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The purpose of this study was to investigate what motivates people to sing in choirs as a leisure activity. Subjects were retrieved from members of 10 amateur choirs of various types in Iceland through a paper-based survey. Results indicated that participants gain both personal and social benefits from singing in a choir. Findings revealed differences between participants in terms of their perceptions regarding social and personal aspects of choral singing according to gender, age, level of education and music education. Personal enjoyment of singing and a positive social atmosphere seem to be the strongest motivating factors for voluntary participation in choirs.

The purpose of this paper is to demonstrate how amateur choral singers experience collective group support as a method of learning "art music" choral work. Findings are derived from a grounded-theory based, socio-musical case study of an amateur "art music" Bach Choir, in the process of rehearsing and performing the Mass in B Minor by J.S. Bach. Data collection consisted of participant observation, qualitative interviews and a paper-based survey. Findings indicate that in the process of learning a challenging choral work, participants use peer-learning as support and form supportive groups within each voice part, with "informal leaders" supporting others ("followers") who are performing the work for the first time. On the other hand, performing a challenging work can also seem "intimidating" for those less experienced singers. Findings also indicate that whereas followers (and the conductor) benefit from this group support, "leaders" may experience a certain lack of musical challenge.

In multiple myeloma (MM), advancements in treatments and toxicity management have enhanced survival rates. This, coupled with shifting age demographics in MM, necessitates an updated assessment of infection risks in MM patients compared to the general population. Using Swedish population-based registries, we investigated the incidence of infections in 8,672 Swedish symptomatic MM patients diagnosed 2008-2021 and 34,561 matched controls. Overall, MM patients had a 5-fold risk (hazard ratio [HR] =5.30; 95% confidence interval [CI]: 5.14-5.47) of developing a clinically significant infection compared to matched controls. Bacterial infections represented a 5-fold (HR=4.88; 95% CI: 4.70-5.07) increased risk, viral and fungal infections 7-fold compared to controls. The first year after MM diagnosis the risk of infections compared to controls was 7-fold (HR=6.95; 95% CI: 6.61-7.30) and remained elevated up to 5 years after the myeloma diagnosis. The risk of infection compared to controls remained 5-fold in MM patients with follow-up till 2022. Preceding MM diagnosis, the risk compared to matched controls was significantly increased up to 4 years before MM diagnosis (HR=1.16; 95% CI: 1.05-1.28). Among MM patients, 8% had died within 2 months of diagnosis and infection contributed to 32% of all deaths. After 1 year, 20% MM patients had died, and infection-related mortality was 27%. Our data constitute the largest population-based study to date on the risk of infections compared to the normal population in the era of modern MM therapies and confirms that infections still represent a major threat to patients and underscores importance of preventive strategies.

Background: A growing evidence base supports the use of autologous haematopoietic stem cell transplantation (aHSCT) for treatment of relapsing-remitting multiple sclerosis (RRMS), but it has not yet been integrated into most national clinical guidelines. The objective of this study was to assess efficacy and safety when aHSCT is implemented in routine healthcare., Methods: We assessed 231 patients and the final analysis included 174 RRMS patients who were treated with aHSCT in Sweden before 1 January 2020. Efficacy was evaluated by performing a retrospective analysis of prospectively collected data from the Swedish MS registry. Procedure-related safety was assessed by analysing data from electronic patient records covering a period of 100 days following aHSCT., Results: With a median follow-up time of 5.5 (IQR: 3.4-7.5) years, the Kaplan-Meier estimate for no evidence of disease activity was 73% (95% CI 66% to 81%) at 5 years and 65% (95% CI 57% to 75%) at 10 years. Out of the 149 patients with baseline disability, 80 (54%) improved, 55 (37%) were stable and 14 (9%) deteriorated. The mean number of adverse events per patient was 1.7 (±SD: 1.5) for grade 3 events and 0.06 (±SD: 0.3) for grade 4 events. Febrile neutropenia was the most common adverse event, affecting 68% of patients. There was no treatment-related mortality., Conclusions: Treatment with aHSCT for RRMS is associated with freedom from disease activity in a majority of patients, with acceptable adverse events. This procedure should be considered a standard of care for patients with highly active RRMS., Competing Interests: Competing interests: EI has received speakers fee from Merck and honoraria from advisory boards for Sanofi-Aventis, Biogen and Merck. FP previously received research grants from Merck KGaA, Janssen and UCB outside this study. FP has received payment for expert testimony from Novartis. FP has participated in Data Monitoring Committee for clinical trials from Chugai, Lundbeck and Roche. JM has received lecture honorarium from Merck. NL has received honoraria from Sanofi. All other individual authors declare that there is no conflict of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The immunogenicity of repeated vaccination and hybrid immunity in vulnerable patients remains unclear., Methods: We studied the impact of iterative Covid-19 mRNA vaccination and hybrid immunity on antibody levels in immunosuppressed subjects. Patients with liver cirrhosis ( n  = 38), survivors of allogeneic haematopoietic stem cell transplantation (allo-HSCT) ( n  = 36) and patients with autoimmune liver disease ( n  = 14) along with healthy controls ( n  = 20) were monitored for SARS-CoV-2-S1 IgG after their 1st-3rd vaccine doses, 31 of whom became infected with the Omicron variant after the 2nd dose. Ten uninfected allo-HSCT recipients received an additional 4th vaccine dose., Results: Unexpectedly, immunosuppressed patients achieved antibody levels in parity with controls after the 3rd vaccine dose. In all study cohorts, hybrid immunity (effect of vaccination and natural infection) resulted in approximately 10-fold higher antibody levels than vaccine-induced immunity alone., Conclusions: Three doses of the Covid-19 mRNA vaccine entailed high antibody concentrations even in immunocompromised individuals, and hybrid-immunity resulted further augmented levels than vaccination alone. Clinical trial registration: EudraCT 2021-000349-42.

Thrombotic thrombocytopenic purpura (TTP) is a rare life-threatening thrombotic microangiopathy (TMA) characterized by a microangiopathic hemolytic anemia and severe thrombocytopenia, due to platelet consumption. Microthrombi form in small vessels, leading to organ ischemia, most commonly in the central nervous system (CNS). The pathophysiology of TTP is related to a deficiency of ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13), an enzyme that cleaves the von Willebrand multimer. In the absence of ADAMTS13, the von Willebrand multimer is unfolded into an elongated active form that causes platelet activation and aggregation in arterioles and capillaries. Acquired TTP is caused by autoantibodies against ADAMTS13.  The hemolytic anemia is typically DAT-negative and caused by shattering of erythrocytes when passing the microthrombi. Rapid recognition is crucial for the outcome and to initiate the appropriate treatment. It may take several days to get the test results for ADAMTS13 and when there is a high clinical probability for TTP, plasmapheresis must be initiated pending test results. PLASMIC score can be used in determining the probability of low ADAMTS13 in a hospitalized patient with thrombocytopenia and hemolysis to identify the patients that could benefit from early TTP-specific treatment.  First line treatment for acute TTP includes daily plasma exchange, steroids and rituximab. Caplacizumab is an anti-von-Willebrand factor-directed antibody fragment that targets the A1 domain of the von Willebrand factor, thereby inhibiting the interaction between von Willebrand factor multimers and platelets. The treatment has been shown to have beneficial effects when added to standard treatment, without having immunosuppressive effects.

Introduction: In the coming years, an increase in the number of cancer cases can be expected in Iceland. It is important to gain more insight into the experiences of the diagnostic- and treatment phase among those diagnosed with cancer to improve quality of life and life expectancy., Methods: The study included 4575 individuals diagnosed with cancer between 2015 and 2019 in Iceland, 18 years or older at the time. Participants answered an on-line questionnaire once between 2020 and 2021., Results: A total of 1672 (37%) individuals responded to the questionnaire. The mean age at diagnosis was 59 years (±12). The majority of participants were informed on their cancer diagnosis during a doctor's appointment (67%), but a quarter (25%) received the information by telephone. A total of 77% of participants were satisfied with the diagnostic process, thereof relatively fewer women than men (73% vs. 83%) (p<0,001). Fewer of those who received the cancer diagnosis by telephone were pleased with the diagnostic process (62%) compared with those receiving information during a doctor's appointment (85%) (p<0,001). More women (58%) than men (33%) expressed the need for support regarding mental well-being from healthcare professionals during the diagnostic process (p<0.001). In 2015, 36% of participants started treatment more than month after diagnosis, compared with 51% in 2019. The need for various specific resources during treatment, e.g. physiotherapy, psychological services or nutritional counseling were regularly assessed among 20-30% of participants., Conclusion: A quarter of respondents diagnosed with cancer received information about the diagnosis over the phone instead of an interview. There is a suggestion that the time from diagnosis to the start of cancer treatment is increasing. It is necessary to assess whether it is possible to support individuals with cancer better during the diagnostic- and treatment phase based on their individual needs.

Objective: To compare outcomes after treatment with autologous haematopoietic stem cell transplantation (AHSCT) and alemtuzumab (ALZ) in patients with relapsing-remitting multiple sclerosis., Methods: Patients treated with AHSCT (n=69) received a conditioning regimen of cyclophosphamide (200 mg/kg) and rabbit anti-thymocyte globulinerG (6.0 mg/kg). Patients treated with ALZ (n=75) received a dose of 60 mg over 5 days, a repeated dose of 36 mg over 3 days after 1 year and then as needed. Follow-up visits with assessment of the expanded disability status scale score, adverse events and MR investigations were made at least yearly., Results: The Kaplan-Meier estimates of the primary outcome measure 'no evidence of disease activity' was 88% for AHSCT and 37% for ALZ at 3 years, p<0.0001. The secondary endpoint of annualised relapse rate was 0.04 for AHSCT and 0.1 for ALZ, p=0.03. At last follow-up, the proportions of patients who improved, were stable or worsened were 57%/41%/1% (AHSCT) and 45%/43%/12% (ALZ), p=0.06 Adverse events grade three or higher were present in 48/69 patients treated with AHSCT and 0/75 treated with ALZ in the first 100 days after treatment initiation. The most common long-term adverse event was thyroid disease with Kaplan-Meier estimates at 3 years of 21% for AHSCT and 46% for ALZ, p=0.005., Conclusions: In this observational cohort study, treatment with AHSCT was associated with a higher likelihood of maintaining 'no evidence of disease activity'. Adverse events were more frequent with AHSCT in the first 100 days, but thereafter more common in patients treated with ALZ., Competing Interests: Competing interests: AM-L has received compensation for lectures and/or service on advisory boards Roche, Sanofi, Merck Serono, Biogen and Teva. LN has received lecture honoraria from Biogen and Novartis and served on advisory boards for Merck. CM has received compensation for lectures, service on advisory boards and/or travel expenses from Sanofi-Genzyme, Merck, Novartis and Roche. MA has received compensation for lectures and/or service on advisory boards from Biogen, Genzyme, and Novartis. JL has received travel support and/or lecture honoraria from Biogen, Novartis, Merck, Alexion, Roche and SanofiGenzyme; has served on scientific advisory boards for Biogen, Novartis, Merck, Roche, BSM and SanofiGenzyme; serves on the editorial board of the Acta Neurologica Scandinavica; has received unconditional research grants from Biogen, and Novartis., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)