To Örebro University

This study tested adolescent sexual behavior patterns at age 14, their association with mental health at age 17 (psychological well-being, substance use, and self-harm attempts), and the influence of early life adversities upon this association. A British birth cohort (5,593 boys and 5,724 girls from the Millennium Cohort Study) was used. Latent class analysis suggested five subgroups of adolescent sexual behaviors: a "no sexual behavior" (50.74%), a "kisser" (39.92%), a "touching under clothes" (4.71%), a "genital touching" (2.64%), and an "all sexual activities" class (1.99%). Adolescents from the "kisser," "touching under clothes," "genital touching," and "all sexual activities" classes reported significantly more substance use and self-harm attempts compared to adolescents from the "no sexual behavior" group. The associations became weaker after controlling for early life adversities (reducing around 4.38% to 37.35% for boys, and 9.29% to 52.56% for girls), and reduced to a smaller degree after further controlling for mental health variables at 14. The associations between sexual behaviors and psychological well-being became non-significant after controlling for early life adversities. Adolescents who have engaged in low-intensity sexual activities at early age may have poorer reported mental health, a pattern that is stronger for girls and early life adversity may partially explain this association.

Purpose: We aimed to examine if same-sex partnership in men is associated with cardiovascular disease (CVD) and whether this relationship can be explained by accumulated risk factors in late adolescence using causal mediation analysis.

Methods: All men born in Sweden between 1952 and 1956, who participated in mandatory Swedish military service conscription assessments, and had ever been recorded as being in an opposite-sex marriage or a legally recognized same-sex partnership were included (n = 156,612). Hospital-diagnosed CVD between ages 31 and 58 years was identified using medical records. Men were grouped into an opposite-sex marriage category or a same-sex partnership category based on marital status. Risk factors for CVD in late adolescence were identified using five biomarkers (systolic and diastolic blood pressure, pulse pressure, body mass index, and erythrocyte sedimentation rate) obtained at a conscription examination between ages 16 and 20 years. Birth year, childhood socioeconomic characteristics, physical and psychological characteristics in late adolescence, and mental health before the onset of CVD were treated as potential confounders.

Results: Being in a same-sex partnership was associated with increased CVD risk compared with being in an opposite-sex marriage after controlling for potential confounders and risk factors; hazard ratio = 1.61, 95% confidence interval (CI) = 1.27-2.04. The risk factors in late adolescence explained 6.36% (95% CI = 2.72-12.74) of the increased CVD risk associated with being in same-sex partnerships compared with being in opposite-sex marriages.

Conclusions: CVD risk factors accumulated by late adolescence may only partially account for the association between same-sex partnerships and cardiovascular health. 

BACKGROUND: Advantages of robotic technique over laparoscopic technique in rectal tumor surgery have yet to be proven. Large multicenter, register-based cohort studies within an optimized perioperative care protocol are lacking. The aim of this retrospective cohort study was to compare short-term outcomes in robotic, laparoscopic and open rectal tumor resections, while also determining compliance to the enhanced recovery after surgery (ERAS)®Society Guidelines.

METHODS: All patients scheduled for rectal tumor resection and consecutively recorded in the Swedish part of the international ERAS® Interactive Audit System between January 1, 2010 to February 27, 2020, were included (N = 3125). Primary outcomes were postoperative complications and length of stay (LOS) and secondary outcomes compliance to the ERAS protocol, conversion to open surgery, symptoms delaying discharge and reoperations. Uni- and multivariate comparisons were used.

RESULTS: Robotic surgery (N = 827) had a similar rate of postoperative complications (Clavien-Dindo grades 1-5), 35.9% compared to open surgery (N = 1429) 40.9% (OR 1.15, 95% CI (0.93, 1.41)) and laparoscopic surgery (N = 869) 31.2% (OR 0.88, 95% CI (0.71, 1.08)). LOS was longer in the open group, median 9 days (IRR 1.35, 95% CI (1.27, 1.44)) and laparoscopic group, 7 days (IRR 1.14, 95% CI (1.07, 1.21)) compared to the robotic group, 6 days. Pre- and intraoperative compliance to the ERAS protocol were similar between groups.

CONCLUSIONS: In this multicenter cohort study, robotic surgery was associated with shorter LOS compared to both laparoscopic and open surgery and had lower conversion rates vs laparoscopic surgery. The rate of complications was similar between groups.

Importance: Epstein-Barr virus and its acute manifestation, infectious mononucleosis (IM), are associated with an increased risk of multiple sclerosis (MS). Whether this association is confounded by susceptibility to infection is still debated.

Objective: To assess whether hospital-diagnosed IM during childhood, adolescence, or young adulthood is associated with subsequent MS diagnosis independent of shared familial factors.

Design, Setting, and Participants: This population-based cohort study used the Swedish Total Population Register to identify individuals born in Sweden from January 1, 1958, to December 31, 1994. Participants aged 20 years were followed up from January 1, 1978, to December 31, 2018, with a median follow-up of 15.38 (IQR, 8.68-23.55; range, 0.01-40.96) years. Data were analyzed from October 2020 to July 2021.

Exposure: Hospital-diagnosed IM before 25 years of age.

Main Outcomes and Measures: Diagnoses of MS from 20 years of age were identified. Risk of an MS diagnosis associated with IM in childhood (birth to 10 years of age), adolescence (11-19 years of age), and early adulthood (20-24 years of age [time-dependent variable]) were estimated using conventional and stratified (to address familial environmental or genetic confounding) Cox proportional hazards regression.

Results: Of the 2 492 980 individuals (1 312 119 men [52.63%] and 1 180 861 women [47.37%]) included, 5867 (0.24%) had an MS diagnosis from 20 years of age (median age, 31.50 [IQR, 26.78-37.54] years). Infectious mononucleosis in childhood (hazard ratio [HR], 1.98; 95% CI, 1.21-3.23) and adolescence (HR, 3.00; 95% CI, 2.48-3.63) was associated with an increased risk of an MS diagnosis that remained significant after controlling for shared familial factors in stratified Cox proportional hazards regression (HRs, 2.87 [95% CI, 1.44-5.74] and 3.19 [95% CI, 2.29-4.46], respectively). Infectious mononucleosis in early adulthood was also associated with risk of a subsequent MS diagnosis (HR, 1.89; 95% CI, 1.18-3.05), but this risk was attenuated and was not significant after controlling for shared familial factors (HR, 1.51; 95% CI, 0.82-2.76).

Conclusions and Relevance: These findings suggest that IM in childhood and particularly adolescence is a risk factor associated with a diagnosis of MS, independent of shared familial factors.

This study quantified changes in self-reported sexual orientation from adolescence to early adulthood, and whether childhood gender nonconformity (GNC) predicted sexual orientation changes. Youth (2,678 boys and 3,359 girls; 96.09% ethnically White) from the Avon Longitudinal Study of Parents and Children (ALSPAC) were included. Self-reported sexual orientation was measured using sexual attraction (5-point scale) at ages 15.5, 21, and 23. GNC was measured via Preschool Activities Inventory at ages 2.5. 3.5. and 4.75 years. The prevalence of boys and girls who reported being gay/lesbian increased from 15.5 to 21 years old whereas the proportion of bisexuals was relatively stable for both sexes. Among boys, heterosexuality and being gay were equally stable and relatively more stable compared to bisexuality. Among girls, reporting being lesbian and bisexual were equally unstable and relatively less stable than heterosexuality. Girls reporting being lesbian were more likely to report changes in their sexual orientation than gay adolescent boys. The stability of being lesbian and bisexual among girls, and bisexuality among boys, increased over time. Overall, few people changed their self-reported sexual orientation between ages 21 and 23. GNC at 2.5 years, and changes in GNC from 2.5 to 4.75 years, predicted being lesbian/gay at 15.5, 21, and 23 years and changes from being heterosexual to lesbian/gay from 15.5 to 21 years in each sex. In conclusion. self-reported sexual orientation from adolescence to young adulthood is relatively stable in males compared to females, and childhood GNC is a predictor of any, albeit small, sexual orientation changes.

Background: Evidence for the association between body mass index (BMI) and multiple sclerosis (MS) among men remains mixed.

Objective and methods: Swedish military conscription and other registers identified MS after age of 20 years and BMI at ages 16-20 years (N = 744,548).

Results: Each unit (kg/m(2)) BMI increase was associated with greater MS risk (hazard ratio and 95% confidence interval = 1.034, 1.016-1.053), independent of physical fitness (1.021, 1.001-1.042). Categorised, overweight and obesity were associated with statistically significant raised MS risk compared to normal weight, but not after adjustment for physical fitness.

Conclusion: MS risk rises with increasing BMI, across the entire BMI range.

The involvement of specific viral and bacterial infections as risk factors for multiple sclerosis has been studied extensively. However, whether this extends to infections in a broader sense is less clear and little is known about whether risk of a multiple sclerosis diagnosis is associated with other types and sites of infections, such as of the CNS. This study aims to assess if hospital-diagnosed infections by type and site before age 20 years are associated with risk of a subsequent multiple sclerosis diagnosis and whether this association is explained entirely by infectious mononucleosis, pneumonia, and CNS infections.

Individuals born in Sweden between 1970-1994 were identified using the Swedish Total Population Register (n = 2,422,969). Multiple sclerosis diagnoses from age 20 years and hospital-diagnosed infections before age 20 years were identified using the Swedish National Patient Register. Risk of a multiple sclerosis diagnosis associated with various infections in adolescence (11-19 years) and earlier childhood (birth-10 years) was estimated using Cox regression, with adjustment for sex, parental socioeconomic position, and infection type. None of the infections by age 10 years were associated with risk of a multiple sclerosis diagnosis. Any infection in adolescence increased the risk of a multiple sclerosis diagnosis (hazard ratio 1.33, 95% confidence interval 1.21-1.46) and remained statistically significant after exclusion of infectious mononucleosis, pneumonia, and CNS infection (hazard ratio 1.17, 95% confidence interval 1.06-1.30). CNS infection in adolescence (excluding encephalomyelitis to avoid including acute disseminated encephalitis) increased the risk of a multiple sclerosis diagnosis (hazard ratio 1.85, 95% confidence interval 1.11-3.07). The increased risk of a multiple sclerosis diagnosis associated with viral infection in adolescence was largely explained by infectious mononucleosis. Bacterial infections in adolescence increased risk of a multiple sclerosis diagnosis, but the magnitude of risk reduced after excluding infectious mononucleosis, pneumonia and CNS infection (hazard ratio 1.31, 95% confidence interval 1.13-1.51). Respiratory infection in adolescence also increased risk of a multiple sclerosis diagnosis (hazard ratio 1.51, 95% confidence interval 1.30-1.75), but was not statistically significant after excluding infectious mononucleosis and pneumonia.

These findings suggest that a variety of serious infections in adolescence, including novel evidence for CNS infections, are risk factors for a subsequent multiple sclerosis diagnosis, further demonstrating adolescence is a critical period of susceptibility to environmental exposures that raise the risk of a multiple sclerosis diagnosis. Importantly, this increased risk cannot be entirely explained by infectious mononucleosis, pneumonia, or CNS infections.

BACKGROUND: Research on risk factors for anastomotic leakage (AL) alone within an Enhanced Recovery After Surgery (ERAS) protocol has not yet been conducted. The aim of this study was to identify risk factors for AL and study short-term outcome after AL in patients operated with anterior resection (AR).

METHODS: All prospectively and consecutively recorded patients operated with AR in the Swedish part of the international ERAS® Interactive Audit System (EIAS) between January 2010 and February 2020 were included. The cohort was evaluated regarding risk factors for AL and short-term outcomes, including uni- and multivariate analysis. Pre-, intra- and postoperative compliance to ERAS®Society guidelines was calculated and evaluated.

RESULTS: Altogether 1900 patients were included, 155 (8.2%) with AL and 1745 without AL. Male gender, obesity, peritoneal contamination, year of surgery 2016-2020, duration of primary surgery and age remained significant predictors for AL in multivariate analysis. There was no significant difference in overall pre- and intraoperative compliance to ERAS®Society guidelines between groups. Only preadmission patient education remained as a significant ERAS variable associated with less AL. AL was associated with longer length of stay (LOS), higher morbidity rate and higher rate of reoperations.

CONCLUSION: Male gender, obesity, peritoneal contamination, duration of surgery, surgery later in study period, age and preadmission patient education were associated with AL in patients operated on with AR. Overall pre- and intraoperative compliance to the ERAS protocol was high in both groups and not associated with AL.

BACKGROUND: This study aims to assess patient coverage, validity and data quality in the Swedish part of the International Enhanced Recovery After Surgery (ERAS) Interactive Audit System (EIAS).

METHOD: All Swedish ERAS centers that recorded colorectal surgery data in EIAS between January 1, 2017, and December 31, 2017, were included (N = 12). Information registered in EIAS was compared with data from electronic medical records at each hospital to assess the overall coverage of EIAS. Twenty random-selected patients from each of the contributing centers were assessed for accuracy for a set of clinically relevant variables. All patients admitted to the contributing centers were included for the assessment of rate of missing on a selection of key clinical variables.

RESULTS: Eight hospitals provided complete information for the evaluation, while four hospitals only allowed assessment of coverage and missing data. The eight hospitals had an overall coverage of 98.8% in EIAS (n = 1301) and the four 86.7% (n = 811). The average agreement for the assessed postoperative outcome variables was 96.5%. The accuracy was excellent for 'length of hospital stay,' 'reoperation,' and 'any complications,' but lower for other types of complications. Only a few variables had more than 5% missing data, and missingness was associated with hospital type and size.

CONCLUSION: This validation of the Swedish part of the international ERAS database suggests high patient coverage in EIAS and high agreement and limited missingness in clinically relevant variables. This validation approach or a modified version can be used for continued validation of the International ERAS database.

Background: Infectious agents in MS etiology have been previously investigated. Theories of pathogenic mechanisms include molecular mimicry or activation of macrophages and natural killer cells with subsequent infiltration of the blood brain barrier. Epstein-Barr virus (EBV) infection often signaled by infectious mononucleosis (IM) is a notable MS risk factors, but other infections including Chlamydia pneumoniae, among others, are also associated with MS. Adolescence is a potentially critical period for susceptibility MS and asso-ciations with exposures in adolescence such as concussion, pneumonia, BMI, and EBV/IM have been found. No studies to our knowledge have examined CNS infection as a risk factor for MS.

Objectives: To determine if CNS infection in childhood (age 0-11 years) or adolescence (age 11-20) is associated with MS risk after age 20 years.

Methods: A cohort born in Sweden between 1970-1994 followed until 31 December 2014, was identified using the Total Population Register, excluding those diagnosed with MS before age 20 years (y) (N=2,422,969). ICD codes from the National Patient Register identified diagnoses of MS after age 20y (n=4,022) (two or more diagnoses), and CNS infection (bacterial and viral) before age 20y. Diagnoses of IM, pneumonia, and other bacterial or viral infections were identified. Infections were classified as present/absent at 0-10y or 11-20y. Cox regression was used to determine associations of CNS infection with MS, with follow-up from age 20y to first MS diagnosis, adjusting for gastrointestinal, genitourinary, respiratory, skin, other infections, sex and parental socioeconomic position.

Results: CNS infection before age 11y was not associated with MS. CNS infection in adolescence was statistically significantly associated with increased MS risk producing an adjusted hazard ratio of 2.80 (95%CI 1.90-4.12). Excluding encephalomyelitis (as this includes acute disseminated encephalitis, often a precursor of MS) the estimate was 1.85 (95%CI 1.11-3.07): an accurate estimate of risk lies between these two hazard ratios. Further adjustment for other infec-tions did not alter the estimates notably.

Conclusions: This novel finding of CNS infection in adolescence associated with MS risk suggests such infections may cause cellular damage in the CNS triggering autoimmune processes pertinent to multiple sclerosis pathogenesis. It also adds to the evidence of a critical susceptibility period in adolescence for MS initiation.