General Swedish Population Research Articles

Measures of insulin resistance and aortic valve calcification in the general population

Abstract Background Insulin resistance (IR) is a key component in several cardiovascular risk factors. The triglyceride-glucose index (TyG index), triglyceride to high density lipoprotein-cholesterol ratio (TG/HDL-C) and visceral adiposity index (VAI) are easily accessible surrogate measures of IR and have been associated with coronary artery calcification and other cardiovascular diseases. Less is known about IR and aortic valve calcification (AVC). Purpose To investigate the association between different measures of IR (TyG index, TG/HDL-C, VAI) and AVC. Method The Swedish Cardiopulmonary Bioimage Study (SCAPIS) recruited 30 154 randomly selected individuals aged 50 to 64 years from the general population in Sweden between 2013 to 2018. AVC was assessed visually on cardiac computed tomography and categorized as present or absent. TyG index was calculated based on triglyceride and glucose levels, TG/HDL-C ratio using triglyceride and HDL-C levels and VAI using waist circumference, triglyceride and HDL-C levels. The association between IR indexes (as continuous variables by 1 unit increment and categorical variables by quartiles) and AVC was assessed using multivariable logistic regression models. Results In total, measures of IR were available in 29 268 participants of whom 2118 (7%) had AVC. Mean IR index levels were higher in participants with compared to without AVC (TyG index: 8.65 vs. 8.49; p<0.01; TG/HDL-C: 1.11 vs. 0.91; p<0.01 and VAI: 1.73 vs. 1.48; p<0.01). All three indices of IR were associated with AVC in continuous analyses. Subsequently, in multivariable logistic regressions adjusted for age, sex, study site and smoking, there was a stepwise increase in the risk of AVC with increasing quartiles of TyG index, TG/HDL-C and VAI (Figure 1). Conclusion Three different surrogate measures of IR (TyG index, TG/HDL-C and VAI) were all associated with AVC in a middle-aged general population suggesting that they could all be used as risk markers in clinical practice.

Are health inequalities decreasing in Sweden?

Abstract Background The overarching national goal for the Swedish public health policy is to create societal conditions for good and equitable health for all and to eliminate avoidable inequalities within a generation (until 2048). To know whether we are heading towards the public health policy goal, a surveillance system which follows a combination of several inequality measures over time, is needed. Methods All-cause mortality in age 25-64 and life expectancy at age 30, in the total population of Sweden, were used as measures of health and followed 2006-2022. Education (low, middle, high) was used to measure socioeconomic position. Both absolute and relative, and both simple and complex measures were used to analyse inequalities in mortality: rate difference (RD), relative risk (RR), population attributable fraction (PAF) and population attributable number (PIN). Life expectancy was analysed as absolute and relative difference in remaining number of years. Results Life expectancy has increased and mortality in age 25-64 have decreased in the Swedish general population. Comparing those with low and high education, both absolute and relative inequalities have increased, e.g. differences in life expectancy increased to > 6 years among men and almost 7 years among women, and relative inequality in mortality in age 25-64 increased to > 3 times higher risk (RR 3.1; CI 3.0-3.3). Inequality, measured with regard to all groups in the population, showed no noticeable changes over time. Conclusions The results show that Sweden is facing a challenge in achieving the public health goal to eliminate avoidable inequalities by 2048, with regard to life expectancy and mortality in age 25-64. To use a combination of health inequality measures strengthens the surveillance system and gives a more nuanced picture of the development. It enables, in parallel with universal health improving efforts, focus on the groups with the poorest health, where efforts have the greatest effect. Key messages • Sweden is facing a challenge in achieving the public health goal to eliminate avoidable inequalities by 2048, with regard to life expectancy and mortality in age 25–64. • A more nuanced picture of inequalities is crucial to be able to parallel universal health-improving efforts with a focus on the groups with the poorest health, where efforts have the greatest effect.

Eosinophil-Derived Neurotoxin Determinants and Reference Values in a Swedish Middle-Aged General Population.

Eosinophil-Derived Neurotoxin Determinants and Reference Values in a Swedish Middle-Aged General Population.

Paradoxical intention as a treatment for insomnia disorder: study protocol for a mixed-methods pilot trial

IntroductionParadoxical intention (PI) is an insomnia treatment developed in the 1970s, which instructs patients to gently attempt to remain awake while in bed at night with the lights off. Previous...

Optimising Abdominal Aortic Aneurysm Screening of 65 Year Old Men by Exploring Risk Factor Based Targeted Screening Strategies in Light of Declining Prevalence of the Disease

A decline in abdominal aortic aneurysm (AAA) prevalence calls into question the credibility of general population screening of 65 year old men. Selectively targeting high risk individuals among this group could be more effective in preventing death from AAA rupture. This cross sectional study analysed risk factor data in a cohort of 65 year old men screened in the Swedish general population based AAA screening program, with the aim of exploring the effectiveness of hypothetical targeted screening strategies. All men attending AAA screening in four neighbouring counties in Sweden between 2006 and 2010 completed a health questionnaire on smoking habits and medical history. Abdominal aortic aneurysm was defined as measuring ≥ 30 mm. The sensitivity and specificity of different targeted screening strategies, with targeted subpopulations defined by duration of smoking with and without additional risk factors, were explored using receiver operating characteristic (ROC) curves. A total of 16 232 men were screened, with 236 (1.5%) screening detected AAAs. A strategy combining smoking, presence of coronary artery disease (CAD), or both was associated with the mathematically optimal balance between sensitivity and specificity (optimal threshold) in the ROC analysis. The optimal threshold corresponded to targeting men having smoked for thirty years or more, a history of CAD, or both, where 74.0% of all AAAs could be detected by screening 33.0% of the population, compared with general screening. Targeting men that have smoked for ten years or more indicated that 84.0% of all AAAs could be detected by screening 55.0% of the population. A simplified strategy of targeting ever smokers resulted in detecting 85.0% of all AAAs by screening 61.0% of the population. Targeted screening of men at high risk of AAA, focusing on smoking history for inclusion, may be a safe and effective alternative to general population screening.

Association of female sex with cataract surgery in the general population but not in plaque brachytherapy-treated uveal melanoma patients

Cataract is a leading cause of blindness worldwide, necessitating a deeper understanding of its risk factors. We analyzed two cohorts: 1000 individuals from the general Swedish population and 933 patients who received plaque brachytherapy for uveal melanoma. Using Kaplan-Meier and cumulative incidence analyses, as well as Cox and competing risk regressions, we assessed whether there is a relationship between sex and cataract surgery. In the general population, female sex was a significant risk factor for cataract surgery, with a 10-year incidence of 16% compared to 10% for males (subdistribution hazard ratio adjusted for age, 1.35, P < 0.001). In the brachytherapy cohort, female sex was not associated with an increased incidence of cataract surgery, with a 10-year incidence of 25% versus 23% for males (HR 1.08, P = 0.61). Visual acuity at the time of cataract surgery did not significantly differ between sexes in either cohort, suggesting that differences in surgery rates are not due to health-seeking behavior or surgery assessment thresholds. These findings indicate that female sex is associated with a higher risk of cataract surgery in the general population, but not among those treated with plaque brachytherapy for uveal melanoma.

Malignancies After Lung Transplantation.

Lung transplantation (LTx) is a well-known treatment for end-stage lung disease. This study aimed to report the incidence of cancer after LTx and long-term outcome among lung transplant recipients with a pretransplant diagnosis of cancer. Patients who underwent LTx between 1990-2016 were included in the study. Detection of cancer was obtained by cross-checking the study population with the Swedish Cancer Registry and the Cause-of-Death registry. A total of 614 patients were followed for a median of 5.1years. In all, 159 malignancies were diagnosed. The excess risk of cancer or standardized incidence ratio (SIR) following LTx was 5.6-fold compared to the general Swedish population. The most common malignancies were non-melanoma skin cancer (NMSC) (SIR 76.5 (95%CI 61.7-94.8); non-Hodgkin lymphoma (SIR 23.5, 95%CI 14.8-37.2); and lung cancer (SIR 8.89, 95%CI 5.67-13.9). There was no significant difference in overall survival between those with and without a history of cancer before LTx (p = 0.56). In total, 159 malignancies were identified after LTx, which was a 5.6-fold higher relative to the general population. A history of previous cancer yields similar survival in selected recipients, compared to those without cancer prior to LTx.

Overall and cause-specific mortality among patients diagnosed with gastric precancerous lesions in Sweden between 1979 and 2014: an observational cohort study

BackgroundThe Correa’s cascade, encompassing chronic non-atrophic gastritis, atrophic gastritis, intestinal metaplasia, and dysplasia, represents the well-recognized pathway for the development of non-cardia gastric cancer. Population-based studies on all-cause and cause-specific mortalities among patients with gastric lesions in Correa’s cascade are scarce.MethodsWe compiled a cohort of 340 744 eligible patients who had undergone endoscopy with biopsy for non-malignant indications during the period 1979–2011, which was followed up until 2014. Standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) provided estimation of the relative risk, using the general Swedish population as reference. Cox regression model was used to estimate hazard ratios (HRs) of death for internal comparison.ResultsA total of 306 117 patients were included in the final analysis, accumulating 3,049,009 person-years of follow-up. In total 106,625 deaths were observed during the study period. Compared to the general population, excess risks of overall mortality were noted in all subgroups, with SMRs ranging from 1.11 (95% CI 1.08–1.14) for the normal mucosa group to 1.54 (95% CI 1.46–1.62) for the dysplasia group. For cause-specific mortalities, mortality from gastric cancer gradually increased along Correa’s cascade, with excess risk rising from 105% for patients with chronic gastritis to more than 600% for the dysplasia group. These results were confirmed in the comparison with the normal mucosa group. For non-cancer conditions, increased death risks were noted for various diseases compared to the general population, especially among patients with more severe gastric precancerous lesions. But the results were confirmed only for “infectious diseases and parasitic diseases”, “respiratory system diseases”, and “digestive system disease”, when using the normal mucosa group as reference.ConclusionsIncreased mortality from gastric cancer suggests that early recognition and intervention of gastric precancerous lesions probably benefit the patients. Excess mortality due to non-cancer conditions should be interpreted with caution, and future studies are warranted.

Anti-SARS-CoV-2 mRNA vaccination among patients living with SLE in Sweden: Coverage and clinical effectiveness.

To describe the uptake of anti-SARS-CoV2 vaccination in 2021 and investigate vaccine effectiveness in systemic lupus erythematosus (SLE) patients in Sweden. The cumulative incidence of first anti-SARS-CoV2 vaccination was estimated among SLE patients from the Swedish National Patient Register and matched comparators living in Sweden on January 1, 2021. To assess vaccine effectiveness, we included the individuals who received two doses of anti-SARS-CoV2 mRNA vaccines before year 2022, with no COVID-19 diagnosis code before the 2nd vaccine dose. Hospitalization rates with COVID-19 as main diagnosis during the year after second dose were compared between SLE patients and comparators in multivariable-adjusted marginal Cox models, overall and stratified by immunosuppressive treatment received during the year before second vaccine dose. Vaccination uptake was similar between SLE patients and comparators. By December 2021, 9% of both SLE and comparators had not received any vaccine doses. Among 5585 SLE patients and 37,102 comparators, 11 COVID-19 hospitalizations in the SLE group and 20 in the comparators occurred. SLE was associated with a higher risk of COVID-19 hospitalization (HR = 3.47, 95%CI 1.63-7.39). The HR was higher for immunosuppressive-treated SLE (7.03 95%CI 3.00-16.46) than for immunosuppressive-untreated (1.50 95%CI 0.34-6.60). Vaccination of immunosuppressive-untreated SLE patients had similar effectiveness as comparators. Anti-SARS-CoV2 vaccination coverage was similar between SLE patients and the general population in Sweden. Even though the incidence of post-vaccination COVID-19 hospitalization was very low, vaccine effectiveness was diminished in SLE patients compared to the general population and lowest in those treated with immunosuppressants.

Individualized treatment effects of a digital alcohol intervention and their associations with participant characteristics and engagement.

Conditional average treatment effects are often reported in intervention studies, in which assumptions are made regarding how effects are similar across a heterogeneous sample. Nonetheless, differing factors, such as genetics, age, and sex, can impact an intervention's effect on outcomes. The study aimed to estimate the individualized effects of a digital alcohol intervention among individuals looking online to reduce their drinking. We used data from a randomized controlled trial (RCT), including 2129 adults from the Swedish general population. The RCT concerned a text message-based alcohol intervention that sought to engender change through increasing knowledge on how to change and instilling confidence in changing behaviour. Outcomes were total weekly alcohol consumption and monthly heavy episodic drinking. Individualized treatment effects were modelled using baseline characteristics (age, gender, alcohol consumption, and psychosocial variables) and engagement with the intervention content. We found evidence that the effects of the digital alcohol intervention were heterogeneous concerning participants' age, baseline alcohol consumption, confidence, and importance. For heavy episodic drinking, there was evidence that effects were heterogeneous concerning age, sex, and baseline alcohol consumption. Overall, women, older individuals, and heavier drinkers benefitted more from the intervention in terms of effect size. In addition, participants who engaged more with the goal-setting and screening content reported better outcomes. The results highlight how different individuals respond differently to a digital alcohol intervention. This allows insight into who benefits the most and least from the intervention and highlights the potential merit of designing interventions adapted to different individuals' needs.

Incidence of cerebral small vessel disease-related MR markers in the Swedish general population ‘Good Aging in Skåne’(GÅS) study

Background and objectivesCerebral small vessel disease (CSVD) is associated to cognitive decline and dementia. Neuroimaging changes of CSVD are highly prevalent above 80 years. Only few studies report on incidence of CSVD in high age. We have investigated the incidence and prevalence of magnetic resonance imaging (MRI) markers of CSVD and risk factors in the general older population.MethodsAs part of the general population Good Aging in Skåne cohort study (GÅS), 241 persons (mean age 76.3 years) underwent two brain MRI, 3-T scanner with a mean interval of 5.9 years. The incidence of white matter hyperintensities (WMH), lacunar infarction, cerebral atrophies and cerebral microbleeds (CMB) were calculated and the relationship to risk factors analysed by a multivariate regression analysis. Medial temporal lobe atrophy (MTA) was graded according to Scheltens’18 scale and CMB were defined as having > 1 small (0.2–0.5 cm) hypointense lesion.ResultsThe 6-year incidence of CMB, WMH and MTA were, 19%, 17% and 13% respectively, corresponding to 170/1,000 py., 172/1,000 py., and respectively 167/1,000 py. The incidence of CSVD according to the modified STRIVE score was 33%, 169/1,000 py and the prevalence at baseline was 73%. Moderate to high intake of alcohol was related to increased incidence of MTA and higher STRIVE score. Exposure to smoking was related to higher incidence of CMB and higher STRIVE score, adjusted for other known risk factors.ConclusionCSVD is highly prevalent in the general older population and the 6-year incidence of WMH, CMB and MTA ranges from 13 to 19 percent. The modifiable lifestyle factors: smoking, and moderate alcohol intake are related to incident CSVD.

PARENTAL OVER-INDEBTEDNESS AND YOUTH CRIME IN SWEDEN: A NATIONWIDE REGISTER-BASED STUDY

Very little is known about whether a child’s delinquency can be related to a parent’s economic problems in terms of financial indebtedness. This would seem to be an important research gap, not least at a time when the repercussions of the 2008 global financial crisis are still being felt by many people. This study concerned boys and girls born in 2002 who had a parent with a registration date for a debt in the Swedish Enforcement Authority register between 2016 and 2017 (n = 3,284). We determined whether the adolescents had been convicted of a crime during the 3-year period when they were 15 to 17 years old, and compared their records with a sample from the general Swedish population (n = 16,435). Results from logistic regressions show that children who, at age 15 to 17, had a parent with debt problems were approximately one and a half times more likely to be convicted of a crime than children who were unexposed to registered debts of parents (OR = 1.55), irrespective of other well-established criminogenic risk factors observed prior to the parent’s date of registration at the Enforcement Authority. The results provide support for the notion that financial challenges and problems with creditors may be an important proximate risk factor of delinquency.

Establishment of the Patient Acceptable Symptom State (PASS) for the Achilles Tendon Total Rupture Score in a Swedish Population.

As the use of patient-reported outcome measures (PROMs) is increasing in orthopaedic research, there is also a growing need for a standardized interpretation of these scores, such as the Patient Acceptable Symptom State (PASS), defined as the value beyond which patients consider themselves well. The Achilles tendon Total Rupture Score (ATRS) is the only PROM specific for Achilles tendon ruptures. To establish the PASS for the ATRS in a Swedish population. Cross-sectional study; Level of evidence, 3. Patients treated for an acute Achilles tendon rupture at a single institution in Sweden (injured between July 1, 2018, and December 31, 2020) were asked to participate in this study. The patients completed a questionnaire consisting of the ATRS and an anchor question: "How satisfied are you with the result of your treatment?" Receiver operating characteristic curve analysis was performed to calculate the PASS threshold for a positive response to the anchor question. Of 516 eligible patients, 316 (61%) were included. The time from injury to completion of the questionnaire ranged from 12 to 27 months. The PASS threshold for the ATRS was found to be 75. The median ATRS of all patients was 80; 66% of patients reached an ATRS ≥75. Overall, 79% of patients were satisfied with the results of their treatment. The estimated PASS for the ATRS was 75 in the general Swedish population at 12 to 27 months after an acute Achilles tendon rupture.

Demographics and risk for containment surgery in patients with unilateral Legg-Calvé-Perthes disease: a national population-based cohort study of 309 patients from the Swedish Pediatric Orthopedic Quality Register.

It is controversial as to which patients affected by Legg-Calvé-Perthes disease (LCPD) benefit from containment surgery. This population-based study based on data from a national quality registry aims to assess the incidence of LCPD and to explore which factors affect the decision for surgical intervention. This observational study involved 309 patients with unilateral LCPD reported between 2015 and 2023 to the Swedish Pediatric Orthopedic Quality Register (SPOQ). Descriptive statistics and logistic regression models were used for analysis. In 2019, the assessed incidence of LCPD in the Swedish population of 2-12-year-olds was 4.2 per 105. 238 (77%) were boys with a mean age of 6 years. At diagnosis, 55 (30%) were overweight or obese, rising to 17 patients (39%) and 16 patients (40%) at 2-year follow-up for surgically and non-surgically treated groups, respectively. At diagnosis, affected hips had reduced abduction compared with healthy hips, and their abduction remained restricted at the 2-year follow-up. Surgically treated patients had inferior abduction compared with non-surgically treated ones at diagnosis. The adjusted risk for containment surgery increased with age and in the presence of a positive Trendelenburg sign but decreased with greater hip abduction. We found a lower national yearly incidence (4.2 per 105) than previously reported in Swedish studies. A higher proportion of overweight or obese patients compared with the general Swedish population of 4-9-year-olds was identified. Increasing age, positive Trendelenburg sign, and limited hip abduction at diagnosis correlated with increased surgical intervention likelihood.

Long-term prognosis of low high-sensitivity cardiac troponin T in the emergency department compared with the general population

BackgroundLong-term prognosis associated with low–high-sensitivity cardiac troponin T (hs-cTnT) concentrations in patients with chest pain is unknown. We investigated these prognostic implications compared with the general population.MethodsAll first visits to...

Financial Homo Ignorans: Development and validation of a scale to measure individual differences in financial information ignorance

Information ignorance refers to the act of deliberately avoiding, neglecting, or distorting information to uphold a positive self-image and protect our identity-based beliefs. We apply this framework to household finance and develop a concise 12-item questionnaire measuring individuals’ receptiveness to financial information, or the lack thereof – the Financial Homo Ignorans (FHI) Scale. We conduct two studies with samples from the general population in Sweden (total N=2508) and show that the FHI scale has high reliability and distinct from other commonly used individual-difference measures in behavioral finance. We show that individual heterogeneity as assessed by the FHI scale explains a substantial variation in financial behaviors and financial well-being, also when controlling for demographics and financial literacy. These results unequivocally demonstrate the utility of the FHI scale as a valuable instrument for researchers and practitioners in comprehending and addressing the challenges posed by the omnipresence of financial information in today's world.

Five-Year Follow-Up of Health-Related Quality of Life in Differentiated Thyroid Cancer Patients Treated with Total Thyroidectomy and Radioiodine in Sweden: A Nationwide Prospective Cohort Study.

Background: Despite a good prognosis, survivors of differentiated thyroid cancer (DTC) may have reduced health-related quality of life (HRQOL) many years after treatment, and it is unclear how suppression of thyroid-stimulating hormone (TSH) may contribute to HRQOL. This study investigated changes in HRQOL in the 5 years following DTC treatment, the association between HRQOL and TSH suppression, and how HRQOL compares to the general population. Methods: In this nationwide prospective cohort study, 487 patients with DTC were identified between 2012 and 2017 from all Swedish hospitals treating patients with DTC. Patients treated with total thyroidectomy and planned for radioiodine answered the Swedish version of the Short Form-36 Health Survey (SF-36) and a study specific questionnaire at treatment and after 1, 3, and 5 years. Summary measures for physical and mental QOL were derived from the SF-36, and TSH values were collected from patient records. To study changes in HRQOL over time, linear mixed models were fitted on multiply imputed data, with all patients and measurement points included in the model. Results: In total, 351 patients consented to participate in the study. In the 5 years following DTC treatment, physical QOL did not change significantly with time, while mental QOL improved by on average 0.61 (p < 0.001) per year. TSH levels were not predictive of either physical or mental QOL, or their change over time. At 5 years, there was a significant difference in physical and mental QOL compared with the Swedish general population, but effect sizes were small (Cohen's d = 0.29 and -0.21, respectively). The SF-36 domains general health, vitality, social functioning, and mental health were lower at 5 years compared with the general population (difference 8.7-13.3), and these differences were clinically significant. Conclusions: The mental component of HRQOL improves over time following DTC treatment. HRQOL in patients with DTC is not explained by TSH suppression. Although overall differences in physical and mental HRQOL compared with the general population were small 5 years after treatment, several specific psychosocial HRQOL domains were clinically meaningfully reduced. Psychosocial health issues should be screened for during DTC follow-up.

Proteome profiling of home-sampled dried blood spots reveals proteins of SARS-CoV-2 infections

BackgroundSelf-sampling of dried blood spots (DBS) offers new routes to gather valuable health-related information from the general population. Yet, the utility of using deep proteome profiling from home-sampled DBS to obtain clinically relevant insights about SARS-CoV-2 infections remains largely unexplored.MethodsOur study involved 228 individuals from the general Swedish population who used a volumetric DBS sampling device and completed questionnaires at home during spring 2020 and summer 2021. Using multi-analyte COVID-19 serology, we stratified the donors by their response phenotypes, divided them into three study sets, and analyzed 276 proteins by proximity extension assays (PEA). After normalizing the data to account for variances in layman-collected samples, we investigated the association of DBS proteomes with serology and self-reported information.ResultsOur three studies display highly consistent variance of protein levels and share associations of proteins with sex (e.g., MMP3) and age (e.g., GDF-15). Studying seropositive (IgG+) and seronegative (IgG-) donors from the first pandemic wave reveals a network of proteins reflecting immunity, inflammation, coagulation, and stress response. A comparison of the early-infection phase (IgM+IgG-) with the post-infection phase (IgM-IgG+) indicates several proteins from the respiratory system. In DBS from the later pandemic wave, we find that levels of a virus receptor on B-cells differ between seropositive (IgG+) and seronegative (IgG-) donors.ConclusionsProteome analysis of volumetric self-sampled DBS facilitates precise analysis of clinically relevant proteins, including those secreted into the circulation or found on blood cells, augmenting previous COVID-19 reports with clinical blood collections. Our population surveys support the usefulness of DBS, underscoring the role of timing the sample collection to complement clinical and precision health monitoring initiatives.

Urban greenspace for social integration: Which types of greenspace do new-Swedes prefer and why?

Urban greenspace (UGS) is a key public resource offering a broad range of nature-based solutions and is increasingly looked to as a potential arena to promote social integration in Europe’s increasingly multicultural urban and peri-urban areas. However, relatively little research has explored the preferences and perceptions of immigrants in relation to UGS, especially in European contexts. Without such knowledge, planners risk entrenching planning structures that inadvertently result in segregation and environmental injustice. Using survey and participatory mapping methods with 261 immigrants in eight sampled settlements across Sweden, this study explores which types of UGS foreign-born immigrants in Sweden (i.e., new-Swedes) prefer and why. We found that new-Swedes are frequent users of a wide spectrum of UGS types, with the most preferred types including forests, large parks and lakes. The majority of respondents were satisfied with the quality (73%), availability (68%) and accessibility (76%) of UGS in their hometowns. Our regression analysis identified 51 key factors that had a meaningful effect on preferences for different types of UGS. Key factors were distributed relatively evenly across blocks of predictor variables concerning characteristics of UGS, socio-demographic factors, activity preferences, and perceptions. Our results indicate that new-Swedes’ UGS preferences are broadly comparable with those of the general population in Sweden. We found little evidence to suggest that ethnocultural factors played a major role in the preferences of our respondents. Furthermore, our results suggest that nature-connectedness might be an important determinant of new-Swedes’ UGS preferences. Based on these findings, we highlight several opportunities to further develop UGS strategies to support different dimensions of social integration, e.g., using popular UGS as interactive spaces for cultural learning, as a platform for intercultural contacts and for maintaining cultural traditions, and to contribute towards a greater sense of social membership in their new country. A crucial implication of our study is that the use of UGS to support social integration may further contribute to the increasing complexity of the UGS planning and management challenge. This implies the need for a systems perspective in UGS research, policy-making, planning and management to consider UGS as part of an integrated urban social-ecological system and to coordinate measures across sectors.

Development and validation of a multi-dimensional diagnosis-based comorbidity index that improves prediction of death in men with prostate cancer: Nationwide, population-based register study.

Assessment of comorbidity is crucial for confounding adjustment and prediction of mortality in register-based studies, but the commonly used Charlson comorbidity index is not sufficiently predictive. We aimed to develop a multidimensional diagnosis-based comorbidity index (MDCI) that captures comorbidity better than the Charlson Comorbidity index. The index was developed based on 286,688 men free of prostate cancer randomly selected from the Swedish general population, and validated in 54,539 men without and 68,357 men with prostate cancer. All ICD-10 codes from inpatient and outpatient discharges during 10 years prior to the index date were used to define variables indicating frequency of code occurrence, recency, and total duration of related hospital admissions. Penalized Cox regression was used to predict 10-year all-cause mortality. The MDCI predicted risk of death better than the Charlson comorbidity index, with a c-index of 0.756 (95% confidence interval [CI] = 0.751, 0.762) vs 0.688 (95% CI = 0.683, 0.693) in the validation cohort of men without prostate cancer. Men in the lowest vs highest MDCI quartile had distinctively different survival in the validation cohort of men with prostate cancer, with an overall hazard ratio [HR] of 5.08 (95% CI = 4.90, 5.26). This was also consistent within strata of age and Charlson comorbidity index, e.g. HR = 5.90 (95% CI = 4.65, 7.50) in men younger than 60 years with CCI 0. These results indicate that comorbidity assessment in register-based studies can be improved by use of all ICD-10 codes and taking related frequency, recency, and duration of hospital admissions into account.