Negative Prognostic Impact of Tumor Deposits in Rectal Cancer: A National Study Cohort.

OBJECTIVE: To investigate whether tumor deposits (TDs) in rectal cancer are associated with increased recurrence risk and decreased survival. BACKGROUND: Tumor deposits (TDs) are considered a risk factor for recurrence after colon cancer resection, and the presence of TDs prompts adjuvant chemotherapy. The prognostic relevance of TDs in rectal cancer requires further exploration. METHODS: All patients treated with abdominal resection surgery for rectal cancer in Sweden between 2011 and 2014 were eligible for inclusion in this retrospective cohort study based on prospectively collected data from the Swedish Colorectal Cancer Registry. The primary endpoint was local recurrence or distant metastasis. Secondary outcomes were overall and relative survival. RESULTS: Five thousand four hundred fifty-five patients were identified of which 3769 patients were analyzed after exclusion. TDs were found in 404 (10.7%) patients, including 140 (3.7%) patients with N1c-status. In TD-positive patients, local recurrence and distant metastasis rates at 5 years were 6.3% [95% CI 3.8-8.8%] and 38.9% [95% CI, 33.6-43.5%] compared with 2.7% [95% CI, 2.1-3.3%] and 14.3% [95% CI, 13.1-15.5%] in TD-negative patients. In multivariable regression analysis, the risk of local recurrence and distant metastasis were increased; HR 1.86 [95% CI, 1.09-3.19; P =0.024] and 1.87 [95% CI, 1.52-2.31; P =<0.001], respectively. Overall survival at 5 years was 68.8% [95% CI, 64.4-73.4%] in TD-positive patients and 80.7% [95% CI, 79.4-82.1%] in TD-negative patients. pN1c-patients had similar outcomes regarding local recurrence, distant metastasis, and survival as pN1a-b stage patients. TD-positive pN1a-b patients had significantly worse outcomes whereas TDs did not affect outcomes in pN2a-b patients. CONCLUSION: This study suggests that TDs have a negative impact on the prognosis in rectal cancer. Thus, efforts should be made to diagnose TD-positive rectal cancer patients preoperatively.

How good is the agreement between clinical diagnoses and classification criteria fulfilment in axial spondyloarthritis? Results from the SPARTAKUS cohort.

OBJECTIVES: To study the agreement between clinical axial spondyloarthritis (axSpA) diagnoses and fulfilment of the Assessment of SpondyloArthritis international Society (ASAS) axSpA and modified New York (mNY) classification criteria, and to compare disease/health status between axSpA subtypes. METHOD: Patients with prevalent, clinical axSpA attending a rheumatology clinic were enrolled in a cross-sectional study. Assessments included physical evaluation, laboratory testing, questionnaires, and appropriate imaging, allowing classification. Standard axSpA outcome measures were compared between patients fulfilling mNY/radiographic versus non-radiographic axSpA (r-axSpA/nr-axSpA) criteria. RESULTS: Of 239 consecutively included patients, 141 fulfilled ASAS r-axSpA and/or mNY criteria, while 57 fulfilled nr-axSpA criteria. The agreement between r-axSpA and mNY criteria fulfilment was 94%. The positive predictive value (PPV) of a clinical ankylosing spondylitis (AS) diagnosis for mNY criteria fulfilment was 71%; the PPV of an undifferentiated axSpA (u-axSpA) diagnosis for fulfilment of nr-axSpA criteria was 30% and 40% for mNY criteria. Patients with r-axSpA/AS were older, more often men, and had longer disease duration, more uveitis, and worse spinal mobility than nr-axSpA patients, who had more enthesitis and dactylitis. CONCLUSION: We found an overall good concordance between clinical axSpA diagnoses and classification criteria fulfilment, with 83% fulfilling ASAS axSpA and/or mNY criteria. Regarding axSpA subtypes, the concordance was weaker, and although the ICD-10 code for AS correctly identified patients meeting mNY criteria in 71% of cases, one-third of mNY-positive patients lacked an AS diagnosis. Moreover, clinical u-axSpA diagnoses could not serve as a proxy to identify nr-axSpA, highlighting the importance of thorough classification in research on axSpA subtypes.

Nowcasting (Short-Term Forecasting) of COVID-19 Hospitalizations Using Syndromic Healthcare Data, Sweden, 2020.

We report on local nowcasting (short-term forecasting) of coronavirus disease (COVID-19) hospitalizations based on syndromic (symptom) data recorded in regular healthcare routines in Östergötland County (population ≈465,000), Sweden, early in the pandemic, when broad laboratory testing was unavailable. Daily nowcasts were supplied to the local healthcare management based on analyses of the time lag between telenursing calls with the chief complaints (cough by adult or fever by adult) and COVID-19 hospitalization. The complaint cough by adult showed satisfactory performance (Pearson correlation coefficient r>0.80; mean absolute percentage error <20%) in nowcasting the incidence of daily COVID-19 hospitalizations 14 days in advance until the incidence decreased to <1.5/100,000 population, whereas the corresponding performance for fever by adult was unsatisfactory. Our results support local nowcasting of hospitalizations on the basis of symptom data recorded in routine healthcare during the initial stage of a pandemic.

Infertility, pregnancy loss and assisted reproduction in women with asthma: a population-based cohort study.

STUDY QUESTION: Is the chance of childbirth, and risk of infertility, pregnancy loss and need for assisted reproduction different for women with asthma compared to women without asthma? SUMMARY ANSWER: Women with asthma had comparable chances of giving birth compared to the reference population, however, their risk of both infertility and pregnancy loss, as well their need for medically assisted reproduction, was higher. WHAT IS KNOWN ALREADY: Reproductive dysfunction has been reported among women with asthma, including longer time to pregnancy, increased risk of pregnancy loss and a higher need of medically assisted reproduction, but their risk of clinical infertility is unknown. STUDY DESIGN, SIZE, DURATION: This longitudinal register-based cohort study included all women with a healthcare visit for delivery, infertility, pregnancy loss or induced abortion in the southernmost county in Sweden, over the last 20 years. PARTICIPANTS/MATERIALS, SETTING, METHODS: Using the Skåne Healthcare Register, we identified all women aged 15-45 between 1998 and 2019, who received a diagnosis of asthma before their first reproductive outcome (n = 6445). Chance of childbirth and risk of infertility, pregnancy loss and assisted reproduction were compared to a healthcare seeking population of women without any asthma (n = 200 248), using modified Poisson regressions. MAIN RESULTS AND THE ROLE OF CHANCE: The chance of childbirth was not different between women with asthma versus those without, adjusted risk ratio (aRR) = 1.02, 95% CI: 1.01-1.03. The risk of seeking care for infertility was increased, aRR = 1.29, 95% CI: 1.21-1.39, and women with asthma more often needed assisted reproduction aRR = 1.34 95% CI: 1.18-1.52. The risk of suffering a pregnancy loss was higher, aRR = 1.21, 95% CI: 1.15-1.28, and induced abortions were more common, aRR = 1.15, 95% CI: 1.11-1.20, among women with asthma. LIMITATIONS, REASONS FOR CAUTION: The study was an observational study based on healthcare visits and lacked detailed anthropometric data, thus residual confounding cannot be excluded. Only women with a healthcare visit for a reproductive outcome were included, which cannot be translated into pregnancy intention. A misclassification, presumed to be non-differential, may arise from an incorrect or missing diagnosis of asthma or female infertility, biasing the results towards the null. WIDER IMPLICATIONS OF THE FINDINGS: This study points towards reproductive dysfunction associated with asthma, specifically in regards to the ability to maintain a pregnancy and the risk of needing medically assisted reproduction following clinical infertility, but reassuringly the chance of subsequently giving birth was not lower for these women. STUDY FUNDING/COMPETING INTEREST(S): This article is part of the ReproUnion collaborative study, co-financed by EU Interreg ÖKS, Capital Region of Denmark, Region Skåne and Ferring Pharmaceuticals. The authors have no competing interests to disclose. TRIAL REGISTRATION NUMBER: N/A.

Health care utilization among individuals who die by suicide as compared to the general population: a population-based register study in Sweden.

BACKGROUND: Globally, 700 000 people die every year by suicide. Health care consultation patterns the period before suicide could be one potential way to identify people at risk for suicide. Therefore, this study examines health care patterns up to one year prior to the suicide by age, sex and prior diagnoses and specifically investigates if and how this differs from the general population of Skåne, Sweden. METHODS: This cohort study includes all individuals, aged 15 and older, that died by suicide in Region Skåne, Sweden from 2004 to 2015 (n = 1653). The individuals were identified through the Cause of death register and then linked to the Skåne healthcare register. Health care data was analyzed as proportions consulting different types of health care the month and year preceding the suicide, we also investigated the impact of age, sex and the occurrence of prior psychiatric and pain diagnoses. Additionally, we compared the proportion of consulting care among the suicide victims and the general population of Skåne. RESULTS: In the month before their death, 53% of the suicide victims had any health care consultation, compared with 20% in the general population of Skåne, a given month (p < 0.0001). The corresponding figures for the year prior to suicide was 86% among those who died by suicide, compared to 69% in the general population of Skåne, a given year (p < 0.0001). Women, and those having a documented history of psychiatric diagnosis were more likely to have health care consultations in the month and year preceding suicide (p < 0.001), compared to men and suicide victims without a history of psychiatric disease. Older adults that died by suicide, were less likely to consult psychiatric care compared to the younger suicide victims (p < 0.001). CONCLUSION: A majority of the suicide victims consulted health care in the near time before death and the proportion of seeking health care was significantly higher than in the general population of Skåne and higher among female suicide victims as compared to males. Alternative preventive screening measures should be considered for individuals consulting health care, especially for older people and individuals outside the psychiatric care.

Diagnostic codes of cancer in Skåne healthcare register: a validation study using individual-level data in southern Sweden.

BACKGROUND: The Swedish healthcare is decentralised to 21 regions. Detailed information on all delivered care in the southernmost region, Skåne, is prospectively collected in the Skåne Healthcare Register (SHR). The data is updated daily and hence a good source for epidemiological studies. However, the diagnostic codes used to identify cancer patients in SHR have not yet been validated. METHODS: We conducted a validation study including 1,473,204 residents in Skåne region during 2005-2014, with at least one physical consultation in SHR. Newly diagnosed cancer from the Swedish Cancer Register was considered the 'gold standard' reference. We estimated the positive predictive value (PPV), sensitivity, and area under the curve (AUC) of a cancer diagnosis based on SHR by level of consultation, for any cancer, and for different cancer types. RESULTS: There were 61,693 cancers from the Swedish Cancer Register, and 87,650 cancers from SHR. The PPV of SHR-based diagnosis of any cancer was 63.76% (95% confidence interval (CI): 63.44-64.08%) with a sensitivity of 90.58% (95% CI: 90.35-90.81%). The AUC was 0.94, for any cancer. The measures of PPV, sensitivity and AUC varied across levels of care and were higher in specialized care than in primary care. The highest PPV was observed for specialist inpatient care in SHR (89.17, 95% CI 88.89-89.45%) whereas the highest sensitivity was observed for specialized outpatient care in SHR (86.39, 95%CI 86.12-86.66%). Robust validity was noted among most cancers, except for cancers of soft tissues, central nervous system and eye, and endocrine glands. CONCLUSIONS: Our study supports that SHR is a valid and robust healthcare register for cancer diagnosis, with varying validities across levels of care and cancer types. This makes SHR a useful data source for cancer epidemiological studies, especially because the data covers the entire cancer care pathways without time lags for further linkage.

Physiotherapist-led rehabilitation for patients with chronic musculoskeletal pain: interventions and promising long-term outcomes.

BACKGROUND: There is no consensus on best content, set-up, category of involved healthcare professionals or duration of rehabilitation-programs for patients with chronic musculoskeletal pain, and outcomes show varying results. Individual care regimes for sub-groups of patients have been proposed. AIM: To describe the type of interventions used in a physiotherapist-led, rehabilitation-program for patients with chronic musculoskeletal pain, refractory to preceding treatments. A second aim was to report clinical outcomes at 1-year follow-up after the intervention period. METHODS: All patients referred to physiotherapist within a specialist pain-unit due to being refractory to preceding treatments, and deemed fit to undergo physiotherapy-based, individualized rehabilitation during 2014-2018 were consecutively included and followed-up 1 year after ending the program. The inclusion was based on structured 'clinical reasoning' using the referral, examination and on patient-relevant outcome measures. The individual interventions, recorded according to a manual used when reading the patients' medical records, were described. Primary outcomes were clinical results of perceived pain, disability and overall health at start, discharge and 1 year after discharge. RESULTS: In total, 274 patients (mean age 42 years, 71% women) were included, suffering from chronic, severe, musculoskeletal pain (VAS median 7/10, duration median 2.8 years) and moderate disability. The most frequent interventions were education, sensorimotor training, physical activity-advice and interventions for structures/functions (for example manual techniques, stretching) for a median of nine sessions during five months. Despite refractory to preceding treatments, 45% of the patients rated clinically important improvements on pain, 61% on disability and 50% on overall health at discharge and the figures were similar at 1-year follow-up. CONCLUSIONS: A physiotherapist-led, one-to-one, rehabilitation-program of median nine sessions during five months, combining individualized education, sensorimotor training, physical activity-advice and interventions for structures/functions rendered clinically relevant improvements on pain, disability and overall health in half of the patients at 1-year follow-up. Since the cohort consisted of patients refractory to preceding treatments, we believe that these results warrant further studies to identify the subgroups of patients with chronic musculoskeletal pain that will improve from new, distinctive, resource-effective rehabilitation-programs involving individualized rehabilitation.

Nowcasting (Short-Term Forecasting) of Influenza Epidemics in Local Settings, Sweden, 2008-2019.

The timing of influenza case incidence during epidemics can differ between regions within nations and states. We conducted a prospective 10-year evaluation (January 2008-February 2019) of a local influenza nowcasting (short-term forecasting) method in 3 urban counties in Sweden with independent public health administrations by using routine health information system data. Detection-of-epidemic-start (detection), peak timing, and peak intensity were nowcasted. Detection displayed satisfactory performance in 2 of the 3 counties for all nonpandemic influenza seasons and in 6 of 9 seasons for the third county. Peak-timing prediction showed satisfactory performance from the influenza season 2011-12 onward. Peak-intensity prediction also was satisfactory for influenza seasons in 2 of the counties but poor in 1 county. Local influenza nowcasting was satisfactory for seasonal influenza in 2 of 3 counties. The less satisfactory performance in 1 of the study counties might be attributable to population mixing with a neighboring metropolitan area.

The value of the Skåne Health-care Register: Prospectively collected individual-level data for population-based studies.

Aims: This study aimed to examine the population-based Skåne Health-care Register (SHR) regarding feasibility for scientific research and also strengths and weaknesses. Methods: To analyse the feasibility of the SHR, we performed a bibliographic search for peer-reviewed articles based on SHR data from 2000 to 2018. To analyse strengths and weaknesses, we used original SHR data about coverage and validity. Results: We identified 58 articles based on SHR data, covering different study designs and disorders. Most studies focused on musculoskeletal disorders with a cohort design. The majority of all consultations recorded in the SHR have an assigned diagnosis. However, this differs between the levels of care and between types of consultation. For inpatient care, the proportion of consultations with an assigned diagnosis was close to 100% between 1998 and 2017. The proportion of consultations with an assigned diagnosis was lowest within primary care, although the proportion markedly increased in 2004 when the prerequisite for consultation reimbursement was linked to the requirement for an assigned diagnosis. Limitations are that the SHR does not cover health-care provided within nursing homes and equivalent facilities or treatments received by the population of Skåne outside the region. Conclusions: The SHR may be used as a reliable data source for analyses of clinical changes and improvements. Extended use of the SHR in a research context may highlight important shortcomings within the register and thus serve as a way of indirect quality control. To enhance the use of the SHR further, better harmonisation between registers, within and outside of the region and internationally, is of crucial importance.

Psychiatric disorders and cardiovascular diseases during the diagnostic workup of potential breast cancer: a population-based cohort study in Skåne, Sweden.

BACKGROUND: An increasing number of women are evaluated for potential breast cancer and may experience mental distress during evaluation. We aim to assess the risks of psychiatric disorders and cardiovascular diseases during the diagnostic workup of potential breast cancer. METHODS: All women with a new diagnosis of unspecified lump in breast (N = 15,714), benign tumor or breast cancer in situ (N = 4435), or breast cancer (N = 8512) during 2005-2014 in Skåne, Sweden, were considered as exposed to a breast diagnostic workup. We used multivariable Poisson regression to compare rates of psychiatric disorders and cardiovascular diseases during the 6 weeks before the date of diagnosis of these women with the corresponding rates of women not undergoing such workup. The commonest waiting time for breast cancer patients was 6 weeks during the study period. A within-individual comparison was performed to control for potential unmeasured time-stationary confounders. RESULTS: Compared to the reference, we found a higher rate of psychiatric disorders during the 6 weeks before diagnosis of benign tumor or breast cancer in situ (incidence rate ratio [IRR], 1.3; 95% confidence interval [CI], 1.1 to 1.5) and breast cancer (IRR, 1.4; 95% CI, 1.2 to 1.6). A higher rate was also noted for cardiovascular diseases (IRR, 1.3; 95% CI, 1.1 to 1.6 for benign tumor or breast cancer in situ, and IRR, 1.9; 95% CI, 1.8 to 2.0 for breast cancer). The rate increases for breast cancer were greater comparing a diagnostic workup due to symptoms to a workup due to screening. Little rate increase of neither psychiatric disorders nor cardiovascular diseases was noted during the 6 weeks before the diagnosis of unspecified lump in breast. The within-individual comparison largely confirmed these findings. CONCLUSIONS: Women with benign and malignant breast tumor had increased rates of psychiatric disorders and cardiovascular diseases during the waiting for a final diagnosis.

Secular trends in sickness absence among Swedish patients with ankylosing spondylitis and psoriatic arthritis.

The aim was to investigate whether secular trends in sickness absence (SA) were present in patients with ankylosing spondylitis (AS) and psoriatic arthritis (PsA) receiving their diagnosis between 2002 and 2011. A repeated cross-sectional study design was used. Patients were identified in the Skåne Healthcare Register (SHR). A washout period of 18 months was applied. The general population seeking health care was used as a reference cohort. SA data from 2003 to 2012 were obtained from the Swedish Social Insurance Agency and converted into net days of SA per year. Within diagnosis and sex, the average number of net days of SA during the calendar year following diagnosis was calculated and plotted against calendar year together with the corresponding SA of the age-standardized reference population. Linear regression on aggregated data, within diagnosis and sex, was applied to formally investigate differences in secular trends among patients and referents. There were 3173 patients and 992,502 referents. Among men diagnosed with AS, the average amount of SA declined by 8.1 net days per year in patients as compared with 2.4 in the referents (p = 0.01). Among PsA patients, the average amount of SA declined by 11.7 net days per year in women as compared with 2.7 in the referents (p < 0.001) and by 7.6 net days per year in men as compared with 1.9 in the referents (p < 0.001). Secular trends of declining SA were present among AS and PsA patients. Trends were also present among the referents, although not at all of the same magnitude.

Work disability in non-radiographic axial spondyloarthritis patients before and after start of anti-TNF therapy: a population-based regional cohort study from southern Sweden.

Objective: The aim was to assess work-loss days before and after commencement of anti-TNF treatment in patients with non-radiographic axial spondylarthritis (nr-axSpA). Methods: Bionaïve nr-axSpA patients (n = 75), aged 17-62 years, fulfilling the Assessment of SpondyloArthritis international Society criteria for axial spondyloarthritis and starting anti-TNF treatment during 2004-11, were retrieved from the observational South Swedish Arthritis Treatment Group study. Patient information was linked to Swedish Social Insurance Agency data on sick leave and disability pension from 1 year before to 2 years after anti-TNF initiation. Matched population references were included for comparison and to adjust for secular trends. Results: The nr-axSpA patients had a median age of 35 years and disease duration of 6 years at the start of treatment. During the 2 years after anti-TNF initiation, mean work-loss days (including both sick leave and disability pension) in the nr-axSpA group decreased significantly from 3.4 to 1.9 times more than among the population references. The effect was seen on sick leave, whereas disability pension levels remained similar in both groups throughout. Conclusion: Anti-TNF therapy in nr-axSpA was associated with a significant and sustained improvement of work disability over 2 years. However, the proportion of work-loss days remained almost twice as high as in the general population at the end of follow-up.

International comparisons of the consultation prevalence of musculoskeletal conditions using population-based healthcare data from England and Sweden.

OBJECTIVES: To assess the consultation prevalence of musculoskeletal (MSK) conditions as presented in different healthcare systems, and to determine the feasibility of comparing prevalence figures between nations. METHODS: The settings were an English regional database (Consultations in Primary Care Archive (CiPCA)) and the Swedish Skåne County Health Care Register. Case definitions, data extraction and analysis procedures were harmonised. The number of people consulting per 10 000 registered population in primary care, and in primary or secondary care, in the year 2010 (annual consultation prevalence) were determined for doctor-diagnosed osteoarthritis (OA), rheumatoid arthritis (RA), low back pain, and spondyloarthritis including psoriatic arthritis and ankylosing spondylitis (AS). Seven-year period consultation prevalences were also determined. RESULTS: Combining primary and secondary care, annual consultation prevalences of any MSK condition (2143 vs 1610/10 000) and low back pain (587 vs 294/10 000) were higher in England than in Sweden, but higher for RA, spondyloarthritis and psoriatic arthritis in Sweden. Annual primary care prevalence figures for OA (176 vs 196/10 000), RA (25 vs 26/10 000), spondyloarthritis (both 8/10 000) and psoriatic arthritis (5 vs 3/10 000) were similar between England and Sweden. AS was rarely recorded in Swedish primary care. These patterns were also observed for 7-year period consultation prevalences. CONCLUSIONS: A rigorous methodological approach allowed feasible comparison of MSK consultation prevalence between England and Sweden. Differences in prevalence of inflammatory and unspecific pain conditions may be partially explained by known variations in healthcare systems and recording practice. Routine healthcare data offers potential for investigating variations in occurrence and outcome of MSK conditions between nations.

Socioeconomic status and the risk for being diagnosed with spondyloarthritis and chronic pain: a nested case-control study.

Socioeconomic status could potentially impact on which type of rheumatic diagnosis a patient receives. We determined whether different socioeconomic status is a risk factor for being diagnosed with spondyloarthritis (SpA) or chronic pain. In a nested case-control study, we identified two sets of adult cases diagnosed with (i) SpA (n = 1,194) and (ii) chronic pain (n = 3,730) during 2010-2012 in Skåne region, Sweden. We randomly sampled controls matched for age and sex. Level of education, marital status, and income were identified in national registers 4 years before inclusion. We also studied health-care utilization, prescribed pharmaceuticals, and work status. We used conditional logistic regressions and included socioeconomic variables and geographic area in the models. Low (odds ratio [OR] 1.69 95 % CI 1.50-1.91) or moderate education (OR 1.43 95 % CI 1.30-1.57), and low (OR 1.40 95 % CI 1.25-1.57) or moderate income (OR 1.24 95 % CI 1.10-1.38) were associated with a chronic pain diagnosis. For a SpA diagnosis, moderate income (OR 1.25 95 % CI 1.04-1.50) was the only significant factor identified. Both case groups had a larger proportion that did not work (P < 0.001), used more health care (P < 0.001), and were more frequently prescribed NSAIDs (P < 0.001) 4 years before diagnosis than controls. We confirmed that lower levels of education and income are associated with a chronic pain diagnosis. This association may reflect a true higher incidence of chronic pain and/or increased consultation propensity for such pain in people with socioeconomic status. We found no such association for SpA.

Tattoos as a risk factor for malignant lymphoma: a population-based case-control study.

Background: The popularity of tattoos has increased dramatically over the last few decades. Tattoo ink often contains carcinogenic chemicals, e.g., primary aromatic amines, polycyclic aromatic hydrocarbons, and metals. The tattooing process invokes an immunologic response that causes translocation of tattoo ink from the injection site. Deposition of tattoo pigment in lymph nodes has been confirmed but the long-term health effects remain unexplored. We used Swedish National Authority Registers with full population coverage to investigate the association between tattoo exposure and overall malignant lymphoma as well as lymphoma subtypes. Methods: We performed a case-control study where we identified all incident cases of malignant lymphoma diagnosed between 2007 and 2017 in individuals aged 20-60 years in the Swedish National Cancer Register. Three random age- and sex-matched controls per case were sampled from the Total Population Register using incidence density sampling. We assessed exposure through a questionnaire in 2021, and data on potential confounders were retrieved from registers. We used multivariable logistic regression to estimate the incidence rate ratio (IRR) of malignant lymphoma in tattooed individuals. Findings: The study population consisted of 11,905 individuals, and the response rate was 54% among cases (n = 1398) and 47% among controls (n = 4193). The tattoo prevalence was 21% among cases and 18% among controls. Tattooed individuals had a higher adjusted risk of overall lymphoma (IRR = 1.21; 95% CI 0.99-1.48). The risk of lymphoma was highest in individuals with less than two years between their first tattoo and the index year (IRR = 1.81; 95% CI 1.03-3.20). The risk decreased with intermediate exposure duration (three to ten years) but increased again in individuals who received their first tattoo ≥11 years before the index year (IRR = 1.19; 95% CI 0.94-1.50). We found no evidence of increasing risk with a larger area of total tattooed body surface. The risk associated with tattoo exposure seemed to be highest for diffuse large B-cell lymphoma (IRR 1.30; 95% CI 0.99-1.71) and follicular lymphoma (IRR 1.29; 95% CI 0.92-1.82). Interpretation: Our findings suggested that tattoo exposure was associated with an increased risk of malignant lymphoma. More epidemiologic research is urgently needed to establish causality. Funding: The Swedish Research Council for Health, Working Life and Welfare.

Influence of the COVID-19 pandemic on births and induced abortions in Southern Sweden: a register-based study.

BACKGROUND: Pandemics are linked with declining birth rates, but little is known about how the COVID-19 pandemic has influenced childbearing decisions. We aimed to investigate the associations between the COVID-19 pandemic and reproductive decisions, specifically to identify potential changes in the frequency of deliveries and induced abortions in Skåne, Sweden. METHODS: Using the Skåne Healthcare Register, we identified women aged 15-45 years who had at least one pregnancy-related care visit registered between 1 January 2013 and 11 November 11 2021. Deliveries and induced abortions were identified, and changes in weekly delivery and abortion counts were assessed using an interrupted time series design. Relative risks (RRs) and 95% confidence intervals (CIs) were estimated from a Poisson regression model. RESULTS: During the study period we identified 129 131 deliveries and 38 591 abortions. Compared with the counterfactual (exposed interval assuming COVID-19 had not occurred), pandemic exposure was associated with fewer deliveries (RR 0.93; 95% CI 0.89 to 0.98). For abortions, pandemic exposure appeared to be associated with fewer abortions (RR 0.95; 95% CI 0.90 to 1.00); however, age-related differences were found. Among women aged 25 years and over, pandemic exposure was more strongly associated with fewer abortions. Contrastingly, among women aged under 25 years, abortions appeared to increase. CONCLUSIONS: The COVID-19 pandemic seemed to have contributed to a decline in births in Southern Sweden. During the same period, abortions declined in women in the older age range, but contrastingly increased among younger women.

Promoting work ability in a structured national rehabilitation program in patients with musculoskeletal disorders: outcomes and predictors in a prospective cohort study.

BACKGROUND: Musculoskeletal disorders (MSDs) are a major reason for impaired work productivity and sick leave. In 2009, a national rehabilitation program was introduced in Sweden to promote work ability, and patients with MSDs were offered multimodal rehabilitation. The aim of this study was to analyse the effect of this program on health related quality of life, function, sick leave and work ability. METHODS: We conducted a prospective, observational cohort study including 406 patients with MSDs attending multimodal rehabilitation. Changes over time and differences between groups were analysed concerning function, health related quality of life, work ability and sick leave. Regression analyses were used to study the outcome variables health related quality of life (measured with EQ-5D), and sick leave. RESULTS: Functional ability and health related quality of life improved after rehabilitation. Patients with no sick leave/disability pension the year before rehabilitation, improved health related quality of life more than patients with sick leave/disability pension the year before rehabilitation (p = 0.044). During a period of -/+ four months from rehabilitation start, patients with EQ-5D ≥ 0.5 at rehabilitation start, reduced their net sick leave days with 0.5 days and patients with EQ-5D <0.5 at rehabilitation start, increased net sick leave days with 1.5 days (p = 0.019). Factors negatively associated with sick leave at follow-up were earlier episodes of sick leave/disability pension, problems with exercise tolerance functions and mobility after rehabilitation. Higher age was associated with not being on sick leave at follow-up and reaching an EQ-5D ≥ 0.5 at follow-up. Severe pain after rehabilitation, problems with exercise tolerance functions, born outside of Sweden and full-time sick leave/disability pension the year before rehabilitation were all associated with an EQ-5D level < 0.5 at follow-up. CONCLUSIONS: Patients with MSDs participating in a national work promoting rehabilitation program significantly improved their health related quality of life and functional ability, especially those with no sick leave. This shows that vocational rehabilitation programs in a primary health care setting are effective. The findings of this study can also be valuable for more appropriate patient selection for rehabilitation programs for MSDs.