Ethical aspects of registry-based research in the Nordic countries

Prevalence of dementia diagnosis in Sweden by geographical region and sociodemographic subgroups: a nationwide observational study

Background

Although dementia incidence has decreased in high-income countries, it is important to monitor the prevalence of dementia and identify potential underdiagnosis in population subgroups. This study provides the most up-to-date prevalence of dementia diagnosis in Sweden, by geographical regions and sociodemographic groups.

Methods

We identified all individuals aged ≥62 years, registered and alive in Sweden at the end of 2022 (n = 2.48 million). Dementia diagnoses were identified using ICD-9/10 codes in the National Patient Register since 1987, as well as anti-dementia drug use from the Prescribed Drug Register since 2005.

Findings

At the end of 2022, 3.7% (92,293/2,483,798) of people aged ≥62 years in Sweden had a dementia diagnosis from specialist care or drug prescriptions and varied from 0.6% in ages 62-69 to 14.8% in ages ≥90. The prevalence of cognitive impairment diagnosis was 2.5%. There was some geographical variation in the prevalence of dementia diagnosis, with a larger proportion of diagnoses coming from drug prescriptions than from specialist care in northern Sweden. While people born abroad and people without a close relative had a slightly higher prevalence of dementia diagnosis than Swedish born and those with close relatives, the prevalence was substantially lower for people living alone than for cohabiting individuals.

Interpretation

Comparing case estimates from previous screening cohorts, our results suggest underdiagnosis of dementia in the general older population, particularly among people who live alone. In more rural areas with lower availability of memory clinics, primary care may play an important role in diagnosing older adults with dementia.

Funding

Swedish Research Council for Health, Working Life and Welfare; Swedish Research Council; Region Stockholm.

Inflammatory eye disease is a risk factor for future microscopic colitis: A nationwide population-based matched case control study

BACKGROUND

Microscopic colitis (MC) is an inflammatory disorder of the colon. To date, the relationship between inflammatory eye diseases and MC is unclear.

OBJECTIVE

To assess whether inflammatory eye disease (iridocyclitis and episcleritis) is a risk factor for MC.

METHODS

We conducted a nationwide matched case control study in Sweden leveraging the ESPRESSO-study (a Swedish database containing data on all biopsies from the gastrointestinal tract from 1965 to 2017). In total, we identified 14,338 patients with biopsy-verified MC (diagnosed from 1981 to 2017). Patients with MC were matched (by age, sex, county and year of birth) with 68,753 controls from the general population and the occurrence of preceding inflammatory eye diseases (defined as diagnosis of episcleritis or iridocyclitis) in the two groups was compared. Multivariable adjusted odds ratios (aORs) were calculated using conditional logistic regression conditioned on the matching variables.

RESULTS

A majority of patients with MC were women (71.9%) and the median age at MC diagnosis was 63.3 years (interquartile range (IQR) = 50.7-72.6). Some 225 (1.6%) MC patients had an earlier record of inflammatory eye disease compared with 614 (0.9%) in controls. These figures corresponded to an aOR of 1.77 (95% CI = 1.52-2.07) for inflammatory eye diseases in patients with MC. Compared to siblings, the aOR for previous inflammatory eye diseases in MC was 1.52 (95% CI = 1.17-1.98) and patients treated with budesonide, as a proxy for clinically significant disease, had a somewhat higher aOR for previous inflammatory eye diseases.

CONCLUSION

Inflammatory eye diseases are more common in patients subsequently being diagnosed with MC. Our findings highlight that these conditions may have shared causes and inflammatory pathways and are of clinical interest to gastroenterologists, ophthalmologists and general practitioners.

Spondyloarthritis in First-Degree Relatives and Spouses of Patients with Inflammatory Bowel Disease: A Nationwide Population-based Cohort Study from Sweden

BACKGROUND AND AIMS

Register-based research suggests a shared pathophysiology between inflammatory bowel disease [IBD] and spondyloarthritis [SpA], but the role of familial [genetic and environmental] factors in this shared susceptibility is largely unknown. We aimed to compare the risk of SpA in first-degree relatives [FDRs] and spouses of IBD patients with FDRs and spouses of matched, population-based, reference individuals.

METHODS

We identified 147 080 FDRs and 25 945 spouses of patients with incident IBD [N = 39 203] during 2006-2016, and 1 453 429 FDRs and 258 098 spouses of matched reference individuals [N = 390 490], by linking nationwide Swedish registers and gastrointestinal biopsy data. Study participants were followed 1987-2017. Cox regression was used to estimate hazard ratios [HRs] of SpA.

RESULTS

During follow-up, 2430 FDRs of IBD patients [6.5/10 000 person-years] and 17 761 FDRs of reference individuals [4.8/10 000 person-years] were diagnosed with SpA, corresponding to an HR of 1.35 [95% CI:1.29, 1.41]. In subgroup analyses, the increased risk of SpA was most pronounced in FDRs of Crohn's disease patients [HR = 1.44; 95% CI:1.34,1.5 6] and of IBD patients aged <18 years at diagnosis [HR = 1.46; 95% CI: 1.27, 1.68]. IBD patients' spouses also had a higher SpA rate than reference individuals' spouses, but the difference was less pronounced [4.3 vs 3.5/10 000 person-years; HR = 1.22; 95% CI:1.09, 1.37]. No subgroup-specific risk pattern was identified among spouses.

CONCLUSIONS

The observed shared familial risks between IBD and SpA support shared genetic factors in their pathogenesis. However, spouses of IBD patients were also at increased risk for SpA, reflecting the influence of environmental exposures or similarities in health-seeking patterns.

Exploring the Bidirectional Relationship Between Periodontitis and Rheumatoid Arthritis in a Large Danish Cohort

OBJECTIVE

We investigated the bidirectional relationship between rheumatoid arthritis (RA) and periodontitis and their cross-sectional association using national administrative health care data.

METHODS

The sample included 3,308,903 individuals aged 20 to 79 years who resided in Denmark in 2000 and had remained free of RA and periodontitis in the previous 10 years. RA and periodontitis were defined using diagnosis and treatment codes. Marginal structural survival models were employed to estimate the effects of RA on periodontitis incidence and vice versa from 2000 to 2017. Using a cross-sectional sample of 2,574,536 individuals from 2017, the association of periodontitis with RA was investigated using regression analyses and probabilistic quantitative bias analyses, simulating RA and periodontitis misclassification and unmeasured confounding of smoking.

RESULTS

Between 2000 and 2017, 20,348 individuals developed RA and 740,799 developed periodontitis. The estimated hazard ratio (HR) for the effect of periodontitis on incident RA was 1.05 (95% confidence interval [CI] 0.88-1.25), resulting in a restricted mean survival time difference of one day. The HR for the effect of RA on incident periodontitis was 0.84 (95% CI 0.80-0.88), corresponding to a restricted mean survival time difference of 151 days. Cross-sectionally, the unadjusted prevalence ratio for the association was 1.15 (95% CI 1.11-1.19), whereas the estimate adjusted for measured and simulated confounding was practically null (0.99, 95% simulation interval 0.93-1.04).

CONCLUSION

These findings challenge previously reported bidirectional relationships between periodontitis and RA, pointing to potential residual confounding as an important link and prompting reconsideration of the biologic plausibility and clinical significance of these associations.

Coeliac disease and type 2 diabetes risk: a nationwide matched cohort and Mendelian randomisation study

AIMS/HYPOTHESIS

While the association between coeliac disease and type 1 diabetes is well documented, the association of coeliac disease with type 2 diabetes risk remains undetermined. We conducted a nationwide cohort and Mendelian randomisation analysis to investigate this link.

METHODS

This nationwide matched cohort used data from the Swedish ESPRESSO cohort including 46,150 individuals with coeliac disease and 219,763 matched individuals in the comparator group selected from the general population, followed up from 1969 to 2021. Data from 9053 individuals with coeliac disease who underwent a second biopsy were used to examine the association between persistent villous atrophy and type 2 diabetes. Multivariable Cox regression was employed to estimate the associations. In Mendelian randomisation analysis, 37 independent genetic variants associated with clinically diagnosed coeliac disease at p<5×10-8 were used to proxy genetic liability to coeliac disease. Summary-level data for type 2 diabetes were obtained from the DIAGRAM consortium (80,154 cases) and the FinnGen study (42,593 cases).

RESULTS

Over a median 15.7 years' follow-up, there were 6132 (13.3%) and 30,138 (13.7%) incident cases of type 2 diabetes in people with coeliac disease and comparator individuals, respectively. Those with coeliac disease were not at increased risk of incident type 2 diabetes with an HR of 1.00 (95% CI 0.97, 1.03) compared with comparator individuals. Persistent villous atrophy was not associated with an increased risk of type 2 diabetes compared with mucosal healing among participants with coeliac disease (HR 1.02, 95% CI 0.90, 1.16). Genetic liability to coeliac disease was not associated with type 2 diabetes in DIAGRAM (OR 1.01, 95% CI 0.99, 1.03) or in FinnGen (OR 1.01, 95% CI 0.99-1.04).

CONCLUSIONS/INTERPRETATION

Coeliac disease was not associated with type 2 diabetes risk.

Structural changes in a Danish social housing area: The impact of forced permanent rehousing on contact frequency with general practitioner and use of antidepressants

There is a lack of knowledge about the health consequences of politically initiated forced permanent rehousing (FPR) of residents in social housing areas. This study investigates if FPR is associated with the contact frequency with general practitioner (GP) and the proportion of residents who use antidepressants. The study included 432 rehoused residents matched 1:2 with remaining residents and residents from a comparable neighbouring area without exposure to rehousing. For GP contact frequency, we conducted a difference-in-difference analysis while the proportion of residents who used antidepressants was investigated through descriptive statistics. We found high GP contact frequency in the three groups, but no significant differences. Further, we found a low proportion of residents who used antidepressants in all groups, but a small increase from baseline to follow-up. Our results thus suggest that FPR neither affected the rehoused residents' GP contact frequency nor the proportion who used antidepressants.

Association of celiac disease with eosinophilic esophagitis: Nationwide register-based cohort study with sibling analyses

Background

Celiac disease (CeD) is associated with several immune-mediated disorders, but it is unclear whether it is associated with eosinophilic esophagitis (EoE).

Objective

We sought to examine the risk of EoE in patients with biopsy-verified CeD compared with matched controls and siblings.

Methods

Using nationwide population-based histopathology data, we identified 27,338 patients with CeD diagnosed in the period 2002 to 2017 in Sweden. Patients with CeD were age- and sex-matched with up to 5 reference individuals (n = 134,987) from the general population. Cox Regression was used to estimate hazard ratios (HRs) for developing biopsy-verified EoE. In a secondary analysis, we used unaffected siblings of patients with CeD as comparators to adjust for intrafamilial confounding.

Results

The median age at CeD diagnosis was 27 years, and 63.3% were female patients. During a median follow-up of 8.1 years, 17 patients with CeD and 13 matched reference individuals were diagnosed with EoE. This corresponded to incidence rates of 0.08 versus 0.01 per 1000 person-years, respectively, and an adjusted HR for EoE of 6.65 (95% CI, 3.26-13.81). Compared with their siblings without CeD, patients with CeD were however at a no increased risk of EoE (HR, 1.39; 95% CI, 0.55-3.51).

Conclusions

In this study, individuals with CeD were at a 6.6-fold increased risk of later EoE compared with the general population. This association might be explained by an altered health-seeking behavior or through shared genetic or early environmental factors because the excess risk disappeared in sibling analyses.

Establishment of the Norwegian hearing register for children

Introduction

The Norwegian Directorate of Health approved the Norwegian Hearing Register for Children in 2022. The main objective of the register is to improve the quality of treatment for children with permanent hearing loss, by measures, follow-ups and monitoring the quality and results of the health care system.

Methods

Inclusion criteria are children who do not pass universal newborn hearing screening and/or children with permanent hearing loss <18 years of age. Hearing loss is defined as pure-tone audiometry threshold of (PTA4) > 20 dB in at least one ear. Data are registered at the Ear, Nose and Throat departments at inclusion and at follow-ups at the age of 3, 6, 10, and 15 years. The register collects information about the child within a holistic perspective. The key elements of the register are (a) data concerning newborn hearing screening; (b) data concerning hearing, medical information, hearing amplification and intervention (c) patient reported outcome measures registered by caregivers using three questionnaires; Pediatric Quality of Life Inventory, Strengths and Difficulties Questionnaire and Parents' Evaluation of Aural/Oral Performance of Children.

Results

The register has established four quality indicators regarding newborn hearing screening and early intervention (a) the rate of false positive neonatal screens; (b) testing for congenital cytomegalovirus within 3 weeks of age for children who do not pass newborn hearing screening; (c) audiological evaluation to confirm the hearing status no later than 3 months of age and (d) initiated intervention within 3 months after confirmation of hearing status.

Discussion

The register will include the total population of hearing impaired children over long time periods. Thus, the register enables each hospital to monitor their quality indicator scores continuously and compare them with national levels in real time. This facilitates and accelerates identification of improvement areas in the hospitals and will be an important contributor for quality improvement in NHS, diagnostics and hearing intervention for children in Norway. In addition, data from the register will be a unique source for research, and study designs with a long follow-up time can be applied.

Contemporary Trends in Antiseptic Pocket Rinse in Primary Breast Implant Surgery

BACKGROUND

Broad evidence supports the use of antiseptic pocket rinse in breast implant surgery to minimize the risk of capsular contracture or other complications. However, there is limited consensus or standardization of antiseptic rinse in practice.

OBJECTIVES

In this preliminary study, we sought to determine contemporary trends in antiseptic rinse use in primary breast implant surgery based on Australian Breast Device Registry (ABDR) data, and whether these trends align with the suggestions of the 14-point plan. This further served as a feasibility study for subsequent comparison of antiseptic rinse effects on clinical outcomes.

METHODS

Institutional ethics approval was obtained and national ABDR data for primary breast implant surgery from 2015 to 2020 were analyzed for the use and type of antiseptic rinse. The surgeon-reported data were homogenized with regard to terminology and categorized by major trends, and the literature was reviewed.

RESULTS

We analyzed data for 37,143 patients, totaling 73,935 primary implants. Antiseptic rinse included povidone-iodine (PVP-I) in 35,859 (48.5%), no antiseptic use in 24,216 (32.8%), other concentrations of PVP-I in 4200 (5.7%), and Betadine triple antibiotic in 1831 implants (2.5%). Multiple other antiseptic permutations were noted in 7004 implants (9.5%).

CONCLUSIONS

The majority (56.7%) of Australian practitioners utilize previously described antiseptic pocket irrigation solutions that align with the 14-point plan. A third (32.8%), however, do not record any antiseptic pocket irrigation. These findings will permit a subsequent (ongoing) study of outcomes comparing PVP-I pocket rinse to no antiseptic pocket rinse, which will likely constitute the largest study of its kind.

Maternal Steroid Hormone Levels in Early Pregnancy and Autism in the Offspring: A Population-Based, Nested Case-Control Study

BACKGROUND

A role for prenatal steroid hormones in the etiology of autism has been proposed, but evidence is conflicting.

METHODS

Here, we examined serum levels of maternal estradiol, testosterone, 17-hydroxyprogesterone (OHP), and cortisol from the first trimester of gestation (mean = 10.1 weeks) in relation to the odds of diagnosed autism with and without co-occurring intellectual disability (ID) in the offspring (n = 118 autism with ID, n = 249 autism without ID, n = 477 control). Levels of maternal hormones were measured using highly sensitive liquid chromatography tandem mass spectrometry, standardized according to gestational timing of sample collection, and analyzed with restricted cubic spline logistic regression models adjusting for child's sex and maternal health, demographic, and socioeconomic factors.

RESULTS

We observed significant nonlinear associations between maternal estradiol, 17-OHP, and cortisol with autism, which varied with the presence of co-occurring ID. Compared to mean levels, lower levels of estradiol were associated with higher odds of autism with ID (odds ratio for concentrations 1 SD below the mean = 1.66; 95% CI, 1.24-2.11), while higher cortisol levels were associated with lower odds (odds ratio for 1 SD above the mean = 0.55; 95% CI, 0.36-0.88). In contrast, higher 17-OHP was associated with increased odds of autism without ID (odds ratio for 1 SD above the mean = 1.49; 95% CI, 1.11-1.99). We observed no evidence for interaction with sex of the child.

CONCLUSIONS

These findings support the notion that the maternal steroid hormonal environment in early pregnancy may contribute to autism, but also emphasize the complex relationship between early-life steroid exposure and autism.

Psychiatric Disorders Among 5,800 Patients With Microscopic Colitis: A Nationwide Population-Based Matched Cohort Study

INTRODUCTION

Microscopic colitis (MC) is an inflammatory condition of the large intestine. Primarily diagnosed in middle-aged and older adults, the incidence of the disease has increased markedly during the past few decades. While MC is associated with a reduced quality of life, large-scale studies on the association with future psychiatric disorders are lacking.

METHODS

We conducted a nationwide matched cohort study in Sweden from 2006 to 2021. Through a nationwide histopathology database (the Epidemiology Strengthened by histoPathology Reports in Sweden study), we identified 5,816 patients with a colorectal biopsy consistent with MC. These patients were matched with 21,509 reference individuals from the general population all of whom with no previous record of psychiatric disorders.

RESULTS

From 2006 to 2021, 519 patients with MC (median age 64.4 years [interquartile range = 49.5-73.3]) and 1,313 reference individuals were diagnosed with psychiatric disorders (9.9 vs 6.5 events per 1,000 person-years), corresponding to 1 extra case of psychiatric disorder in 29 patients with MC over 10 years. After adjustments, the hazard ratio for psychiatric disorders was 1.57 (95% confidence interval = 1.42-1.74). We found significantly elevated estimates up to 10 years after MC diagnosis and a trend toward higher risk with increasing age. Specifically, we observed increased risks for unipolar depression, anxiety disorders, stress-related disorders, substance abuse, and suicide attempts. In sibling-controlled analysis, the adjusted hazard ratio was 1.76 (95% confidence interval = 1.44-2.15).

DISCUSSION

Patients with MC are at increased risk of incident psychiatric disorders compared with the general population.

Adolescent Cardiorespiratory Fitness and Risk of Cancer in Late Adulthood: Nationwide Sibling-Controlled Cohort Study

Objective

To investigate whether the higher risks of certain cancers associated with high cardiorespiratory fitness can be explained by increased detection and unobserved confounders.

Design

Nationwide sibling-controlled cohort study of adolescents.

Setting

Sweden.

Participants

1 124 049 men of which 477 453 were full siblings, who underwent mandatory military conscription examinations between 1972 and 1995 at a mean age of 18.3 years.

Main outcome measures

Hazard ratios (HR) and 95% confidence intervals (CI) of overall cancer diagnosis and cancer mortality, and 14 site-specific cancers (diagnosis or death), as recorded in the Swedish National Patient Register or Cause of Death Register until 31 December 2023, modelled using flexible parametric regressions.

Results

Participants were followed until a median (maximum) age of 55.9 (73.5) years, during which 98 410 were diagnosed with cancer and 16 789 had a cancer-related death (41 293 and 6908 among full siblings respectively). The most common cancers were non-melanoma skin (27 105 diagnoses & 227 deaths) and prostate cancer (24 211 diagnoses & 869 deaths). In cohort analysis, those in the highest quartile of cardiorespiratory fitness had a higher risk of prostate (adjusted HR 1.10; 95% CI: 1.05 to 1.16) and skin cancer (e.g., non-melanoma HR 1.44; 1.37 to 1.50) compared to those in the lowest quartile, which led to a higher risk of any type of cancer diagnosis (HR 1.08; 1.06 to 1.11). However, those in the highest quartile had a lower risk of cancer mortality (HR 0.71; 0.67 to 0.76). When comparing full siblings, and thereby controlling for all behavioural, environmental, and genetic factors they share, the excess risk of prostate (HR 1.01; 0.90 to 1.13) and skin cancer (e.g., non-melanoma HR 1.09; 0.99 to 1.20) attenuated to the null. In contrast, the lower risk of overall cancer mortality was still statistically significant after control for such shared confounders (HR 0.78; 0.68 to 0.89). For other site-specific cancers, the influence of such confounding tended to vary, but none showed the same excess risk as prostate and non-melanoma skin cancer.

Conclusions

The association between high levels of adolescent cardiorespiratory fitness and excess risk of some cancers, such as prostate and non-melanoma skin cancer, appears to be fully explained by unobserved confounders shared between full siblings. However, the protective association with cancer mortality persists even after control for such confounding.

Sickness absence and disability pension patterns before and after ischemic stroke: A Swedish longitudinal cohort study with matched references

INTRODUCTION

The aim was to determine ischemic stroke patients' sickness absence and disability pension before and after stroke, and compare these to that of matched references.

PATIENTS AND METHODS

All working-aged individuals (aged 18-61) in Sweden with incident ischemic stroke in year 2000, 2005, 2010, or 2015, respectively, and five population-based matched references to each stroke patient. Each cohort was followed 1 year prior stroke and 3 years after. We calculated rates and mean days of sickness absence and disability pension among stroke patients and references and computed trajectories of absence days with predictors of high sickness absence and disability pension.

RESULTS

Number of patients with incident ischemic stroke in 2000 (N = 2728), 2005 (N = 2738), 2010 (N = 2767), and 2015 (N = 2531). Mean stroke age was 53 years and rate of men was 64%. Mortality rate within 12 months after stroke date decreased from 8.1% in 2000 to 4.8% in 2015. Sickness absence for patients was 31.1% in the year prior their stroke, versus 13.7% for references, both groups mainly due to mental and musculoskeletal diagnoses. Factors associated with future high mean number of sickness absence and disability pension days were elementary educational level; adjusted OR (CI) 3.47(2.38-5.05), being single; 1.67(1.29-2.16), female sex 1.72(1.31-2.26), diabetes; 1.86(1.18-2.92), and aged >50; 2.25(1.69-2.98).

DISCUSSION AND CONCLUSION

Ischemic stroke patients have more absence days compared to matched references even before the stroke, mainly related to mental and musculoskeletal diagnoses. Future research should address the impact of efficient stroke treatment on sickness absence and disability pension.

Real-world impact of continuous positive airway pressure on sleepiness in patients with obstructive sleep apnea in a national registry

OBJECTIVE

Excessive daytime sleepiness (EDS) persists in some patients with obstructive sleep apnea (OSA) despite continuous positive airway pressure (CPAP) treatment. This study characterized response to CPAP and factors associated with residual EDS.

METHODS

Danish National Patient Registry data were analyzed. Patients with OSA diagnosis (1994-2016), Epworth Sleepiness Scale (ESS) scores and apnea-hypopnea index recorded before beginning CPAP (baseline) and after 1-13 months of CPAP use, and CPAP adherence were included. Odds ratios (OR) for residual EDS after CPAP treatment were estimated using multivariate logistic regression.

RESULTS

Of 1174 patients (mean age, 57 years; 75.5% male), 41.1% had baseline EDS (mild, 13.2%; moderate, 14.0%; severe, 13.9%); 58.9% did not. After CPAP treatment, follow-up mean ESS scores were normal (≤10) for all baseline EDS subgroups; however, 15.6% (n = 183) of patients had residual EDS (mild, 6.7%; moderate, 5.5%; severe, 3.4%). Odds of residual EDS were higher for patients with mild (OR, 5.2; 95% confidence interval [CI], 3.2-8.6), moderate (OR, 4.5; 95% CI, 2.7-7.4), and severe (OR, 13.0; 95% CI, 8.0-21.2) EDS at baseline compared with those with normal daytime sleepiness at baseline. Patients adherent with CPAP use were 38.2% less likely to have residual EDS compared with nonadherent patients (OR, 0.62; 95% CI, 0.43-0.88).

CONCLUSIONS

EDS was common in this cohort of Danish patients with OSA. Baseline EDS severity predicted higher odds of residual EDS. After CPAP treatment, adherence was associated with reduced odds of residual EDS, but EDS persisted in a subgroup of patients.

Maternal gestational hypertension, smoking and pre-eclampsia are associated with metabolic dysfunction-associated fatty liver disease in overweight offspring

INTRODUCTION

Due to a steep increase in obesity, metabolic dysfunction-associated fatty liver disease (MAFLD) has also become the most common chronic hepatic condition among children and adolescents. Various maternal and pregnancy-related factors have also been implicated in the development of MAFLD, but human studies remain scarce.

MATERIAL AND METHODS

Comprehensive data of 460 overweight or obese children aged 2-16 years were collected and combined with data on selected maternal and pregnancy-related factors for a case-control study. MALFD was defined as alanine aminotransferase >2× upper limit of normal. Children with and without MAFLD were compared regarding to the study variables and multivariable regression analysis was utilized.

RESULTS

Median age of the study children was 11.8 (quartiles 9.1-14.2) years; 44% were girls and 17.8% had MAFLD. Children with MAFLD were older (12.7 vs. 11.6 years, p = 0.002), while the groups did not differ age-standardized body mass index (BMI-SDS) or gender. Factors associated with MAFLD in a multivariable model considering also the offspring's present BMI-SDS, sex, and maternal prepregnancy overweight, were child's older age (odds ratio [OR] 1.16, 95% confidence interval [CI]: 1.06-1.28), maternal gestational smoking (OR 2.01, 95% CI: 1.16-3.47), gestational hypertension (OR 3.44, 95% CI: 1.08-11.0) and pre-eclampsia (OR 2.93, 95% CI: 1.15-7.45). There was no significant association between MAFLD and maternal BMI, birth anthropometrics or perinatal complications.

CONCLUSIONS

Maternal smoking, gestational hypertension and pre-eclampsia were associated with MAFLD among overweight or obese children. Further prospective studies are needed to verify causal relationships.

Dental service use among adults with incident type 2 diabetes, rheumatoid arthritis or inflammatory bowel disease

OBJECTIVES

It is not clear if or how the incidence of systemic conditions like type 2 diabetes mellitus (DM2), rheumatoid arthritis (RA) or inflammatory bowel disease (IBD) affects dental service utilization. Using nationwide Danish register data, the aim of this study was to analyse the use of dental services 7 years before and after being diagnosed with DM2, RA or IBD between 1997 and 2011.

METHODS

Information about incident DM2 was obtained from the National Diabetes Register, and incident RA and IBD were defined based on diagnosis codes of hospital contacts identified through the National Patient Register. Separately, for each of the three conditions, each individual with the incident condition was matched to one control individual based on age, gender, country of origin, municipality of residence, highest completed education, the main source of income and income using coarsened exact matching in the year of incidence. The use of dental services and treatments received within each calendar year from 7 years before to 7 years after getting the condition were analysed with generalized estimating equations.

RESULTS

People with incident DM2 were less likely (by seven percentage points) to be dental service users within a year than people without incident DM2 for a period extending from up to 7 years prior to 7 years after the diagnosis. This difference even slightly increased after the diagnosis. Those with incident IBD exhibited a consistently but modestly higher proportion of dental service use (three percentage points) than those without incident IBD before and after the diagnosis. Differences in the use of services between those with or without incident RA were minor. For all three systemic diseases, detected differences mainly mirrored differences in the provision of supragingival scaling and restorative treatment.

CONCLUSIONS

The findings suggest that the impact of these three systemic conditions on dental service use was minor.

Gastrointestinal cancer precursor risk and mortality in pancreatic intraductal papillary mucinous neoplasms: a nationwide cohort study

BACKGROUND AND AIMS

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a precursor of pancreatic cancer. While earlier research has shown a high prevalence of synchronous/metachronous extrapancreatic tumors in IPMN patients, these studies have often been small with retrospective data collection. The aim of the study was to examine absolute and relative risks of non-pancreatic gastrointestinal (GI) cancer precursors and mortality in histologically confirmed IPMN.

METHODS

Through the nationwide ESPRESSO histopathology cohort, we retrieved data on IPMN between 1965 and 2016. Each index case was matched to ≤5 general population controls. Through Cox regression, we estimated hazard ratios (HRs) for future GI cancer precursors and death.

RESULTS

A total of 117 patients with IPMN and 539 age- and sex-matched controls were included. Over a median of 2.1 years of follow up, we confirmed two (1.7%) incident GI cancer precursors in IPMN vs. four (0.7%) in controls, corresponding to an HR of 1.89 (95%CI = 0.34-10.55). By contrast, IPMN patients were at increased risk of death (HR 3.61 (95%CI = 1.79-7.27)). The most common cause of death in IPMN was pancreatic cancer (n = 14; 45.2% of all deaths).

CONCLUSIONS

We found no association between IPMN and other GI cancer precursors. This argues against comprehensive routine surveillance for other GI cancer precursors in IPMN patients. Mortality was increased in IPMN with pancreatic cancer being the most common cause of death, indicating the need for lifelong follow up in all resected and non-resected patients with IPMN. However, results should be confirmed in larger cohorts.

From office to digital primary care services: analysing income-related inequalities in utilization

The use of digital technologies to deliver primary health care has increased over the past decade. While some technologies have been shown to be medically effective and efficient, the effects of digital primary care on the policy goal of equality in the use of such types of care have not been studied using large register data. The aim of this study was to analyse how digital contacts differ from officebased visits by income as an indicator of socioeconomic status. Specifically, we estimated differences in primary care utilization across income, factors of contribution to these inequalities, and applied a needs-based standardisation of utilization to estimate differences in equity.We used a purposively built consultation level dataset with 726 000 Swedish adult patients diagnosed with an infection, including clinical and sociodemographic variables. Applying concentration indexes (CI) and graphical illustrations we measured how the two types of services are distributed relative to income. We estimated how much of the inequalities were attributed to different sociodemographic factors by decomposing the concentration indexes. Standardised utilization for sex, age and comorbidity allowed for the estimation of horizontal inequity indexes for both types of services.Utilization by the two types of care showed large income inequalities. Office-based visits were propoor (CI -0.116), meaning lowincome patients utilized relatively more of these services, while digital contacts were prorich (CI 0.205). However, within the patient group who had at least one digital contact, the utilization was also propoor (CI -0,101), although these patients had higher incomes on average. The standardised utilization showed a smaller prorich digital utilization (CI 0.143), although large differences remained. Decomposing the concentration indexes showed that education level and being born in Sweden were strong attributes of prorich digital service utilization.The prorich utilization effects of digital primary care may risk undermining the policy goals of access and utilization to services regardless of socioeconomic status. As digital health technologies continue to expand, policy makers need to be aware of the risk.

Antipsychotic use during pregnancy and risk of specific neurodevelopmental disorders and learning difficulties in children: a multinational cohort study

Background

Antipsychotics are commonly prescribed to treat a range of psychiatric conditions in women of reproductive age and during pregnancy, including schizophrenia, bipolar disorder, anxiety, depression, autism spectrum disorder, and insomnia. This study aimed to evaluate whether children exposed to antipsychotic medication prenatally are at increased risk of specific neurodevelopmental disorders and learning difficulties.

Methods

Our population-based cohort study used nationwide register data (1 January 2000-31 December 2020) on pregnant women diagnosed with a psychiatric disorder and their live-born singletons from Denmark, Finland, Iceland, Norway, and Sweden. Cox proportional hazard regression yielded propensity score-weighted hazard ratios (aHRs) and 95% confidence intervals (CIs) for risk of intellectual-, speech or language-, learning-developmental disorders, and a composite outcome of the listed disorders. We defined poor performance as scoring within the lowest quartile on national school tests in mathematics and language arts. We estimated propensity score-weighted risk ratios (aRRs) using Poisson regression. We analysed data from Denmark separately and pooled results using random effects meta-analysis.

Findings

Among 213,302 children (median follow-up: 6.7 years), 11 626 (5.5%) were exposed to antipsychotics prenatally. Adjusted risk estimates did not suggest an increased risk of neurodevelopmental disorders: aHR of 1.06 (95% CI 0.94-1.20) for the composite outcome, or for poor academic performance: aRR of 1.04 (95% CI 0.91-1.18) in mathematics, and of 1.00 (95% CI 0.87-1.15) in language arts. Results were generally consistent across individual medications, trimesters of exposure, sibling- and sensitivity analyses.

Interpretation

The findings of this large multinational cohort study suggest there is little to no increased risk of child neurodevelopmental disorders or learning difficulties after prenatal exposure to antipsychotics. Our findings can assist clinicians and women managing mental illness during pregnancy.

Funding

This study was funded by the NordForsk Nordic Program on Health and Welfare (Nordic Pregnancy Drug Safety Studies, project No. 83539), by the Research Council of Norway (International Pregnancy Drug Safety Studies, project No. 273366) and by the Research Council of Norway through its Centres of Excellence funding scheme (project No. 262700), and UNSW Scientia Programme Awards (PS46019, PS46019-A).

Microscopic Colitis and Risk of Incident Psoriasis: A Nationwide Population-Based Matched Cohort Study

Background

Microscopic colitis (MC) has been associated with several immune-mediated diseases including psoriasis, but earlier research has been limited to psoriasis occurring before MC. Data from large-scale cohort studies investigating MC and risk of future psoriasis are lacking.

Objective

To examine the association between MC and psoriasis.

Methods

In a nationwide, population-based, matched cohort study in Sweden from 2007 to 2021, we identified 8404 patients with biopsy-verified MC (diagnosed in 2007-2017), 37,033 matched reference individuals, and 8381 siblings without MC. Information on MC was obtained through the ESPRESSO cohort (a Swedish histopathology database with nationwide coverage). Using Cox regression, we calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for psoriasis up until 2021.

Results

During a median follow-up of 9.2 years (interquartile range = 6.7-11.7), 179 MC patients and 440 reference individuals were diagnosed with psoriasis (241.1 vs 131.8 events per 100,000 person-years), corresponding to one extra case of psoriasis in 91 patients with MC over 10 years. After adjustment for the matching variables (birth year, sex, county of residence, and calendar period) and level of education, we computed an adjusted hazard ratio (aHR) of 1.82 (95% CI = 1.53-2.17). Stratified by sex, estimates were similar and when examining the aHR across different lengths of follow-up, we found significantly elevated estimates up to 10 years after MC diagnosis. Compared to MC-free siblings, the aHR was 1.85 (95% CI = 1.36-2.51).

Conclusion

Patients with MC are at an almost doubled risk of psoriasis compared to the general population. Clinicians need to consider psoriasis in MC patients with skin lesions.

Validation of IgA nephropathy diagnosis in the Swedish Renal Registry

AIM

The Swedish Renal Registry (SRR) is a unique national quality registry that monitors the clinical trajectory of patients with chronic kidney disease (CKD). We have validated the biopsy data registered in the SRR for IgA Nephropathy (IgAN) diagnosis.

METHODS

In total 25% of all patients (n = 142), registered with IgAN in the SRR after having performed a kidney biopsy during 2015-2019, were randomly selected. We obtained original biopsy and medical records for 139 (98%) patients. We evaluated the IgAN diagnosis using a standardized template, calculated its positive predictive value (PPV) with 95% confidence interval (CI) and reported clinical features at the time of diagnosis.

RESULTS

A histological and clinical diagnosis of IgAN was confirmed in 132 of the 139 patients, yielding a PPV of 95% (95% CI 90-98%). Median age was 46 years (range: 18-85) and the male:female ratio was 2.1:1. The median creatinine level was 123 µmol/L, with a corresponding estimated glomerular filtration rate (eGFR) level of 51 mL/min/1.73m2. Histological features of IgA deposits were seen in all patients, hypercellularity in 102/132 (77.2%), C3 deposits in 98/132 (72.4%) and C1q deposits in 27/132 (20.5%) of the cases.

CONCLUSION

Validating data is not research per se, but continuous validation of medical registries is an important feature necessary to ensure reliable data and the foundation of good epidemiological data for future research. Our validation showed a high PPV (95%) for IgAN diagnosis registered in the SRR. Clinical characteristics were consistent with previous reports. The biopsy data in the SRR will be a valuable resource in future IgAN research.

[Genetic studies on forensic-psychiatric inpatients? : Clinical, ethical and legal considerations]

BACKGROUND

Research on people deprived of liberty raises serious questions, especially concerning behavioral genetic studies.

QUESTION

Does including criminally detained patients with mental disorders in genetic studies lead to a gain of new knowledge and can this be ethically and legally justified?

METHOD

Evaluation of existing literature and interdisciplinary reflection.

RESULTS

After a review of research ethics and legal norms, we consider the benefits and risks of behavioral genetic research, taking the unique situation of test persons deprived of their liberty into account. The fundamental right to freedom of research also justifies foundational research in forensic psychiatry and psychotherapy. The possible future benefits of improving treatment plans must be weighed against the risks resulting from potential data leaks and inappropriate public reception of research results. Then we analyze possible threats to voluntary and informed consent to study participation in more detail by the ethical concept of vulnerability. Alongside problems with grasping complex issues, above all dependencies and power dynamics in the correctional system play a pivotal role. Recommendations on the ethical and legal inclusion of this study population are given.

CONCLUSION

Including criminally detained study participants can be ethically and legally justified when autonomous consent is supported by specific organizational and legal procedures and measures, for example via a clear professional and organizational separation of correction and research.

Eosinophilic esophagitis is associated with increased risk of later inflammatory bowel disease in a nationwide Swedish population cohort

BACKGROUND

Earlier studies on the possible association between eosinophilic esophagitis (EoE) and inflammatory bowel disease (IBD) have been contradictory.

METHODS

Patients with biopsy-verified EoE diagnosed between 1990 and 2017 in Sweden (n = 1587) were age- and sex-matched with up to five general population reference individuals (n = 7808). EoE was defined using pathology reports from all 28 pathology centers in Sweden (the ESPRESSO study). Multivariate Cox regression then estimated hazard ratios for future IBD. IBD was defined based on the international classification of disease codes and histopathology codes. In secondary analyses, sibling comparators were used to further reduce potential familial confounding. Additionally, we performed logistic regression examining earlier IBD in EoE.

RESULTS

During follow-up until 2020, 16 (0.01%) EoE patients and 21 (0.003%) general population reference individuals diagnosed with IBD, corresponding to a 3.5-fold increased risk of future IBD (aHR = 3.56; 95% CI 1.79-7.11). EoE was linked to Crohn's disease (aHR = 3.39 [95% CI 1.02-9.60]) but not to ulcerative colitis (aHR = 1.37; 95% CI 0.38-4.86). Compared to their siblings, patients with EoE were at a 2.48-fold increased risk of IBD (aHR = 2.48; 95% CI 0.92-6.70). Earlier IBD was 15 times more likely in EoE patients than in matched reference individuals (odds ratio, 15.39; 95% CI 7.68-33.59).

CONCLUSION

In this nationwide cohort study, EoE was associated with a 3.5-fold increased risk of later IBD diagnosis. This risk increase may be due to shared genetic or early environmental risk factors, but also surveillance bias could play a role.

Older age of celiac disease diagnosis and risk of autoimmune disease: A nationwide matched case-control study

OBJECTIVES

Celiac disease (CeD) has been linked to an increased risk of other autoimmune diseases, yet the impact of delayed CeD diagnosis on risk of developing additional autoimmune diseases remains uncertain. We investigated this through a nationwide matched case-control study.

METHODS

Using the ESPRESSO cohort with histophatology data from Sweden's 28 pathology departments, we assessed 46,575 biopsy-confirmed CeD cases from 1964 to 2017. We extracted 225,295 matched controls without histopathology information from the Swedish Total Population Register. Autoimmune disease was defined through diagnostic codes in the National Patient Register. Through conditional logistic regression we estimated odds ratio (OR) of autoimmune disease up until CeD diagnosis/matching date comparing CeD cases to controls across different age strata.

RESULTS

A total of 3059 (6.6 %) CeD patients and 4076 (1.8 %) controls had earlier autoimmune disease. The overall OR for autoimmune disease in CeD was 3.50 (95%CI 3.32-3.70). The risk of autoimmune disease did not escalate with increasing age at CeD diagnosis. Compared with controls, the OR of autoimmune disease in CeD patients was 7.70 (95%CI 4.71-12.57) in those diagnosed with CeD in 0-4 years, 19.02 (95%CI 13.80-26.23) in 5-9 years, 6.18 (95%CI 5.14-7.44) in 10-14 years, 4.80 (95%CI 3.97-5.79) in 15-19 years, 4.24 (95%CI 3.55-5.07) in 20-29 years, 4.65 (95%CI 3.93-5.51) in 30-39 years, 3.67 (95%CI 3.30-4.09) in 40-59 years, and 1.67 (95%CI 1.50-1.85) in ≥60 years.

CONCLUSIONS

This study revealed an increased risk of autoimmune disease among CeD patients compared with controls. However, older age at CeD diagnosis did not seem to escalate the risk of autoimmune diseases.

Incident cardiac arrhythmias associated with metabolic dysfunction-associated steatotic liver disease: a nationwide histology cohort study

BACKGROUND

Prior studies suggest a link between metabolic dysfunction-associated steatotic liver disease (MASLD) and incident arrhythmias, including atrial fibrillation (AF). However, robust data are lacking from cohorts with liver histology, which remains the gold standard for staging MASLD severity.

METHODS

This population-based cohort included all Swedish adults with histologically-confirmed MASLD and without prior cardiac arrhythmias (1966-2016; n = 11,206). MASLD was defined from prospectively-recorded histopathology, and characterized as simple steatosis, non-fibrotic steatohepatitis (MASH), non-cirrhotic fibrosis, or cirrhosis. MASLD patients were matched to ≤ 5 controls without MASLD or arrhythmias, by age, sex, calendar year and county (n = 51,856). Using Cox proportional hazards modeling, we calculated multivariable-adjusted hazard ratios (aHRs) for incident arrhythmias (including AF, bradyarrhythmias, other supraventricular arrhythmias, ventricular arrhythmias/cardiac arrest).

RESULTS

Over a median follow-up of 10.8 years, incident arrhythmias were confirmed in 1351 MASLD patients (10.3/1000 person-years [PY]) and 6493 controls (8.7/1000PY; difference = 1.7/1000PY; aHR = 1.30, 95%CI 1.22-1.38), and MASLD patients had significantly higher rates of incident AF (difference = 0.9/1000PY; aHR = 1.26, 95%CI 1.18-1.35). Rates of both overall arrhythmias and AF were significantly elevated across all MASLD histological groups, particularly cirrhosis (differences, 8.5/1000PY and 5.3/1000PY, respectively). In secondary analyses, MASLD patients also had significantly higher rates of incident ventricular arrhythmias/cardiac arrest (aHR = 1.53, 95%CI 1.30-1.80), bradyarrhythmias (aHR = 1.26, 95%CI 1.06-1.48), and other supraventricular arrhythmias (aHR = 1.27, 95%CI 1.00-1.62), compared to controls.

CONCLUSIONS

Compared to matched controls, patients with biopsy-confirmed MASLD had modest but significantly higher incidence of cardiac arrhythmias, including AF, bradyarrhythmias, other supraventricular arrhythmias and ventricular arrhythmias/cardiac arrest. Excess risk was observed across all stages of MASLD and was highest with cirrhosis.

What happens after forensic psychiatric care? A latent class analysis of dimensions of welfare for former forensic psychiatric patients

BACKGROUND

Mentally disordered offenders are a heterogenous group regarding psychopathology as well as background factors, which makes it likely that more than one stereotypical life situation will apply to all forensic psychiatric patients following discharge. Knowledge about typical life situations would be valuable for optimising support for improving the overall life situation of these individuals. This paper investigates life situations from the perspective of level of living research and resources in terms of different welfare dimensions.

METHODS

Included were all all individuals (n = 1146) who had been discharged from forensic psychiatric care in Sweden during 2009-2018 and were included in the Swedish National Forensic Psychiatric Register. Follow-up time varied from 4 to 3644 days, (m = 1697, Md = 1685). Register data from several different registers was combined. Data was analysed using latent class analysis, and multinominal logistic regression analysis investigated what background factors were associated with class membership.

RESULTS

The results show that there are four subgroups of post-discharge life situations: the high support group, the general psychiatric needs group, the working group, and the family group. The high support group was the largest, representing 54% of the entire sample. There are background factors associated with group membership, including both age at discharge, length of stay in forensic psychiatric care and pre-index crime historical factors.

CONCLUSIONS

This study contributes to the understanding of the post-discharge lives of former forensic psychiatric patients and shows that for several subgroups, negative outcomes are rare. Knowledge about these subgroups could be drawn upon to make informed decisions about in- and outpatient forensic psychiatric care, discharge from forensic psychiatric services, and what support is offered to former forensic psychiatric patients.

Progression of non-alcoholic fatty liver disease and long-term outcomes: A nationwide paired liver biopsy cohort study

BACKGROUND & AIMS

More data are needed regarding the long-term impact of the histological progression of non-alcoholic fatty liver disease (NAFLD) on long-term outcomes, including end-stage liver disease (ESLD) and mortality.

METHODS

We included Swedish adults with biopsy-confirmed non-cirrhotic NAFLD and ≥2 liver biopsies >6 months apart (1969-2017; n = 718). NAFLD was categorized at initial biopsy as simple steatosis, non-fibrotic steatohepatitis (NASH), or non-cirrhotic fibrosis. NAFLD progression was defined by histological changes between biopsies (i.e. incident NASH, incident fibrosis, fibrosis progression, cirrhosis). Using Cox regression, we estimated multivariable adjusted hazard ratios (aHRs) and 95% CIs for incident ESLD (i.e. hospitalization for decompensated cirrhosis, hepatocellular carcinoma or liver transplantation) and mortality, according to NAFLD progression vs. stable/regressed disease.

RESULTS

At initial biopsy, 497 patients (69.2%) had simple steatosis, 90 (12.5%) had non-fibrotic NASH, and 131 (18.2%) had non-cirrhotic fibrosis. Over a median of 3.4 years between biopsies, 30.4% (218/718) experienced NAFLD progression, including 12.5% (62/497) with incident non-fibrotic NASH, 24.0% (141/587) with incident fibrosis, and 5.6% (40/718) with cirrhosis. Compared to stable/regressed disease, NAFLD progression was associated with significantly higher rates of developing incident ESLD (23.8 vs. 11.4/1,000 person-years [PY]; difference = 12.4/1,000 PY; aHR 1.65, 95% CI 1.17-2.32). While the highest ESLD incidence occurred with progression to cirrhosis (difference vs. stable/regressed disease = 56.3/1,000 PY), significant excess risk was also found with earlier transitions, including from simple steatosis to incident fibrosis (difference vs. stable/regressed disease = 18.9/1,000 PY). In contrast, all-cause mortality rates did not appear to differ when NAFLD progression was compared to stable/regressed disease (difference = 4.7/1,000 PY; aHR 0.99, 95% CI 0.78-1.24).

CONCLUSIONS

In a nationwide, real-world cohort of patients with paired NAFLD biopsies, histological disease progression contributed to significantly higher rates of developing incident ESLD, but did not appear to impact all-cause mortality.

IMPACT AND IMPLICATIONS

Currently, data are scarce regarding the long-term impact of histological progression or regression of non-alcoholic fatty liver disease (NAFLD) on subsequent risk of adverse clinical outcomes, including the development of end-stage liver disease and mortality. This is particularly important because randomized-controlled trials of NAFLD therapeutics currently focus on short-term histological endpoints as presumed surrogates for those major clinical outcomes. Thus, the results from this study can help inform the optimal design of future NAFLD therapeutic trials, while also providing the necessary evidence base for public health policies focused on preventing the development and progression of NAFLD.

Pregnancy Outcomes in Females with Eosinophilic Esophagitis: A Nationwide Population-Based Study

Introduction

Eosinophilic esophagitis (EoE) is a chronic, allergic inflammatory disease of the esophagus. It has a peak incidence in the 2nd and 3rd decades of life. Despite this, little is known about pregnancy outcomes in patients with EoE.

Methods

Using a validated histopathologic and nationwide population-based cohort for the diagnosis of EoE, we examined maternal and fetal outcomes, with preterm birth as the primary outcome, in females with EoE compared to matched controls. Odds ratios (ORs) were calculated using logistic regression.

Results

Between 1992 and 2016, we identified 19 females with EoE who gave birth to 23 children (reference births: n = 115). There was 1 (4.3%) preterm birth in the EoE cohort versus 8 (7.0%) in the reference cohort (OR = 0.60; 95% CI = 0.07-5.14). Secondary fetal outcomes included stillbirth, neonatal death, small for gestational age, low birth weight (LBW), and low Apgar score. Of these, LBW (<2,500 g) in patients with EoE compared to controls correlated to an OR of 12.42 (95% CI = 1.26-122.42); however, this finding was based on very low numbers. The remaining fetal outcomes were not significantly different between females with EoE and controls. Secondary pregnancy and maternal outcomes including induction of labor, instrumental delivery, gestational diabetes, or pre-eclampsia were not significantly different between patients with EoE and controls.

Discussion/Conclusion

Overall in this nationwide cohort study, we did not find increased association of preterm birth in patients with EoE.

Microscopic colitis and risk of incident rheumatoid arthritis: A nationwide population-based matched cohort study

BACKGROUND

Microscopic colitis (MC) has been linked to several autoimmune conditions. Results from previous studies on the association with rheumatoid arthritis (RA) have been inconsistent.

AIM

To assess the risk of future RA in MC.

METHODS

We conducted a nationwide matched cohort study in Sweden of 8179 patients with biopsy-verified MC (diagnosed in 2007-2017), 36,400 matched reference individuals and 8202 siblings without MC, with follow-up until 2021. Information on MC was obtained from all of Sweden's regional pathology registers (n = 28) through the ESPRESSO cohort. Data on incident RA were collected from the National Patient Register. Using Cox regression, we calculated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

During a median follow-up of 9.1 years (interquartile range = 6.7-11.7), 73 MC patients and 183 reference individuals from the general population were diagnosed with RA (99 vs. 55 events per 100,000 person-years), equivalent to one extra case of RA in 226 patients with MC followed for 10 years. These rates corresponded to an aHR of 1.83 (95% CI = 1.39-2.41). The aHR was highest during the first year of follow-up (2.31 [95% CI = 1.08-4.97]) and remained significantly elevated up to 5 years after MC diagnosis (aHR 2.16; 95% CI = 1.42-3.30). Compared to siblings, without MC, the aHR was 2.04 (95% CI = 1.18-3.56).

CONCLUSION

Patients with MC are at a nearly two-fold risk of developing RA compared to the general population. Knowledge of this increased risk may expedite evaluation for RA in patients with MC presenting with joint symptoms and/or arthralgia, thus preventing delay until RA diagnosis.

Gastrointestinal biopsy of normal mucosa or nonspecific inflammation and risk of neurodegenerative disease: Nationwide matched cohort study

BACKGROUND AND PURPOSE

Evidence has accumulated to support the early involvement of altered gastrointestinal (GI) function in neurodegenerative disease. However, risk of Alzheimer disease (AD) and Parkinson disease (PD) among individuals with a GI biopsy of normal mucosa or nonspecific inflammation is unknown.

METHODS

This matched cohort study included all individuals in Sweden with a GI biopsy of normal mucosa (n = 480,346) or nonspecific inflammation (n = 655,937) during 1965-2016 (exposed group) as well as their individually matched population references and unexposed full siblings. A flexible parametric model and stratified Cox model were used to estimate hazard ratio (HR) and its 95% confidence interval (CI).

RESULTS

Individuals with normal mucosa or nonspecific inflammation had a higher risk of AD and PD during the 20 years after biopsy. Compared with the population references, individuals with normal mucosa had an increased risk of AD (incidence rate [IR] difference = 13.53 per 100,000 person-years, HR [95% CI] = 1.15 [1.11-1.20]) and PD (IR difference = 6.72, HR [95% CI] = 1.16 [1.10-1.23]). Elevated risk was also observed for nonspecific inflammation regarding AD (IR difference = 13.28, HR [95% CI] = 1.11 [1.08-1.14]) and PD (IR difference = 6.83, HR [95% CI] = 1.10 [1.06-1.14]). Similar results were observed in subgroup and sensitivity analyses and when comparing with their unexposed siblings.

CONCLUSIONS

Individuals with a GI biopsy of normal mucosa or nonspecific inflammation had an increased risk of AD and PD. This adds new evidence of the early involvement of GI dysfunction in neurodegenerative disease.

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.

Microscopic Colitis and Risk of Incident Acute Pancreatitis: A Nationwide Population-Based Matched Cohort Study

INTRODUCTION

Several gastrointestinal diseases have been linked to acute pancreatitis, but the risk of acute pancreatitis in microscopic colitis (MC) has not been studied.

METHODS

We conducted a nationwide, population-based, matched cohort study in Sweden of 12,140 patients with biopsy-verified MC (diagnosed in 2003-2017), 57,806 matched reference individuals, and 12,781 siblings without MC with a follow-up until 2021. Data on MC were obtained from all of Sweden's regional pathology registers (n = 28) through the ESPRESSO cohort. Data on acute pancreatitis were collected from the National Patient Register. Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were calculated using Cox regression.

RESULTS

During a mean follow-up of 9.9 years (SD = 4.3), 146 patients with MC and 437 reference individuals were diagnosed with acute pancreatitis (127.8 vs 80.1 per 100,000 person-years), corresponding to an aHR of 1.57 (95% CI = 1.30-1.90). Moreover, we found a positive association between MC and acute nongallstone-related pancreatitis (aHR 1.99 [95% CI = 1.57-2.51]), but not with acute gallstone-related pancreatitis (aHR 1.08 [95% CI = 0.78-1.49]). Comparing patients with MC with their unaffected siblings yielded an aHR of 1.28 (95% CI = 0.92-1.78). The risk of acute pancreatitis remained elevated also for patients with MC with a follow-up exceeding 10 years (aHR 1.75 [95% CI = 1.14-2.67]).

DISCUSSION

This nationwide study of more than 12,000 patients with MC demonstrated an increased risk of acute pancreatitis after MC. Hence, clinicians should have a low threshold for the evaluation of acute pancreatitis in patients with MC. In addition, these patients should receive advice and care aimed at reducing the risk of acute pancreatitis.

Population frailty trends by education and income levels over a period of 30 years: findings from Swedish registry data

BACKGROUND

Frailty is an age-related health condition affecting an estimated 18% of older adults in Europe and past evidence has shown a relationship between socioeconomic factors and frailty. We examined population frailty trends and the association between frailty and 5-year mortality by education tertiles and income quartiles at ages 75, 85 and 95 in Swedish registry data.

METHODS

All Swedish residents born in 1895-1945 and in the Total Population Register from 1990 to 2020 were included. Frailty was assessed with the Hospital Frailty Risk Score (HFRS), which sums 109 weighted International Classification of Diseases (ICD codes), collected from the National Patient Register.

RESULTS

Regardless of education and income, frailty increased over time, though the association between frailty and 5-year mortality remained stable. Particularly in earlier birth cohorts, although the highest education and income levels had the highest mean HFRS scores, the lowest education and income levels accounted for greater proportions among the frail. These trends varied slightly by sex and age. Men and women had similar levels of frailty, but frailty was more strongly associated with mortality among men.

CONCLUSION

Over time, education and income levels were more equally represented among the frail population in more recent years. More equitable distribution over time may suggest improvement in health disparities, though more work is needed. The overall increase in frailty and unchanged association with mortality indicates that additional research is needed to better understand how to best support the growing ageing population. This would then support the long-term viability of the healthcare system.

Long-term risk of arrhythmias in patients with inflammatory bowel disease: A population-based, sibling-controlled cohort study

BACKGROUND

Although previous evidence has suggested an increased risk of cardiovascular disease (CVD) in patients with inflammatory bowel disease (IBD), its association with arrhythmias is inconclusive. In this study, we aimed to explore the long-term risk of arrhythmias in patients with IBD.

METHODS AND FINDINGS

Through a nationwide histopathology cohort, we identified patients with biopsy-confirmed IBD in Sweden during 1969 to 2017, including Crohn's disease (CD: n = 24,954; median age at diagnosis: 38.4 years; female: 52.2%), ulcerative colitis (UC: n = 46,856; 42.1 years; 46.3%), and IBD-unclassified (IBD-U: n = 12,067; 43.8 years; 49.6%), as well as their matched reference individuals and IBD-free full siblings. Outcomes included overall and specific arrhythmias (e.g., atrial fibrillation/flutter, bradyarrhythmias, other supraventricular arrhythmias, and ventricular arrhythmias/cardiac arrest). Flexible parametric survival models estimated hazard ratios (aHR) with 95% confidence intervals (95% CIs), after adjustment for birth year, sex, county of residence, calendar year, country of birth, educational attainment, number of healthcare visits, and cardiovascular-related comorbidities. Over a median of approximately 10 years of follow-up, 1,904 (7.6%) patients with CD, 4,154 (8.9%) patients with UC, and 990 (8.2%) patients with IBD-U developed arrhythmias, compared with 6.7%, 7.5%, and 6.0% in reference individuals, respectively. Compared with reference individuals, overall arrhythmias were increased in patients with CD [54.6 versus 46.1 per 10,000 person-years; aHR = 1.15 (95% CI [1.09, 1.21], P < 0.001)], patients with UC [64.7 versus 53.3 per 10,000 person-years; aHR = 1.14 (95% CI [1.10, 1.18], P < 0.001)], and patients with IBD-U [78.1 versus 53.5 per 10,000 person-years; aHR = 1.30 (95% CI [1.20, 1.41], P < 0.001)]. The increased risk persisted 25 years after diagnosis, corresponding to 1 extra arrhythmia case per 80 CD, 58 UC, and 29 IBD-U cases over the same period. Patients with IBD also had a significantly increased risk of specific arrhythmias, except for bradyarrhythmias. Sibling comparison analyses confirmed the main findings. Study limitations include lack of clinical data to define IBD activity, not considering the potential role of IBD medications and disease activity, and the potential residual confounding from unmeasured factors for arrhythmias.

CONCLUSIONS

In this study, we observed that patients with IBD were at an increased risk of developing arrhythmias. The excess risk persisted even 25 years after IBD diagnosis. Our findings indicate a need for awareness of this excess risk among healthcare professionals.

Neonatal outcomes of elective labor induction in low-risk term pregnancies

The rate of labor induction has increased in recent years. The results of previously conducted studies examining associations between elective induction of labor (IOL) and neonatal outcomes have been contradictory. The aim of this study was to examine the intrinsic neonatal risks following IOL. We conducted a population-based cohort study, including all women with recorded low-risk singleton pregnancies at a gestational age between 37 + 0 and 41 + 6 weeks in Sweden from 1999 to 2017. Data were collected from the Swedish Medical Birth register. Two study groups were compared-the elective induction group with the spontaneous labor onset group. The results showed that the rate of elective IOL increased from 7.2% in 1999 to 16.4% in 2017. Elective IOL was associated with a higher OR for chorioamnionitis, bacterial sepsis, intracranial hemorrhage, assisted ventilation, hyperbilirubinemia, APGAR < 7 at 5 min, and neonatal seizures compared to deliveries with spontaneous labor onset. Regarding mortality outcomes, no significant differences were shown between the groups for either early term or full-term deliveries. We conclude that IOL is associated with neonatal complications, although causality could not be established in this observational study. It is important to be aware of the increased risk and perform IOL with caution.

Use of Linked Nordic Registries for Population Studies in Hematologic Cancers: The Case of Multiple Myeloma

Purpose

Linked health-care registries and high coverage in Nordic countries lend themselves well to epidemiologic research. Given its relatively high incidence in Western Europe, complexity in diagnosis, and challenges in registration, multiple myeloma (MM) was selected to compare registries in Denmark, Finland, and Sweden.

Patients and Methods

Data were obtained from four archetypal registries in each country (spanning January 2005-October 2018): National Patient Registry (NPR), Prescribed Drug Registry (PDR), Cancer Registry (CR), and Cause of Death Registry. Patients newly diagnosed with MM who received MM-specific treatment were included. PDR/NPR treatment records were used to assess incident NPR cases. The registration quality of MM-specific drugs in the PDR of each country was also evaluated.

Results

In Denmark, only 6% of patients in the NPR were not registered in the CR; in Sweden, it was 16.9%. No systematic differences were identified that could explain this discrepancy. In Denmark, lenalidomide and bortezomib were registered in the NPR with high coverage, but less expensive drugs typically given in combination with bortezomib were not covered in any of the registries. In Finland and Sweden, bortezomib records were not identified in the PDR, but some were in the NPR; other drugs had good coverage in the PDR.

Conclusions

The registries evaluated in this study can be used to identify the MM population; however, given the gaps in MM registration in the Finnish and Swedish CRs, Danish registries provide the most comprehensive datasets for research on treatment patterns for MM.

Validity of distal radius fracture diagnoses in the Swedish National Patient Register

Distal radius fractures are one of the most common fractures in adults. More research is needed to establish evidence-based clinical practice guidelines to generate cost-effective and fair fracture treatment. The Swedish National Patient Register is a principal source for population-based epidemiologic studies in Sweden. The validity of some-but not all-diagnoses in the register is high. Little is known regarding the validity of registration of distal radius fractures.A dataset of cases registered with diagnosis of distal radius fracture (S52.5) or distal radius and ulna fracture (S52.6) were collected from the Swedish National Inpatient and Outpatient Registers. Six cohorts, each containing 240 simple random samples, were constructed. Radiographic reports and medical records were reviewed to confirm or reject the diagnosis as well as, in relevant cases, the surgical intervention. Positive predictive values (PPV) were calculated.The PPV for distal radius fracture in the register ranges between 92 and 100%, lower if coded as S52.6 and higher if there was an adherent code of surgical intervention. Codes for surgical intervention reached a PPV of 95-100%.In conclusion, the validity of the codes for diagnosis and the surgical treatment of distal radius fracture is high in the Swedish National Patient Register. According to our results, the register may be used as a reliable data source for population-based research of distal radius fractures.

Migrant mortality by duration of residence and co-ethnic density - A register-based study on Finnish migrants in Sweden with matched controls in the origin and the destination

Migrant health depends on factors both at the origin and at the destination. Health-related behaviors established before migration may change at the destination. We compare the mortality rates from alcohol- and smoking-related causes and cardiovascular diseases (CVD) of Finnish migrants in Sweden to matched controls in both Sweden and Finland with similar sociodemographic characteristics. Migrant mortality rates from behavioral risk factors lie in-between the rates of non-migrants in the origin and destination. A longer duration of residence is associated with lower mortality and with mortality patterns more similar to Swedes for men. For women, a longer duration of residence is associated with higher mortality, in particular smoking-related mortality, with no tendency of a gradual convergence. The density of Finnish migrants in the local area is modestly associated with mortality. However, CVD mortality tends to be higher and more similar to the level in Finland for migrants in areas with a higher density of Finnish migrants. The results suggest that behavioral changes can reduce mortality differences between migrants and natives and that this can be either beneficial or detrimental to migrant health.

Statin use and risk of colorectal cancer in patients with inflammatory bowel disease

Background

Statin use has been linked to a reduced risk of advanced colorectal adenomas, but its association with colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD) - a high risk population for CRC - remains inconclusive.

Methods

From a nationwide IBD cohort in Sweden, we identified 5273 statin users and 5273 non-statin users (1:1 propensity score matching) from July 2006 to December 2018. Statin use was defined as the first filled prescription for ≥30 cumulative defined daily doses and followed until December 2019. Primary outcome was incident CRC. Secondary outcomes were CRC-related mortality and all-cause mortality. Cox regression estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

Findings

During a median follow-up of 5.6 years, 70 statin users (incidence rate (IR): 21.2 per 10,000 person-years) versus 90 non-statin users (IR: 29.2) were diagnosed with incident CRC (rate difference (RD), -8.0 (95% CIs: -15.8 to -0.2 per 10,000 person-years); aHR = 0.76 (95% CIs: 0.61 to 0.96)). The benefit for incident CRC was duration-dependent in a nested case-control design: as compared to short-term use (30 days to <1 year), the adjusted odd ratios were 0.59 (0.25 to 1.43) for 1 to <2 years of use, 0.46 (0.21 to 0.98) for 2 to <5 years of use, and 0.38 (0.16 to 0.86) for ≥5 years of use (Pfor tread = 0.016). Compared with non-statin users, statin users also had a decreased risk for CRC-related mortality (IR: 6.0 vs. 11.9; RD, -5.9 (-10.5 to -1.2); aHR, 0.56 (0.37 to 0.83)) and all-cause mortality (IR: 156.4 vs. 231.4; RD, -75.0 (-96.6 to -53.4); aHR, 0.63 (0.57 to 0.69)).

Interpretation

Statin use was associated with a lower risk of incident CRC, CRC-related mortality, and all-cause mortality. The benefit for incident CRC was duration-dependent, with a significantly lower risk after ≥2 years of statin use.

Funding

This research was supported by Forte (i.e., the Swedish Research Council for Health, Working Life and Welfare).

Incidence, prevalence and mortality of chronic liver diseases in Sweden between 2005 and 2019

BACKGROUND

Updated data on the incidence, prevalence, and regional differences of chronic liver disease are missing from many countries. In this study, we aimed to describe time trends, incidence, prevalence, and mortality of a wide range of chronic liver diseases in Sweden.

METHODS

In this register-based, nationwide observational study, patients with a register-based diagnosis of chronic liver disease, during 2005-2019, were retrieved from the Swedish National Board of Health and Welfare. Annual age-standardized incidence and mortality rates, and prevalence per 100,000 inhabitants was calculated and stratified on age, sex, and geographical region.

RESULTS

The incidence of alcohol-related cirrhosis increased by 47% (2.6% annually), reaching an incidence rate of 13.1/100,000 inhabitants. The incidence rate of non-alcoholic fatty liver disease and unspecified liver cirrhosis increased by 217% and 87% (8.0 and 4.3% annually), respectively, reaching an incidence rate of 15.2 and 18.7/100,000 inhabitants, and a prevalence of 24.7 and 44.8/100,000 inhabitants. Furthermore, incidence rates of chronic hepatitis C declined steeply, but liver malignancies have become more common. The most common causes of liver-related mortality were alcohol-related liver disease and unspecified liver disease.

CONCLUSION

The incidence rates of diagnosed non-alcoholic fatty liver disease, alcohol-related cirrhosis, unspecified liver cirrhosis, and liver malignancies have increased during the last 15 years. Worryingly, mortality in several liver diseases increased, likely reflecting increasing incidences of cirrhosis in spite of a decreasing rate of hepatitis C. Significant disparities exist across sex and geographical regions, which need to be considered when allocating healthcare resources.

Predicting risk of suicidal behaviour after initiation of selective serotonin reuptake inhibitors in children, adolescents and young adults: protocol for development and validation of clinical prediction models

INTRODUCTION

There is concern regarding suicidal behaviour risk during selective serotonin reuptake inhibitor (SSRI) treatment among the young. A clinically useful model for predicting suicidal behaviour risk should have high predictive performance in terms of discrimination and calibration; transparency and ease of implementation are desirable.

METHODS AND ANALYSIS

Using Swedish national registers, we will identify individuals initiating an SSRI aged 8-24 years 2007-2020. We will develop: (A) a model based on a broad set of predictors, and (B) a model based on a restricted set of predictors. For the broad predictor model, we will consider an ensemble of four base models: XGBoost (XG), neural net (NN), elastic net logistic regression (EN) and support vector machine (SVM). The predictors with the greatest contribution to predictive performance in the base models will be determined. For the restricted predictor model, clinical input will be used to select predictors based on the top predictors in the broad model, and inputted in each of the XG, NN, EN and SVM models. If any show superiority in predictive performance as defined by the area under the receiver-operator curve, this model will be selected as the final model; otherwise, the EN model will be selected. The training and testing samples will consist of data from 2007 to 2017 and from 2018 to 2020, respectively. We will additionally assess the final model performance in individuals receiving a depression diagnosis within 90 days before SSRI initiation.The aims are to (A) develop a model predicting suicidal behaviour risk after SSRI initiation among children and youths, using machine learning methods, and (B) develop a model with a restricted set of predictors, favouring transparency and scalability.

ETHICS AND DISSEMINATION

The research is approved by the Swedish Ethical Review Authority (2020-06540). We will disseminate findings by publishing in peer-reviewed open-access journals, and presenting at international conferences.

Gender differences in earnings among people with multiple sclerosis and associations with type of occupation and family composition: A population-based study with matched references

Gender differences in earnings exist worldwide. Gender segregation or familial status have been previously stated as possible explanations for these differences as well as health differences between women and men. Women are diagnosed with multiple sclerosis (MS) as twice much as men. Moreover, MS limitations may affect the work capacity of people with MS (PwMS) implying a reduction in their earnings. We aimed to explore gender differences in earnings among people with MS and without MS and between groups of those diagnosed while also considering types of occupation and family composition, and how these possible differences relate to sickness absence (SA) and disability pension (DP). We conducted a population-based cohort study in Sweden with microdata from several nationwide registers. PwMS aged 19-57 years (n = 5128) living in Sweden and 31,767 matched references from the population without MS. Outcome measures included earnings, number of SA and DP days combined (SA/DP). A four-way weighted least-squares analysis of covariance was performed to explore the associations of gender, MS, type of occupation, and family composition with earnings. Risk of SA and DP days was assessed with logistic regression. Overall, and across all occupations, women earned less than men, although less so among managers with MS. Annual gender differences in earnings were larger if living with children at home compared to not living with children. Nevertheless, these gender differences decreased after adjusting for SA/DP, both among PwMS and references. PwMS had considerably more SA/DP days than references. Women also had more SA/DP days than men. We observed that working women earned less than working men, and that gender differences in earnings were present in all occupations, although less evident among PwMS in managerial positions. The combination of gender, occupation, family composition, and MS, was associated with earnings, even when adjusting for the number of SA and DP days.

Risk of All-Cause Dementia, Alzheimer Disease, and Vascular Dementia in Breast Cancer Survivors: A Longitudinal Register-Based Study

Background and Objectives

Now more than two-thirds of cancer survivors are aged 65 years or older, but evidence about their long-term health is thin. Cancer and its treatments have been linked to accelerated aging, so there is a concern that aging cancer survivors have an increased risk of age-related diseases, including dementia.

Methods

We examined the risk of dementia among 5-year breast cancer survivors using a matched cohort study design. We included breast cancer survivors aged 50 years and older at diagnosis (n = 26,741) and cancer-free comparison participants (n = 249,540). Women eligible for inclusion in the study were those born 1935-1975 and registered in the Swedish Total Population Register between January 1, 1991, and December 31, 2015. We defined breast cancer survivors as women with an initial breast cancer diagnosis between 1991 and 2005 who survived 5 or more years after their first diagnosis. We assessed all-cause dementia, Alzheimer disease (AD), and vascular dementia (VaD) using International Classification of Diseases codes. Survival analyses were conducted using age-adjusted subdistribution hazard models accounting for competing risk of death.

Results

We did not observe an association between breast cancer survivorship and risk of all-cause dementia, AD, or VaD. However, in models stratified by age at cancer diagnosis, women diagnosed with cancer after age 65 years had a higher risk of all-cause dementia (subdistribution hazard ratio [SHR] = 1.30, 95% CI 1.07-1.58), AD (SHR = 1.35, 95% CI 1.05-1.75), and VaD (SHR = 1.64, 95% CI 1.11-2.43) in models adjusted for age, education, and country of origin.

Discussion

Older breast cancer survivors who survive cancer have a higher risk for dementia than their peers without a cancer diagnosis, in contrast to earlier studies showing that prevalent or incident cancer is associated with a lower risk of dementia. With the older adult population growing rapidly and because cancer and dementia are 2 of the most common and debilitating diseases among older adults, it is critical that we understand the link between the 2.

No Increased Risk of Cardiac Birth Defects in Infants of Mothers With Celiac Disease: A Population and Sibling Comparison

INTRODUCTION

Several earlier studies have indicated an increased risk of cardiac birth defects among infants born to mothers with celiac disease (CeD). Through linking nationwide Swedish health care registries, we aimed to investigate maternal CeD and risk of any or cardiac birth defects in their offspring.

METHODS

We performed a retrospective cohort study of infants born between 2002 and 2016 to women with biopsy-proven CeD (villous atrophy, Marsh III) matched to infants born to nonceliac women from the general population. Conditional logistic regression with odds ratios (OR) and their 95% confidence intervals (CI) was used to determine the association between maternal CeD and birth defects. To minimize the impact of intrafamilial confounding, we also compared infants born to mothers with CeD with infants born to their nonaffected sisters.

RESULTS

A total of 6,990 infants were born to mothers with diagnosed CeD compared with 34,643 infants born to reference mothers. Any birth defect was seen in 234 (33 per 1,000 infants) and 1,244 (36/1,000) reference infants corresponding to an OR of 0.93 (95% CI 0.81-1.08). Cardiac birth defects were seen in 113 (16/1,000) vs 569 (16/1,000) infants (OR 0.98, 95% CI 0.80-1.20). Similar OR for any and cardiac birth defects were also seen in sibling comparisons.

DISCUSSION

We found no statistically significant risk of any or cardiac birth defects in infants born to mothers with diagnosed CeD compared with the general population and to their nonaffected sisters.

Mortality in small bowel cancers and adenomas - A nationwide, population-based matched cohort study

BACKGROUND

Small bowel adenocarcinoma (SBA), neuroendocrine tumors (NET) and gastrointestinal stromal tumors (GIST) are neoplastic lesions of the small bowel while small bowel adenomas are precursors of SBA.

AIM

To examine mortality in patients diagnosed with SBA, small bowel adenomas, NET and GIST.

METHODS

We performed a population-based matched cohort study encompassing all individuals with SBA (n = 2289), adenomas (n = 3700), NET (n = 1884) and GIST (n = 509) in the small bowel diagnosed at any of Sweden's 28 pathology departments between 2000 and 2016 (the "ESPRESSO study"). Each case was matched by sex, age, calendar year and county of residence to up to 5 comparators from the general population. Through Cox regression we estimated hazard ratios (HRs) and 95% confidence intervals (95%CIs) for death and cause-specific death adjusting for education.

RESULTS

During follow-up until December 31, 2017, 1836 (80%) deaths occurred in SBA patients, 1615 (44%) in adenoma, 866 (46%) in NET and 162 (32%) in GIST patients. This corresponded to incidence rates of 295, 74, 80 and 62/1000 person-years respectively and adjusted HRs of 7.60 (95%CI=6.95-8.31), 2.21 (2.07-2.36), 2.74 (2.50-3.01) and 2.33 (1.90-2.87). Adjustment for education had a substantial impact on the HR for death in SBA but not for other neoplasias. The predominant cause of excess death was cancer in all groups.

CONCLUSION

This study confirms earlier findings of increased death rates in patients with SBA and NET in a modern study population. We also demonstrate a more than 2-fold increased risk of death in both GIST and the SBA precursor adenoma.

Association of inflammatory bowel disease in first-degree relatives with risk of colorectal cancer: A nationwide case-control study in Sweden

This study aims to assess the association between inflammatory bowel disease (IBD) history in first-degree relatives (FDRs) and colorectal cancer (CRC) risk. We conducted a nationwide case-control study in Sweden among 69 659 CRC cases and 343 032 non-CRC controls matched on age, sex, birth year and residence county. Through linkage of multi-generation register and the nationwide ESPRESSO (Epidemiology Strengthened by histoPathology Reports in Sweden) cohort, we ascertained IBD diagnoses among parents, full siblings and offspring of the index individuals. Odds ratios (ORs) of CRC associated with IBD family history were calculated using conditional logistic regression. 2.2% of both CRC cases (1566/69659) and controls (7676/343027) had ≥1 FDR with IBD history. After adjusting for family history of CRC, we observed no increased risk of CRC in FDRs of IBD patients (OR, 0.96; 95%CI, 0.91-1.02). The null association was consistent according to IBD subtype (Crohn's disease or ulcerative colitis), number of FDRs with IBD (1 or ≥ 2), age at first IBD diagnosis in FDRs (<18, 18-39, 40-59 or ≥60 years), maximum location/extent of IBD or FDR relation (parent, sibling or offspring). The null association remained for early-onset CRC (diagnosed at age <50 years). In conclusion, IBD history in FDRs was not associated with an increased risk of CRC. Our findings suggest that extra screening for CRC may not be needed in the offspring, siblings or parents of IBD patients, and strengthen the theory that it is the actual inflammation or atypia of the colon in IBD patients that confers the increased CRC risk.

Post-traumatic stress disorder and the risk of violent crime conviction in Sweden: a nationwide, register-based cohort study

BACKGROUND

Post-traumatic stress disorder (PTSD) has been linked to violent crime in veteran populations. However, whether there is a link between PTSD and violent crime in the general population is not known. This study aimed to investigate the hypothesised association between PTSD and violent crime in the Swedish general population and to investigate the extent to which familial factors might explain this association using unaffected sibling control individuals.

METHODS

This nationwide, register-based cohort study assessed individuals born in Sweden in 1958-93 for eligibility for inclusion. Individuals who died or emigrated before their 15th birthday, were adopted, were twins, or whose biological parents could not be identified were excluded. Participants were identified and included from the National Patient Register (1973-2013), the Multi-Generation Register (1932-2013), the Total Population Register (1947-2013), and the National Crime Register (1973-2013). Participants with PTSD were matched (1:10) with randomly selected control individuals from the population without PTSD by birth year, sex, and county of residence in the year of PTSD diagnosis for the matched individual. Each participant was followed up from the date of matching (ie, the index person's first PTSD diagnosis) until violent crime conviction or until being censored at emigration, death, or Dec 31, 2013, whichever occurred first. Stratified Cox regressions were used to estimate the hazard ratio of time to violent crime conviction ascertained from national registers in individuals with PTSD compared with control individuals. To account for familial confounding, sibling analyses were conducted, comparing the risk of violent crime in a subsample of individuals with PTSD with their unaffected full biological siblings.

FINDINGS

Of 3 890 765 eligible individuals, 13 119 had a PTSD diagnosis (9856 [75·1%] of whom were female and 3263 [24·9%] of whom were male), were matched with 131 190 individuals who did not, and were included in the matched cohort. 9114 individuals with PTSD and 14 613 full biological siblings without PTSD were also included in the sibling cohort. In the sibling cohort, 6956 (76·3%) of 9114 participants were female and 2158 (23·7%) were male. Cumulative incidence of violent crime convictions after 5 years was 5·0% (95% CI 4·6-5·5) in individuals diagnosed with PTSD versus 0·7% (0·6-0·7) in individuals without PTSD. At the end of follow-up (median follow-up time 4·2 years, IQR 2·0-7·6), cumulative incidence was 13·5% (11·3-16·6) versus 2·3% (1·9-2·6). Individuals with PTSD had a significantly higher risk of violent crime than the matched control population in the fully-adjusted model (hazard ratio [HR] 6·4, 95% CI 5·7-7·2). In the sibling cohort, the risk of violent crime was also significantly higher in the siblings with PTSD (3·2, 2·6-4·0).

INTERPRETATION

PTSD was associated with increased risk of violent crime conviction, even after controlling for familial effects shared by siblings and in the absence of SUD or a history of violent crime. Although our results might not be generalisable to less severe or undetected PTSD, our study could inform interventions that aim to reduce violent crime in this vulnerable population.

FUNDING

None.

Towards trust-based governance of health data research

Developments in medical big data analytics may bring societal benefits but are also challenging privacy and other ethical values. At the same time, an overly restrictive data protection regime can form a serious threat to valuable observational studies. Discussions about whether data privacy or data solidarity should be the foundational value of research policies, have remained unresolved. We add to this debate with an empirically informed ethical analysis. First, experiences with the implementation of the General Data Protection Regulation (GDPR) within a European research consortium demonstrate a gap between the aims of the regulation and its effects in practice. Namely, strictly formalised data protection requirements may cause routinisation among researchers instead of substantive ethical reflection, and may crowd out trust between actors in the health data research ecosystem; while harmonisation across Europe and data sharing between countries is hampered by different interpretations of the law, which partly stem from different views about ethical values. Then, building on these observations, we use theory to argue that the concept of trust provides an escape from the privacy-solidarity debate. Lastly, the paper details three aspects of trust that can help to create a responsible research environment and to mitigate the encountered challenges: trust as multi-agent concept; trust as a rational and democratic value; and trust as method for priority setting. Mutual cooperation in research-among researchers and with data subjects-is grounded in trust, which should be more explicitly recognised in the governance of health data research.

Development of Smart Clothing to Prevent Pressure Injuries in Bedridden Persons and/or with Severely Impaired Mobility: 4NoPressure Research Protocol

Pressure injuries (PIs) are a major public health problem and can be used as quality-of-care indicators. An incipient development in the field of medical devices takes the form of Smart Health Textiles, which can possess innovative properties such as thermoregulation, sensing, and antibacterial control. This protocol aims to describe the process for the development of a new type of smart clothing for individuals with reduced mobility and/or who are bedridden in order to prevent PIs. This paper's main purpose is to present the eight phases of the project, each consisting of tasks in specific phases: (i) product and process requirements and specifications; (ii and iii) study of the fibrous structure technology, textiles, and design; (iv and v) investigation of the sensor technology with respect to pressure, temperature, humidity, and bioactive properties; (vi and vii) production layout and adaptations in the manufacturing process; (viii) clinical trial. This project will introduce a new structural system and design for smart clothing to prevent PIs. New materials and architectures will be studied that provide better pressure relief, thermo-physiological control of the cutaneous microclimate, and personalisation of care.

β2-Adrenoreceptor Agonists, Montelukast, and Parkinson Disease Risk

OBJECTIVE

This study was undertaken to examine the association between montelukast use, β2-adrenoreceptor (β2AR) agonist use, and later Parkinson disease (PD).

METHODS

We ascertained use of β2AR agonists (430,885 individuals) and montelukast (23,315 individuals) from July 1, 2005 to June 30, 2007, and followed 5,186,886 PD-free individuals from July 1, 2007 to December 31, 2013 for incident PD diagnosis. We estimated hazard ratios and 95% confidence intervals using Cox regressions.

RESULTS

We observed 16,383 PD cases during on average 6.1 years of follow-up. Overall, use of β2AR agonists and montelukast were not related to PD incidence. A 38% lower PD incidence was noted among high-dose montelukast users when restricted to PD registered as the primary diagnosis.

INTERPRETATION

Overall, our data do not support inverse associations between β2AR agonists, montelukast, and PD. The prospect of lower PD incidence with high-dose montelukast exposure warrants further investigation, especially with adjustment for high-quality data on smoking. ANN NEUROL 2023;93:1023-1028.