To Örebro University

Death anniversaries may trigger stress responses that negatively affect health in bereaved individuals. Little is known about such reactions after adult sibling loss. This study examined whether mortality risk increases around the anniversary of a sibling's death. Using Swedish national register data (1990-2016), we conducted a time-stratified case-crossover study including 12,789 adults who experienced sibling loss and later died. Conditional logistic regression estimated associations between mortality and death anniversaries (including pre- and post-anniversary periods), adjusting for time-invariant confounders. Analyses were stratified by the bereaved's sex and age, the sibling's sex, sibling order, and whether ≥1 parent was alive at the bereaved's death. Among women, mortality risk was lower on the anniversary date (OR 0.44; 95% CI 0.21-0.93), and in the period from one day before and up to the anniversary date for women who lost a younger or same-age sibling (OR 0.45; 95% CI 0.20-1.00). In contrast, men bereaved before age 50 had a heightened risk in the period ranging from 12 days before and up to the anniversary (OR 1.40; 95 % CI 1.05-1.86). Overall, sibling-death anniversaries were not associated with elevated mortality, though observed sex- and age-specific patterns merits further investigation.

If Epstein-Barr virus is essential for multiple sclerosis (MS) pathogenesis, there may be differences in MS risk for auxiliary exposures that occur before or after Epstein-Barr virus infection. Infectious mononucleosis (IM) during adolescence typically represents the primary Epstein-Barr virus infection, so can be used as a proxy marker, while concussion in adolescence is considered a separate non-essential risk factor for MS. The objective here was to examine if concussion before or after IM during adolescence is differently associated with MS risk. Using national Swedish health registers, among those born from 1980 with follow-up to 2023, we identified a cohort with IM between ages 11 and 20 years among people without a demyelinating disease diagnosis by age 20 years (n = 37 432), among whom 174 had a subsequent MS diagnosis. The median age (and interquartile range) at IM was 17.00 (15.52-18.59) years among those without MS and 16.66 (15.15-18.29) years among those with MS. In this cohort, between ages 11 and 20 years, there were 1474 episodes of concussion before IM and 1171 occurring afterwards. Associations between concussion and MS risk were estimated using Cox regression, with age as the underlying timescale and adjustment for age at IM, year of birth (both modelled as continuous measures using restricted cubic splines), sex and county. Notably, only concussion occurring before, but not after, IM was associated with increased MS risk producing adjusted hazard ratios (with 95% confidence intervals) of 2.23 (1.24-4.03; P = 0.008) for concussion before IM and 0.85 (0.35-2.09; P = 0.726) for concussion after IM. However, there is no statistically significant effect modification for MS with an interaction for concussion before and after IM of 1.60 (0.16-15.60; P = 0.685). Our findings suggest that changes in the environment of the CNS caused by concussion facilitate development of MS if present before primary Epstein-Barr virus infection.

Background: The COVID-19 pandemic compelled governments worldwide to adopt diverse public health and economic policies. However, the relative efficiency of these interventions across European countries has not been comprehensively evaluated. This study assessed the efficiency of COVID-19 policy responses in 27 European countries of the Organization for Economic Co-operation and Development (OECD), with the aim of identifying factors associated with effective pandemic management. The time period of this study is from January 1, 2020 to December 31, 2022.

Methods: A data envelopment analysis (DEA) framework was applied to evaluate the efficiency of national responses. Policy inputs, including healthcare resources, economic support, and stringency indices, were assessed against outputs reflecting adverse outcomes, namely COVID-19 cases, mortality, and virus transmission. Data were obtained from the Oxford COVID-19 Government Response Tracker and other publicly available international databases.

Results: Marked heterogeneity in policy efficiency was observed. Countries that implemented early, stringent, and adaptive measures demonstrated superior efficiency scores. Italy, Greece, and Austria consistently ranked among the most efficient, while nations with delayed or inflexible strategies performed less effectively despite comparable resource availability. Importantly, policy flexibility and dynamic adjustment to epidemiological trends emerged as critical determinants of sustained efficiency.

Conclusions: This study provides a robust comparative evaluation of COVID-19 policy efficiency across European OECD countries. The findings emphasize that timeliness of interventions, adaptability of policy measures, and judicious resource allocation were more influential than absolute resource capacity. Incorporating efficiency assessments into pandemic preparedness strategies may enhance resilience and inform evidence-based decision-making for future global health emergencies.

OBJECTIVES: European countries implemented highly diverse mitigation policies during the COVID-19 pandemic, ranging from strict nationwide lockdowns to more voluntary approaches. This study aims to understanding how timing, stringency, and comprehensiveness of policy responses influenced epidemic trajectories by applying machine learning-based counterfactual analysis.

METHODS: Data from 27 European OECD countries between January 2020 and December 2022 were analysed. Daily epidemiological data, including COVID-19 cases, deaths, effective reproduction number were linked with government response indicators, demographics, vaccination, testing, and mobility data. Temporal Fusion Transformer (TFT) models were applied for multi-horizon time series forecasting by capturing nonlinear relationships between policy response indicators and COVID-19 outcome variables. Simulations were conducted under eight hypothetical response scenarios, ranging from the loosest to the strictest policy bundles. The impacts of policy responses on COVID-19 outcomes were assessed by comparing the counterfactual scenarios with the factual outcomes.

RESULTS: TFT models achieved excellent predictive accuracy (percentage mean absolute error <10%). The strictest responses were associated with reduced daily COVID-19 cases by over 10% in several countries, notably Hungary, Switzerland, and Turkey, while the loosest responses were associated with increased incidence by 10-20%, with the highest value observed in Poland. Associations with mortality were smaller and heterogeneous, with potentially maximum reductions of 7-10% in Belgium, Portugal, and Switzerland under strict scenarios. Over early relaxation from the restrictions might lead to outcomes as adverse as those under continuously loose policies. Feature importance analyses highlighted restrictions on mobility and gatherings, vaccination, testing, and fiscal measures as dominant drivers, alongside country-level factors such as age structure and chronic disease burden.

CONCLUSIONS: The TFT-based machine learning framework demonstrated favourable feasibility and interpretability, reinforcing its value in guiding policy decisions. Comprehensive, multi-domain interventions outperformed partial or short-lived restrictions. Lifting measures before achieving sufficient immunity and epidemic control posed substantial risks. Stringent policies reduced transmission, but their impact on mortality was constrained, which might be due to demographic and systemic vulnerabilities. Adaptive, data-driven strategies integrating epidemiology, policy, and structural context are essential to strengthen policy responses against future pandemics.

OBJECTIVE: We aimed to examine the variability of chronic obstructive pulmonary disease (COPD) exacerbations and mortality, between primary healthcare centres, and their associations with comorbid diseases and body mass index, during an 8-year follow-up.

DESIGN: This was a cohort study using multilevel modelling with follow-up from 2014 to 2022. Data came from questionnaires in 2014 and 2022 and medical record reviews between 2004 and 2014. The main outcomes were exacerbations in 2022 and mortality by 2022. Exacerbations were defined as any emergency visit, and/or use of oral steroids or antibiotics due to worsening of COPD symptoms during the previous 6 months.

SETTING: The PRAXIS study included patients at 76 primary healthcare centres in central Sweden.

PARTICIPANTS: Primary care patients aged ≤75 years and with a diagnosis of COPD in their medical records between 2007 and 2010 were included in 2014 (n=1163) and followed up in 2022 (n=906). There were no other exclusion criteria.

RESULTS: The 809 patients with complete data attended 70 primary care centres. Multilevel multinomial regression estimated risks of exacerbations and mortality, calculating relative risk ratios (RRRs) with 95% CIs. The intraclass correlation coefficient (ICC) quantified the proportion of variance attributed to variability between centres. The ICC was 0.024, indicating 2.4% of the variation was explained by differences between centres. Patients with a history of depression in 2014 had an increased risk of subsequent exacerbations (RRR 1.95, 95% CI 1.13 to 3.39). For mortality, there were associations with history of anxiety, RRR 3.71 (95% CI 2.06 to 6.87), or cardiovascular disease, especially chronic heart failure, RRR 2.69 (95% CI 1.36 to 5.33). Body mass index had a U-shaped association with mortality.

CONCLUSIONS: The variability between centres was small and patient factors appear to be of more importance for COPD exacerbations and mortality than differences between these primary care settings. As expected, pre-existing cardiovascular disease is associated with future excess mortality risk, but, notably, anxiety may also be an important risk factor. Individualised care and management of comorbidity is thus essential among patients in primary care with COPD.

Background and Aims: Informal caregiving has increased over recent decades. Caregivers may face an increased risk of accidental falls because of care tasks or their consequences, such as fatigue. However, this association has not been investigated. Therefore, we aimed to examine whether giving personal care to someone at home increases fall risk.

Methods: Using longitudinal repeated measures for adults aged over 50 years in 17 European countries, with biennial data collection in 2004-2017 (N = 51,132), we compared periods of caregiving to non-caregiving for falls (outcome) using fixed-effects logistic models, estimating odds ratios (OR) with 95% confidence intervals (95% CI) while controlling for measured time-varying variables as well as unmeasured time-invariant confounders. To shed light on mechanisms, we tested effect modification by sociodemographic characteristics, and examined whether fatigue, sleep problems, lower concentration, and changes in behaviour mediate the association.

Results: Compared with the period of not giving care, the period of providing care was associated with higher fall risk (OR 1.19 [95% CI 1.05-1.35]). This association differed by baseline household income (below or above median). In higher-income households, there was no statistically significant difference in fall risk between the period giving and not giving care (OR 1.07 [95% CI 0.90, 1.26]). In contrast, in lower-income households, the caregiving period was associated with higher fall risk (OR 1.36 [95% CI 1.14-1.63]), which was equivalent to 29% (95% CI 12-46) increased probability of falls in caregiving periods. Fatigue, sleep problems, lower concentration, and behavioural changes jointly mediated 12% of the effect; thus, most of the effect of caregiving on falls is a direct effect.

Conclusion: There was an increased fall risk among caregivers who provide personal care at home in lower-income households. Fatigue and other consequences of caregiving mediated only small effects. Other factors, such as lack of equipment and living space, may relate to mechanisms.

There is evidence that persistent dysregulation of the immune system caused by SARS-CoV-2 infection may increase susceptibility to other infections. Here, we assessed whether it is associated with subsequent diagnoses of infectious mononucleosis due to Epstein-Barr virus (EBV-IM). Residents of Sweden aged 3-100 years without a prior diagnosis of EBV-IM were followed between January 1, 2020, and November 30, 2022, comprising a total of 9 978 860 participants. Individuals were categorized into those without a COVID-19 diagnosis, those with a positive SARS-CoV-2 polymerase chain reaction (PCR) test only - less severe exposure, and those admitted to hospital with COVID-19 - more severe exposure. Cox regression was used to estimate hazard ratios (HR) with 95% confidence intervals (95% CI) for the association between the exposure, modeled as a time-varying covariate, and EBV-IM occurrence. EBV-IM rates per 100 000 person-years and 95% CIs were 4.6 (4.4-4.9) for individuals not diagnosed with COVID-19, 7.8 (6.9-8.9) for those with a positive SARS-CoV-2 test only, and 10.5 (6.2-17.6) for patients admitted to hospital with COVID-19. HR and 95% CI were 1.61 (1.39-1.88) for people with a positive PCR test only and 5.71 (3.33-9.79) for those admitted to hospital with COVID-19 compared with people without a COVID-19 diagnosis, after adjustment for birth year, sex, Swedish healthcare region, region of birth, and Charlson comorbidity index. SARS-CoV-2 infection was associated with a subsequent raised risk of EBV-IM, including among those with less severe acute infection, signaling immune perturbation and the possibility of further delayed sequelae linked with EBV-IM.

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.