Long-Term Effect of Maintenance Electroconvulsive Therapy in Patients With Depression-Data From a Small Randomized Controlled Trial.

OBJECTIVES: This study aimed to compare the long-term effects of maintenance electroconvulsive therapy (M-ECT) with medication and medication only in patients with depression. METHODS: A randomized controlled trial of 1 year of M-ECT with medication or medication only investigated relapse/recurrence among 56 patients in remission after electroconvulsive therapy (ECT) for depression was conducted. The results of the first year are published already and showed a significant advantage of M-ECT with medication.The current study was a long-term follow-up. When the randomized treatment allocation ended, medication was continued in both groups but M-ECT was terminated. Patients were followed for up to 10 years via Swedish national registers until the study endpoint of a new psychiatric diagnosis as an inpatient, suicide, suspected suicide, or death of another cause. Time to relapse was compared between the M-ECT with medication group and the medication-only group using Kaplan-Meier estimates. RESULTS: The median follow-up time was 6.5 years for the M-ECT and medication group and 3.1 years for the medication-only group. One year after randomization 22 patients remained in the M-ECT and medication group, and 14 patients remained in the medication-only group. Relapse patterns between the treatment groups after the completion of M-ECT seemed to be similar according to visual inspection. CONCLUSIONS: This long-term follow-up study suggests that most of the benefit achieved during the treatment period with M-ECT is maintained over several years, but the small sample size, with accompanying large statistical imprecision, makes the results uncertain. More long-term studies of M-ECT are required.Trial registration: ClinicalTrials.gov identifier: NCT00627887.

Treatment and outcome of AO/OTA type C distal radius fractures: 12 199 fractures from the Swedish Fracture Register.

The aim of this study was to examine the epidemiology, treatment, and patient-reported outcome of AO/OTA type C distal radius fractures (DRF) using data from a large national fracture register. We used prospectively collected data from the Swedish Fracture Register covering all AO/OTA type C DRFs registered between April 2012 and December 2018. Data on fracture type, epidemiology, trauma-mechanism, and treatment had been recorded by the treating physician. Patients had been sent an outcome questionnaire including EQ-VAS, EQ-5D, and the SMFA at the time of injury and 12 months after. A total of 12 199 cases with AO/OTA type C fracture were identified. AO/OTA type C1 fracture was most common, with 5400 cases, followed by AO type C2 with 4304 and AO/OTA type C3 with 2495. Cast treatment and surgical treatment with volar locking plate fixation were the most common treatments. Patient-reported outcome measures worsened significantly one year after the fracture, and 56% reported moderate problems with pain and discomfort one year after the fracture. Patients treated with a volar plate reported a significantly larger deterioration in EQ-5D outcome compared to patients treated with a cast. No treatment method was found to be superior. A good outcome after a type C fracture is possible, but many patients do not recover completely. Our findings indicate a relatively better self-reported outcome for patients treated with a cast, but as treatment was not randomized the clinical relevance is unclear.

Suicidal ideation and ECT, ECT and suicidal ideation: A register study.

OBJECTIVE: Although electroconvulsive therapy (ECT) is anti-suicidal, it is not known whether the presence of suicidal ideation (SI) at baseline predicts response and remission after ECT. The aim of the study was to analyze the impact of baseline SI on response and remission following ECT treatment in a large sample of patients with depression and to assess SI before and after ECT. METHODS: This population-based register study used data from the Swedish National Quality Register for ECT and the Swedish Patient Register. Patients aged 18 years or older who had received ECT for a unipolar or bipolar depressive episode between 2011 and 2018 were included in the study. SI was defined as a score of ≥4 on the last item of the Montgomery-Åsberg Depression Rating Scale - Self Assessment (MADRS-S). Using a logistic regression model, SI at baseline was used to predict response and remission following ECT, while controlling for depression severity, psychotic symptoms, presence of a comorbid personality disorder, age, sex, electrode position, unipolar or bipolar disorder, and number of previous suicide attempts at baseline. RESULTS: In patients who exhibited SI at baseline, 53.7% (N = 632) of cases showed a response to ECT, whereas 68.4% (N = 690) of patients without SI showed a response. In addition, 27.2% (N = 320) of cases with SI achieved remission, whereas 48.5% (N = 489) of cases without SI achieved remission. The odds of achieving response and remission for patients with SI were 0.75 and 0.58 times, respectively, those for patients without SI. Of the 1178 patients with pre-treatment SI, 75.64% (N = 891) exhibited no SI at the end of treatment. Moreover, in this subgroup, the presence of a personality disorder, higher MADRS-S-score, and younger age were associated with persistent SI. CONCLUSION: The presence of SI was associated with lower ECT response and remission rates. Nevertheless, depressive symptoms and SI were reduced in a large proportion of patients across both patient groups. Clinicians should be aware of the lower likelihood of achieving a successful outcome following ECT in younger patients who present with a non-psychotic depressive episode, SI, and (suspected) personality disorders. More research is warranted regarding if these patients can achieve similar or better results with other treatments.

Validity of diagnoses, treatment dates, and rating scales in the Swedish national quality register for electroconvulsive therapy.

BACKGROUND: The Swedish national quality register for electroconvulsive therapy (Q-ECT) contains data on patients receiving treatment with electroconvulsive therapy (ECT) in Sweden. AIM: This study determined the validity of diagnoses, treatment dates, and rating scales in the Q-ECT by investigating the degree of accordance between data from the Q-ECT and patient records. MATERIALS AND METHODS: From January 2016 to December 2017, 200 treatment series were randomly selected from the Q-ECT. The corresponding patient records were requested from the treating hospitals. Data on the indicative diagnosis, dates for the first and the last ECT session, and rating scales were compared between the Q-ECT and patient records using (i) a strict and (ii) a liberal method of assessment. Using the liberal method, each variable was assessed as accordant if it belonged to the same diagnosis group, or if the dates differed by less than 1 week, or ratings differed by only 1 point on the Clinical Global Impression Scale (CGI- S), or no more than 3 points on the Montgomery Åsberg Depression Rating Scale between the Q-ECT and the patient record. RESULTS: A total of 179 patient records were received. The strict method of assessment showed an accordance of 89% or higher for all studied variables. The liberal method showed an accordance of 95% or higher. CONCLUSIONS: We conclude that data on the studied variables in the Q-ECT have high validity. However, limited use of some rating scales makes the results uncertain. Measures can be taken to further improve the data quality.

Relapse risk after in-ward electroconvulsive therapy for acute polymorphic psychotic disorder.

PURPOSE: Acute polymorphic psychotic disorder (APPD) without symptoms of schizophrenia is a serious psychiatric condition. APPD can be effectively treated with electroconvulsive therapy (ECT), but little is known about relapse prevention after ECT for APPD. MATERIALS AND METHODS: This was a retrospective register-based study conducted with 97 patients with APPD (ICD-10 diagnosis F23.0). We estimated the rates of readmission and suicide, and the prognostic factors of these outcomes after ECT. We combined data from several national Swedish registers and used Cox's regression analysis to identify demographic factors, disease characteristics, and relapse preventive treatments that predicted time to readmission or suicide (relapse). Data registered between 2011 and 2016 were used in the study. RESULTS: Twenty percent of cases relapsed within a year. Thereafter, relapse rate was low. Two cases died during follow-up, whereof one by suicide. Anxiolytic treatment, lamotrigine treatment, and having more than four previous psychiatric hospital admissions were associated with shorter time to relapse. The most robust of these associations was between anxiolytics and relapse risk. CONCLUSIONS: The first year after discharge from APPD is the period associated with the highest risk of relapse. Having many previous admissions was associated to relapse risk after ECT for APPD. The associations between anxiolytics, lamotrigine, and relapse are uncertain and might be influenced by indication bias.

Dyspnea Index: An upper airway obstruction instrument; translation and validation in Swedish.

OBJECTIVE: Upper airway dyspnoea is a challenging condition in which assessing the discomfort experienced by the patient is essential. There are three patient-reported outcome (PRO) instruments developed particularly for this patient group, none of which is available in Swedish. The aim of this study was to translate the Dyspnea Index (DI) into Swedish and validate the instrument for use in the Swedish-speaking population by investigating its basic psychometric properties. DESIGN: A prospective instrument validation study. SETTING: Tertiary referral centre. PARTICIPANTS: Fifty-three (n = 53) patients with upper airway dyspnoea and 19 healthy controls. MAIN OUTCOME MEASURES: The questionnaire was translated into Swedish (swDI) with a forward-backward method. Reliability, repeatability, responsiveness and construct validity were assessed by asking the subjects to complete the swDI, a visual analog scale (VAS) at exertion and at rest and the Voice Handicap Index (VHI). RESULTS: The swDI showed excellent internal consistency (Cronbach's α: 0.85) and repeatability (interclass correlation coefficient: 0.87 and Pearson's r: .89) in the patient group. No ceiling effect was observed (maximum score achieved was 39; 85% of the patients scored ≤ 36). SwDI scores moderately correlated with VAS at exertion (r: .59) and at rest (r: .42), yet poorly with the VHI (r: .36). The effect size (ES) was 3.8. CONCLUSIONS: The swDI is a valid, robust and reliable questionnaire for self-assessment in Swedish-speaking patients with upper airway obstruction. A future anchor-based longitudinal study is needed to assess the smallest detectable change (SDC) and minimal important change (MIC) that were not estimated in our study.

Rehospitalization of Postpartum Depression and Psychosis After Electroconvulsive Therapy: A Population-Based Study With a Matched Control Group.

OBJECTIVES: Electroconvulsive therapy (ECT) is used in some cases of postpartum depression (PPD) and postpartum psychosis (PPP). The risk of relapse for PPD and PPP after ECT is unknown. This study compared the relapse rate after ECT between women who had been treated for PPD and/or PPP and women who had been treated for depression and/or psychosis outside the postpartum period. METHODS: The Swedish National Quality Register for ECT and the Swedish National Patient Register were used to identify women with PPD and/or PPP who had been treated with ECT within 6 months after delivery. For each case, a control (treated with ECT but not postpartum) patient was also selected. A Kaplan-Meier estimator was used to calculate the relapse rate (defined as rehospitalization or suicide) after ECT. Cox regression was used to identify variables associated with relapse. RESULTS: A total of 180 patients were included in each group. The proportions of patients who suffered relapse after 6 months, 1 year, and 2 years were 28%, 31%, and 40% for the postpartum group and 39%, 50%, and 55% for the nonpostpartum group. Treatment with benzodiazepines, several previous psychiatric admissions, and the absence of improvement after ECT were associated with relapse. CONCLUSIONS: The risk of relapse after ECT is lower for patients with PPD and/or PPP than for patients outside the postpartum period, but the risk is nonetheless substantial in both groups.

Revision Arthroplasty of the Wrist in Patients With Rheumatoid Arthritis, Mean Follow-Up 6.6 Years.

PURPOSE: Management of failed total wrist arthroplasty (TWA) can be challenging; surgical treatment options include salvage arthrodesis, revision arthroplasty, and resection arthroplasty. There are few studies regarding salvage arthrodesis, and revision arthroplasty has been infrequently investigated. The aim of the study was to report the outcome after revision arthroplasty of the wrist. METHODS: A retrospective cohort of 16 revision TWAs was evaluated between 2003 and 2016. Data were collected before surgery and 1 and 5 years after surgery. The indication for revision arthroplasty was failed TWA. The primary end point was implant survival. Secondary outcome measures included visual analog scale (VAS) pain scores, range of motion, handgrip strength, and functional scoring with the Canadian Occupational Performance Measure (COPM), Patient-Rated Wrist Evaluation (PRWE), and Disabilities of the Arm, Shoulder, and Hand (DASH). RESULTS: Mean follow-up was 6.6 years. Synthetic bone graft was used in 9 cases, allograft corticocancellous bone graft in 1 case, and cement in 6 cases. Of the 16 revision TWAs, 4 were re-revised, 1 because of infection, and 3 cases underwent total wrist arthrodesis. In the non-re-revised cases, range of motion and grip strength was preserved compared with preoperative results. The VAS pain score in activity improved, but not significantly, at 1 (median, 1; range, 0-4.5) and 5 years after surgery (median, 0) compared with before surgery (median, 5). The COPM performance and satisfaction as well as PRWE scores improved significantly at 1 year (median COPM performance, 4.8; COPM satisfaction, 5.6; and PRWE, 24) and improved, but not significantly, at the 5-year follow (median COPM performance, 4.8; COPM satisfaction, 5.0; and PRWE, 37) in the non-re-revised cases. CONCLUSIONS: Revision arthroplasty of the wrist is a valid motion-preserving option to wrist arthrodesis in the management of failed TWA. However, the outcome is uncertain and as many as 25% require additional surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Subjective Memory Immediately Following Electroconvulsive Therapy.

OBJECTIVES: The aims of the present study were to describe the short-term rate of subjective memory worsening (SMW) and identify factors of importance for SMW in a large clinical sample treated for depression with electroconvulsive therapy (ECT). METHODS: This register-based study included 1212 patients from the Swedish National Quality Register for ECT. Subjective memory worsening was defined as a 2-point worsening on the memory item of the Comprehensive Psychopathological Rating Scale from before to within 1 week after treatment. Associations between patient characteristics and treatment factors were examined using logistic regression. RESULTS: Subjective memory worsening was experienced in 26%. It was more common in women than in men (31% vs 18%; P < 0.001) and more common in patients aged 18 to 39 years than in patients 65 years or older (32% vs 22%; P = 0.008). Patients with less subjective memory disturbances before ECT had a greater risk of SMW. Patients in remission after ECT had a lower risk of SMW. A brief pulse width stimulus gave higher risk of SMW compared with ultrabrief pulse (odds ratio, 1.61; 95% confidence interval, 1.05-2.47). CONCLUSIONS: Subjective memory worsening is reported by a minority of patients. However, young women are at risk of experiencing SMW. Ultrabrief pulse width stimulus could be considered for patients treated with unilateral electrode placement who experience SMW. Each patient should be monitored with regard to symptoms and adverse effects, and treatment should be adjusted on an individual basis to maximize the clinical effect and with efforts to minimize the cognitive adverse effects.

Improvement of cycloid psychosis following electroconvulsive therapy.

BACKGROUND: The treatment of choice for cycloid psychosis has traditionally been electroconvulsive therapy (ECT), but there is a lack of studies on its effectiveness. AIMS: The primary aim of this register study was to determine the rates of remission and response after ECT for cycloid psychosis. The secondary aim was to examine possible predictors of outcome. METHODS: Data were obtained from the National Quality Register for ECT in Sweden. The study population was patients (n = 42) who received ECT for acute polymorphic psychotic disorder without symptoms of schizophrenia or for cycloid psychosis between 2011-2015 in 13 hospitals. Remission and response rates were calculated using Clinical Global Impression-Severity (CGI-S) and -Improvement scores, respectively. Variables with possible predictive value were tested using Chi-square and Fisher's exact test. RESULTS: The response rate was 90.5%. The remission rate was 45.2%. Of 42 patients, 40 improved their CGI-S score after ECT (p < 0.001). The mean number of ECT treatments was 2.5 for non-responders and 7.0 for responders (p = 0.010). The mean number of ECT treatments did not differ significantly between remitters and non-remitters (7.2 vs 6.1, p = 0.31). None of the other investigated potential predictors was statistically significantly associated with outcome. CONCLUSIONS: ECT is an effective treatment for cycloid psychosis. Future studies need to compare the outcome of ECT to that of other treatment strategies. CLINICAL IMPLICATIONS: The high response rate with ECT indicates that cycloid psychosis is a clinically useful diagnosis.

Total Wrist Arthroplasty: A Single-Center Study of 219 Cases With 5-Year Follow-up.

PURPOSE: To assess implant survival and radiographic loosening after total wrist arthroplasty (TWA) operated at a single tertiary referral center in Sweden. METHODS: In a prospective cohort study, we evaluated 189 consecutive patients with a TWA (219 wrists). The wrists were implanted between 2002 and 2013. The primary end point was revision for any reason. The mean follow-up period was 7 years (range, 2-13 years). In addition, radiological examination was done for evidence of prosthetic loosening 5 years postoperatively. Implant survival was estimated using the Kaplan-Meier method. Secondary outcome measures included range of motion, visual analog scale pain scores, hand grip strength, and patient-related outcome measures. RESULTS: Cumulative implant survival after 8 years was 81% for Biax, 94% for Remotion, and 95% for Maestro implants. Radiographic loosening was present in 26% of wrists with the Biax design, 18% of those with Remotion, and 2% of those with Maestro. Visual analog scale pain scores and patient-related outcome scores improved significantly for all TWAs. Improved hand grip strength was noted for all TWAs except for the Universal 2. Range of motion improved somewhat, especially for the Biax and Maestro TWAs. CONCLUSIONS: Good midterm to long-term results were achieved in patients undergoing TWA. Radiographic loosening did not necessarily correlate with implant survival rates, but rather to severe arthritic destruction of the wrist preoperatively. All TWA implants studied offered a high level of patient satisfaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Continuation electroconvulsive therapy with pharmacotherapy versus pharmacotherapy alone for prevention of relapse of depression: a randomized controlled trial.

OBJECTIVE: The primary aim of the study was to test the hypothesis that relapse prevention with continuation electroconvulsive therapy (ECT) plus pharmacotherapy is more effective than pharmacotherapy alone after a course of ECT for depression. METHODS: A multicenter, nonblinded, randomized controlled trial with 2 parallel groups was performed from 2008 to 2012 in 4 hospitals in Sweden. Patients eligible had unipolar or bipolar depression and had responded to a course of ECT. The patients (n = 56) were randomly assigned (1:1) to receiving either 29 treatments of continuation ECT with pharmacotherapy or pharmacotherapy alone for 1 year. The pharmacotherapy consisted of antidepressants (98%), lithium (56%), and antipsychotics (30%). The main outcome was relapse of depression within 1 year. Relapse was defined as 20 or more points on the Montgomery Åsberg Depression Rating Scale or inpatient psychiatric care or suicide or suspected suicide. All 56 patients randomized were analyzed according to an intention to treat analysis. RESULTS: Sixty-one percent of the patients treated with pharmacotherapy versus 32% of the patients treated with ECT plus pharmacotherapy relapsed within 1 year (P = 0.036). The Cox proportional hazard ratio was 2.32 (1.03-5.22).Cognitive function and memory measures were stable for patients without relapse in both groups.One suspected suicide and 3 suicide attempts by intoxication occurred, all in the pharmacotherapy-alone group. CONCLUSIONS: The post-ECT relapse rates were substantial in both treatment groups with a statistically significant advantage for combined treatment with pharmacotherapy and continuation ECT. Further studies are needed to define indications for continuation ECT, pharmacotherapy, and their combination.

Predictors of regained occupational functioning after electroconvulsive therapy (ECT) in patients with major depressive disorder--a population based cohort study.

AIMS: The aim of the present study is to investigate the rate of regained occupational functioning among patients treated with electroconvulsive therapy (ECT) for major depression and to define predictors of time to regained occupational functioning. METHODS: A nested cohort study was performed of patients treated by ECT for unipolar major depressive disorder registered in the Quality register for ECT and in the Swedish Social Insurance Agency registry. Predictive values of single clinical variables and their relative importance were tested with Cox regression analysis. RESULTS: 394 patients were identified. Of those, 266 were on non-permanent sick leave and 128 on disability pension during ECT. Within 1 year post-ECT, 71% of the patients with non-permanent sick leave regained occupational functioning. Factors independently associated with a statistically significant increased time to regained occupational functioning were longer duration of sick leave pre-ECT, milder depression pre-ECT, less complete improvement with ECT, benzodiazepine treatment after ECT and co-morbid substance dependence. CONCLUSIONS: A large proportion of the patients do not return to work within several months post-ECT. Paradoxically, patients with more severe depression pre-ECT had a reduced time to regained occupational functioning, indicating a larger effect in this patients group of the treatment. Moreover, the period with sick leave compensation might be reduced if ECT is initiated within the first 3 months of sick leave. CLINICAL IMPLICATIONS: Most patients on non-permanent sick leave regain occupational functioning after ECT. However, it usually takes a few months even in symptomatically improved patients.

Validation of the scandinavian guidelines for initial management of minor and moderate head trauma in children.

BACKGROUND: Head trauma in children is common, with a low rate of clinically important traumatic brain injury. CT scan is the reference standard for diagnosis of traumatic brain injury, of which the increasing use is alarming because of the risk of induction of lethal malignancies. Recently, the Scandinavian Neurotrauma Committee derived new guidelines for the initial management of minor and moderate head trauma. Our aim was to validate these guidelines. METHODS: We applied the guidelines to a population consisting of children with mild and moderate head trauma, enrolled in the study: "Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study" by Kuppermann et al. (Lancet 374(9696):1160-1170, https://doi.org/10.1016/S0140-6736(09)61558-0 , 2009). We calculated the negative predictive values of the guidelines to assess their ability to distinguish children without clinically-important traumatic brain injuries and traumatic brain injuries on CT scans, for whom CT could be omitted. RESULTS: We analysed a population of 43,025 children. For clinically-important brain injuries among children with minimal head injuries, the negative predictive value was 99.8% and the rate was 0.15%. For traumatic findings on CT, the negative predictive value was 96.9%. Traumatic finding on CT was detected in 3.1% of children with minimal head injuries who underwent a CT examination, which accounts for 0.45% of all children in this group. CONCLUSION: Children with minimal head injuries can be safely discharged with oral and written instructions. Use of the SNC-G will potentially reduce the use of CT.

Lithium for suicide and readmission prevention after electroconvulsive therapy for unipolar depression: population-based register study.

BACKGROUND: Electroconvulsive therapy (ECT) is effective for unipolar depression but relapse and suicide are significant challenges. Lithium could potentially lower these risks, but is used only in a minority of patients.AimsThis study quantifies the effect of lithium on risk of suicide and readmission and identifies factors that are associate with readmission and suicide. METHOD: This population-based register study used data from the Swedish National Quality Register for ECT and other Swedish national registers. Patients who have received ECT for unipolar depression as in-patients between 2011 and 2016 were followed until death, readmission to hospital or the termination of the study at the end of 2016. Cox regression was used to estimate hazard ratios (HR) of readmission and suicide in adjusted models. RESULTS: Out of 7350 patients, 56 died by suicide and 4203 were readmitted. Lithium was prescribed to 638 (9%) patients. Mean follow-up was 1.4 years. Lithium was significantly associated with lower risk of suicide (P = 0.014) and readmission (HR 0.84 95% CI 0.75-0.93). The number needed to be treated with lithium to prevent one readmission was 16. In addition, the following factors were statistically associated with suicide: male gender, being a widow, substance use disorder and a history of suicide attempts. Readmission was associated with young age, being divorced or unemployed, comorbid anxiety disorder, nonpsychotic depression, more severe symptoms before ECT, no improvement with ECT, not receiving continuation ECT or antidepressants, usage of antipsychotics, anxiolytics or benzodiazepines, severity of medication resistance and number of previous admissions. CONCLUSIONS: More patients could benefit from lithium treatment.Declaration of interestNone.

Incidence, prevalence and clinical outcome of anaemia in inflammatory bowel disease: a population-based cohort study.

BACKGROUND: The incidence and short-term outcome of anaemia in inflammatory bowel disease (IBD) are largely unknown. AIM: To determine the incidence, prevalence and clinical outcome of anaemia in terms of resolution of anaemia within 12 months. We also planned to assess risk factors for anaemia in IBD. METHODS: A random sample of 342 patients was obtained from the population-based IBD cohort of Örebro University Hospital, Sweden, consisting of 1405 patients diagnosed between 1963 and 2010. Haemoglobin measurements recorded from 1 January 2011 to 31 December 2013 were extracted from the Clinical Chemistry data system. RESULTS: In Crohn's disease, the incidence rate of anaemia was 19.3 (95% CI: 15.4-23.7) per 100 person-years and the prevalence was 28.7% (CI: 22.0-36.2), compared with 12.9 (CI: 9.8-16.5) and 16.5% (CI: 11.2-22.9) for ulcerative colitis. Crohn's disease was associated with an increased incidence (OR = 1.60; CI: 1.02-2.51) and prevalence of anaemia (OR = 2.04; CI: 1.20-3.46) compared to ulcerative colitis. Stricturing disease phenotype in Crohn's disease (HR = 2.59; CI: 1.00-6.79) and extensive disease in ulcerative colitis (HR = 2.40; CI: 1.10-5.36) were associated with an increased risk of anaemia. Despite a higher probability of receiving specific therapy within 3 months from the diagnosis of anaemia, Crohn's disease patients had a worse outcome in terms of resolution of anaemia within 12 months (56% vs 75%; P = 0.03). CONCLUSIONS: Anaemia is a common manifestation of IBD even beyond the first years after the diagnosis of IBD. Crohn's disease is associated with both an increased risk and a worse outcome.

Rehospitalization and suicide following electroconvulsive therapy for bipolar depression-A population-based register study.

BACKGROUND: Electroconvulsive therapy (ECT) is effective in bipolar depression, but relapse is common. The aim of the study was (i) to identify prognostic factors (ii) and to determine the impact of pharmacological approaches on the risk for rehospitalization or suicide. METHODS: This register study analyzed data from individuals treated with inpatient ECT for bipolar depression. Subjects were identified using the Swedish National Patient Register between 2011 and 2014 and the Swedish National Quality Register for ECT. Other national registers provided data on psychopharmacotherapy, socio-demographic factors, and causes of death. The endpoint was the composite of rehospitalization for any psychiatric disorder, suicide attempt or completed suicide (RoS). Cox regression was used to calculate hazard ratios in univariate and multivariate models. RESULTS: Data from 1255 patients were analyzed. The mean period of follow-up was 346 days. A total of 29%, 41%, and 52% of patients reached RoS at 3, 6, and 12 months post-discharge. A history of multiple psychiatric admissions, lower age, and post-discharge treatment with antipsychotics or benzodiazepines was associated with RoS. LIMITATIONS: Indication bias may have affected the results. CONCLUSIONS: A history of multiple hospital admissions and lower age are key predictors of the composite of rehospitalization or suicide in patients treated with ECT for bipolar depression. Lithium might be effective. By contrast, antipsychotics and benzodiazepines were associated with increased risk, but possibly this finding was influenced by indication bias.

Improvement of postpartum depression and psychosis after electroconvulsive therapy: A population-based study with a matched comparison group.

INTRODUCTION: Electroconvulsive therapy (ECT) is used to treat postpartum depression and psychosis based on clinical experience and small observational studies. AIMS: The primary aim was to test the hypothesis that the response rate to ECT for depression and psychosis is higher during the postpartum period than outside this period. The secondary aim was to identify predictors of a response to ECT during the postpartum period. MATERIALS AND METHODS: Cases with postpartum depression and/or psychosis received ECT within 6 months of delivery. A matched comparison group with depression and/or psychosis (not within the postpartum period) was identified from the Swedish National Quality Register for ECT. The improvement 1 week after ECT was classified according to the Clinical Global Impressions Scale - Improvement scale (CGI-I) as responder (CGI-I score 1-2) or non-responder (CGI-I score 3-7). RESULTS: 185 cases and 185 comparison group subjects were included (46% with psychosis in each groups). More cases (87.0%) than comparison group subjects (73.5%) responded to ECT (p = 0.001). Adjusted binary regression analysis revealed that more severe symptoms prior to treatment were the only statistically significant predictor of response. LIMITATIONS: There was no control group without ECT treatment. CONCLUSION: The response rate of those with postpartum depression and/or psychosis to ECT was high. The response rate of patients with psychosis or depression was higher during the postpartum period than outside it. This study supports the use of ECT for severe forms of postpartum depression and/or psychosis.

Auricular acupuncture for substance use: a randomized controlled trial of effects on anxiety, sleep, drug use and use of addiction treatment services.

BACKGROUND: A common alternative treatment for substance abuse is auricular acupuncture. The aim of the study was to evaluate the short and long-term effect of auricular acupuncture on anxiety, sleep, drug use and addiction treatment utilization in adults with substance abuse. METHOD: Of the patients included, 280 adults with substance abuse and psychiatric comorbidity, 80 were randomly assigned to auricular acupuncture according to the NADA protocol, 80 to auricular acupuncture according to a local protocol (LP), and 120 to relaxation (controls). The primary outcomes anxiety (Beck Anxiety Inventory; BAI) and insomnia (Insomnia Severity Index; ISI) were measured at baseline and at follow-ups 5 weeks and 3 months after the baseline assessment. Secondary outcomes were drug use and addiction service utilization. Complete datasets regarding BAI/ISI were obtained from 37/34 subjects in the NADA group, 28/28 in the LP group and 36/35 controls. Data were analyzed using Chi-square, Analysis of Variance, Kruskal Wallis, Repeated Measures Analysis of Variance, Eta square (η(2)), and Wilcoxon Signed Ranks tests. RESULTS: Participants in NADA, LP and control group improved significantly on the ISI and BAI. There was no significant difference in change over time between the three groups in any of the primary (effect size: BAI, η(2) = 0.03, ISI, η(2) = 0.05) or secondary outcomes. Neither of the two acupuncture treatments resulted in differences in sleep, anxiety or drug use from the control group at 5 weeks or 3 months. CONCLUSION: No evidence was found that acupuncture as delivered in this study is more effective than relaxation for problems with anxiety, sleep or substance use or in reducing the need for further addiction treatment in patients with substance use problems and comorbid psychiatric disorders. The substantial attrition at follow-up is a main limitation of the study. TRIAL REGISTRATION: Clinical Trials NCT02604706 (retrospectively registered).

Patient related functional outcome after total wrist arthroplasty: a single center study of 206 cases.

OBJECTIVES: To prospectively evaluate patient related outcome measures after total wrist arthroplasty (TWA) using four different total wrist implants operated at a single referral center in Sweden. METHODS: 206 primary TWAs were assessed preoperatively and after one year postoperatively with respect to the following eight outcome measures: Range of motion (flexion/extension, radial/ulnar deviation, pronation/supination), hand grip strength, Canadian Occupational Performance Measure (COPM), performance and satisfaction, Visual Analog Scale (VAS) pain scores at rest and in activity. RESULTS: The Maestro TWA had a significantly greater improvement of radial/ulnar deviation than the Biax and Remotion TWAs. COPM performance and satisfaction improved more for the Maestro and Universal 2 prostheses than the Biax and Remotion. CONCLUSIONS: All four TWAs offer reduced VAS-scores and improved COPM-scores with preserved hand grip strength and somewhat improved range of motion. The Maestro TWA performed favorably compared to the Remotion TWA. Implant design may affect patient related outcome.