Repeated hospital admission for intentional poisonings among older adults - a Swedish national register-based study

BACKGROUND

Poisoning injuries is an increasing concern among older people, and so is the repetition of intentional poisonings. To date, few studies have documented the pattern and individual risk factors for repeated poisonings. This national study aims to shed light on the burden, pattern, and health-related risk factors of repeated intentional poisoning leading to hospitalization or death among older Swedish adults (50 years and older), with a focus on the year following a first event.

METHODS

We conducted a nationwide register-based cohort study of people aged 50-100, hospitalized for intentional poisoning (ICD10: X60-69) during 2006-2016 (n = 15,219) and re-hospitalized by poisoning of any intent within a year (n = 1710), i.e., up to the end of 2017. We considered in turn, the distribution of the second poisoning in 30-day intervals stratified by intent; poisoning lethality within a month and a year; and the sex-specific association between health conditions and being re-hospitalized for intentional poisoning within one year as compared to being hospitalized only once using logistic regression (odds ratios (OR) with 95% confidence intervals (95% CI)).

RESULTS

Following an intentional poisoning, re-hospitalization within a year was predominantly for a new intentional poisoning (89.7%) and occurred most typically within a month (median 4 days). Death within 30 days occurred in similar proportion for the first and second poisoning (2.3% vs. 2.1% respectively). Among both men and women, comorbidity of psychiatric illness was strongly associated with re-hospitalization for intentional poisoning (adjusted ORs = 1.70; 95% CI = 1.45-2.01 and 1.89 (95% CI = 1.60-2.19) respectively).

CONCLUSION

Most re-hospitalizations within a year after intentional poisoning are also for intentional poisoning and occur most typically within days. Re-hospitalization is associated with several conditions that are characteristic of poor mental health and there are more similarities than differences between men and women in that respect.

Cardiovascular Disease and Risk Factors in Individuals With a History of Out-of-home Care

BACKGROUND

Exposure to childhood out-of-home care (foster family and residential care) is associated with an increased risk of ill-health and disability in adulthood, but the risk for cardiovascular disease has not previously been studied longitudinally.

METHODS

This was a national cohort study generated from linkage of a range of population-based registers, resulting in a national cohort of 881 731 of whom 26 310 (3.0%) had a history of out-of-home care. The study population, born 1972 to 1981, was followed from age 18 to age 39 to 48 years for hospitalizations and death.

RESULTS

After adjusting for year of birth and maternal education, individuals with a history of childhood out-of-home-care experienced a doubling of the risk for coronary disease (hazard ratio; 95% confidence interval: 2.05; 1.74-2.41) and stroke (hazard ratio 1.85; 1.59-2.15), compared with the general population, with similar estimates for men and women. Women with a history of out-of-home care had a more than doubled risk for cigarette smoking in early pregnancy, with a relative risk of 2.26; (2.18-2.34) and a moderately increased risk for gestational diabetes relative risk 1.49 (1.19-1.86). There was marked attenuation (40% to 90%) in effect estimates for disease and risk factors after further control for cohort members educational achievement at age 15-16 years.

CONCLUSIONS

A history of childhood out-of-home care was associated with a doubled risk of early cardiovascular disease events. Cigarette smoking and educational underachievement were the main identified risk factors.

Accuracy of the Swedish quality registry for caries and periodontal diseases (SKaPa) - evaluation in 6- and 12-year-olds in the region of Värmland, Sweden

OBJECTIVES

This study evaluates the agreement of data on dental caries between electronic dental records and data retrieved from the national SKaPa-registry (Swedish Quality Registry for caries and periodontal disease), with special reference to e/M in deft/DMFT.

METHODS

In a random sample of 500 6- and 12-year-old children having received dental care in 2014 in the county region of Värmland, Sweden, the diagnostic accuracy of data in electronic dental records with corresponding data obtained from the SKaPa-registry was compared by using Cohen's Kappa and Intraclass correlation coefficient (ICC).

RESULTS

For dft/DFT the Kappa was 0.95, and ICC 0.98 (total population). For deft/DMFT in the total population the Kappa was 0.80 and ICC 0.96. For 6-year-olds (deft) the Kappa was 0.89 and ICC 0.99 and for 12-year-olds (DMFT) the Kappa was 0.70, and ICC 0.83. The corresponding figures for Kappa and ICC when excluding individuals without caries (deft/DMFT = 0) were: Total population 0.63 and 0.94; 6-year-olds 0.79 and 0.99; 12-year-olds 0.42 and 0.68.

CONCLUSION

Agreement between data in the dental records and SKaPa was very high for dft/DFT confirming that transfer from the dental records to the SKaPa-registry is safe and correct. As the accuracy of deft/DMFT was considerably lower than for dft/DFT we advise against using deft/DMFT data from SKaPa for research purposes at this point.

A solidarity paradox - welfare state data in global health data economy

Nordic welfare states have well institutionalised practises of gathering health and social wellbeing data from their citizens. The establishment of population registers coincided with the building of welfare state institutions and a social contract relying on solidarity. During the last decade, the significance of Nordic registers and health data has increased and they have become sources of economic value. Recent policies expect registers, health data and biobanks to attract international investments, making Nordic countries world-leaders in the global health data economy. In this article we question the conditions and boundaries of solidarity in the emerging data-driven health economy. We argue that the logics of welfare state and data-driven health economy create a paradox - the data economy is not possible without the welfare state data regime, but the logic of data-driven health economy contradicts the value bases of the welfare state data regime and therefore the justifications for data gathering and use become questionable. We develop the concept of solidarization to describe the process by which individuals are expected to behave in a solidaristic way to support data gathering and related policy processes. We demonstrate the solidarity paradox through a recent legislative and data infrastructure reform in Finland and discuss it in relation to academic literature on solidarity.

The association between exposure to clozapine, olanzapine, and quetiapine and the outcomes perimyocarditis and heart failure: A population-based cohort study

The risk of cardiac adverse events following clozapine use is debated and is unknown for the chemically related and widely used antipsychotics olanzapine and quetiapine. National Swedish registers were used to identify all patients 16-75 years old with antipsychotic dispensations between 2005 and 2018. The short-term outcome was a diagnosis of perimyocarditis (pericarditis and/or myocarditis) within two months of first dispensation, and the long-term outcome was heart failure (including cardiomyopathy) within three years. Cox regressions with time varying exposure were used to estimate hazard rates (HR) and their 95% confidence intervals (CI). A total of 201,045 individuals were included in the cohort. The risk of developing perimyocarditis during clozapine treatment tripled compared to no antipsychotic treatment (HR 3.4, CI 1.6-7.3), although the absolute rate remained comparably low. The long-term risk of heart failure during clozapine treatment was also elevated (HR 1.3, CI 1.1-1.7). Treatment with either or both olanzapine or quetiapine was not associated with an increased relative risk of perimyocarditis, or heart failure compared to no antipsychotic treatment. Clozapine use is therefore associated with a substantially elevated short-term risk of perimyocarditis and an increased risk of heart failure within three years.

Early childhood adversity and non-affective psychosis: a study of refugees and international adoptees in Sweden

BACKGROUND

Previous Scandinavian studies have shown increased levels of psychiatric morbidity in young refugees and international adoptees with an origin outside Europe. This study investigated their risk of non-affective psychotic disorders (NAPD) and whether this risk is influenced by early childhood adversity, operationalised as age at adoption/residency, and/or gender.

METHODS

Register study in Swedish national cohorts born 1972-1990 including 21 615 non-European international adoptees, 42 732 non-European refugees that settled in Sweden at age 0-14 years and 1 610 233 Swedish born. The study population was followed from age 18 to year 2016 for hospitalisations with a discharge diagnosis of NAPD. Hazard ratios (HRs) were calculated in gender stratified Cox regression models, adjusted for household income at age 17.

RESULTS

The adjusted risks of NAPD were 2.33 [95% confidence interval (CI) 2.07-2.63] for the international adoptees and 1.92 (1.76-2.09) for the former child refugees, relative to the Swedish-born population. For the international adoptees there was a stepwise gradient for NAPD by age of adoption from adjusted HR 1.66 (1.29-2.03) when adopted during the first year of life to adjusted HR 4.56 (3.22-6.46) when adopted at ages 5-14 years, with a similar risk pattern in women and men. Age at residency did not influence the risk of NAPD in the refugees, but their male to female risk ratio was higher than in Swedish-born and the adoptees.

CONCLUSION

The risk pattern in the international adoptees gives support to a link between early childhood adversity and NAPD. Male gender increased the risk of NAPD more among the refugees.

Validity and reliability of the diagnostic codes for hypochondriasis and dysmorphophobia in the Swedish National Patient Register: a retrospective chart review

OBJECTIVES

In the International Classification of Diseases, Tenth Edition (ICD-10), hypochondriasis (illness anxiety disorder) and dysmorphophobia (body dysmorphic disorder) share the same diagnostic code (F45.2). However, the Swedish ICD-10 allows for these disorders to be coded separately (F45.2 and F45.2A, respectively), potentially offering unique opportunities for register-based research on these conditions. We assessed the validity and reliability of their ICD-10 codes in the Swedish National Patient Register (NPR).

DESIGN

Retrospective chart review.

METHODS

Six hundred individuals with a diagnosis of hypochondriasis or dysmorphophobia (300 each) were randomly selected from the NPR. Their medical files were requested from the corresponding clinics, located anywhere in Sweden. Two independent raters assessed each file according to ICD-10 definitions and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision and Fifth Edition criteria. Raters also completed the Clinical Global Impression-Severity (CGI-S) and the Global Assessment of Functioning (GAF).

PRIMARY OUTCOME MEASURE

Per cent between-rater agreement and positive predictive value (PPV). Intraclass correlation coefficients for the CGI-S and the GAF.

RESULTS

Eighty-four hypochondriasis and 122 dysmorphophobia files were received and analysed. The inter-rater agreement rate regarding the presence or absence of a diagnosis was 95.2% for hypochondriasis and 92.6% for dysmorphophobia. Sixty-seven hypochondriasis files (79.8%) and 111 dysmorphophobia files (91.0%) were considered 'true positive' cases (PPV=0.80 and PPV=0.91, respectively). CGI-S scores indicated that symptoms were moderately to markedly severe, while GAF scores suggested moderate impairment for hypochondriasis cases and moderate to serious impairment for dysmorphophobia cases. CGI-S and GAF inter-rater agreement were good for hypochondriasis and moderate for dysmorphophobia.

CONCLUSIONS

The Swedish ICD-10 codes for hypochondriasis and dysmorphophobia are sufficiently valid and reliable for register-based studies. The results of such studies should be interpreted in the context of a possible over-representation of severe and highly impaired cases in the register, particularly for dysmorphophobia.

Post-injury benzodiazepine and opioid use among older adults involved in road traffic crashes: A Swedish register-based longitudinal study

AIM

Psychotropic drugs like opioids and benzodiazepines are prescribed for traumas resulting from road traffic crashes and the risk of developing an addiction deserves consideration. This study aims to shed light on how the consumption of those drugs evolves over time among older road traffic injury (RTI) victims.

METHODS

We conducted a nationwide Swedish register-based longitudinal study to identify trajectories of post-RTI psychotropic drug use. All individuals aged 50 years and older who had a hospital visit for an RTI from 2007 to 2015 were followed up during a 2-year period; those who used the drugs prior to the RTI were excluded. Trajectories were identified by performing latent class trajectory analysis on drug dispensation data for opioids and benzodiazepines separately (66 034 and 66 859 adults, respectively, in total).

RESULTS

Three trajectories were identified for opioids and four for benzodiazepines. The largest group in both instances included people with no-use/minimal use throughout the follow-up (81.3% and 92.8%). "Sporadic users" were more frequent among users of opioids (16.7%) than benzodiazepines (4.3%), whereas "chronic users" were found in similar proportions (2.0% and 1.8%). "Delayed chronic use" characterized the fourth group of benzodiazepine users (1.0%).

CONCLUSION

Several trajectories of psychotropic drug use were identified after RTI, from limited to chronic. Although chronic use was uncommon, a better understanding of the factors likely to increase that risk is warranted given the seriousness of the problem.

Swedish quality registry for caries and periodontal diseases (SKaPa): validation of data on dental caries in 6- and 12-year-old children

Background

The Swedish Quality Registry for caries and periodontal disease (SKaPa) automatically collects data on caries and periodontitis from patients’ electronic dental records. Provided the data entries are reliable and accurate, the registry has potential value as a data source for registry-based research. The aim of this study was to evaluate the reliability and accuracy of the SKaPa registry information on dental caries in 6- and 12-year-old children.

Method

This diagnostic accuracy study compared dental caries data registered at an examination with dental health status registered in the patient’s electronic dental records, and with corresponding data retrieved from the SKaPa registry. Clinical examinations of 170 6- and 12-year-old children were undertaken by one of the researchers in conjunction with the children’s regular annual dental examinations where the number of teeth were registered, and dental caries was diagnosed using ICDAS II. Teeth with fillings were defined as filled and were added to the ICDAS II score and subsequently dft/DFT was calculated for each individual. Cohen’s Kappa, the intraclass correlation coefficient (ICC), and sensitivity and specificity were calculated to test the agreement of the ‘decayed and filled teeth’ in deciduous and permanent teeth (dft/DFT) from the three sources.

Results

Cohen’s Kappa of the dft/DFT-values was calculated to 0.79 between the researcher and the patient record, to 0.95 between patient dental record and SKaPa, and to 0.76 between the researcher and SKaPa. Intraclass correlation coefficient (ICC) was calculated to 0.96 between the researcher and the patient journal, to 0.99 between the patient dental record vs. SKaPa, and to 0.95 between the researcher and SKaPa.

Conclusion

The SKaPa registry information demonstrated satisfactory reliability and accuracy on dental caries in 6- and 12-year-old children and is a reliable source for registry-based research.

Trial registration The study was registered in Clinical Trials (www.ClinicalTrials.gov, NCT03039010)

Willingness to Share yet Maintain Influence: A Cross-Sectional Study on Attitudes in Sweden to the Use of Electronic Health Data

We have investigated attitudes towards the use of health data among the Swedish population by analyzing data from a survey answered by 1645 persons. Health data are potentially useful for a variety of purposes. Yet information about health remains sensitive. A balance therefore has to be struck between these opposing considerations in a number of contexts. The attitudes among those whose data is concerned will influence the perceived legitimacy of policies regulating health data use. We aimed to investigate what views are held by the general public, and what aspects matter for the willingness to let one's data be used not only for one's own care but also for other purposes. We found that while there is a broad willingness to let one's data be used, the possibility to influence that use is considered important. The study also indicated that when respondents are required to balance different interests, priority is typically given to compulsory schemes ensuring that data are available where needed, rather than voluntary participation and data protection. The policy implications to be drawn from this are not self-evident, however, since the fact that a majority has a certain attitude does not by itself determine the most adequate policy.

Validity and reliability of social anxiety disorder diagnoses in the Swedish National Patient Register

BACKGROUND

Population-based administrative registers are often used for research purposes. However, their potential usefulness depends on the validity of the registered information. This study assessed the validity of the recorded codes for social anxiety disorder (SAD), also known as social phobia, in the Swedish National Patient Register (NPR).

METHODS

The personal identification numbers of 300 randomly selected individuals with a diagnosis of SAD recorded in the NPR were obtained from the Swedish National Board of Health and Welfare. The medical files of these individuals were then requested from clinics nationally. A total of 117 files were received and two independent raters reviewed each file to assess the presence or absence of SAD, according to the definition of the International Classification of Diseases, Tenth Edition (ICD-10) and the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). When disagreements between the two raters were found, a third rater reviewed the file to establish a best estimate diagnosis. Positive predictive values (PPV) and agreement between the two initial raters (using Cohen's kappa) were calculated. Additionally, raters completed the Clinical Global Impression - Severity (CGI-S) and the Global Assessment of Functioning (GAF) rating scales for each file. Inter-rater agreement for the CGI-S and the GAF was assessed using intraclass correlation coefficients (ICC).

RESULTS

After exclusion of files not containing sufficient information, 95 files were included in the analyses. Of these, 77 files (81.05%) were considered to be 'true positive' cases (PPV = 0.81, 95% confidence interval = 0.72-0.88). Inter-rater agreement regarding the presence or absence of SAD was substantial (κ = 0.72). CGI-S and GAF scores indicated that patients were in the moderate range of severity and functional impairment. Inter-rater agreement for the CGI-S and the GAF was moderate to good (ICC = 0.72 and ICC = 0.82, respectively).

CONCLUSIONS

The ICD-10 codes for SAD in the Swedish NPR are generally valid and reliable, but we recommend sensitivity analyses in future register-based studies to minimise the impact of potential diagnostic misclassification. Most patients were moderately severe and impaired, suggesting that results from register-based studies of SAD may be generalizable.

Standard mortality rates and years of life lost for serologically defined adult-onset type 1 and type 2 diabetes - A fifteen year follow-up

AIMS

The Diabetes Incidence in Kronoberg (DIK) study of adult-onset diabetes used serological classification. Standard Mortality Rates (SMR) and Years of Life Lost (YLL) 15 years after adult-onset (18-100 years) of diabetes were compared to the population of Kronoberg.

METHODS

Of 1609/1660 (97%) patients, 112 (7%) had type 1 (T1D) (GADA⁺ and/or ICA⁺, and/or C-peptide < 0.25 nmol/l), and 1497 (93%) had type 2 diabetes (T2D) (antibody^- and C-peptide ≥ 0.25 nmol/l). The National Swedish Mortality Register provided time of death.

RESULTS

For T1D SMR did not differ from the Kronoberg population in any age group. In T2D SMR was 1.20 (1.12-1.29). After 15 years 26% (29/112) T1D and 52% (785/1497) T2D patients had died, p < 0.0001. In T2D SMR was 5.6 (30-39 years), 2 (40-59 years), 1.4 (60-69 years), and thereafter no difference. There were no significant sex differences in mortality, and no YLL to adult-onset T1D, but five YLL to T2D for onset at ages 20-60 years.

CONCLUSIONS

For adult-onset T1D SMR did not differ from the general population, in contrast to previous findings in childhood-onset (< 30 years of age) T1D. The difference in mortality between persons with diabetes and the general population was due to higher mortality in T2D.

Invasive Procedures Associated With the Development of Infective Endocarditis

BACKGROUND

Various invasive medical procedures might induce bacteremia and, hence, act as triggers for infective endocarditis. However, empirical data in humans on the potential dangers of invasive medical procedures in this regard are very sparse. Due to lack of sufficient data, it is currently debated whether the risk for endocarditis with medical procedures is substantial or rather negligible.

OBJECTIVES

The purpose of this nationwide case-crossover study was to quantify the excess risk for infective endocarditis in association with invasive medical and surgical procedures.

METHODS

The authors identified all adult patients treated for endocarditis in hospitals in Sweden between January 1, 1998, and December 31, 2011. The authors applied a case-crossover design and compared the occurrence of invasive medical procedures 12 weeks before endocarditis with a corresponding 12-week time period exactly 1 year earlier. The authors considered all invasive nondental medical procedures except for those that are likely to be undertaken due to endocarditis or sepsis or due to infections that could possibly lead to endocarditis.

RESULTS

The authors identified 7,013 cases of infective endocarditis during the study period. Among others, several cardiovascular procedures, especially coronary artery bypass grafting; procedures of the skin and management of wounds; transfusion; dialysis; bone marrow puncture; and some endoscopies, particularly bronchoscopy, were strongly associated with an increased risk for infective endocarditis.

CONCLUSIONS

This study suggests that several invasive nondental medical procedures are associated with a markedly increased risk for infective endocarditis.

The Swedish dental health register - validation study of remaining and intact teeth

BACKGROUND

Sweden has a long tradition of nationwide registers enabling population-based research of high quality and validity. We aimed to describe the content and validity of reported number of remaining and intact teeth in the Swedish Dental Health Register and report some descriptive data on dental health care utilization.

METHODS

The Swedish Dental Health Register was initiated in July 1st 2008 and contains individual data on dental health care to the whole adult population of Sweden. The dental care given freely to children and young adults is not included. Descriptive data on remaining, intact teeth and dental health care utilization is presented by proportion of the population stratified by sex and age. We conducted a validation study, by manual review of randomly sampled 1500 dental health visits records, to assess reported number of teeth to the register with what was actually recorded in the dental health care record (gold standard), analyzed by positive predictive value (PPV) and Bland-Altman plots.

RESULTS

Of the Swedish adult population 2014, 2.6 million (69%) men and 2.9 million (76%) women had at least one visit to a dentist during a two-year period 2013 to 2014. More than half of the population up to age 64 have all remaining teeth (28 teeth or more). Of the 1500 requested dental records 1131 (75%) were received. The positive predictive value for patients reported to the register as having at least 1 tooth up to 31 intact teeth was 91.5% (95% confidence interval 89.0-93.5, 567 manually reviewed to be correct out of 620 reported).

CONCLUSIONS

For patients coded as having less than 32 intact teeth but not being edentulous the reported number of remaining and intact teeth is to a very high degree correct. However, the correctness for those coded as edentulous or having 32 remaining intact teeth is low and varies substantially by age.

Adult height is associated with risk of cancer and mortality in 5.5 million Swedish women and men

BACKGROUND

Previous studies have indicated that taller individuals are at greater risk of developing cancer. Death from cancer and other specific causes have also been linked to height, but the results have been inconclusive. We aimed to shed further light on the associations between height, cancer incidence and mortality.

METHODS

We conducted a nationwide, population-based prospective cohort study, including 5.5 million Swedish women and men (aged 20-74). They were followed over a period of up to 54 years. Heights were retrieved from national registers (mainly the Passport Register where heights are most often self-reported). The risks of overall and specific cancers, as well as overall and cause-specific mortality, were presented as HR with 95% CIs per 10 cm increase in height.

RESULTS

A total of 278 299 cases of cancer and 139 393 cases of death were identified. For overall cancer, HR was 1.19 (1.18-1.20) in women and 1.11 (1.10-1.12) in men for every 10 cm increase in height. All 15 specific cancer types were positively associated with height-most strongly for malignant melanoma in both genders, with HRs of 1.39 (1.35-1.43) in women and 1.34 (1.30-1.38) in men. For overall mortality, HR was 0.98 (0.97-0.99) in women and 0.91 (0.90-0.92) in men for every 10 cm increase in height. Cancer mortality was increased in taller individuals, with HR 1.15 (1.13-1.17) in women and 1.05 (1.03-1.07) in men for every 10 cm increase in height, whereas shorter individuals had increased overall mortality due to a number of other causes, such as cardiovascular disease.

CONCLUSION

Overall and specific cancer risks, particularly malignant melanoma, were positively associated with height. Cancer mortality also increased with height. In contrast, overall mortality was decreased with height, particularly in men due to inverse associations with height for other causes of death.

The Effect of Rotavirus Vaccine on Socioeconomic Differentials of Paediatric Care Due to Gastroenteritis in Swedish Infants

Background: Previous Swedish studies have shown a social gradient on paediatric care for viral gastroenteritis. Aim: To study the effect of a free rotavirus vaccine programme on hospital care for viral gastroenteritis. Method: A register-based national cohort study of paediatric in- and outpatient care for viral gastroenteritis in children <2 years old in two Swedish counties in 2014–2017, with the rest of the country as comparison. Adjusted hazard ratios were estimated by the differences-in-differences (DiD) estimator in Cox regression in the entire cohort and by social indicators. Results: Reductions of 37% and 24% for inpatient care, and 11 % and 21% for outpatient care for viral gastroenteritis were found in the Stockholm and Jönköping counties, respectively, after adjusting for time trends and social indicators. For inpatient care, the change was similar over social groups in both counties. In the larger county of Stockholm, smaller reductions in outpatient care were detected for children in socially disadvantaged families. Conclusions: A free rotavirus vaccination programme moderately reduced paediatric care for viral gastroenteritis. There were indications of an increase in socioeconomic differences in paediatric outpatient care for viral gastroenteritis, but further studies are needed to confirm this result in a broader health care perspective.

Clinical presentation of intussusception in Swedish children under 3 years of age and the validity of diagnostic coding

PURPOSE

Intussusception has been associated with rotavirus vaccine. The rotavirus vaccine will soon be introduced in the Swedish national immunization program. A validation of the diagnosis of intussusception among Swedish children in the Swedish National Patient Register is needed, as a basis for future vaccine safety surveillance by Swedish registers.

METHODS

This diagnostic study reviewed the medical admission records of 392 Swedish children with intussusception from 1987 to 2013. The records were randomly selected by The National Board of Health and Welfare from all Sweden and from both pediatric and pediatric surgery care. Positive predictive values (PPV) were calculated to study the concordance between the diagnosis coded in the Swedish Patient Register and the accepted international criteria of case definitions.

RESULTS

The PPV for a definitive diagnosis, based on certain radiology findings or surgery, was 84%. When clinically probable cases were added the PPV was 87%. When cases of possible intussusception were added the PPV was 89%. The PPV for the 240 children under 1 year was 88%.

CONCLUSION

Swedish health care registers can be used in the evaluation of incidences of intussusception when rotavirus vaccine will be introduced, due to a high validity of the diagnosis of intussusception in the registers.

Temporal trends in incidence, recurrence and prevalence of stroke in an era of ageing populations, a longitudinal study of the total Swedish population

BACKGROUND

Stroke incidence has declined during the past decades. Yet, there is a concern that an ageing population together with improved survival after stroke will result in a raised proportion of the population who have experienced a stroke, as well as increasing incidence rate of recurrent strokes, and, absolute numbers of strokes. The objectives of this study were to investigate how the age specific incidence rates of recurrent strokes have developed in relation to the incidence rates of first strokes and how the postponement in age look like, and to see how the prevalence proportion of stroke as well as the absolute number of incident strokes has changed over time.

METHODS

This study includes the total Swedish population born 1890-1954 living in Sweden from 1987. Stroke was identified through hospital admissions and deaths in national health registers (mandatory for all hospitals in Sweden). Age specific incidence rates were calculated for first, second, all recurrent, and all strokes for each calendar year between 1994 and 2014 for each age between 60 and 104 years. The proportion in the population with a history of stroke up to 7 years back in time was also calculated for different age groups and for different calendar years.

RESULTS

Not only the incidence rate of first stroke but also of recurrent strokes have declined. The declines are evident in all ages up to 90 years of age, but not in ages above 90 years. Despite improved survival in stroke, the prevalence proportion has declined over the period and was around 3% in 2014 (somewhat higher for men than women). Even incident cases of stroke in absolute number has declined.

CONCLUSIONS

Decreasing incidence rates of stroke have offset an increase in both absolute and relative numbers of stroke that otherwise would have taken place due to improved survival and an ageing population. The decline in stroke recurrence has been as strong as the decline in first strokes.

Hospital care for viral gastroenteritis in socio-economic and geographical context in Sweden 2006-2013

AIM

We investigated socio-economic and geographical determinants of hospital care for viral gastroenteritis in young children.

METHOD

This is a register-based study in a national birth cohort of 752 078 children 0-5 years of age in Sweden during 2006-2012. Hazard ratios (HR) of time to first admission and first episode of outpatient emergency department (ED) care with a diagnosis of viral gastroenteritis were estimated with Cox regression.

RESULTS

The adjusted HRs for hospital admission with a diagnosis of viral gastroenteritis were increased when the mother was below 25 years at the birth of the child, 1.30 (95% CI: 1.24-1.35), had a short (<=9 years) education, 1.18 (95% CI: 1.12-1.23), a psychiatric disorder, 1.34 (95% CI: 1.30-1.39), and/or when parents were born outside Europe, 1.23 (95% CI: 1.18-1.29). In contrast, the disposable income of the family was only marginally associated with such hospital admissions. The pattern of HRs for outpatient ED hospital care was similar. Hospital care incidences for viral gastroenteritis differed considerably between Swedish counties.

CONCLUSION

Parental indicators associated with a lower level of health literacy increase the risk for hospital care due to gastroenteritis in young children. Information about oral rehydration should be provided in ways that are accessible to these parents.

Big data: what it can and cannot achieve

This article looks at the use of large health records datasets, typically linked with other data sources, and their use in mental health research. The most comprehensive examples of this kind of big data are typically found in Scandinavian countries however there are also many useful sources in the UK. There are a number of promising methodological innovations from studies using big data in UK mental health research, including: hybrid study designs, examples of data linkage and enhanced study recruitment. It is, though, important to be aware of the limitations of research using big data, particularly the various analysis pitfalls. We therefore caution against throwing out the methodological baby with the bathwater and argue that other data sources are equally valuable and ideally research should incorporate a range of data.

Validation of Obesity Surgery Data in the Swedish National Patient Registry and Scandinavian Obesity Registry (SOReg)

BACKGROUND AND AIM

Swedish health registries are common sources of data for studies on the effects of obesity surgery, and there is a need to assess the quality of data in these registries. The aim of this study was to validate the registration of obesity surgery in the National Patient Registry (NPR) and the Scandinavian Obesity Surgery Registry (SOReg).

METHOD

We randomly selected 962 out of 8501 registrations of obesity surgery in 2011 from the NPR and SOReg. Registered surgical procedures in the NPR and SOReg were compared to the medical records, and concordance was analyzed by calculating positive predictive value (PPV) with 95 % confidence interval (CI).

RESULTS

We received 938 (98 %) medical records for manual review. The overall PPV for obesity surgery was high in the NPR (PPV 97.0; 95 % CI 95.6-98.4) and even higher in SOReg (PPV 99.7; 95 % CI 99.3-100). Accuracy was higher for gastric bypass surgery than for other types of obesity surgery. Registrations that were misclassified as obesity surgery (n = 44) included reoperations due to complications or reconstruction to normal anatomy after previous obesity surgery (n = 11) and endoscopic procedures (n = 10).

CONCLUSION

Obesity surgery registrations in the NPR and SOReg have high accuracy and are reliable sources of data to identify patients having undergone obesity surgery. When it is of importance to distinguish between specific surgical procedures, non-gastric bypass surgeries in the NPR should ideally be supplemented with data from other sources.

Intestinal failure after necrotising enterocolitis: incidence and risk factors in a Swedish population-based longitudinal study

BACKGROUND AND OBJECTIVE

Paediatric intestinal failure (IF) is a disease entity characterised by gut insufficiency often related to short bowel syndrome. It is commonly caused by surgical removal of a large section of the small intestine in association with necrotising enterocolitis (NEC), which usually affects premature infants. This study investigated the incidence and risk of IF in preterm infants with or without NEC.

DESIGN

A matched cohort study to investigate the incidence and risk factors for IF in a population-based setting in Sweden from 1987 to 2009 using the Swedish Patient Register.

PARTICIPANTS

Infants with a diagnosis of NEC (n=720) were matched for gestational age and year of birth with reference individuals without NEC (n=3656). The study cohort was censored at death, IF or at end of follow-up (2 years of age). We calculated HRs with 95%CIs for IF using Cox regression, adjusting for pertinent perinatal factors.

RESULTS

IF was 15 times more common in the infants with NEC compared with the reference infants (HR=7.2, with 95% CI 3.7 to 14.0). Other risk factors for IF were small for gestational age, extreme preterm birth and abdominal surgery. Neonatal mortality in infants with NEC decreased from 20.6% in 1987-1993 to 10.4% in 2007-2009.

CONCLUSION

IF was more common in the infants with NEC but was also linked to extreme preterm birth, a history of abdominal surgery and small for gestational age. IF was more common at the end of the study period, indicating that it increases when more preterm infants with NEC survive the neonatal period.

Pharmacological agents preceding a diagnosis of immune thrombocytopenia in adult patients developing the chronic form: A Swedish national register study

Patients with primary chronic immune thrombocytopenia (cITP) have been reported to use more anti-infective medications, even before diagnosis of immune thrombocytopenia (ITP). The more common use of anti-infective medications may be due to general health problems, requiring medication in the early stages of cITP and before the diagnosis is set, rather than infections preceding the disease. Accordingly, cITP may not only be associated with use of anti-infective medications but also with medications for more general symptoms.

OBJECTIVE

To investigate use of medications for general symptoms, such as analgesics and vitamin supplements in patients with ITP developing the chronic form, the year preceding their first primary diagnosis in comparison with such use in the general population.

METHOD

Swedish Health Registers were used to identify adult patients (n=1087) with primary cITP during 2006-2012 and data on medications. Standardized Incidence Ratios (SIRs) and 95% confidence intervals (CI), were estimated as a measure of relative risk.

RESULTS

The association for overall studied medications was SIR=1.36 (95% CI 1.32-1.41). A majority of the point estimates were above unity.

CONCLUSION

In patients with cITP, prescription fills for medications used to treat pain conditions and vitamin deficiencies are more common in the year preceding their first diagnosis as compared with prescription fills in the general population. Our results suggest that patients later diagnosed with cITP receive treatment due to symptoms that could be signs of an early ITP. Accordingly, in investigations for unspecific pain symptoms and vitamin deficiencies, cITP should be considered as a differential diagnosis.

The use of psychiatric services by young adults who came to Sweden as teenage refugees: a national cohort study

AIMS

To investigate the patterns of use of different forms of psychiatric care in refugees who settled in Sweden as teenagers.

METHOD

Cox proportional hazards models were used to estimate the use of different forms of psychiatric care from 2009 to 2012 in a population of 35 457 refugees, aged from 20 to 36, who had settled in Sweden as teenagers between 1989 and 2004. These findings were compared with 1.26 million peers from the same birth cohorts in the general Swedish population.

RESULTS

Unaccompanied and accompanied refugees were more likely to experience compulsory admission to a psychiatric hospital compared with the native Swedish population, with hazard ratios (HRs) of 2.76 (1.86-4.10) and 1.89 (1.53-2.34), respectively, as well as psychiatric inpatient care, with HRs of 1.62 (1.34-1.94) and 1.37 (1.25-1.50). Outpatient care visits by the young refugees were similar to the native Swedish population. The longer the refugees had residency in Sweden, the more they used outpatient psychiatric care. Refugees born in the Horn of Africa and Iran were most likely to undergo compulsory admission, with HRs of 3.98 (2.12-7.46) and 3.07 (1.52-6.19), respectively. They were also the groups who were most likely to receive inpatient care, with HRs of 1.55 (1.17-2.06) and 1.84 (1.37-2.47), respectively. Our results also indicated that the use of psychiatric care services increased with the level of education in the refugee population, while the opposite was true for the native Swedish population. In fact, the risks of compulsory admissions were particularly higher among refugees who had received a secondary education, compared with native Swedish residents, with HRs of 4.72 (3.06-7.29) for unaccompanied refugees and 2.04 (1.51-2.73) for accompanied refugees.

CONCLUSIONS

Young refugees received more psychiatric inpatient care than the native Swedish population, with the highest rates seen in refugees who were not accompanied by their parents. The discrepancy between the use of inpatient and outpatient care by young refugees suggests that there are barriers to outpatient care, but we did note that living in Sweden longer increased the use of outpatient services. Further research is needed to clarify the role that education levels among Sweden's refugee populations have on their mental health and health-seeking behaviour.

Estimating incidence and prevalence from population registers: example from myocardial infarction

AIM

To illustrate how the fundamental epidemiological measures, incidence rate and prevalence proportion, can be estimated based on Swedish population registers using acute myocardial infarction (MI) as an example, together with a discussion about the analytical decisions.

METHODS

All individuals in Sweden aged 60-89 (born 1904-1954) during the study period 1994-2014 were identified through the Total Population Register. Cases of MI were defined and identified from information on hospital admissions and causes of death. Incidence rates of all, first, and recurrent MI were calculated together with prevalence proportions.

RESULTS

The incidence rate of all, first, and recurrent MI declined over the study period. While the incidence rates of first MI are lower for women than men, the incidence rates of recurrent MI are considerably higher but similar for men and women. The prevalence calculated with duration of disease set at 28 days also declined. This was despite improved survival from MI and increased life expectancy over the same period meaning that the decline in incidence was large enough to compensate for increased survival.

CONCLUSIONS

Calculating incidence and prevalence of diseases using population registers requires detailed and well-reasoned definitions. The definitions will affect both the study population and the number of disease events and it is essential that the cases and the study population are defined in a coherent way. Different measures of disease occurrence contribute with different aspects of the disease panorama and a joint interpretation contributes to a thorough understanding of the disease development in a population.

Suicide, Self-harm, and Depression After Gastric Bypass Surgery: A Nationwide Cohort Study

OBJECTIVE

The aim of this study was to examine risk of self-harm, hospitalization for depression and death by suicide after gastric bypass surgery (GBP).

SUMMARY OF BACKGROUND DATA

Concerns regarding severe adverse psychiatric outcomes after GBP have been raised.

METHODS

This nationwide, longitudinal, self-matched cohort encompassed 22,539 patients who underwent GBP during 2008 to 2012. They were identified through the Swedish National Patient Register, the Prescribed Drug Register, and the Causes of Death Register. Follow-up time was up to 2 years. Main outcome measures were hazard ratios (HRs) for post-surgery self-harm or hospitalization for depression in patients with presurgery self-harm and/or depression compared to patients without this exposure; and standardized mortality ratio (SMR) for suicide post-surgery.

RESULTS

A diagnosis of self-harm in the 2 years preceding surgery was associated with an HR of 36.6 (95% confidence interval [CI] 25.5-52.4) for self-harm during the 2 years of follow up, compared to GBP patients who had no self-harm diagnosis before surgery. Patients with a diagnosis of depression preceding GBP surgery had an HR of 52.3 (95% CI 30.6-89.2) for hospitalization owing to depression after GBP, compared to GBP patients without a previous diagnosis of depression. The SMR for suicide after GBP was increased among females (n = 13), 4.50 (95% CI 2.50-7.50). The SMR among males (n = 4), was 1.71 (95% CI 0.54-4.12).

CONCLUSIONS

The increased risk of post-surgery self-harm and hospitalization for depression is mainly attributable to patients who have a diagnosis of self-harm or depression before surgery. Raised awareness is needed to identify vulnerable patients with history of self-harm or depression, which may be in need of psychiatric support after GBP.

Psychiatric morbidity and its impact on surgical outcomes for esophageal and gastric cancer patients: A nationwide cohort study

Background

Due to the lack of detailed clinical information, existed evidence regarding a link between psychiatric factors and adverse cancer prognosis was inclusive.

Results

We identified 1,340 patients (48.8%) with perioperative psychiatric morbidity. Preoperative psychiatric morbidity was significantly associated with both general and surgical complications within 30 days (RR = 1.3, 95% confidence interval [CI] 1.1–1.5), and the risk of death within 90 days (RR = 1.6; 95% CI 1.1–2.2) after surgery. The hazards for mortality beyond 90 days was approximately 2-fold increased among patients with perioperative psychiatric morbidity (HR = 2.0, 95% CI 1.7–2.3 for overall mortality).

Materials and Methods

Based on the Swedish National Registry for Esophageal and Gastric cancer (NREV), we constructed a nationwide prospective cohort containing 2,745 surgically treated patients in 2006–2012. Perioperative psychiatric morbidity was defined as a clinical diagnosis of psychiatric disorder, from two years before to two years after surgery. Using propensity scores, we applied inverse probability of treatment weights (IPTW)-weighted Poisson regression model to evaluate relative risk (RR) of short-term surgical outcomes in relation to perioperative psychiatric morbidity. Further, IPTW-weighted Cox proportional hazards model was used to estimate hazard ratios (HRs) for mortality that occurred after 90 days of surgery.

Conclusions

Perioperative psychiatric morbidity could worsen both short-term and long-term surgical outcomes among patients with gastric or esophageal cancer.

Angiotensin II receptor blockers and risk of acute pancreatitis - a population based case-control study in Sweden

Background

Acute pancreatitis is a potentially lethal disease, with a rising incidence in the Western world. Yet, no pharmacological prevention or specific treatment for acute pancreatitis exists. Also, the connection with severity of acute pancreatitis is unknown. Experimental and epidemiological research suggests a protective effect of angiotensin II receptor blockers.

Methods

During 2006 to 2008, we performed a nationwide case–control study on Swedish residents aged 40–84 years. First-time cases with acute pancreatitis were identified in the National Patient Register and data on dispensed prescriptions was retrieved from the Prescribed Drug Register. Controls were randomly selected from the general population in Sweden frequency-matched on sex, age, and calendar year. To estimate relative risk of acute pancreatitis, by degree of severity, among users of angiotensin II receptor blockers, as compared to non-users, we used multivariable logistic regression analysis to calculate odds ratios (OR) with 95% confidence interval (CI).

Results

Among 6,161 cases of acute pancreatitis and 61,637 controls, current use of angiotensin II receptor blockers was followed by a decreased risk of acute pancreatitis, compared to non-users, adjusted OR 0 · 77 (95% CI 0 · 69–0 · 86). No protective association, but an increased risk was found for users of angiotensin-converting enzyme inhibitors (adjusted OR 1 · 11, 95% CI: 1 · 01–1 · 21), analysed for comparison reasons. There was a significant decreased risk associated with both severe acute pancreatitis, (OR 0 · 71 (0 · 59–0 · 85), and mild acute pancreatitis; adjusted OR 0 · 81 (0 · 70–0 · 94).

Conclusion

This population-based case–control study indicates that use of angiotensin II receptor blockers might be associated with a lesser risk of acute pancreatitis, and that the protective association was significant among cases of both severe and mild acute pancreatitis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-017-0595-8) contains supplementary material, which is available to authorized users.

Healthcare resource use, comorbidity, treatment and clinical outcomes for patients with primary intracranial tumors: a Swedish population-based register study

BACKGROUND

Primary intracranial tumors are relatively uncommon and heterogeneous, which make them challenging to study. We coupled data from unique Swedish population-based registries in order to deeper analyze the most common intracranical tumor types. Patient characteristics (e.g. comorbidities), care process measures like adherence to national guidelines, healthcare resource use and clinical outcome was evaluated.

MATERIALS AND METHODS

A register-based study including several population-based registries for all patients living in Stockholm-Gotland, diagnosed with primary intracranial tumor between 2001 and 2013 was performed. Patient characteristics were captured and investigated in relation to survival, healthcare resource use (inpatient-, outpatient- and primary care) and treatment process.

RESULTS

High-grade glioma and meningioma were the most common tumor types and most patients (76%) were above the age of 40 in the patient population (n = 3664). Older age, comorbidity (Elixhauser comorbidity index) and type of tumor (high-grade glioma) were associated with lower survival rate and increased use of healthcare resources, analyzed for patients living in Stockholm (n = 3031). The analyses of healthcare use and survival showed no differences between males and females, when stratifying by tumor types. Healthcare processes were not always consistent with existing national treatment recommendations for patients with high-grade gliomas (n = 474) with regard to specified lead times, analyzed in the Swedish Brain Tumor Registry, as also observed at the national level.

CONCLUSIONS

Age, comorbidity and high-grade gliomas, but not sex, were associated with decreased survival and increased use of healthcare resources. Fewer patients than aimed for in national guidelines received care according to specified lead times. The analysis of comprehensive population-based register data can be used to improve future care processes and outcomes.

Hospital Admission and Criminality Associated with Substance Misuse in Young Refugees - A Swedish National Cohort Study

Background

High rates of mental health problems have been described in young refugees, but few studies have been conducted on substance misuse. This study aimed to investigate the patterns of hospital care and criminality associated with substance misuse in refugees who settled in Sweden as teenagers.

Methods

Gender stratified Cox regression models were used to estimate the risks of criminal convictions and hospital care associated with substance misuse from national Swedish data for 2005–2012. We focused on 22,992 accompanied and 5,686 unaccompanied refugees who were aged 13–19 years when they settled in Sweden and compared them with 1 million native Swedish youths from the same birth cohort.

Results

The risks of criminal conviction associated with substance misuse increased with the length of residency in male refugees, after adjustment for age and domicile. The hazard ratios (HRs) were 5.21 (4.39–6.19) for unaccompanied and 3.85 (3.42–4.18) for accompanied refugees after more than 10 years of residency, compared with the native population. The risks were slightly lower for hospital care, at 2.88 (2.18–3.79) and 2.52(2.01–3.01) respectively. Risks were particularly pronounced for male refugees from the Horn of Africa and Iran. The risks for all male refugees decreased substantially when income was adjusted for. Young female refugees had similar risks to the general population.

Conclusion

The risks of criminality and hospital care associated with substance misuse in young male refugees increased with time of residency in Sweden and were associated with a low level of income compared with the native Swedish population. Risks were similar in accompanied and unaccompanied refugees.

The First Decade with the Swedish Prescribed Drug Register - A Systematic Review of the Output in the Scientific Literature

The aim of this study was to quantify and characterize the scientific output from the Swedish Prescribed Drug Register (SPDR) the first decade after its establishment. A systematic literature search was performed in Medline, EMBASE and PubMed (2005-2014). Additional publications were identified by personal knowledge, reference lists, contact with active authors and a citation search in Web of Sciences. Publications using SPDR data were included in the analysis and characterized regarding study type, presence of patient-level record linkage, target population and topic. A total of 719 publications were identified in the literature search and an additional 148 by other strategies. Three hundred and thirty-eight studies fulfilled the inclusion criteria. The majority were analytic (n = 166; 49.1%) or descriptive (n = 100; 29.5%). The remaining studies focused on validation (n = 20; 5.9%), health economics (n = 16; 4.7%) or miscellaneous (n = 36; 10.7%). The analytic studies investigating effects of drug exposure focused mainly on safety (n = 46) and/or effectiveness (n = 24). The first publications appeared in 2007 (n = 6), and in 2014, 90 articles using SPDR were published. Over the years, linkage with other registers using the personal identity number increased (0-88.9% of the publications). The population was often selected by age (49.7%), condition (45.0%) and/or drug (22.8%) and concerned predominantly psychiatric (29.0%) and cardiovascular (20.4%) diseases. In conclusion, this study illustrates that the establishment of a nationwide individual-based register on dispensed prescription drugs facilitates an encouraging development of pharmacoepidemiological research, both regarding the number of publications and the scientific level of the analyses.

Hormone therapy and risk of cardiovascular outcomes and mortality in women treated with statins

Objective

This work aims to study the effects of hormone therapy (HT) on the risk of cardiovascular outcomes and all-cause mortality in women treated with statins.

Methods

We included women aged 40 to 74 years and living in Sweden who filled a first statin prescription between 2006 and 2007. Women were categorized as HT users or as nonusers. Information on dispensed drugs, comorbidity, cardiovascular outcomes, and all-cause mortality was obtained from national health registers.

Results

A total of 40,958 statin users—2,862 (7%) HT users and 38,096 nonusers—were followed for a mean of 4.0 years. In total, 70% of the women used statins as primary prevention. Among HT users, there were five cardiovascular deaths per 10,000 person-years. The corresponding rate among nonusers was 18, which yielded a hazard ratio of 0.38 (95% CI, 0.12-1.19). The all-cause mortality rates were 33 and 87, respectively, and the hazard ratio was 0.53 (95% CI, 0.34-0.81). There were no associations with cardiovascular events. A similar pattern was found for both primary and secondary prevention.

Conclusions

HT is associated with a reduced risk of all-cause mortality in women treated with statins. Although confounding factors, such as lifestyle and disease severity, might have influenced the results, HT does not seem to be detrimental to statin-treated women.

Risk of Coronary Heart Disease in Men With Poor Emotional Control: A Prospective Study

OBJECTIVE

Many psychosocial factors have been associated with coronary heart disease (CHD), including hostility, anger, and depression. We tested the hypothesis that these factors may have their basis in emotion regulation abilities. Our aim was to determine whether poor emotional control predicted long-term risk of CHD.

METHODS

This Swedish national study includes 46,393 men who were conscripted for military service in 1969 and 1970. The men were aged 18 to 20 years at the time of conscription. Psychologists used a brief semistructured interview to retrospectively assess the conscripts' level of emotional control in childhood and adolescence. The outcome measure was a first fatal or nonfatal event of CHD. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for poor and adequate versus good emotional control.

RESULTS

After 38 years of follow-up (1971-2009), 2456 incident cases of CHD had occurred. Poor emotional control increased the risk of CHD (HR = 1.31, 95% CI = 1.18-1.45), adjusting for childhood socioeconomic position, anxiety, depression, and parental history of CHD. Further adjustment for life-style-related factors, for example, smoking and body mass index, attenuated the HR to 1.08 (95% CI = 0.97-1.21). In stratified analyses, the fully adjusted association between poor emotional control with CHD remained significantly elevated among men with a parental history of CHD (HR = 1.49, 95% CI = 1.11-2.01, p interaction = .037).

CONCLUSIONS

In the overall study population, poor emotional control had no direct effect on CHD beyond life-style-related factors. However, in men with a parental history of CHD, poor emotional control in adolescence remained significantly predictive of long-term CHD risk even when adjusting for life-style-related factors.

Origin and schizophrenia in young refugees and inter-country adoptees from Latin America and East Africa in Sweden: a comparative study

BACKGROUND

Migrants' socioeconomic adversity has been linked to schizophrenia.

AIMS

To investigate whether the more favourable socioeconomic situation of adoptees prevents them from the high risk of schizophrenia found in other migrants.

METHOD

Register study in a cohort of refugees and inter-country adoptees aged 16-40 years, born in East Africa (n=8389), Latin America (n=11 572) and 1.2 million native Swedes. Cox-regression models estimated hazard ratios (HRs) of schizophrenia in data from psychiatric care.

RESULTS

Despite diverse income levels, HRs for schizophrenia were similar for refugees and adoptees, with East Africans having the highest HRs: 5.83 (3.30-10.27) and 5.80 (5.03-6.70), followed by Latin Americans: HRs 3.09 (2.49-3.83) and 2.31 (1.79-2.97), compared with native Swedes. Adjustment for income decreased these risks slightly for refugees, but not for adoptees.

CONCLUSIONS

This study suggests that risk factors associated with origin are more important determinants of schizophrenia than socioeconomic adversity in the country of settlement.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© 2016 The Royal College of Psychiatrists. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Use of SSRI and SNRI Antidepressants during Pregnancy: A Population-Based Study from Denmark, Iceland, Norway and Sweden

Background

The purpose was to describe utilization of selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs), including trends in prevalence, characteristics of users, drug switching and changes in prescribed doses in a large group of pregnant women across four Nordic countries.

Methods

A drug utilization study based on linked individual-level data from the nationwide prescription- and medical birth registers in Denmark, Iceland, Norway and Sweden. The study population comprised all pregnancies in these countries, resulting in a live birth or stillbirth after gestational week 22 from January 1^st 2008 to December 31^st 2012 (N = 1 162 470). In addition to the main study drugs SSRIs and SNRIs, we included (concurrent) use of other antidepressants, antipsychotics, anxiolytics and hypnotics.

Results

A total of 38 219 (3.3%) pregnancies were exposed to SSRIs and 5 634 (0.5%) to SNRIs. Prevalence of SSRI and SNRI use varied by country (1.8% in Norway to 7.0% in Iceland). Use and prescribed dosages decreased with each passing trimester of pregnancy; prevalence was 2.7% at conception, and 2.1%, 1.7% and 1.3% respectively in 1^st, 2^nd and 3^rd trimester. In 0.6% of pregnancies women filled a prescription before pregnancy and in every trimester. In one third of exposed pregnancies, women were also dispensed anxiolytics, hypnotics or sedatives.

Conclusion

Use of SSRI and SNRI use during pregnancy varied between the Nordic countries, but the overall prevalence remained low and relatively stable from 2008 to 2012. The low prevalence of use and high proportion of women who discontinue treatment in pregnancy raise questions about adequate treatment of depression in pregnant women.

Gout and its comorbidities in the total population of Stockholm

OBJECTIVE

Study of prevalence of gout with concomitant diseases.

METHODS

Study population included all living persons in Stockholm County, Sweden, on January 1st 2013 (N=2,124,959). A diagnosis of gout was identified during 2013-2014, with information of diabetes mellitus and insulin resistance, hypertension, chronic heart failure, chronic kidney disease, alcohol abuse, and malignancies. Age-adjusted odds ratios (ORs) with 95% confidence intervals (95% CI) for women and men with gout, using individuals without gout as referents, were calculated.

RESULTS

Age-adjusted odds of co-morbidities among individuals with gout vs. those without gout were: diabetes mellitus and insulin resistance 3.97 (95% CI 3.65-4.31) in women and 1.88 (95% CI 1.78-1.99) in men; hypertension 4.02 (95% CI 3.69-4.37) in women and 3.21 (95% CI 3.06-3.37) in men; chronic heart failure 4.72 (95% CI 4.31-5.19) in women and 2.84 (95% CI 2.66-3.04) in men; chronic kidney disease 2.08 (95% CI 1.50-2.87) in women and 2.39 (95% CI 2.15-2.66) in men; alcohol abuse 8.98 (95% CI 8.15-9.80) in women and 4.38 (95% CI 4.10-4.69) in men; and malignancies 1.32 (95% CI 1.17-1.48) in women and 1.13 (95% CI 1.06-1.21) men.

CONCLUSION

Gout is a warning sign for concomitant diseases, e.g. alcoholism, diabetes, cardiovascular diseases, and cancer. KEY MESSAGES.

The Stockholm CREAtinine Measurements (SCREAM) project: protocol overview and regional representativeness

BACKGROUND

We here describe the construction of the Stockholm CREAtinine Measurement (SCREAM) cohort and assess its coverage/representativeness of the Stockholm county in Sweden. SCREAM has the principal aims to estimate the burden and consequences of chronic kidney disease (CKD) and to identify inappropriate drug use (prescription of nephrotoxic, contraindicated or ill-dosed drugs).

METHODS

SCREAM is a repository of laboratory data of individuals, residing or accessing healthcare in the region of Stockholm, who underwent creatinine assessments between 2006-11. Laboratory tests were linked to administrative databases with complete information on socioeconomic status, demographic data, healthcare utilization, diagnoses, vital status and dispensed prescription medicines.

RESULTS

SCREAM identified 1 118 507 adult Stockholm citizens with available creatinine tests between 2006-11. This corresponded to 66% of the complete population in the region. Geographical coverage was uniform, ranging between 62 and 72% throughout its 26 municipalities. Population coverage was higher across older age strata (50% coverage for age range 18-44 years, >75% for 45-64 years and >90% coverage for ≥65 years). Of note, 97 and 98% of all individuals with a diagnosis of diabetes mellitus or cardiovascular disease, respectively, were captured by SCREAM. Further, 89% of all deaths registered in the period occurred in individuals with a creatinine test undertaken.

CONCLUSION

SCREAM represents the largest cohort to estimate the burden and healthcare implications of CKD in Sweden. The coverage and representativeness of the region of Stockholm was high and in accordance to both the commonness of creatinine assessment, and the medical indications for creatinine testing. The inclusion of individuals who sought medical care and had a creatinine test undertaken resulted in a slight over-representation of elderly and comorbid patients.

Unexplained acute chest pain in young adults: disease patterns and medication use 25 years later

BACKGROUND

Patients with unexplained chest pain are commonly revisiting an emergency department with various symptoms, but comprehensive long-term studies are lacking.

METHODS

A total of 150 young adults (aged 18-40 years) with unexplained chest pain who presented at an emergency unit for 16 weeks in mid-1980s were included in a prospective cohort study. An age- and sex-matched control group was randomly selected from the same area. Data were retrieved from registers that recorded death, income, education, country of birth, diagnoses, hospitalizations, outpatient visits, and medications dispensed.

RESULTS

Patients with unexplained acute chest pain had lower levels of education and income and were more often immigrants. Long-term mortality rates did not differ between cases (4%) and controls (5%) during 25 years of follow-up, nor were there differences in diagnosis of ischemic heart disease. Patients with unexplained acute chest pain had more outpatient visits (median, 5 versus 2; p < .0001) and had more often been hospitalized (61.6% ever versus 41.8%; p < .001) during the follow-up period. Several disorders were more common among patients 20 to 25 years later, including atrial fibrillation, esophageal/gastric disorders, chest pain, palpitations, abdominal discomfort, musculoskeletal symptoms, sleeping disturbance, and stress reactions (p values < .05). More patients had been given antihypertensives, anticoagulants, antidepressants, analgesics, and hypnotics/tranquilizers (p values < .05).

CONCLUSIONS

Young patients admitted to the emergency department with unexplained acute chest pain showed no increased risk of mortality or ischemic heart disease during 25 years of follow-up, but they had higher incidence of a wide range of disorders and used more medications. Early identification and preventive interventions may improve health outcomes in these patients.

Danish nationwide registers for public health and health-related research

Aims: The Nordic countries have a strong tradition of using nationwide social and health registers for research purposes. The aim of the current paper is to provide an overview of the Danish population-based registers in public health and health-related research, and to discuss their strengths and limitations. Methods: Danish registers on somatic and psychiatric hospital contacts as well as care provided by general practitioners were reviewed. The availability of demographic, individual-level variables of relevance for health-related research was summarized. Results: Since 1968, every person living in Denmark has a unique identifier. This identifier is listed in Danish registers enabling linkage of information from a range of registers on an individual level. The nationwide coverage of all patient contacts at somatic and psychiatric hospitals, consultations with general practitioners, purchases of prescribed medications, and a complete follow-up with respect to causes of death support public health studies surveying trends of prevalence and incidence. Historical data on psychiatric and somatic hospitalizations since 1969 and 1977, respectively, allow an in-depth assessment of the burden of disease and time trends. Demographic characteristics of individuals and family units, together with information on education, employment, income, place of residence and migration, are provided by social registers. Conclusions: Register data are fully representative of the entire population with no loss to follow-up. Nationwide coverage also ensures a large sample to investigate events and conditions with low base rates. Clinical observations are limited and often only available for select patient populations. However, the opportunities available for public health research through linkage of register data with the increasing number of nationwide clinical databases, bio-banks and surveys entail promising perspectives for future research.

Psychosocial outcomes of fetal alcohol syndrome in adulthood

BACKGROUND AND OBJECTIVE

Primary disabilities in children prenatally exposed to alcohol have a major impact on their daily life. It is suggested that these issues persist into adulthood, but few studies have addressed the outcome in adults with prenatal exposure, especially those with fetal alcohol syndrome (FAS). The aim of this follow-up study was to investigate outcome variables, such as education, employment, health, and criminal acts, in 79 adults diagnosed with FAS.

METHODS

We carried out a national register-based study of 79 adults with an FAS diagnosis, at a mean age of 32. Education, social adjustment, and mental health outcomes were analyzed and compared with 3160 comparison individuals matched on age, gender, and place of birth.

RESULTS

The FAS group was much more likely to have received special education (25% vs 2%), be unemployed (51% vs 15%), and receive a disability pension (31% vs 3%) than the comparisons, but the levels of criminal offenses were similar. The FAS group had higher hospital admission rates for alcohol abuse (9% vs 2%) and psychiatric disorders (33% vs 5%) and was more likely to be prescribed psychotropic drugs (57% vs 27%).

CONCLUSIONS

Swedish children with FAS have quite diverse psychosocial outcomes in adulthood, considerably worse than for majority population peers. Potential risk and protective factors within the FAS group deserve study to enable development of effective interventions.

Psychiatric morbidity and survival after surgery for esophageal cancer: a population-based cohort study

PURPOSE

To determine the cumulative incidence of and risk factors for psychiatric morbidity and establish the impact on survival among surgically treated patients with esophageal cancer.

PATIENTS AND METHODS

A nationwide Swedish cohort of 1,615 patients who underwent surgery for esophageal cancer between 1987 and 2010 with follow-up until 2012 was linked to national health registries for information on psychiatric morbidity (inferred from mental health care use). Multivariable logistic regressions were used to determine potential risk factors for postoperative psychiatric morbidity. A multivariable-adjusted Cox proportional hazard model was used to analyze overall survival.

RESULTS

In patients without a history of psychiatric morbidity, the 2-year cumulative incidence for treatment in psychiatric in-patient care was 2.5%, for psychiatric out-patient care was 4.2%, and for treatment with psychotropic drugs was 32.3%. Married patients were less likely to be treated postoperatively in psychiatric in-patient care (odds ratio [OR], 0.42; 95% CI, 0.22 to 0.80) or out-patient care (OR, 0.41; 95% CI, 0.17 to 1.02), whereas patients with higher tumor stage were more likely to be treated in psychiatric out-patient care (OR, 4.99; 95% CI, 1.16 to 21.38) or with psychotropic drugs (OR, 2.78; 95% CI, 1.10 to 7.01). Bearing in mind possible residual confounding, new-onset psychiatric morbidity was associated with mortality (hazard ratio [HR], 1.65 [95% CI, 1.17 to 2.33] for treatment in psychiatric in-patient care; HR, 1.93 [95% CI, 1.18 to 3.16] for treatment in psychiatric out-patient care; and HR, 2.77 [95% CI, 1.72 to 4.44] for treatment with psychotropic drugs).

CONCLUSION

These results highlight the importance of recognizing and addressing psychiatric morbidity in surgically treated patients with esophageal cancer.

Use of antidepressants and association with elective termination of pregnancy: population based case-control study

OBJECTIVE

To assess whether the use of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, mirtazapine, venlafaxine or other antidepressants is associated with late elective termination of pregnancy.

DESIGN

Case-control study using data from national registers.

SETTING

Denmark, Finland, and Norway during the period 1996-2007.

POPULATION

A total of 14,902 women were included as cases and 148,929 women were included as controls.

METHODS

Cases were women with elective termination of pregnancy at 12-23 weeks of gestation. Controls continued their pregnancy and were matched with cases on key factors.

MAIN OUTCOME MEASURES

Association between antidepressant use during pregnancy and elective termination of pregnancy at 12-23 weeks of gestation for fetal anomalies, or for maternal ill health or socio-economic disadvantage.

RESULTS

At least one prescription of antidepressants was filled by 3.7% of the cases and 2.2% of the controls. Use of any type of antidepressant was associated with elective termination of pregnancy for maternal ill health or socio-economic disadvantage (odds ratio, OR 2.3; 95% confidence interval, 95% CI 2.0-2.5). Elective termination of pregnancy for fetal anomalies was associated with the use of mirtazapine (OR 2.2, 95% CI 1.1-4.5). There was no association between the use of any of the other antidepressants and elective termination of pregnancy for fetal anomalies.

CONCLUSION

The use of any type of antidepressants was associated with elective termination of pregnancy at 12-23 weeks for maternal ill health or socio-economic disadvantage, but not with terminations for fetal anomalies. Further studies need to confirm the findings concerning mirtazapine and termination of pregnancy for fetal anomalies.

Risks for stroke and bleeding with warfarin or aspirin treatment in patients with atrial fibrillation at different CHA(2)DS(2)VASc scores: experience from the Stockholm region

PURPOSE

This study evaluated the benefits of and possible contraindications to warfarin treatment in patients with atrial fibrillation (AF) prior to the introduction of new oral anticoagulants using health registry data from inpatient care, specialist ambulatory care, and primary care.

METHODS

This is a cohort study including all patients in the region of Stockholm, Sweden (2.1 million inhabitants) with a diagnosis of non-valvular AF (n = 41 810) recorded during 2005-2009. The risks of suffering ischemic stroke, bleeding, or death with warfarin, aspirin, or no antithrombotic treatment during 2010 were related to CHA2DS2VASc scores, age, and complicating co-morbidities.

RESULTS

One-year risks for ischemic stroke were 1.0-1.2 % with aspirin, 0-0.3 % with warfarin, and 0.1-0.2 % without treatment at CHA2DS2VASc scores 0-1. Among the aspirin-treated patients with CHA2DS2VASc scores ≥2, half had possible contraindications and high risks for ischemic stroke (5.2 %), bleeding (5.0 %), and death (19.3 %). The other half of the patients with no identified contraindications had a high risk for ischemic stroke (4.0 %) but a low bleeding risk (1.8 %) and a moderate mortality rate (8.4 %).

CONCLUSIONS

The present observations confirm earlier findings of undertreatment with warfarin and half of the high-risk patients treated with aspirin were obvious candidates for anticoagulant treatment. However, the other half of the patients had complicating co-morbidities, high bleeding risk, and poor prognosis. This and possible overtreatment of low-risk patients should be taken into account when considering more aggressive use of anticoagulant treatment.

Diabetes and psychiatric illness in the total population of Stockholm

OBJECTIVE

Concomitant psychiatric disorders in people with diabetes affect morbidity and mortality. We aimed to study psychiatric morbidity in people with diabetes and the general population using administrative health care data in Stockholm County.

METHODS

The study population included all living persons who resided in Stockholm County, Sweden, on January 1, 2011 (N=2,058,408). Subjects with a diagnosis of diabetes were identified with data from all consultations in primary health care, specialist outpatient care and inpatient care during the time span 2009-2013. As outcome, information was obtained on all consultations due to any psychiatric diagnosis as well as, specifically, schizophrenia, bipolar disorders, depression, and anxiety disorders, in 2011-2013. Analyses were performed by age group and gender. Age-adjusted odds ratios (ORs) with 95% confidence intervals (95% CI) for women and men with diabetes, using individuals without diabetes as referents, were calculated.

RESULTS

Age-adjusted OR for all psychiatric diagnoses among people with diabetes was 1.296 (95% CI 1.267-1.326) for women and 1.399 (95% CI 1.368-1.432) for men. The greatest excess risk was found for schizophrenia, with OR 3.439 (95% CI 3.057-3.868) in women and 2.787 (95% CI 2.514-3.089) in men, with ORs between 1.276 (95% CI 1.227-1.327) and 1.714 (95% CI 1.540-1.905) for the remaining diagnoses.

CONCLUSION

The prevalence of psychiatric disorders is elevated in people with diabetes, which calls for preventive action to be taken to minimize suffering and costs to society.

Horizontal inequality in rationing by waiting lists

The objective of this article was to investigate the existence of horizontal inequality in access to care for six categories of elective surgery in a publicly funded system, when care is rationed through waiting lists. Administrative waiting time data on all elective surgeries (n = 4,634) performed in Ostergötland, Sweden, in 2007 were linked to national registers containing variables on socioeconomic indicators. Using multiple regression, we tested five hypotheses reflecting that more resourceful groups receive priority when rationing by waiting lists. Low disposable household income predicted longer waiting times for orthopedic surgery (27%, p < 0.01) and general surgery (34%, p < 0.05). However, no significant differences on the basis of ethnicity and gender were detected. A particularly noteworthy finding was that disposable household income appeared to be an increasingly influential factor when the waiting times were longer. Our findings reveal horizontal inequalities in access to elective surgeries, but only to a limited extent. Whether this is good or bad depends on one's moral inclination. From a policymaker's perspective, it is nevertheless important to recognize that horizontal inequalities arise even though care is not rationed through ability to pay.

Nordic databases to evaluate medications in pregnancy

The objective of this review is to describe the possibilities to assess drugs used in pregnancy by means of the Nordic health registers. The Nordic countries comprise five countries: Denmark, Finland, Iceland, Norway and Sweden and have a total population of 25 million. All five countries have in their national health registers for many years recorded information concerning all births, cancer diagnoses, hospital contacts, causes of death and dispensed drugs. The registers can be used for studying drugs dispensed during pregnancy and though most previous studies focused on risks of congenital abnormalities, other health consequences of maternal medication can also be assessed.