To Örebro University

Purpose This study aims to analyze global prescribing patterns for analgosedation in neonates during four critical care scenarios. The research explores existing patterns, their association with geographic and sociodemographic index (SDI), and adherence to evidence-based practices.

Methods Data from a 2024 global survey of 924 responses to 28 questions were analyzed, focusing on four items for their high variability: premedication in intubation (Q17), sedation in preterm (Q19) and full-term newborns (Q23), and perinatal asphyxia (Q26). Latent class analysis (LCA) classified neonatal intensive care unit (NICU) prescriptions into patterns, assigning participants to the most likely class. Demographic variables, including geographic region and SDI, were compared using chi-square tests to assess associations.

Results Three distinct prescribing patterns emerged for each scenario. In premedication during intubation, Europe and North America predominantly used Class 1, adhering to guidelines with fentanyl, atropine, and muscle relaxants. In contrast, Class 2, standard in Asia and Latin America-Caribbean, primarily utilized fentanyl and midazolam, with rare use of atropine and muscle relaxants. For analgosedation in newborns, higher-SDI NICUs favored fentanyl, while lower-SDI NICUs preferred midazolam or morphine combinations. In perinatal asphyxia cases, fentanyl was the leading choice in Class 3, especially in Europe. Dexmedetomidine use was limited, primarily appearing in Class 1 NICUs. 

Conclusion The study highlights substantial regional variability in neonatal analgosedation, influenced by SDI and geography. Despite established guidelines, gaps in evidence-based implementation persist. These findings underscore the need for global standardization of neonatal care protocols and further research on the long-term safety of midazolam and dexmedetomidine. 

The main aim of this study was to evaluate longitudinal associations between atopic dermatitis (AD) in late adolescence and occupational socioeconomic group, labour market participation, income from work, and marital status later in adult life. Using Swedish population-based registry data a total of 205,394 men were included, born between 1952 and 1956 in Sweden and who underwent military conscription examination including assessment of atopic dermatitis (AD) and AD severity. The associations between AD and AD severity in late adolescence and labour market participation, income from work, marital status, and medication for anxiety and depression later in adult life were examined. In this study, men with AD in adolescence, especially those with severe AD, more often had a prescription for antidepressants or anxiolytics at the age of 50-57 years (unadjusted HR 1.55, 95% CI 1.32-1.81). Interestingly, despite increased risk of poorer mental health, AD was not found to be associated with a disadvantage in terms of occupational socioeconomic group, income from work, and unemployment benefits. Individuals with mild AD showed a lower risk of holding routine and lower technical jobs compared with men without AD. Persons with AD in late adolescence seem not to differ regarding registered partnerships and marital status compared with those without AD.

The main aim of this study was to evaluate longitudinal associations between atopic dermatitis (AD) in late adolescence and occupational socioeconomic group, labour market participation, income from work, and marital status later in adult life. Using Swedish population-based registry data a total of 205,394 men were included, born between 1952 and 1956 in Sweden and who underwent military conscription examination including assessment of atopic dermatitis (AD) and AD severity. The associations between AD and AD severity in late adolescence and labour market participation, income from work, marital status, and medication for anxiety and depression later in adult life were examined. In this study, men with AD in adolescence, especially those with severe AD, more often had a prescription for antidepressants or anxiolytics at the age of 50-57 years (unadjusted HR 1.55, 95% CI 1.32-1.81). Interestingly, despite increased risk of poorer mental health, AD was not found to be associated with a disadvantage in terms of occupational socioeconomic group, income from work, and unemployment benefits. Individuals with mild AD showed a lower risk of holding routine and lower technical jobs compared with men without AD. Persons with AD in late adolescence seem not to differ regarding registered partnerships and marital status compared with those without AD.

BACKGROUND: Comorbid conditions and breathlessness are associated with poor outcomes in chronic obstructive pulmonary disease (COPD). We evaluated the associations of comorbid heart disease and depression/anxiety with breathlessness in daily life among people with COPD.

METHODS: Cross-sectional analysis from the PRAXIS cohort in central Sweden. Data on patient characteristics and the modified Medical Research Council (mMRC) and Dyspnea-12 breathlessness instruments (D-12) were obtained from questionnaires in 2022. Lung function data were collected from record review. Outcome variables were clinically significant breathlessness defined as mMRC≥2 and D-12 total (>2.7), physical (>1.4) and affective (>1.2) scores above published minimal clinical important differences. Associations of heart disease and depression/anxiety with each outcome were analyzed using multivariable Poisson regression adjusted for relevant confounders.

RESULTS: In 522 included patients, mMRC >2 was present in 59% and increased D-12 total, physical and affective domain scores in 69%, 74%, and 50%, respectively. Heart disease was independently associated with mMRC (relative risk ratio [95% confidence interval] 1.34 [1.17-1.53]), D12 physical domain (1.12[1.02-1.24]) and D-12 affective domain (1.20[1.02-1.42]). Depression/anxiety was independently associated with increased D-12 affective domain (1.25[1.04-1.49]). In addition, previous exacerbations and GOLD stage 3-4 were associated with mMRC and D-12, respectively.

CONCLUSION: In COPD, comorbid heart disease is associated with both activity-related breathlessness and with physical and affective domains of breathlessness while depression/anxiety is associated with the affective domain of breathlessness. As the influence of different dimensions of breathlessness may differ according to comorbidity the D-12 instrument adds more information when assessing breathlessness in patients with COPD.

BACKGROUND: There is a knowledge gap regarding the effectiveness and utility of various preventive interventions during the COVID-19 pandemic. In this study, we aimed to evaluate the cost-effectiveness of various COVID-19 preventive interventions, including non-medical interventions (NMIs) and vaccination programs, using real-world data across different demographic and socioeconomic contexts worldwide.

METHODS: We searched Medline, Cochrane Library, Embase, and Web of Science Core Collection from December 2019 to March 2024. We identified 75 studies which compared 34 COVID-19 preventive interventions. We conducted a network meta-analysis to assess the incremental net benefits (INB) of these interventions from both societal and health care system perspectives. We adjusted purchasing power parity (PPP) and standardised willingness to pay (WTP) to enhance the comparability of cost-effectiveness across different economic levels. We performed sensitivity and subgroup analyses to examine the robustness of the results.

RESULTS: Movement restrictions and expanding testing emerged as the most cost-effective strategies from a societal perspective, with WTP-standardised INB values of USD 21 050 and USD 11 144. In contrast, combinations of NMIs with vaccination were less cost-effective, particularly in high-income regions. From a health care system perspective, vaccination plus distancing and test, trace, and isolate strategy were highly cost-effective, while masking requirements were less economically viable. The effectiveness of interventions varied significantly across different economic contexts, underlining the necessity for region-specific strategies.

CONCLUSIONS: In this study, we highlight significant variations in the cost-effectiveness of COVID-19 preventive interventions. Tailoring strategies to specific regional economic and infrastructural conditions is crucial. Continuous evaluation and adaptation of these strategies are essential for effective management of ongoing and future public health threats.

REGISTRATION: PROSPERO: CRD42023385169.

BACKGROUND: We aimed to examine if patients with COPD and comorbid type 2 diabetes, or COPD with comorbid depression or anxiety, had disproportionally raised excess risks of subsequent cardiovascular disease and mortality.

METHODS: This general population-based cohort study used data from Swedish national registers, with follow-up during 2005-2018. Cox regression estimated risks of cardiovascular disease or mortality, producing hazard ratios (HR) with (95% confidence intervals). Interaction testing quantified disproportionally increased excess risks.

RESULTS: Among 5,624,306 individuals, 332,549 had a COPD diagnosis. Compared with individuals who did not have COPD or type 2 diabetes, all-cause mortality risk was higher for individuals who had either COPD or type 2 diabetes, with HR 2.68 (2.66-2.69) and 1.70 (1.69-1.71), respectively. Having both conditions produced an HR of 3.72 (3.68-3.76). Among cardiovascular outcomes, the highest risks were found for chronic heart failure: COPD only, HR 2.87 (2.84-2.90); type 2 diabetes only, 1.86 (1.84-1.88); and both, 4.55 (4.46-4.64). Having both COPD and type 2 diabetes was associated with disproportionally higher excess risks than expected from the sum of the individual diseases, except for cerebrovascular disease or ischemic heart disease. For COPD and depression/anxiety, all-cause mortality risk was associated with COPD only, HR 2.74 (2.72-2.76); depression/anxiety only, 2.39 (2.38-2.40); and both 4.72 (4.68-4.75). Chronic heart failure was associated with COPD only, HR 2.74 (2.71-2.78); depression/anxiety only, 1.31 (1.30-1.32); and both, 3.45 (3.40-3.50). This disease combination was associated with disproportionally higher excess risks than expected, except for atrial fibrillation.

CONCLUSIONS: Type 2 diabetes or depression/anxiety in COPD patients were associated with disproportionally excess risks for cardiovascular disease and mortality. It is important for clinicians to be aware of these greater than expected risks, to prevent further cardiovascular morbidity and mortality.

PURPOSE: Multiple sclerosis (MS) is often diagnosed in people of reproductive age. However, family planning counselling is not always integrated within MS care. Decisions on family planning can be further complicated by potential side effects associated with several disease-modifying therapies. While neurologists may lack training in contraceptive use and family planning counselling, obstetricians and gynaecologists (OB-GYNs) and other health care professionals involved in reproductive life planning (RHCPs) may lack detailed knowledge and experience around the use of contemporary MS treatments.

MATERIAL AND METHODS: Through a modified Delphi consensus programme, a multidisciplinary steering committee of 13 international experts developed practical clinical recommendations on contraceptive use and family planning for people with MS (PwMS). This article offers insights to help OB-GYNs and RHCPs implement these recommendations, focusing on contraceptive decision-making and MS medications.

RESULTS: The perspectives discussed emphasise providing education on MS to OB-GYNs and other RHCPs, enabling informed counselling for PwMS and their partners regarding contraception and family planning. Close collaboration among the multidisciplinary team, including neurologists, is crucial in providing reproductive care for PwMS.

CONCLUSIONS: The detailed perspectives provided aim to enable OB-GYNs and other RHCPs to provide informed counselling for PwMS and their partners regarding contraception and family planning.

INTRODUCTION: Despite increasing numbers of working-age cancer survivors, evidence on their future work-related circumstances is limited. This study examined their future sick leave, disability pension, and unemployment benefits compared to matched cancer-free individuals.

METHODS: A matched cohort study was conducted using nationwide Swedish registers. In total, 94,411 individuals aged 25 to 59 years when diagnosed with incident cancer in 2001-2012 and who returned to work after cancer were compared with their matched cancer-free individuals (N = 354,814). Follow-up started from the year before cancer diagnosis and continued up to 14 years. Generalized estimating equations were used to calculate incidence rate ratios (IRR) and odds ratios for the difference between cancer survivors and matched cancer-free individuals.

RESULTS: Compared with cancer-free individuals, cancer survivors had six times higher sick-leave days per year after cancer (IRR 6.25 [95% CI, 5.97-6.54] for men; IRR, 5.51 [5.39-5.64] for women). This higher number of sick-leave days declined over time but a two-fold difference persisted. An approximate 1.5 times higher risk of receiving disability pension remained during follow-up. The unemployment days tended to be lower for cancer survivors (IRR, 0.84 [0.75-0.94] for men; IRR, 0.91 [0.86-0.96] for women). Risk of sick leave and disability pension was higher among those with leukemia, colorectal, and breast cancer than skin and genitourinary cancers.

CONCLUSIONS: Cancer survivors who returned to work experienced a high and persisting sick leave and disability pension for over a decade. Prolonged receipt of a high amount of benefits may have long-term adverse impacts on financial circumstances; more knowledge to promote the environment that encourages returning to and remaining in work is needed.

BACKGROUND AND AIM: Patients with COPD and concurrent depression and/or anxiety are known to have an increased risk of exacerbations, morbidity, mortality, and deteriorated quality of life. Early detection of depression/anxiety may enable early interventions. The aims of this study were to describe the occurrence of depression and anxiety in primary care patients with COPD in Sweden, and to investigate age and gender differences together with other clinical factors associated with this comorbidity.

METHODS: A cross-sectional study was performed on a cohort of patients with doctor's diagnoses of COPD. Patients were randomly selected based on the patients' contact with 98 primary healthcare centers and 13 hospitals in Sweden in 2014. Information about self-reported depression/anxiety, patient characteristics, symptoms, and comorbidity, were collected using patient self-completion questionnaires. Lung function data were extracted from medical records.

RESULTS: Of the 2245 patients recruited, 23% (n = 524) reported depression/anxiety, 29% in women and 16% in men (p <0.001). Factors associated with depression/anxiety were being a woman (OR = 2.06 [95% CI 1.56-2.72]), current smoking (1.83 [1.37-2.43]), comorbid asthma (1.77 [1.32-2.37]), dyspnea (the modified Medical Research Council dyspnea scale ≥2 points) (1.58 [1.17-2.13]) and age <65 years (1.57 [1.17-2.10]). The youngest age groups had the highest proportions of patients with depression/anxiety.

CONCLUSIONS: Healthcare professionals need to be particularly aware of depression/anxiety in patients with COPD who are younger, women, current smokers, have comorbid asthma, or dyspnea.

OBJECTIVE: To estimate the effect on healthcare resource use after introducing the World Health Organization diagnostic criteria (WHO-2013) for gestational diabetes mellitus (GDM) compared to former criteria in Sweden (SWE-GDM). DESIGN: A cost-analysis alongside the Changing Diagnostic Criteria for Gestational Diabetes (CDC4G) randomised controlled trial.

SETTING: Sweden, with risk-factor based screening for GDM. POPULATION: 47 080 pregnant women and their infants. METHODS: A register-based cost-analysis from a healthcare perspective alongside a stepped-wedge cluster RCT of switching from SWE-GDM to WHO-2013 criteria in 2018. Analyses were made on the population level and repeated in the subgroup affected by the intervention, that is, those with plasma glucose values between SWE-GDM and WHO-2013 criteria. Sensitivity analysis by bootstrapping was performed.

MAIN OUTCOME MEASURES: Estimated costs for obstetric surveillance (including GDM-management), delivery and neonatal healthcare until 28 days postpartum. RESULTS: On a population level, the WHO-2013 criteria were associated with increased costs of obstetric surveillance (adjusted mean [bootstrap confidence interval]) €94.0 [24.5-169.1], delivery care €20.4 [-33.5 to 75.4] and neonatal care €331.0 [75.1-589.0] per pregnancy, and in the affected subgroup €606.9 [377.7-872.4], €348.5 [126.0-542.0] and €129.3 [-559.0 to 980.9] respectively.

CONCLUSIONS: Implementation of the WHO-2013 criteria in Sweden was associated with increased costs for obstetric surveillance and delivery on a population level, driven by the affected subgroup. The increased costs for neonatal care were associated with large uncertainty. A detailed understanding of the changes in resource use can guide decisions to mitigate cost increases.