Forced expiratory flows and volumes in a Swedish cohort of healthy term infants

BACKGROUND

The use of pulmonary function tests (PFTs) in infants has increased during the last decades, making the need for equipment- and ethnic-specific reference data mandatory for appropriate interpretation of the results.

AIM

Our aim was to investigate how well the already published reference equations for infant spirometry fit a healthy population of Swedish infants.

METHOD

We performed forced tidal and raised volume expiratory maneuvers in healthy infants using Jaeger BabyBody equipment.

RESULTS

PFT data were collected from 91 healthy infants aged between 3 months to 2 years at 143 occasions. Mean (standard deviation) z-scores were 0.68(1.33) for maximal flow at functional residual capacity (V'_max FRC), -0.15(0.96) for forced vital capacity (FVC), 0.40(1.33) for the forced expired volume in the initial 0.5 seconds (FEV_0.5 ) and 0.52(0.93) for the ratio FEV_0.5 /FVC, respectively. Z-scores for all indices but FEV_0.5 /FVC were highly dependent on length.

CONCLUSIONS

We have shown that the use of previously published reference equations may result in an age-related misinterpretation of lung function measure in a Swedish infant population.

Bilateral Risk-Reducing Mastectomies with Implant-Based Reconstructions Followed Long Term: A Consecutive Series of 185 Patients

BACKGROUND

Bilateral risk-reducing mastectomy (BRRM) is the most effective method to prevent breast cancer in genetically predisposed women and is often performed concomitantly with breast reconstruction. The reconstruction time varies and corrective surgeries are common.

METHODS

This study evaluated 185 consecutive cases of BRRM and immediate breast reconstruction with implants with regard to surgical outcome and resource consumption. With an 18-year observation period, it was possible to compare permanent expander implants (PEIs) with permanent fixed volume implants (PIs).

RESULTS

A minimum follow-up of 2 years for all participants but one was achieved. Seventy-five percent (n = 138) of the women received PEI and 25% (n = 47) PI. In a multivariate analysis including age, BMI (<25, ≥25), smoking (yes, no), implant type (PEI, PI), incision technique, operation time and specimen weight <350 g, ≥350 g), only BMI ≥25 was associated with an increased risk of an early complication (OR 7.1, 95% CI 2.44-20.4). As expected, there was a significant difference in median reconstruction time between PEI and PI (12.4 vs. 1.0 months, p < 0.001). The cumulative reoperation-free 2-year survival was significantly higher in the PI than in the PEI group (81% vs. 26%, p < 0.001).

CONCLUSION

Implant-based reconstruction remains a valid option after BRRM in high-risk women. Whenever possible (low BMI and small breast volume without severe ptosis), permanent fixed volume implants can be safely recommended and are resource saving in comparison with permanent expander implants.

Blood Pressure After Endovascular Thrombectomy: Modeling for Outcomes Based on Recanalization Status

Background and Purpose- The optimal level for blood pressure after endovascular thrombectomy in acute ischemic stroke is not well established. We sought to evaluate the association of post-endovascular thrombectomy systolic blood pressure (SBP) levels with clinical outcomes. Methods- We included endovascular thrombectomy-treated patients registered from 2014 to 2017 in the Safe Implementation of Treatments in Stroke International Thrombectomy Registry. The mean 24-hour SBP after endovascular thrombectomy treatment was analyzed both as a continuous variable and in intervals. The primary outcome was 3-month functional independence (modified Rankin Scale score of 0-2). The secondary outcomes were symptomatic intracerebral hemorrhage (SICH) and 3-month mortality. The SBP interval with the highest proportion of functional independence was chosen as reference. All analyses were performed for successful or unsuccessful recanalization (modified Treatment in Cerebral Ischemia score ≥2b or <2b, respectively). The results were adjusted for known confounders in logistic regression models. Results- In the multivariable analyses, a higher SBP value as a continuous variable was associated unfavorably with all outcomes in patients with successful recanalization (n=2920) and with more SICH in patients with unsuccessful recanalization (n=711). SBP interval ≥160 mm Hg was associated with less functional independence (adjusted odds ratio, 0.28 [95% CIs, 0.15-0.53]) and more SICH (adjusted odds ratio, 6.82 [95% CIs, 1.53-38.09]) compared with reference 100 to 119 mm Hg in patients with successful recanalization. SBP ≥160 mm Hg was associated with more SICH (adjusted odds ratio, 6.62 [95% CIs, 1.07-51.05]) compared with reference 120 to 139 mm Hg in patients with unsuccessful recanalization. Conclusions- Higher SBP values were associated with less functional independence at 3 months in patients with successful recanalization and with more SICH regardless of recanalization status.

Predicting the duration of sickness absence spells due to back pain: a population-based study from Sweden

Objectives

We aimed to develop and validate a prediction model for the duration of sickness absence (SA) spells due to back pain (International Statistical Classification of Diseases and Related Health Problems 10th Revision: M54), using Swedish nationwide register microdata.

Methods

Information on all new SA spells >14 days from 1 January 2010 to 30 June 2012 and on possible predictors were obtained. The duration of SA was predicted by using piecewise constant hazard models. Nine predictors were selected for the final model based on a priori decision and log-likelihood loss. The final model was estimated in a random sample of 70% of the SA spells and later validated in the remaining 30%.

Results

Overall, 64 048 SA spells due to back pain were identified during the 2.5 years; 74% lasted ≤90 days, and 9% >365 days. The predictors included in the final model were age, sex, geographical region, employment status, multimorbidity, SA extent at the start of the spell, initiation of SA spell in primary healthcare and number of SA days and specialised outpatient healthcare visits from the preceding year. The overall c-statistic (0.547, 95% CI 0.542 to 0.552) suggested a low discriminatory capacity at the individual level. The c-statistic was 0.643 (95% CI 0.634 to 0.652) to predict >90 days spells, 0.686 (95% CI 0.676 to 0.697) to predict >180 spells and 0.753 (95% CI 0.740 to 0.766) to predict >365 days spells.

Conclusions

The model discriminates SA spells >365 days from shorter SA spells with good discriminatory accuracy.

Effect of radiotherapy for rectal cancer on female sexual function: a prospective cohort study

Background

Clinical experience and limited data show that female sexual function is influenced negatively by preoperative radiotherapy (RT) for rectal cancer. The aim of this prospective study was to investigate the impact of RT on sexual function and ovarian reserve measured by levels of anti-Müllerian hormone (AMH).

Methods

Women with stage I–III rectal cancer scheduled for surgery with or without preoperative (chemo)RT were included and followed for 2 years. Female Sexual Function Index (FSFI) questionnaire responses and blood samples for hormone analyses, including AMH in women aged 45 years or less, were collected at baseline and during follow-up.

Results

In the group of 109 women who received preoperative RT, median scores in all FSFI domains decreased over time, as did the total FSFI score (from 18·5 (range 2·0–36·0) at baseline to 10·8 (2·0–34·8) at 2 years; P &lt; 0·001). In the group of 30 women who did not receive preoperative RT, only satisfaction declined over time (from 3·2 (0·8–6·0) to 1·8 (0·8–6·0); P = 0·012). In longitudinal regression analysis, the mean decline in FSFI total score was –9·33 (95 per cent c.i. –16·66 to –1·99; P = 0·013) for women who had preoperative RT compared with those who did not, with adjustment for age, Psychological General Well-being Index score and relationship with partner. A corresponding association was seen for arousal, lubrication, orgasm and pain. Five of six women aged 45 years or less with detectable serum levels of AMH at baseline had undetectable levels after RT.

Conclusion

Preoperative RT was associated with impairment in sexual function in women with rectal cancer. This needs to be considered when discussing choice of treatment and rehabilitation. In younger women, undetectable AMH levels after RT indicate an irreversible loss of ovarian follicles.

Clinical risk assessment in early pregnancy for preeclampsia in nulliparous women: A population based cohort study

Objective

To evaluate the capacity of multivariable prediction of preeclampsia during pregnancy, based on detailed routinely collected early pregnancy data in nulliparous women.

Design and setting

A population-based cohort study of 62 562 pregnancies of nulliparous women with deliveries 2008–13 in the Stockholm-Gotland Counties in Sweden.

Methods

Maternal social, reproductive and medical history and medical examinations (including mean arterial pressure, proteinuria, hemoglobin and capillary glucose levels) routinely collected at the first visit in antenatal care, constitute the predictive variables. Predictive models for preeclampsia were created by three methods; logistic regression models using 1) pre-specified variables (similar to the Fetal Medicine Foundation model including maternal factors and mean arterial pressure), 2) backward selection starting from the full suite of variables, and 3) a Random forest model using the same candidate variables. The performance of the British National Institute for Health and Care Excellence (NICE) binary risk classification guidelines for preeclampsia was also evaluated. The outcome measures were diagnosis of preeclampsia with delivery <34, <37, and ≥37 weeks’ gestation.

Results

A total of 2 773 (4.4%) nulliparous women subsequently developed preeclampsia. The pre-specified variables model was superior the other two models, regarding prediction of preeclampsia with delivery <34 and <37 weeks, both with areas under the curve of 0.68, and sensitivity of 30.6% (95% CI 24.5–37.2) and 29.2% (95% CI 25.2–33.4) at a 10% false positive rate, respectively. The performance of these customizable multivariable models at the chosen false positive rate, was significantly better than the binary NICE-guidelines for preeclampsia with delivery <37 and ≥37 weeks’ gestation.

Conclusion

Multivariable models in early pregnancy had a modest performance, although providing advantages over the NICE-guidelines, in predicting preeclampsia in nulliparous women. Use of a machine learning algorithm (Random forest) did not result in superior prediction.

Tissue immune profiles supporting response to mesenchymal stromal cell therapy in acute graft-versus-host disease-a gut feeling

Acute graft-versus-host disease (aGvHD), post-allogeneic hematopoietic stem cell transplantation, is associated with high mortality rates in patients not responding to standard line care with steroids. Adoptive mesenchymal stromal cell (MSC) therapy has been established in some countries as a second-line treatment.

Limitations in our understanding as to MSC mode of action and what segregates patient responders from non-responders to MSC therapy remain. The principal aim of this study was to evaluate the immune cell profile in gut biopsies of patients diagnosed with aGvHD and establish differences in baseline cellular composition between responders and non-responders to subsequent MSC therapy.

Our findings indicate that a pro-inflammatory immune profile within the gut at the point of MSC treatment may impede their therapeutic potential. These findings support the need for further validation in a larger cohort of patients and the development of improved biomarkers in predicting responsiveness to MSC therapy.

Stepped Care Internet-Delivered vs Face-to-Face Cognitive-Behavior Therapy for Pediatric Obsessive-Compulsive Disorder: A Trial Protocol for a Randomized Noninferiority Trial

Importance

Internet-delivered cognitive behavior therapy is an effective treatment for children and adolescents with obsessive-compulsive disorder and has the potential to markedly increase access to treatment for patients while being cost-effective for health care organizations.

Objective

To investigate whether internet-delivered cognitive behavior therapy implemented within a stepped care model is noninferior to, and cost-effective compared with, the gold standard of face-to-face cognitive behavior therapy for pediatric obsessive-compulsive disorder.

Design, Setting, and Participants

Multicenter, single-blind, randomized clinical noninferiority trial implemented at 2 specialist pediatric obsessive-compulsive disorder clinics in Stockholm and Gothenburg, Sweden. Participants are 152 children and adolescents aged 7 to 17 years with obsessive compulsive disorder, recruited through the 2 clinics and online self-referral. Patients will be randomized 1:1 to the stepped care intervention or face-to-face therapy. Blind evaluations will be conducted after treatment and at 3-month and 6-month follow-ups. At the 6-month follow-up (primary end point), noninferiority will be tested and resource use will be compared between the 2 treatment groups. Data will be analyzed according to intention-to-treat principles.

Intervention

Patients randomized to stepped care will first receive internet-delivered cognitive behavior therapy for 16 weeks; patients who are classified as nonresponders 3 months after treatment completion will receive additional face-to-face therapy. The control group will receive 16 weeks of face-to-face cognitive behavior therapy immediately following randomization and nonresponders at the 3-month follow-up will, as in the stepped care group, receive additional face-to-face therapy.

Main Outcomes and Measures

Noninferiority is defined as a 4-point difference on the primary outcome measure (Children's Yale-Brown Obsessive Compulsive Scale).

Discussion

Recruitment started October 6, 2017, and was completed May 24, 2019. Results from the primary end point will be available by May 2020. The naturalistic follow-ups (1, 2, and 5 years after the end of treatment) will continue to 2025. There are no interim analyses planned or stopping rules for the trial.

Trial Registration

ClinicalTrials.gov identifier: NCT03263546.

P4154MicroRNA Signatures Predict Early Major Coronary Events in Middle Aged Men and Women

Background

The role of microRNA as biomarkers able to predict major coronary events (MACE) has not been fully elucidated, reproducibility being a critical issue.

Aim

To identify circulating microRNA signatures able to predict MACE.

Methods

We employed a PCR-based method to screen 754 microRNAs in a cohort of 60-year-olds (60YOs) from Stockholm, using a nested case-control design (100 cases vs 100 matched controls). The association of microRNAs and their interaction with the risk of MACE (myocardial infarction (MI), angina and sudden cardiac death) was estimated with random-effect logistic regression and expressed as OR with 95% CI. A bioinformatics approach identified microRNA clusters based on predicted targets. Main findings were tested in 58 MI and 60 age and sex matched referents from the the Nord-Trøndelag Health (HUNT) Study, a longitudinal population health study conducted in Norway.

Results

Fifty-five microRNAs were found to be associated with risk of MACE in the 60YO. MicroRNA-145-3p was associated with the largest estimated risk increase of MACE after adjustment for the common CV risk factors (OR: 2.18; 95% CI: 1.27–3.75). Interaction analysis revealed that increasing plasma levels of microRNA-320b modulated the association of 16 microRNAs with risk of MACE. As an example the estimated MACE risk associated with microRNA-145-3p was 1.47 (0.87–2.47) in the presence of low (<25th percentile) and 4.00 (1.79- 8.93) in the presence of high (>75th percentile) miRNA 320b expression levels. Sixteen microRNA pairs could be classified in 4 functional clusters with 492 predicted gene targets, mainly involved in the regulation of inflammation, thrombosis and lipid metabolism. Eight miRNAs interacting pairs belonging to cluster 2 and 4 showed a similar association trend with MI risk in the HUNT study.

Conclusions

We report the identification of microRNA signatures predicting risk of MACE in middle-aged Scandinavian men and women. These signatures could be a valuable tool to improve CV disease prediction in the aged.

P655High lipoprotein(a) plasma levels is associated with higher prevalence of cardiovascular disease and poor metabolic control in patients with type 1 diabetes

Background

Lipoprotein(a) [Lp(a)] is a cardiovascular risk factor that has been shown to correlate to cardiovascular disease and aortic valve disease. Plasma levels of Lp(a) has a skewed distribution, is highly influenced by genetic inheritance and is not considered to be affected by age, sex or lifestyle. Its importance for the development of vascular complications in patients with type 1 diabetes is unknown.

Purpose

To assess the contribution of Lp(a) to cardiovascular disease, microvascular complications, aortic valve disease in patients with type 1 diabetes mellitus, and to assess the relationship between diabetes metabolic control and Lp(a) levels.

Methods

We included 1857 consecutive type 1 diabetes patients receiving regular care at our out-patient clinic, department of Endocrinology, into an observational cross sectional registry study. Patient characteristics, cardiovascular history and Lp(a) measurement was extracted from their electronic medical charts. Patients were divided into four groups according to their Lp(a) levels in nmol/L (Very Low <10; Low 10–30; Intermediate 30–120; High >120) and statistical analysis was performed comparing the prevalence of mikro- and makrovascular complications between the groups. The relationship between Lp(a) and diabetes control measured as HbA1c (mmol/mol) was studied by comparing the subgroups with good (<52), average (52–70) and poor (>70) metabolic control.

Results

The mean (SD) age and diabetes duration in the cohort was 49.9 (15.8) years and 26.7 (15.5) years, respectively, and the Lp(a) median (inter quartile range) was 20.4 (7.8–75.1) nmol/L. Patients in the high Lp(a) group had significantly higher prevalence of cardiovascular and microvascular complications compared to patients with very low levels. The relative risk (confidence interval) increase to be affected by ischemic heart disease was 2.42 (1.41–4.15) (p=0.001), by albuminuria 1.87 1.26–2.78) (p=0.002) and by aortic valve disease 2.96 (1.53–5.78) (p=0.001). The relationship between Lp(a) and vascular complications was sustained when data was adjusted for age and smoking status between the groups albeit at a weaker level. No significant relationship was detected between cerebrovascular disease or the microvascular complications retinopathy and neuropathy and Lp(a) levels. Significantly higher Lp(a) levels were observed in patients with poor and average metabolic control compared to patients with good control (p<0.05). The 80:th percentile of Lp(a) was 78.6 nmol/L, 105.2 nmol/L and 100.6 nmol/L for good, average and poor metabolic control respectively (Figure 1).

Figure 1. Lp(a) levels in relation to HbA1c

Conclusions

Lp(a) is a significant risk factor for cardiovascular complications and aortic valve disease in patients with type 1 diabetes. Poor metabolic control of the diabetes disease is associated to high Lp(a) levels.

Acknowledgement/Funding

Swedish Heart Foundation (PP), The Swedish Research Council (PP), Karolinska Institutet (PP, JB), Investigator initiated study grant from Sanofi (JB)

Picky eating in an obesity intervention for preschool-aged children - what role does it play, and does the measurement instrument matter?

INTRODUCTION

Research on picky eating in childhood obesity treatment is limited and inconsistent, with various instruments and questions used. This study examines the role of picky eating in a randomized controlled obesity intervention for preschoolers using subscales from two instruments: The Child Eating Behavior Questionnaire (CEBQ) and the Lifestyle Behavior Checklist (LBC).

METHOD

The study includes 130 children (mean age 5.2 years (SD 0.7), 54% girls, mean Body Mass Index (BMI) z-score 2.9 (SD 0.6)) and their parents (nearly 60% of non-Swedish background, 40% with university degree). Families were randomized to a parent-group treatment focusing on evidence-based parenting practices or to standard treatment focusing on lifestyle changes. The children's heights and weights (BMI z-score) were measured at baseline, and at 3, 6 and 12 months post baseline. At these time-points, picky eating was reported by parents using the CEBQ (Food Fussiness scale, 6 items) and 5 items from the LBC. Child food intake was reported with a Food Frequency Questionnaire (FFQ). Pearson correlation was used to study associations between baseline picky eating and baseline BMI z-scores and food intake. Mixed effects models were used to study associations between the two measurements of picky eating and changes in picky eating, to assess the effects of changes in picky eating on BMI z-scores, and to evaluate baseline picky eating as a predictor of changes in BMI z-scores.

RESULTS

Neither the standard treatment nor the parent-group treatment reduced the degree of picky eating (measured with CEBQ or LBC). Baseline picky eating measured with the CEBQ was associated with a lower BMI z-score and lower intake of vegetables. Children with a higher degree of picky eating at baseline (measured with the CEBQ) displayed a lower degree of weight loss. When degree of picky eating was examined, for 25% of the children, the CEBQ and the LBC yielded diverging results.

CONCLUSIONS

Baseline picky eating may weaken the effectiveness of obesity treatment, and assessments should be conducted before treatment to adjust the treatment approach. Different measurements of picky eating may lead to different results. The CEBQ seems more robust than the LBC in measuring picky eating.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT01792531. Registered 15 February 2013 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT01792531.

Adherence to oxygen saturation targets increased in preterm infants when a higher target range and tighter alarm limits were introduced

AIM

European consensus guidelines published in May 2013 recommended a target peripheral capillary oxygen saturation (SpO₂ ) range of 90-95% for preterm infants. These were incorporated into guidelines at the Karolinska University Hospital, Sweden, in November 2013. This study compared clinical practice before and after those local guidelines.

METHODS

We included infants who were born between 23 + 0 and 30 + 6 weeks from January 1, 2013 to December, 31 2015 and received intensive care in two Karolinska units. The lower saturation target of 88-92% and alarm limits of 85-95% used before November 2013 were compared to the new higher saturation target of 90-95% and alarm limits of 89-96%.

RESULTS

Data from 399 infants were analysed. The mean SpO₂ was 92.4% with the higher target (n = 301) and 91.1% with the lower target (n = 98). Using the higher instead of lower target meant that the SpO₂ was within the prescribed target range more frequently (51% versus 30%) and the proportion of time with SpO₂ >95% was increased by 9% (95% confidence interval 7-11%, p < 0.001).

CONCLUSION

The higher saturation target and tighter alarm limits led to higher mean oxygen saturation, increased adherence to the target and increased time with hyperoxaemia.

Sex differences in repair rates and outcomes of patients with ruptured abdominal aortic aneurysm

BACKGROUND

Data are conflicting on sex differences in ruptured abdominal aortic aneurysm (rAAA) repair rates and outcomes have rarely been addressed. The aim of this study was to investigate differences in the management and outcome of rAAA in men and women, and to describe time trends over a 15-year interval.

METHODS

Data on patients with rAAA were extracted from the Swedish National Patient Registry and the Cause of Death Registry for the interval 2001-2015. The study included patients with rAAA whether or not they were admitted to any hospital in Sweden. A propensity score-matched model was used to determine sex differences in repair type and outcome after rupture. Time trends for rAAA events and mortality were investigated.

RESULTS

Some 10 724 patients were identified. A higher percentage of men were admitted to hospital (79·8 versus 77·5 per cent; P = 0·011). Of those admitted, a higher percentage of men than women were treated (56·6 versus 40·4 per cent, P < 0·001). Women were less likely to be treated when diagnosed with rAAA (average treatment effect (ATE) in the model -0·080, 95 per cent c.i. -0·106 to -0·055; P < 0·001). Thirty-day mortality was also higher in women (ATE 0·094, 0·053 to 0·135; P < 0·001); this effect persisted to 1 year (ATE 0·095, 0·052 to 0·137; P < 0·001). Time trends indicated a decrease in rAAA incidence, mostly owing to a decrease among men.

CONCLUSION

In this study, fewer women with rAAA received surgery and 30-day mortality was higher than in men. There was an overall decrease in rAAA incidence, principally in men.

Prearrest prediction of favourable neurological survival following in-hospital cardiac arrest: The Prediction of outcome for In-Hospital Cardiac Arrest (PIHCA) score

BACKGROUND

A prearrest prediction tool can aid clinicians in consolidating objective findings with clinical judgement and in balance with the values of the patient be a part of the decision process for do-not-attempt-resuscitation (DNAR) orders. A previous prearrest prediction tool for in-hospital cardiac arrest (IHCA) have not performed satisfactory in external validation in a Swedish cohort. Therefore our aim was to develop a prediction model for the Swedish setting.

METHODS

Model development was based on previous external validation of The Good Outcome Following Attempted Resuscitation (GO-FAR) score, with 717 adult IHCAs. It included redefinition and reduction of predictors, and addition of chronic comorbidity, to create a full model of 9 predictors. Outcome was favourable neurological survival defined as Cerebral Performance Category score 1-2  at discharge. The likelihood of favourable neurological survival was categorised into very low (<1%), low (1-3%) and above low (>3%).

RESULTS

We called the model the Prediction of outcome for In-Hospital Cardiac Arrest (PIHCA) score. The AUROC was 0.808 (95% CI 0.807-0.810) and calibration was satisfactory. With a cutoff of 3% likelihood of favourable neurological survival sensitivity was 99.4% and specificity 8.4%. Although specificity was limited, predictive value for classification into ≤3% likelihood of favorable neurological survival was high (97.4%) and false classification into ≤3% likelihood of favourable neurological survival was low (0.6%).

CONCLUSION

The PIHCA score has the potential to be used as an objective tool in prearrest prediction of outcome after IHCA, as part of the decision process for a DNAR order.

Statin Use Is Associated With Improved Outcomes of Patients With Primary Sclerosing Cholangitis

BACKGROUND & AIMS

There is increasing evidence that statins can benefit patients with chronic liver diseases, but their effects have not been studied in patients with primary sclerosing cholangitis (PSC). We performed a nationwide study in Sweden to determine the effects of exposure to drugs, including statins, in patients with PSC.

METHODS

We studied a population-based cohort of patients in Sweden with PSC and concomitant ulcerative colitis or Crohn's disease from 2005 through 2014 (n = 2914), followed through 2016. We collected analyzed data from the patient register, the prescribed drug register, the death certificate register and the cancer register. We calculated risk or death, liver transplantation, bleeding of esophageal varices, and cancer in relation to drug exposure.

RESULTS

The mean age of patients at the time of diagnosis with PSC was 41.4 years (inter-quartile range [IQR], 25.6-56.1 years). The total follow-up time was 11769 person-years, during which 3.4% of patients received liver transplants and 19.9% died. Proportions of patients exposed to drugs were: ursodeoxycholic acid, 60.2%; 5-aminosalicylic acid, 74.4%; azathioprine or mercaptopurins, 33.7%; and statins, 13.9%. Statin use was associated with a reduced risk of all-cause mortality (hazard ratio [HR], 0.68; 95% CI, 0.54-0.88) and death or liver transplantation (HR, 0.50; 95% CI, 0.28-0.66). Use of azathioprine was also associated with reduced mortality (HR, 0.66; 95% CI, 0.52-0.84) and risk of death or liver transplantation (HR, 0.65; 95% CI, 0.50-0.83). Exposure to ursodeoxycholic acid did not affect mortality (HR, 1.04; 95% CI, 0.87-1.25).

CONCLUSION

In a population-based cohort of patients in Sweden with PSC, we associated use of statins and azathioprine with decreased risks of death and death or liver transplantation. Exposure to ursodeoxycholic acid was not associated with reduced mortality.

Acute primary testicular failure due to radiotherapy increases risk of severe postoperative adverse events in rectal cancer patients

AIM

The aim of this study is to analyze postoperative adverse events (AE) in relation to acute primary testicular failure after radiotherapy (RT) for rectal cancer.

METHOD

This relation was assessed in 104 men, included in a previous prospective cohort study of men treated with surgical resection of the rectum for rectal cancer stage I-III. Postoperative AE were graded according to Clavien-Dindo (2004). Grade 3 or more was set as cut-off for severe postoperative AE. The impact of primary testicular failure on postoperative AE was related to the cumulative mean testicular dose (TD) and the change in Testosterone (T) and Luteinizing hormone (LH) sampled at baseline and after RT.

RESULTS

Twenty-six study participants (25%) had severe postoperative AE. Baseline characteristics and endocrine testicular function did not differ significantly between groups with (AE+) and without severe postoperative AE (AE-). After RT, the LH/T-ratio was higher in AE+, 0.603 (0.2-2.5) vs 0.452 (0.127-5.926) (p = 0.035). The longitudinal regression analysis showed that preoperative change in T (OR 0.844, 95% CI 0.720-0.990, p = 0.034), LH/T-ratio (OR 2.020, 95% CI 1.010-4.039, p = 0.047) and low T (<8 nmol/L, OR 2.605, 95 CI 0.951-7.139, p = 0.063) were related to severe postoperative AE.

CONCLUSION

Preoperative decline in T due to primary testicular failure induced by preoperative RT could be a risk factor regarding short-term outcome of surgery in men with rectal cancer.

Lack of clinically relevant correlation between subjective and objective cognitive function in ICU survivors: a prospective 12-month follow-up study

Background

Cognitive impairment and psychological distress are common in intensive care unit (ICU) survivors. Early identification of affected individuals is important, so intervention and treatment can be utilized at an early stage. Cognitive Failures Questionnaire (CFQ) is commonly used to screen for subjective cognitive function, but it is unclear whether CFQ scores correlate to objective cognitive function in this population.

Methods

Between 2014 and 2018, 100 ICU survivors aged 18–70 years from the general ICU at the Karolinska University Hospital, Solna, were included in the study. Out of these, 58 patients completed follow-up at 3 months after ICU discharge, 51 at 6 months, and 45 at 12 months. Follow-up included objective cognitive function testing using the Cambridge Neuropsychological Test Automated Battery (CANTAB) and subjective cognitive function testing with the self-rating Cognitive Failures Questionnaire (CFQ), as well as psychological self-rating with the Post-Traumatic Stress Symptoms Scale-10 (PTSS-10) and Hospital Anxiety and Depression Scale (HADS).

Results

The prevalence of cognitive impairment as measured by four selected CANTAB tests was 34% at 3 months after discharge, 18% at 6 months, and 16% at 12 months. There was a lack of significant correlation between CANTAB scores and CFQ scores at 3 months (r = − 0.134–0.207, p > 0.05), at 6 months (r = − 0.106–0.257, p > 0.05), and at 12 months after discharge (r = − 0.070–0.109, p > 0.05). Correlations between CFQ and PTSS-10 scores and HADS scores, respectively, were significant over the follow-up period (r = 0.372–0.710, p ≤ 0.001–0.023). In contrast, CANTAB test scores showed a weak correlation with PTSS-10 and HADS scores, respectively, at 3 months only (r = − 0.319–0.348, p = 0.008–0.015).

Conclusion

We found no clinically relevant correlation between subjective and objective cognitive function in this cohort of ICU survivors, while subjective cognitive function correlated significantly with psychological symptoms throughout the follow-up period. Treatment and evaluation of ICU survivors’ recovery need to consider both subjective and objective aspects of cognitive impairment, and subjective reports must be interpreted with caution as an indicator of objective cognitive function.

Estimation of Relative and Absolute Risks in a Competing-Risks Setting Using a Nested Case-Control Study Design: Example From the ProMort Study

In this paper, we describe the Prognostic Factors for Mortality in Prostate Cancer (ProMort) study and use it to demonstrate how the weighted likelihood method can be used in nested case-control studies to estimate both relative and absolute risks in the competing-risks setting. ProMort is a case-control study nested within the National Prostate Cancer Register (NPCR) of Sweden, comprising 1,710 men diagnosed with low- or intermediate-risk prostate cancer between 1998 and 2011 who died from prostate cancer (cases) and 1,710 matched controls. Cause-specific hazard ratios and cumulative incidence functions (CIFs) for prostate cancer death were estimated in ProMort using weighted flexible parametric models and compared with the corresponding estimates from the NPCR cohort. We further drew 1,500 random nested case-control subsamples of the NPCR cohort and quantified the bias in the hazard ratio and CIF estimates. Finally, we compared the ProMort estimates with those obtained by augmenting competing-risks cases and by augmenting both competing-risks cases and controls. The hazard ratios for prostate cancer death estimated in ProMort were comparable to those in the NPCR. The hazard ratios for dying from other causes were biased, which introduced bias in the CIFs estimated in the competing-risks setting. When augmenting both competing-risks cases and controls, the bias was reduced.

A prediction model for duration of sickness absence due to stress-related disorders

BACKGROUND

Stress-related disorders are leading causes of long-term sickness absence (SA) and there is a great need for decision support tools to identify patients with a high risk for long-term SA due to them.

AIMS

To develop a clinically implementable prediction model for the duration of SA due to stress-related disorders.

METHODS

All new SA spells with F43 diagnosis code lasting >14 days and initiated between 2010-01-01 and 2012-06-30 were identified through data from the Social Insurance Agency. Information on baseline predictors was linked on individual level from other nationwide registers. Piecewise-constant hazard regression was used to predict the duration of the SA. Split-sample validation was used to develop and validate the model, and c-statistics and calibration plots to evaluate it.

RESULTS

Overall 83,443 SA spells, belonging to 77,173 individuals were identified. The median SA duration was 55 days (10% were >365 days). Age, sex, geographical region, employment status, educational level, extent of SA at start and SA days, outpatient healthcare visits, and multi-morbidity in the preceding 365 days were selected to the final model. The model was well calibrated. The overall c-statistics was 0.54 (95% confidence intervals: 0.53-0.54) and 0.70 (95% confidence intervals: 0.69-0.71) for predicting SA spells >365 days.

LIMITATIONS

The heterogeneity of the F43-diagnosis and the exclusive use of register-based predictors limited our possibility to increase the discriminatory accuracy of the prediction.

CONCLUSION

The final model could be implementable in clinical settings to predict duration of SA due to stress-related disorders and could satisfyingly discriminate long-term SA.

MON-530 Hypoparathyroidism in Sweden

Introduction: Hypoparathyroidism (HP) is a rare disorder. It is characterized by low serum calcium and inappropriately low parathyroid hormone (PTH) levels. Patients with HP suffer from renal, vascular and neural complications but knowledge about the extent and prevalence of these are sparse. Sweden offers an excellent infrastructure for research in this area through merging data from different high-quality population-based registers. Calcium is always prescribed to HP patients in Sweden making correlations between calcium intake and complications possible. Purpose: The aim of this study was to examine the prevalence of complications in HP adult patients in Sweden in correlation to substitution treatment. Materials and methods: We have conducted a population-based cohort study in patients with HP in Sweden. Through the Swedish National Patient Register (SNPR) and the Swedish Prescribed Drug Register (SPDR), we identified patients with a diagnosis of HP and treatment with either 1) active vitamin D and calcium, 2) active vitamin D, calcium and PTH, 3) calcium and PTH and 4) vitamin D and calcium. For each HP patient ten controls matched by age, sex and county of residence was identified in the National Population Registry. Results: We identified a total of 406 patients who had an HP diagnosis and where alive when the SPDR started in July 2005. Of the 406 HP patients, 66 % were female and 34 % male. Mean age at the time of the HP diagnosis was 60.5 years (SD 19.6), 58.0 years (SD 21.0) for women and 61.7 years (SD 18.8) for men. 346 had combination treatment with active vitamin D and calcium, 1 had active vitamin D, calcium and PTH, 3 had calcium and PTH, 67 had vitamin D and calcium. The incidence of complications and drug prescriptions other than for HP was investigated in each group. Conclusion: This is the first study of HP using the large Swedish epidemiological registries. The admission rate and the prevalence of comorbidity are studied through the SNPR and the drug prescription patterns before and after HP diagnosis are studied through the SPDR and these are compared to controls. Disclosures: This research was supported by a grant from Shire.

Predictive models for short-term and long-term improvement in women under physiotherapy for chronic disabling neck pain: a longitudinal cohort study

OBJECTIVES

To develop predictive models for short-term and long-term clinically important improvement in women with non-specific chronic disabling neck pain during the clinical course of physiotherapy.

DESIGN

Longitudinal cohort study based on data from a randomised controlled trial evaluating short-term and long-term effects on sensorimotor function over 11 weeks of physiotherapy.

PARTICIPANTS AND SETTINGS

Eighty-nine women aged 31-65 years with non-specific chronic disabling neck pain from Gävle, Sweden.

MEASURES

The outcome, clinically important improvement, was measured with the Patient Global Impression of Change Scale (PGICS) and the Neck Disability Index (NDI), assessed by self-administered questionnaires at 3, 9 and 15 months from the start of the interventions (baseline). Twelve baseline prognostic factors were considered in the analyses. The predictive models were built using random-effects logistic regression. The predictive ability of the models was measured by the area under the receiver operating characteristic curve (AUC). Internal validity was assessed with cross-validation using the bootstrap resampling technique.

RESULTS

Factors included in the final PGICS model were neck disability and age, and in the NDI model, neck disability, depression and catastrophising. In both models, the odds for short-term and long-term improvement increased with higher baseline neck disability, while the odds decreased with increasing age (PGICS model), and with increasing level of depression (NDI model). In the NDI model, higher baseline levels of catastrophising indicated increased odds for short-term improvement and decreased odds for long-term improvement. Both models showed acceptable predictive validity with an AUC of 0.64 (95% CI 0.55 to 0.73) and 0.67 (95% CI 0.59 to 0.75), respectively.

CONCLUSION

Age, neck disability and psychological factors seem to be important predictors of improvement, and may inform clinical decisions about physiotherapy in women with chronic neck pain. Before using the developed predictive models in clinical practice, however, they should be validated in other populations and tested in clinical settings.

Mortality in IgA Nephropathy: A Nationwide Population-Based Cohort Study

BACKGROUND

The clinical course of IgA nephropathy (IgAN) varies from asymptomatic nonprogressive to aggressive disease, with up to one in four patients manifesting ESRD within 20 years of diagnosis. Although some studies have suggested that mortality appears to be increased in IgAN, such studies lacked matched controls and did not report absolute risk.

METHODS

We conducted a population-based cohort study in Sweden, involving patients with biopsy-verified IgAN diagnosed in 1974-2011; main outcome measures were death and ESRD. Using data from three national registers, we linked 3622 patients with IgAN with 18,041 matched controls; we also conducted a sibling analysis using 2773 patients with IgAN with 6210 siblings and a spousal analysis that included 2234 pairs.

RESULTS

During a median follow-up of 13.6 years, 577 (1.1%) patients with IgAN died (10.67 per 1000 person-years) compared with 2066 deaths (0.7%) in the reference population during a median follow-up of 14.1 years (7.45 per 1000 person-years). This corresponded to a 1.53-fold increased risk and an absolute excess mortality of 3.23 per 1000 person-years (equaling one extra death per 310 person-years) and a 6-year reduction in median life expectancy. Similar increases in risk were seen in comparisons with siblings and spouses. IgAN was associated with one extra case of ESRD per 54 person-years. Mortality preceding ESRD was not significantly increased compared with controls, spouses, or siblings. Overall mortality did not differ significantly between patients with IgAN-associated ESRD and patients with ESRD from other causes.

CONCLUSIONS

Patients with IgAN have an increased mortality compared with matched controls, with one extra death per 310 person-years and a 6-year reduction in life expectancy.

Outcome after intravenous thrombolysis in patients with acute lacunar stroke: An observational study based on SITS international registry and a meta-analysis

BACKGROUND

Intravenous thrombolysis (IVT) for lacunar stroke (LS) is debated, as the underlying pathophysiological mechanism may not be thrombogenic.

AIMS

To investigate outcomes after IVT in LS in the SITS International Stroke Thrombolysis Register and perform a meta-analysis.

METHODS

LS was identified by both baseline NIHSS-subscores and discharge ICD-10 codes, and contrasted by IVT to non-IVT treated. IVT patients were predominantly from Europe, non-IVT patients predominantly from South America and Asia. Outcome measurements were functional independence (modified Rankin Scale [mRS] score ≤2), excellent outcome (mRS ≤ 1), and mortality at three months. Matched-control comparisons of symptomatic intracerebral hemorrhage (SICH) between IVT-treated LS and IVT-treated non-LS patients were performed. Additionally, we performed a meta-analysis.

RESULTS

Median age for IVT-treated LS patients (n = 4610) was 66 years vs. 64 years and NIHSS score was 6 vs. 3, compared to non-IVT-treated LS (n = 1221). Univariate outcomes did not differ; however, IVT-treated LS patients had higher adjusted odds ratios (aOR) for functional independence (aOR = 1.65, 95% CI = 1.28-2.13) but similar mortality at three months (aOR = 0.57, 0.29-1.13) than non-IVT-LS. Propensity-score matched analysis showed that IVT-treated LS patients had a 7.1% higher chance of functional independency than non-IVT LS patients (p < 0.001). IVT-treated LS patients had lower odds for SICH (aOR = 0.33, 0.19-0.58 per SITS, aOR = 0.40, 0.27-0.57 per ECASS-2) than matched non-LS controls, which was mirrored in the meta-analysis.

CONCLUSIONS

Our adjusted results show that IVT treatment in LS patients was associated with better functional outcome than non-IVT-treated LS and less SICH than IVT-treated non-LS patients.