patients was clearly associated with the COVID-19 admission rate. Admission of healthier patients between pandemic waves and delayed ICU care during wave peaks could contribute to this pattern. The study supports measures to flatten-the-curve to reduce the number of COVID-19 patients admitted to hospital.

Background: Severe asthma increases the risk of severe COVID-19 outcomes such as hospitalization and death. However, more studies are needed to understand the association between asthma and severe COVID-19., Methods: A cohort of 150,430 adult asthma patients were identified in the Swedish National Airway Register (SNAR) from 2013 to December 2020. Data on body mass index, smoking habits, lung function, and asthma control test (ACT) were obtained from SNAR, and uncontrolled asthma was defined as ACT ⩽19. Patients with severe COVID-19 were identified following hospitalization or in death certificates based on ICD-10 codes U07.1 and U07.2. The Swedish Prescribed Drug register was used to identify comorbidities and data from Statistics Sweden for educational level. Multivariate logistic regression analyses were used to estimate associations with severe COVID-19., Results: Severe COVID-19 was identified in 1067 patients (0.7%). Older age (OR = 1.04, 95% CI = 1.03-1.04), male sex (1.42, 1.25-1.61), overweight (1.56, 1.27-1.91), obesity (2.12, 1.73-2.60), high-dose inhaled corticosteroids in combination with long-acting β-agonists (1.40, 1.22-1.60), dispensed oral corticosteroids ⩾2 (1.48, 1.25-1.75), uncontrolled asthma (1.64, 1.35-2.00), cardiovascular disease (1.20, 1.03-1.40), depression (1.47, 1.28-1.68), and diabetes (1.52, 1.29-1.78) were associated with severe COVID-19, while current smoking was inversely associated (0.63, 0.47-0.85). When comparing patients who died from COVID-19 with those discharged alive from hospital until 31 December 2020, older age, male sex, and current smoking were associated with COVID-19 death., Conclusion: Patients with uncontrolled asthma and high disease burden, including increased asthma medication intensity, should be identified as risk patients for severe COVID-19. Furthermore, current smoking is strongly associated with COVID-19 death in asthma.

Background: Life-sustaining treatment limitation (LSTL) on the intensive care unit (ICU) may affect the rate of organ donation after brain death (DBD). The primary aim of this study was to examine whether there is a relationship between LSTL and DBD. Furthermore, we aimed to determine the rate of LSTL involved in ICU deaths and to describe technical and procedural characteristics of LSTL on Swedish ICUs., Methods: This was an observational cohort study on all ICU deaths (n = 13 156) in Sweden between 2014 and 2017. We analysed differences in DBD rates between deaths in ICU with and those without LSTL, using descriptive statistics and logistic regression., Results: After excluding 1084 deaths on specialised ICUs and units not registering goals of treatment, the study population comprised 12 072 deaths including 615 DBDs, of which 7865 had LSTL, 1706 had no LSTL and 2501 had no stated goals of treatment. The final cohort on which the relationship between DBD and LSTL was analysed comprised 9571 deaths including 419 DBDs. When no LSTL was documented, the rate of organ donation was 9.5% compared to 3.3% when LSTL was documented (P < .001). LSTL was associated with a lower DBD rate after adjusting for patient- and ICU-related factors (OR 0.41, 95% CI 0.31-0.53, P < .001)., Conclusion: There was an inverse relationship between LSTL and DBD amongst patients who died on the ICU. This relationship remained after adjusting for factors known to influence organ donation. The reason remains to be determined., (© 2021 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: There is a lack of studies of Huntington's disease (HD) in immigrants., Objective: To study the association between country of birth and incident HD in first-generation immigrants versus Swedish-born individuals and in second-generation immigrants versus Swedish-born individuals with Swedish-born parents., Methods: Study populations included all adults aged 18 years and older in Sweden, i.e., in the first-generation study 6,042,891 individuals with 1034 HD cases and in the second-generation study 4,860,469 individuals with 1001 cases. HD was defined as having at least one registered diagnosis of HD in the National Patient Register. The incidence of HD in different first-generation immigrant groups versus Swedish-born individuals was assessed by Cox regression, expressed as hazard ratios (HRs) and 95% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, and neighborhood socioeconomic status., Results: Mean age-standardized incidence rates per 100,000 person-years were for all Swedish-born 0.82 and for all foreign born 0.53 and for all men 0.73 and for all women 0.81, with the highest incidence rates for the group 80-84 years of age. After adjusting for potential confounders, the HRs were lower in women in the first- and second-generation, i.e., 0.49 (95% CI 0.36-0.67) and 0.63 (95% 0.45-0.87), respectively, and also among women from Finland or with parents from Finland., Significance: In general, the risk of HD was lower in first-generation and second-generation immigrant women but not among male immigrants., (© 2021. The Author(s).)

Objectives: Socioeconomic disparities in smoking prevalence remain a challenge to public health. The objective of this study was to present a simple methodology that displays intersectional patterns of smoking and quantify heterogeneities within groups to avoid inappropriate and potentially stigmatising conclusions exclusively based on group averages., Setting: This is a cross-sectional observational study based on data from the National Health Surveys for Sweden (2004-2016 and 2018) including 136 301 individuals. We excluded people under 30 years of age, or missing information on education, household composition or smoking habits. The final sample consisted on 110 044 individuals or 80.7% of the original sample., Outcome: Applying intersectional analysis of individual heterogeneity and discriminatory accuracy (AIHDA), we investigated the risk of self-reported smoking across 72 intersectional strata defined by age, gender, educational achievement, migration status and household composition., Results: The distribution of smoking habit risk in the population was very heterogeneous. For instance, immigrant men aged 30-44 with low educational achievement that lived alone had a prevalence of smoking of 54% (95% CI 44% to 64%), around nine times higher than native women aged 65-84 with high educational achievement and living with other(s) that had a prevalence of 6% (95% CI 5% to 7%). The discriminatory accuracy of the information was moderate., Conclusion: A more detailed, intersectional mapping of the socioeconomic and demographic disparities of smoking can assist in public health management aiming to eliminate this unhealthy habit from the community. Intersectionality theory together with AIHDA provides information that can guide resource allocation according to the concept proportionate universalism., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Low socioeconomic status has been associated with worse outcome after cardiac arrest. This study aims to investigate if patients´ income influences the probability to receive early coronary angiography in out-of-hospital cardiac arrest (OHCA) patients., Methods: In this nationwide retrospective observational study, 3906 OHCA patients admitted alive and registered in the Swedish Registry for Cardiopulmonary Resuscitation were included. Individual data on income and educational level, prehospital parameters, coronary angiography results and comorbidity were linked from SWEDEHEART and other national registers., Results: Patients were divided into quarters depending on their income level. In the unadjusted model there was a strong correlation between income level and rate of early coronary angiography where 35.5% of patients in the highest income quarters received early angiography compared to 15.4% in the lowest income quarters. When adjusting for educational level, sex, age, comorbidity and hospital type, there were still higher chance of receiving early coronary angiography with increasing income, OR 1.31 (CI 1.01-1.68) and 1.67 (CI 1.29-2.16) for the two highest income quarters respectively compared to the lowest income quarter. When adding potential mediators to the model (first recorded ECG rhythm by the EMS, location, response time, bystander cardiopulmonary resuscitation and if the arrest was witnessed) no difference in early angiography related to income level where found. The main mediator was first recorded ECG rhythm., Conclusion: Income level is associated with the probability to undergo early coronary angiography in OHCA patients. This association seems to be mediated by the initial ECG rhythm., (Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objectives: Risk of multiple sclerosis (MS) is low among first-generation immigrants in Sweden. We aimed to study incident MS in first- and second-generation immigrant groups., Materials & Methods: We included adults aged 18 years and older in Sweden in first-generation (n = 6 042 891) and second-generation (n = 4 860 469) sub-studies. MS was defined via two diagnoses in the Swedish National Patient Register. MS risk was estimated by Cox regression, with hazard ratios (HRs) and 95% confidence intervals (CI), in different immigrant groups, using Swedish-born as referents in first-generation sub-study, and individuals with Swedish-born parents in the second-generation. Full models were adjusted for age, geographic residence in Sweden, educational level, marital status, neighborhood socioeconomic status, and co-morbidity., Results: MS was diagnosed among 10 746 individuals in the first-generation sub-study, (men 3055 and women 7691), and 11 737 in the second-generation sub-study (men 3549 and women 8188) in the period 1998-2015. The annual incidence rate was higher in Swedish-born compared to foreign-born, 11.5 vs 6.3 per 100 000 person-years (age-standardized to the European standard population). Fully adjusted HRs were lower in first-generation immigrant men (HR 0.72, 0.64-0.82) and women (HR 0.67, 0.62-0.73), and in second-generation immigrant men (HR 0.88, 0.79-0.97) and women (HR 0.79; 0.73-0.84). Among first-generation immigrants, lower HRs were found in most groups., Significance: The MS risk was lower in first- and second-generation immigrants compared to Swedish-born or individuals with Swedish-born parents., (© 2020 The Authors. Acta Neurologica Scandinavica published by John Wiley & Sons Ltd.)

Background: Recent studies have reported substantially decreased hospital mortality for sepsis, but data are scarcer on outcomes after hospital discharge. We studied mortality up to 1 year in Swedish intensive care unit (ICU) patients with and without sepsis., Methods: Demographic and medical data for all registered adult general ICU patients admitted between 01-01-2008 and 30-09-2016 were retrieved from the Swedish Intensive Care Registry and linked with the National Patient Register for comorbidity data and the Cause of Death Register for death dates. The population was divided in two cohorts; (a) Patients with a diagnosis of severe sepsis or septic shock and (b) All other ICU patients. Crude yearly mortality was calculated, and logistic regression was used to analyse predictors of mortality., Results: 28 886 sepsis and 221 941 nonsepsis ICU patients were identified. In the sepsis cohort, in 2008 unadjusted mortality was 32.6% at hospital discharge, 32.7% at 30 days, 39% at 90 days and 46.8% at 365 days. In 2016, mortality was 30.5% at hospital discharge, 31.9% at 30 days and 38% at 90 days. Mortality at 365 days was 45.3% in 2015. Corresponding nonsepsis mortality was 15.4%, 16.2%, 20% and 26% in 2008 and 15.6%, 17.1%, 20.7% and 26.7% in 2016/2015. No consistent decrease in odds of mortality was seen in the adjusted analysis., Conclusions: Mortality in severe sepsis and septic shock is high, with more than one in three patients not surviving three months after ICU admission, and adjusted mortality has not decreased convincingly in Sweden 2008-2016., Trial Registration: The study was registered prospectively, ClinicalTrials.gov ID: NCT03489447., (© 2020 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Background: There is a lack of studies of Parkinson's disease (PD) in immigrants., Objective: To study the association between country of birth and incident PD in immigrants in Sweden versus Swedish-born individuals., Methods: Study population included all adults aged 50 years and older in Sweden (n = 2775736). PD was defined as having at least one registered diagnosis of PD in the National Patient Register. The incidence of PD in different first-generation immigrant groups versus Swedish-born individuals was assessed by Cox regression, expressed as hazard ratios (HRs) and 95% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, neighbourhood socioeconomic status and co-morbidity., Results: Totally 35833 individuals had an incident diagnosis of PD (20401 men and 15432 women). Incidence rates per 100,000 person-years were for all Swedish-born 95.9 and for all foreign-born 60.1; for all men 112.3 and for all women 73.4, with a male to female ratio of 1.53, with the highest incidence rates for the group 80-84 years of age. After adjusting for potential confounders, the overall relative risk of PD was lower in immigrant men (HR 0.78; 95% CI 0.74-0.82) and women (HR 0.92; 95% CI 0.87-0.98). Among immigrant subgroups, a higher risk of PD was found among women from Finland (HR 1.13; 95% CI 1.05-1.23)., Conclusion: In general, the risk of PD was lower in first-generation immigrant men and women compared to Swedish-born. The only group with a higher risk of PD was women from Finland.

Purpose: The purpose of this study was to identify and report demographic data of patients with severe-to-profound hearing loss, assess participation in audiological rehabilitation and analyze the benefits of various rehabilitation methods. Materials and methods: Data on 4286 patients with severe-to-profound hearing impairments registered in the Swedish Quality Register of Otorhinolaryngology over a period from 2006-2015 were studied. Demographic data, gender differences, audiological rehabilitation and benefits of the rehabilitation were analyzed. Results: Group rehabilitation and visits to a hearing rehabilitation educator provided the most benefits in audiological rehabilitation. Only 40.5% of the patients received extended audiological rehabilitation, of which 54.5% were women. A total of 9.5% of patients participated in group rehabilitation, with 59.5% being women. Women also visited technicians, welfare officers, hearing rehabilitation educators, psychologists and physicians and received communication rehabilitation in a group and fit with cochlea implants significantly more often than did men. Conclusions: The study emphasizes the importance of being given the opportunity to participate in group rehabilitation and meet a hearing rehabilitation educator to experience the benefits of hearing rehabilitation. There is a need to offer extended audiological rehabilitation, especially in terms of gender differences, to provide the same impact for women and men.Implications for RehabilitationSignificantly more women than men with severe-to-profound hearing impairment receive audiological rehabilitation.Hearing impairment appears to have a significantly more negative impact on women's quality of life than men's.It is important to offer extended audiological rehabilitation to all patients with severe-to-profound hearing loss to obtain an equal hearing health care regardless of gender.

Introduction: We investigated the impact of gender in performance and findings of early coronary angiography (CAG) and percutaneous coronary intervention (PCI), comorbidity and outcome in a large population of out-of-hospital cardiac arrest (OHCA) patients with an initially shockable rhythm., Methods: Retrospective cohort study. Data retrieved 2008-2013 from the Swedish Register for Cardio-Pulmonary Resuscitation, Swedeheart Registry and National Patient Register., Results: We identified 1498 patients of whom 78% were men. Men and women had the same pathology on the first registered electrocardiogram (ECG): 30% vs. 29% had ST-elevation and 10% vs. 9% had left bundle branch block (LBBB) (P = 0.97). Proportions of performed CAG did not differ between genders. Among patients without ST-elevation/LBBB men more often had at least one significant stenosis, 78% vs. 54% (P = 0.001), more multi-vessel disease (P = 0.01), had normal coronary angiography less often, 22% vs. 46% and PCI more often, 59% vs. 42% (P = 0.03). Among patients without ST-elevation/LBBB on the initial ECG, more men had previously known ischaemic heart disease, 27% vs. 19% (P = 0.02) and a presumed cardiac origin of the cardiac arrest, 86% vs. 72% (P < 0.001). Multivariable analysis showed no association between gender and evaluation by early CAG. In men and women, 1-year survival was 56% vs. 50% (P = 0.22) in patients with ST-elevation/LBBB and 48% vs. 51% (P = 0.50) in patients without., Conclusion: Despite no gender differences in ECG findings indicating an early CAG, men had more severe coronary artery disease while women more frequently had normal coronary angiography. However, this did not influence 1-year survival., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Aim: This study described the basic characteristics of children aged 0-16 years who were treated in intensive care units (ICUs) and paediatric ICUs (PICUs), compared their outcomes and examined any causes of death., Methods: This was a retrospective cohort study of admissions to 74 ICUs and three PICUs in Sweden that were recorded in the Swedish Intensive Care Registry from January 1, 2008 to December 31, 2012., Results: We retrieved data on 12 756 children who were admitted 17 003 times. The case mix differed between the ICUs, which were mainly admissions for injuries, accidents and observation, and PICUs, which were mainly admissions for malformations, genetic abnormalities and respiratory problems (p < 0.001). The median stays in the ICUs and PICUs were 1.4 and 3.5 days (p < 0.001), respectively. The respective crude mortality rates were 1.1% and 2.0, and the Paediatric Index of Mortality version 2 standardised mortality ratios were 0.43 and 0.50. None of these differences were significant. Most deaths were within 24 hours: About 57% in the ICUs, mainly from brain anomalies, and 13% in the PICUs, mainly from circulatory problems., Conclusion: Sweden had a low mortality rate in both ICUs and PICUs and the children admitted to these two types of unit differed., (©2018 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background: Diphtheria is caused by Corynebacterium diphtheriae. Although waning in incidence diphtheria can cause severe disease as in this rare Swedish case with several complications., Case Presentation: A 55-year old male presented to the emergency room with severe respiratory symptoms and greyish membranes in the airways, which turned positive for C. diphtheriae. He was put on ventilator support and remained hospitalized for three months. During care he developed myocarditis and severe neurological disease and he was also co-infected with tuberculosis. The patient was discharged with a favorable outcome., Conclusions: Diphtheria should be suspected in patients with life-threatening pneumonia especially if the patient has a history of travelling. Our patient was not treated with diphtheria anti-toxin (DAT) which may have contributed to the severity of the disease.

Background: The potential benefit of early coronary angiography in out-of-hospital cardiac arrest (OHCA) patients without ST elevation on ECG is unclear. The aim of this study was to evaluate the association between early coronary angiography and survival in these patients., Methods: Nationwide observational study between 2008 and 2013. Included were patients admitted to hospital after witnessed OHCA, with shockable rhythm, age 18 to 80 years and unconscious. Patients with ST-elevation on ECG were excluded. Patients that underwent early CAG (within 24 hours) were compared with no early CAG (later during the hospital stay or not at all). Outcomes were survival at 30 days, 1 year, and 3 years. Multivariate analysis included pre-hospital factors, comorbidity and ECG-findings., Results: In total, 799 OHCA patients fulfilled the inclusion criteria, of which 275 (34%) received early CAG versus 524 (66%) with no early CAG. In the early CAG group, the proportion of patients with an occluded coronary artery was 27% and 70% had at least one significant coronary stenosis (defined as narrowing of coronary lumen diameter of ≥50%). The 30-day survival rate was 65% in early CAG group versus 52% with no early CAG (P < .001). The adjusted OR was 1.42 (95% CI 1.00-2.02). The one-year survival rate was 62% in the early CAG group versus 48% in the no early CAG group with the adjusted hazard ratio of 1.35 (95% CI 1.04-1.77)., Conclusion: In this population of bystander-witnessed cases of out-of-hospital cardiac arrest with shockable rhythm and ECG without ST elevation, early coronary angiography may be associated with improved short and long term survival., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Acute coronary syndrome is a common cause of out-of-hospital cardiac arrest (OHCA). In patients with OHCA presenting with ST elevation, immediate coronary angiography and potential percutaneous coronary intervention (PCI) after return of spontaneous circulation are recommended. However, the evidence for this invasive strategy in patients without ST elevation is limited. Observational studies have shown a culprit coronary artery occlusion in about 30% of these patients, indicating the electrocardiogram's (ECG's) limited sensitivity. The aim of this study is to determine whether immediate coronary angiography and subsequent PCI will provide outcome benefits in OHCA patients without ST elevation., Methods/design: We describe the design of the DIrect or Subacute Coronary angiography in Out-of-hospital cardiac arrest study (DISCO)-a pragmatic national, multicenter, randomized, clinical study. OHCA patients presenting with no ST elevation on their first recorded ECG will be randomized to a strategy of immediate coronary angiography or to standard of care with admission to intensive care and angiography after 3days at the earliest unless the patient shows signs of acute ischemia or hemodynamic instability. Primary end point is 30-day survival. An estimated 1,006 patients give 80% power (α = .05) to detect a 20% improved 30-day survival rate from 45% to 54%. Secondary outcomes include good neurologic recovery at 30days and 6months, and cognitive function and cardiac function at 6months., Conclusion: This randomized clinical study will evaluate the effect of immediate coronary angiography after OHCA on 30-day survival in patients without ST elevation on their first recorded ECG., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: This study aimed to evaluate the use of second-look resection (SLR) in stage T1 bladder cancer (BC) in a population-based Swedish cohort., Materials and Methods: All patients diagnosed with stage T1 BC in 2008-2009 were identified in the Swedish National Registry for Urinary Bladder Cancer. Registry data on TNM stage, grade, primary treatment and pathological reports from the SLR performed within 8 weeks of the primary transurethral resection were validated against patient charts. The endpoint was cancer-specific survival (CSS)., Results: In total, 903 patients with a mean age of 74 years (range 28-99 years) were included. SLR was performed in 501 patients (55%), who had the following stages at SLR: 172 (35%) T0, 83 (17%) Ta/Tis, 210 (43%) T1 and 26 (5%) T2-4. The use of SLR varied from 18% to 77% in the six healthcare regions. Multiple adjuvant intravesical instillations were given to 420 patients (47%). SLR was associated with intravesical instillations, age younger than 74 years, discussion at multidisciplinary tumour conference, G3 tumour and treatment at high-volume hospitals. Patients undergoing SLR had a lower risk of dying from BC (hazard ratio 0.62, 95% confidence interval 0.45-0.84, p < .0022). Five-year CSS rates were as follows, in patients with the indicated tumours at SLR (p = .001): 82% in those with T1, 90% in T0, 90% in Ta/Tis and 56% in T2-4., Conclusions: There are large geographical differences in the use of SLR in stage T1 BC in Sweden, which are presumably related to local treatment traditions. Patients treated with SLR have a high rate of residual tumour but lower age, which suggests that a selection bias affects CSS.

In order to assess the potential radiological risk to humans and the environment from a geological repository for radioactive waste, a safety assessment must be performed. This implies that the release and transfer of radionuclides from the repository into the surface environment are calculated and that the effects in the biosphere are evaluated for an assessment period up to one hundred thousand years according to Swedish regulations. This paper discusses the challenges associated with the modelling of surface ecosystems over such long time scales, using the recently completed assessment for the extension of the existing repository for the low- and intermediate-level nuclear waste (called SFR) in Forsmark, Sweden as an applied example. In the assessment, natural variation and uncertainties in climate during the assessment period were captured by using a set of climate cases, primarily reflecting different expectations on the effects of global warming. Development of the landscape at the site, due to post-glacial isostatic rebound, was modelled, and areas where modelling indicated that radionuclides could discharge into the biosphere were identified. Transfers of surface water and groundwater were described with spatially distributed hydrological models. The projected release of radionuclides from the bedrock was then fed into a biosphere radionuclide transport model, simulating the transport and fate of radionuclides within and between ecosystems in the landscape. Annual doses for human inhabitants were calculated by combining activity concentrations in environmental media (soil, water, air and plants) with assumptions on habits and land-use of future human inhabitants. Similarly, dose rates to representative organisms of non-human biota were calculated from activity concentrations in relevant habitats, following the ERICA methodology. In the main scenario, the calculated risk for humans did not exceed the risk criteria or the screening dose rate for non-human biota, indicating that the repository design is sufficient to protect future populations and the environment. Although the combination of radionuclides, land-uses/habitats, type of most exposed population and area of exposure that contribute most to the total dose shifts over time, the total calculated dose shows limited variability. Significant reductions in the dose only occur during submerged periods and under periglacial climate conditions. As several different water and food pathways were equally important for endpoint results, it is concluded that it would be difficult to represent the biosphere with one or a set of simplified models. Instead, we found that it is important to maintain a diversity of food and water pathways, as key pathways for radionuclide accumulation and exposure partly worked in parallel., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives and Study Design: Information about how patients with voice disorders use their voices in natural communicative situations is scarce. Such long-term data have for the first time been uploaded to a central database from different hospitals in Sweden. The purpose was to investigate the potential use of a large set of long-term data for establishing reference values regarding voice use in natural situations., Methods: VoxLog (Sonvox AB, Umeå, Sweden) was tested for deployment in clinical practice by speech-language pathologists working at nine hospitals in Sweden. Files from 20 patients (16 females and 4 males) with functional, organic, or neurological voice disorders and 10 vocally healthy individuals (eight females and two males) were uploaded to a remote central database. All participants had vocally demanding occupations and had been monitored for more than 2 days. The total recording time was 681 hours and 50 minutes. Data on fundamental frequency (F0, Hz), phonation time (seconds and percentage), voice sound pressure level (SPL, dB), and background noise level (dB) were analyzed for each recorded day and compared between the 2 days. Variations across each day were measured using coefficients of variation., Results: Average F0, voice SPL, and especially the level of background noise varied considerably for all participants across each day. Average F0 and voice SPL were considerably higher than reference values from laboratory recordings., Conclusions: The use of a remote central database and strict protocols can accelerate data collection from larger groups of participants and contribute to establishing reference values regarding voice use in natural situations and from patients with voice disorders. Information about activities and voice symptoms would supplement the objective data and is recommended in future studies., (Copyright © 2015 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Treatment of localized prostate cancer (PC) is controversial. This is the first randomized study comparing an open surgery procedure (radical prostatectomy) with a combination of high-dose rate brachytherapy (2×10 Gy) and external beam radiotherapy (25×2 Gy) in PC patients in Sweden 1996-2001. The two randomization arms were compared regarding differences in patients-reported outcomes, such as complications and health-related quality of life (HRQoL)., Material and Methods: The patients had localized/locally advanced PC, clinical category T1b-T3a, N0, M0 and PSA≤50 ng/ml. All underwent total androgen blockade (six months). Self-reported HRQoL and symptoms including urinary, bowel, and sexual side effects were investigated prospectively before randomization and 12 and 24 months after randomization. A total of 89 patients were randomized and completed the EORTC QLQ C-33 and EORTC PR-25 questionnaires., Results: Over the study period, there were no discernible differences in HRQoL, or complications between the two groups. Emotional functioning, however, improved statistically significantly over time, whereas Social functioning decreased, and financial difficulties increased. No statistically significant differences in group-by-time interactions were found. The survival rate was 76%. Only eight patients (9%) died of PC., Conclusion: Open radical prostatectomy and the combined high-dose rate brachytherapy with external beam radiation appeared to be comparable in the measured outcomes. It was not possible to draw any conclusion on the efficacy of the two treatments due to insufficient power of the study.

Objective: The aim of this study was to analyse the rate of use of bacillus Calmette-Guérin (BCG) at a population-based level, and the overall mortality and bladder cancer mortality due to stage T1 bladder cancer in a national, population-based register., Materials and Methods: In total, 3758 patients with primary stage T1 bladder cancer, registered in the Swedish Bladder Cancer Register between 1997 and 2006, were included. Age, gender, tumour grade and primary treatment in the first 3-6 months were registered. High-volume hospitals registered 10 or more T1 tumours per year. Date and cause of death were obtained from the National Board of Health and Welfare Cause of Death Register., Results: BCG was given to 896 patients (24%). The use of BCG increased from 18% between 1997 and 2000, to 24% between 2001 and 2003, and to 31% between 2004 and 2006. BCG was given more often to patients with G3 tumours, patients younger than 75 years and patients attending high-volume hospitals. BCG treatment, grade 2 tumours and patient age younger than 75 years were associated with lower mortality due to bladder cancer. Hospital volume, gender and year of diagnosis were not related to bladder cancer mortality. However, selection factors might have affected the results since comorbidity, number of tumours and tumour size were unknown., Conclusions: Intravesical BCG is underused at a population-based level in stage T1 bladder cancer in Sweden, particularly in patients 75 years or older, and in those treated at low-volume hospitals. BCG should be offered more frequently to patients with stage T1 bladder cancer in Sweden.

Objective: The aim of this study was to investigate recurrence and progression of non-muscle-invasive bladder cancer (NMIBC) in a large population-based setting., Materials and Methods: Patients with bladder cancer (stage Ta, T1 or carcinoma in situ) diagnosed in 2004-2007 (n = 5839) in Sweden were investigated 5 years after diagnosis using a questionnaire. Differences in time to recurrence and progression were analysed in relation to age, gender, tumour stage and grade, intravesical treatment, healthcare region, and hospital volume of NMIBC patients (stratified in three equally large groups)., Results: Local bladder recurrence and progression occurred in 50 and 9% of the patients, respectively. The rate of local recurrence was 56% in the southern healthcare region compared to 37% in the northern region. A multivariate Cox proportional hazards model, adjusting for age, gender, tumour stage and grade, intravesical treatment, healthcare region and hospital volume, showed that recurrence was associated with TaG2 and T1 disease, no intravesical treatment and treatment in the southern healthcare region, but indicated a lower risk of recurrence in the northern healthcare region. Adjusting for the same factors in a multivariate analysis suggested that increased relative risk of progression correlated with older age, higher tumour stage and grade, and diagnosis in the Uppsala/Örebro healthcare region, whereas such risk was decreased by intravesical treatment (relative risk 0.72, 95% confidence interval 0.55-0.93, p = 0.012)., Conclusions: The incidence of NMIBC recurrence and progression was found to be high in Sweden, and important disparities in outcome related to care patterns appear to exist between different healthcare regions.

Aim of the Study: To investigate serum levels of glial fibrillary acidic protein (GFAP) for evaluation of neurological outcome in cardiac arrest (CA) patients and compare GFAP sensitivity and specificity to that of more studied biomarkers neuron-specific enolas (NSE) and S100B., Method: A prospective observational study was performed in three hospitals in Sweden during 2008-2012. The participants were 125 CA patients treated with therapeutic hypothermia (TH) to 32-34 °C for 24 hours. Samples were collected from peripheral blood (n=125) and the jugular bulb (n=47) up to 108 hours post-CA. GFAP serum levels were quantified using a novel, fully automated immunochemical method. Other biomarkers investigated were NSE and S100B. Neurological outcome was assessed using the Cerebral Performance Categories scale (CPC) and dichotomized into good and poor outcome., Results: GFAP predicted poor neurological outcome with 100% specificity and 14-23% sensitivity at 24, 48 and 72 hours post-CA. The corresponding values for NSE were 27-50% sensitivity and for S100B 21-30% sensitivity when specificity was set to 100%. A logistic regression with stepwise combination of the investigated biomarkers, GFAP, did not increase the ability to predict neurological outcome. No differences were found in GFAP, NSE and S100B levels when peripheral and jugular bulb blood samples were compared., Conclusion: Serum GFAP increase in patients with poor outcome but did not show sufficient sensitivity to predict neurological outcome after CA. Both NSE and S100B were shown to be better predictors. The ability to predict neurological outcome did not increased when combining the three biomarkers., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Autologous haematopoietic stem cell transplantation (HSCT) is a viable option for treatment of aggressive multiple sclerosis (MS). No randomised controlled trial has been performed, and thus, experiences from systematic and sustained follow-up of treated patients constitute important information about safety and efficacy. In this observational study, we describe the characteristics and outcome of the Swedish patients treated with HSCT for MS., Methods: Neurologists from the major hospitals in Sweden filled out a follow-up form with prospectively collected data. Fifty-two patients were identified in total; 48 were included in the study and evaluated for safety and side effects; 41 patients had at least 1 year of follow-up and were further analysed for clinical and radiological outcome. In this cohort, 34 patients (83%) had relapsing-remitting MS, and mean follow-up time was 47 months., Results: At 5 years, relapse-free survival was 87%; MRI event-free survival 85%; expanded disability status scale (EDSS) score progression-free survival 77%; and disease-free survival (no relapses, no new MRI lesions and no EDSS progression) 68%. Presence of gadolinium-enhancing lesions prior to HSCT was associated with a favourable outcome (disease-free survival 79% vs 46%, p=0.028). There was no mortality. The most common long-term side effects were herpes zoster reactivation (15%) and thyroid disease (8.4%)., Conclusions: HSCT is a very effective treatment of inflammatory active MS and can be performed with a high degree of safety at experienced centres., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Cystectomy combined with pelvic lymph-node dissection and urinary diversion entails high morbidity and mortality. Improvements are needed, and a first step is to collect information on the current situation. In 2011, this group took the initiative to start a population-based database in Sweden (population 9.5 million in 2011) with prospective registration of patients and complications until 90 days after cystectomy. This article reports findings from the first year of registration., Material and Methods: Participation was voluntary, and data were reported by local urologists or research nurses. Perioperative parameters and early complications classified according to the modified Clavien system were registered, and selected variables of possible importance for complications were analysed by univariate and multivariate logistic regression., Results: During 2011, 285 (65%) of 435 cystectomies performed in Sweden were registered in the database, the majority reported by the seven academic centres. Median blood loss was 1000 ml, operating time 318 min, and length of hospital stay 15 days. Any complications were registered for 103 patients (36%). Clavien grades 1-2 and 3-5 were noted in 19% and 15%, respectively. Thirty-seven patients (13%) were reoperated on at least once. In logistic regression analysis elevated risk of complications was significantly associated with operating time exceeding 318 min in both univariate and multivariate analysis, and with age 76-89 years only in multivariate analysis., Conclusions: It was feasible to start a national population-based registry of radical cystectomies for bladder cancer. The evaluation of the first year shows an increased risk of complications in patients with longer operating time and higher age. The results agree with some previously published series but should be interpreted with caution considering the relatively low coverage, which is expected to be higher in the future.

Aim of the Study: To describe differences over time in outcome, physical and cognitive function among survivors of cardiac arrest treated with hypothermia and to examine survivors' life satisfaction 6 months after cardiac arrest as well as gender differences., Methods: The study was prospective and included 45 cardiac arrest survivors admitted to three Swedish hospitals between 2008 and 2012. Participants were followed from intensive care unit discharge to one and six months after cardiac arrest. In addition to cerebral performance category (CPC), participants were asked to complete questionnaires regarding activities in daily life (Barthel index), cognitive function (mini mental state examination), and life satisfaction (LiSat-11)., Results: Outcome measured using CPC scores improved over time. At 6 months, all participants were classified as having a good outcome. At one month, participants were impaired but improved over time in their activities in daily life and cognitive function. At 6 months satisfaction with "life as a whole" was seen in 70%., Conclusions: Cardiac arrest survivors are satisfied with life as a whole despite a severe illness that has impaired their physical and cognitive function, which seemed to improve over time. Predicting patients' functional outcome in early stages is difficult, and the CPC score alone is not sufficient to assess patients' function. It is a need to reach a consensus to which instruments best reflect physical and cognitive function as well as to specify a rehabilitation plan., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Aim of the Study: To investigate whether there were any changes in and correlations between anxiety, depression and health-related quality of life (HRQoL) over time, between hospital discharge and one and six months after cardiac arrest (CA), in patients treated with therapeutic hypothermia (TH)., Method: During a 4-year period at three hospitals in Sweden, 26 patients were prospectively included after CA treated with TH. All patients completed the questionnaires Hospital Anxiety and Depression Scale (HADS), Euroqol (EQ5D), Euroqol visual analogue scale (EQ-VAS) and Short Form 12 (SF12) at three occasions, at hospital discharge, and at one and 6 months after CA., Result: There was improvement over time in HRQoL, the EQ5D index (p=0.002) and the SF12 physical component score (PCS) (p=0.005). Changes over time in anxiety and depression were not found. Seventy-three percent of patients had an EQ-VAS score below 70 (scale 0-100) on overall health status at discharge from hospital; at 6 months the corresponding figure was 41%. Physical problems were the most common complaint affecting HRQoL. A correlation was found between depression and HRQoL, and this was strongest at six months (rs=-0.44 to -0.71, p≤0.001)., Conclusion: HRQoL improves over the first 6 months after a CA. Patients reported lower levels of HRQoL on the physical as compared to mental component. The results indicate that the less anxiety and depression patients perceive, the better HRQoL they have and that time can be an important factor in recovery after CA., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: Systemic effects of carbon dioxide (CO2) insufflation during left-sided cardiac surgery were evaluated in a prospective randomized study, with regard to acid-base status, gas exchange, cerebral hemodynamics, and red blood cell morphology., Methods: Twenty patients undergoing elective left-sided cardiac surgery were randomized to de-airing procedure either by CO2 insufflation technique (CO2 group, n = 10) or by Lund technique without CO2 insufflation (Lund group, n = 10). Groups underwent assessment of acid-base status by intermittent arterial blood gases and in-line blood gas monitoring. Capnography was used to determine volume of CO2 produced. Cerebral hemodynamics was measured by transcranial Doppler sonography and near-infrared spectroscopy. Red cell morphology from cardiotomy suction and vent tubing was studied by scanning electron microscopy., Results: Patients in the CO2 group consequently developed significantly higher levels of hypercapnia with a concomitant increase in the volume of CO2 produced despite significantly higher oxygenator gas flows compared with the Lund group. Effects on cerebral hemodynamics were observed in the CO2 group with significantly higher blood flow velocities in the middle cerebral artery and higher regional cerebral saturation. Red blood cell damage was observed in the CO2 group by scanning electron microscopy (97% in CO2 group vs 18% in Lund group)., Conclusions: Insufflation of CO2 into the cardiothoracic wound cavity during left-sided cardiac surgery can induce hypercapnic acidosis and increased cerebral blood flow and local blood cell damage. These systemic effects should be monitored by in-line capnography and acid-base measurements for early and effective correction by increase in gas flows to the oxygenator., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Carcinoma of the renal pelvis and ureter are unusual tumours and our limited knowledge comes mainly from case reports and small series from large academic hospitals, as a rule without histopathological review. This study reports aetiological and demographical factors as well as clinicopathological findings of all patients in a large geographical region., Material and Methods: All patients in western Sweden with a renal pelvic or ureteral tumour diagnosed between 1971 and 1998 (n = 930) were included. Untreated cases were not excluded. Demographic data and results of preoperative examinations were retrieved from the original clinical records. The histopathological slides were reviewed and tumour stage, grade, configuration, presence of carcinoma in situ and angiolymphatic invasion were determined., Results: The majority of patients (80%) had invasive or high-grade tumours. Carcinoma in situ was present among 30% of patients with non-invasive high-grade tumours. Angiolymphatic invasion (62%) and solid (non-papillary) growth pattern (84%) were very common among patients with stage T2-T4 tumours. Twenty-three women out of 138 (16.7%) with ureteral carcinoma had a history of abdominal radiotherapy for gynaecological cancer 22 years (median) earlier. Forty-one patients out of 930 (4.4%) had a history of abuse of phenacetin-containing analgesics., Conclusions: This study demonstrates a very high incidence of high-grade upper tract tumours with carcinoma in situ, angiolymphatic invasion and solid (non-papillary) growth pattern, which underscores the malignant character of the disease. The possible association between pelvic radiotherapy and ureteral carcinoma warrants further study.