Recent Past Research Articles

Cohort profile: the Norwegian Neck and Back Registry (NNRR): a medical quality registry for patients with neck and back complaints

PurposeThe Norwegian Neck and Back Registry (Norsk Nakke og Rygg Register, NNRR) was established to improve the quality of diagnosis and treatment in patients with neck and back complaints at...

Cancer incidence in male and female Canadian Armed Forces personnel and Veterans enrolled between 1976 and 2016: a retrospective population-based cohort study

ObjectivesTo describe rates of overall and type-specific primary cancers in Canadian Armed Forces (CAF) personnel and Veterans with a first enrolment in the CAF between 1976 and 2016, with comparisons...

Toward European harmonization of national myasthenia gravis registries: modified Delphi procedure-based expert consensus on collectable data

BackgroundMyasthenia gravis (MG) is a rare autoimmune disorder. Several new treatment concepts have emerged in recent years, but access to these treatments varies due to differing national reimbursement regulations, leading to disparities across Europe. This highlights the need for high-quality data collection by stakeholders to establish MG registries. A European MG registry could help bridge the treatment access gap across different countries, offering critical data to support regulatory decisions, foster international collaborations, and enhance clinical and epidemiological research. Several national MG registries already exist or are in development. To avoid duplication and ensure harmonization in data collection, a modified Delphi procedure was implemented to identify essential data elements for inclusion in national registries.ResultsFollowing a literature review, consultations with patient associations and pharmaceutical companies, and input from multiple European MG experts, 100 data elements were identified. Of these, 62 reached consensus for inclusion and classification, while only 1 item was agreed for exclusion. 30 items failed to reach the ≥ 80% agreement threshold and were excluded. Among the 62 accepted items, 21 were classified as mandatory data elements, 32 optional, and 9 items pertained to the informed consent form.ConclusionsThrough a modified Delphi procedure, consensus was successfully achieved. This consensus-based approach represents a crucial step toward harmonizing MG registries across Europe. The resulting dataset will facilitate the sharing of knowledge and enhance European collaborations. Furthermore, the harmonized data may assist in regulatory or reimbursement decisions regarding novel therapies, as well as address treatment access disparities between European countries.

Subclassification of second-degree tears at delivery: creation and reported outcomes

BackgroundPerineal tears at delivery are common. The current WHO classification system compacts all the varying extents of second-degree tears into one code. Some tears lead to long-term injuries. The correct identification and classification of disease is necessary for correct clinical management as well as for research. Regulatory standards govern care practices. This article describes the process of creating and testing new subclassifications for second-degree tears at delivery.MethodsThe development and implementation of new subclassifications of second-degree perineal tears after delivery in Sweden are described. The new classification was tested for incidence and relevance via the national perineal laceration register (PLR) in 11,203 women with prospectively recorded second degree tears.ResultsSecond-degree tears after delivery are subdivided into four subgroups according to the anovaginal distance and the extent in length and depth of the largest perineal/vaginal tear, which can be combined with uni-or bilateral levator ani avulsion. Women with larger second-degree tears were more likely than women with smaller tears to report complications after eight weeks (OR 1.41 CI 1.21–1.64, p < 0.001) and one year (OR 1.27, CI 1.1–1.46, p < 0.001).ConclusionDetailed subclassifications of perineal and vaginal tears are implemented in the Swedish ICD-10 coding system and Swedish national registers. The outcomes after second-degree tears differ according to their extent, which corroborates the classification rationale. These subclassifications can be used in studies of preventive measures, treatment and patient-reported outcomes and experiences taking into account the extent of second-degree perineal tears at delivery.Trial registrationData regarding women were prospectively collected from the National perineal laceration register (PLR) from January 1, 2021, to December 31, 2022.

Additional Operations Following Sacroiliac Joint Fusions: A Minimum 3-year Follow-up Cohort Study of Patients Operated for Chronic Sacroiliac Joint Pain.

A retrospective analysis of prospectively collected registry data. To examine the subsequent pattern of surgeries and outcome of sacroiliac joint fusions (SJF) in patients previously operated in the lumbar spine as well as those scheduled for primary SJF. Patients with SI joint pain often have a history of previous back surgery, but it is unclear how often patients require back surgery after SI-joint fusion. We obtained data from the national Swedish spine registry on all patients who underwent a SJF between 1998 and 2019 and identified previous and additional operations of any type after a SJF between 1998 and 2022. The EuroQol EQ VAS and the Oswestry disability index (ODI) were registered preoperatively and 1 year after the last undergone surgery. Satisfaction with treatment was assessed 1 year after surgery. Two hundred seventy-nine patients underwent SJF between 1998 and 2019. Ninety-five of 279 patients (34%) underwent primary SJF, and 184 of 279 patients (66%) underwent SJF after spine surgery. Forty-one of 95 patients (43%) underwent additional spine or SI-joint surgery after a primary SJF. The most common additional procedure was contralateral SJF (22 of 41; 54%). The mean EQ-VAS change after primary SJF was 19 points (95% CI 12-26), whereas the corresponding value for SJF after previous lumbar spine surgery was 9 points (95% CI 2-16). The corresponding values for the mean ODI change were -14 points (95% CI -19 to -10) and -9 points (95% CI -14 to -4) respectively. Seventy-three percent (37 of 51) and 54% (34 of 63) were satisfied after SJF after primary versus secondary SJF. After primary SJF most additional surgeries are for contralateral symptoms and 9% required lumbar surgery after their SJF. Two-thirds of the patients with SJF have had their surgery after lumbar surgery.

Economic burden of myasthenia gravis in China: a nationwide registry-based study

Background The long-term treatment of myasthenia gravis (MG) and impaired productivity related to physical decline incur significant economic burdens on affected populations and society. This study aims to evaluate the costs of MG in China from a societal perspective and to identify the cost-driving factors. Methods A web-based survey was conducted on 1020 MG patients recruited through a national registry system in China. Respondents reported their socio-demographic and disease-related information and annual expenses related to MG under direct medical and non-medical costs. Indirect costs were estimated among 268 working respondents based on hours of missed work and their annual income. Generalized linear models were used to identify factors associated with different categories of costs. Results Among all respondents, the median annual direct medical cost was US$2219.0, with a median of $1860.2 contributed by medical costs and a median of $248.2 by non-medical costs. Higher education, unemployment, hospitalization, use of mechanical ventilation, and use of multiple medications were significant driving factors of direct medical and non-medical costs. Among respondents who are at least part-time employed, the indirect costs were generally minimal. Older age, physical burden of disease, and use of multiple medications were significant predictors of higher income loss. Conclusion Population with MG in China reported heavy economic burdens related to medication. Disease severity is a major driving factor of both direct and indirect costs. Targeted policies are needed to alleviate the financial burden of MG on patients and society at large.

The development of an environmental risk score using Swedish National Registers and its impact on subsequent episodes of major depression.

Stressful life events (SLEs) increase the risk for subsequent major depression (MD) episodes. Most prior studies of SLEs utilized questionnaires or interview-based assessments. We sought to develop and evaluate an environmental risk score (ERS) for MD from multiple classes of SLEs obtained from national Swedish registries. We assessed, in the entire adult population of Sweden (n=7,105,712), the occurrence of 52 categories of SLEs derived from registry information for the 6months prior to January 9, 2010 and the risk for MD registration over the subsequent 6months. Weights for our ERS were obtained from a random half of our sample and ERS and its relationship to MD risk was evaluated in the second half. The ERS was robustly related to risk for subsequent MD episodes. Women were more sensitive to the depressogenic effect of the ERS than men. Those with prior episodes of MD had larger absolute increases in MD risk from our ERS than those without previous episodes. Genetic risk for MD was associated with a greater sensitivity to the depressogenic effects of the ERS. A co-sibling control analysis suggested that most, but not all, of the association between ERS and subsequent risk for MD was causal. Valid measures of SLEs that predispose to risk for MD can be assessed from high-quality registry data. While not all event categories (e.g. interpersonal or romantic difficulties) can be assessed, this method avoids problems with accurate dating and recall bias and can be performed in very large samples.

High Mortality Due to Pneumococcal Meningitis in Children With Sickle Cell Disease: A French Multicenter Observational Study From 2001 to 2021

Background: Sickle cell disease (SCD) predisposes children to bacterial infections, particularly invasive pneumococcal disease. Pneumococcal immunization associated with antibiotic prophylaxis reduced the incidence of invasive pneumococcal disease in these patients. However, the risk remains higher than in the general population. Our main objective was to describe the features of pneumococcal meningitis and estimate the case-fatality rate in children with SCD. The secondary objective was to assess serotype distribution and resistance patterns and the proportion of cases related to vaccine failure. Methods: This nationwide multicenter observational study was conducted in France between 2001 and 2021. All cases of pneumococcal meningitis in children with SCD &lt; 18 years old from the French National Registry of Pediatric Pneumococcal Meningitis were included. Results: Of 2145 pneumococcal meningitis, 25 cases (1.2%, 95% CI: 0.8–1.7) occurred in children with SCD [mean age = 4.6 years (±4)], with a high case-fatality rate (28%, n = 7, 95% CI: 10.4–45.6). Nonvaccine serotypes were predominant (n = 15, 65%, 95% CI: 45.8–84.7) over vaccine serotypes (n = 8, 35%, 95% CI: 15.3–54.3). One case of vaccine failure (4%, n = 1/23) and 2 breakthrough cases (n = 2/23, 9%) were observed. Penicillin-non-susceptible Streptococcus pneumoniae strains were identified in 39% (n = 7). Conclusions: The occurrence of pneumococcal meningitis in children with SCD during the pneumococcal conjugate vaccines era was associated with a high case-fatality rate and a predominance of nonvaccine serotypes. The implementation of new serotype-expanded PCV may have a potentially positive impact on this vulnerable population.

Treatment Patterns for Incident Bipolar Disorder Among Nonrefugee Immigrants, Refugees, Second-Generation Immigrants, and Host Population in Sweden.

Deviations in treatment practices toward immigrant groups compared to host populations are common in mental disorders but unknown in bipolar disorder (BD). We aim to close this research gap by analyzing age-stratified use patterns of antidepressants, mood stabilizers, and antipsychotics following an incident diagnosis of BD in Swedish-born, second- and first-generation nonrefugee immigrants, and refugees. Individuals with incident BD between 2006 and 2018 were identified through Swedish national registers. Medication use was followed up until 5 years after diagnosis. Use rates adjusted for sociodemographic and disease-related covariates were computed with generalized estimation equations for each population group. Marginal means with 95% confidence intervals (CIs) and significance tests for main and interaction effects of population group and time points are presented. Furthermore, significant effects of population group, age group, time point, and their interaction were tested by Type III joint test yielding F and p values. Three months after diagnosis, estimated rates of lack of treatment differed significantly between population groups (p < 0.0001) as Swedish-born (17.3%, CI: 16.8-17.7) lacked disease-specific treatment less often than second-generation immigrants (21.1%, 19.7-22.5), first-generation nonrefugee immigrants (23.1%, 21.3-25.0) and refugees (26.8%, 24.4-29.4). Antidepressant monotherapy was estimated in 17.7% (17.2-18.1) of Swedish-born, 16.8% (15.5-18.3) of second-generation immigrants, 17.7% (16.2-19.4) of first-generation nonrefugee immigrants, and was most prevalent in refugees (20.3%, 18.2-22.7; population group p = 0.0002). Mood stabilizers were most dispensed by Swedish-born (51.3%, 50.6-51.9), followed by second-generation (47.9%, 46.1-49.8) and first-generation nonrefugee immigrants (44.5%, 42.4-46.7) and refugees (35.4%, 32.8-38.2; population group p < 0.0001). Use rates of antipsychotics were similar between population groups (p > 0.05) and estimated at 14.1% (13.7-14.6) in Swedish-born, 14.0% (12.8-15.3) in second-generation, 13.0% in first-generation nonrefugee immigrants (12.0-14.6), and 12.9% (11.1-15.0) in refugees. Following up significant interactions of population and age group, lithium use was estimated to be lower in refugees aged 36-65 years (9.9%, 7.9-12.5; population group p = 0.0008) and olanzapine use to be higher in refugees aged 16-35 (9.2%, 7.1-11.9; population group p = 0.0002), respectively, compared to other population groups of the same age. Immigrants, especially refugees, are at risk of not receiving adequate treatment following BD diagnosis, putatively owing to a lack of transcultural competence in healthcare, economic restraints, and community factors. Antidepressant monotherapy should be reduced, while recommended options such as mood stabilizers and specifically lithium should be considered more often.

Value of hospital administrative data linked to national cancer registry records to identify metastatic disease at time of primary diagnosis in colorectal cancer patients: a study using national data in England.

Routinely collected data are increasingly being used for cancer research and health service evaluation. For both purposes, accurately identifying metastatic disease at diagnosis is essential. We developed an approach to identify metastatic disease at time of primary diagnosis according to national hospital administrative data (HAD) in patients identified with colorectal cancer (CRC) in the English national cancer registry (CR). A national cohort of CRC patients diagnosed between 2013 and 2018 in England identified in CR data were linked to HAD. Metastatic disease was assumed to be present at diagnosis according to HAD if at least one of a set of pre-specified diagnostic ICD-10 codes appeared in a record of a hospital admission between one month before and six months after CRC diagnosis date. Of 186,236 patients, 40,421 (21.7%) had metastatic cancer according to HAD, 42,843 (23.0%) according to CR data, 49,827 (26.8%) according to either data source, and 33,437 (18.0%) according to both. Metastatic information was missing in CR data in 14,065 patients and 1,930 of these (13.7%) had metastatic cancer according to HAD. 1-year mortality was 59.3% (95%-CI: 58.8 - 59.8%) in patients with metastatic disease and 7.4% (7.2 - 7.5%) in patients without if HAD and CR data agreed. Mortality fell between these results if HAD and CR data disagreed. High mortality was seen in patients with missing metastatic data in the CR: 74.4% (72.4 - 76.3%) in patients with metastatic disease and 45.2% (44.3-46.1%) in patients without metastatic disease according to HAD. HAD should be linked to CR data to provide more accurate information on metastatic CRC at diagnosis including sites of metastasis. Linkage to HAD increased the number of patients identified with metastatic CRC by 14%, compared to CR data alone. Patients with metastatic disease at diagnosis in either data source had mortality outcomes expected for patients with metastatic cancer. CRC patients with missing metastasis data in CR data are likely to have metastatic disease and linkage to HAD provides important prognostic information.

Outcome after Anterior Cervical Decompression and Fusion - A Nationwide FinSpine Register Study of Independent Predictors of Outcome at 12 Months after Surgery for Degenerative Cervical Spine.

Longitudinal, nationwide register study. To identify independent predictors of clinical outcomes at 12 months for patients undergoing primary anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease (DCSD). ACDF is an established surgical treatment for DCSD. Identifying factors that predict successful surgical outcomes can improve patient selection and inform decision-making. This study utilized data from the Finnish national spine register (FinSpine), covering all Finnish centers which perform ACDF surgery. Patients undergoing primary ACDF surgery for DCSD between June 2016 and February 2024 without prior cervical spine surgery were included (n=5,517). Patients were grouped based on the patient symptom status ("Improved" vs. "Indifferent or worse") at 12 months post-surgery. Predictive factors were identified using classification tree analysis followed by binary logistic regression. At 12 months, 76.8% (n=1799) of patients reported symptom improvement, while 23.2% (n=542) reported that symptoms were indifferent or worse. Loss to follow-up for the outcome variable was 57.6% at 12-months. The Following factors were associated with better outcomes: shorter preoperative pain duration (≤1 year, OR: 1.95, P<0.001), lower preoperative Neck Disability Index (NDI) scores (≤42, OR: 1.37, P=0.012), and non-smoking (OR: 1.37, P=0.030). The initial diagnosis also influenced outcomes: patients treated for herniated discs and nerve root stenosis were more likely to report improvement compared to those with central canal stenosis or myelopathy (P<0.001). Gender, age, BMI, working status, regular use of pain medication, perioperative complications, muscle weakness, levels fused and use of plate versus stand-alone cage were not independently predictive of outcomes. Shorter preoperative pain duration, lower NDI scores, and non-smoking status were significant predictors of good outcomes at 12 months after ACDF surgery for DCSD. These findings can help to guide preoperative patient counselling and enhance evidence-based decision making for treating DCSD.

Self-reported data validity for assessment of systemic and oral health as risk for dependency in old age: a cohort profile of elderly individuals in mid Sweden

PurposeThe Mid Sweden Cohort (MSC) was established to investigate self-perceived oral and general health among two groups of aging individuals in two counties (Örebro and Östergötland) in Sweden. For internal and external data validation, we linked collected data on health status, behavior, sociodemographic circumstances, and dependency with national register data from Statistics Sweden and compared non-respondents and those lost to follow-up to respondents.ParticipantsMSC is based on a longitudinal multiwave study of aging men and women who answered a cross-sectional questionnaire from MSC: (1) the 1992 cohort including participants aged 50 years in 1992 and (2) the 2007 cohort including participants aged 75 years in 2007. After the baseline surveys, data collection was conducted every 5 years, with the latest wave from 2017 included in our validation. Between 1992 and 2017, 8,879 participants were included in cohort 1, while 5,191 individuals were included in cohort 2 between 2007 and 2017.ResultsAfter linking self-reported data with national register-based data and analyzing loss to follow-up and non-response numbers, we found that, besides age, factors such as being male, having immigrant status, lower income and education level, being single, and being in poor health were predictors of non-response and loss to follow-up, aligning with the findings of other studies. Based on our results, we conclude the MSC is reliable for further research, provided the observed bias is taken into account.Future plansUsing the MSC, we aim to analyze self-reported oral health changes as a predictor of dependency in the elderly and track oral health status over time. Furthermore, we plan to link data with register-based clinical oral health records. We also intend to add the 2022 wave data and future waves into the existing dataset.

Predictors of short stature in Israeli children aged 6–7 years: a retrospective cohort study

There are differences in the rates of short stature (WHO height-z score < -2SD) between the various sectors in Israeli children aged 6–7 years, with higher rates in the ultraorthodox Jewish population. We aimed to: (a) Compare the anthropometric data at 0–2 years of age and the obstetric and demographic data of children with short stature at 6–7 years of age with those of children with normal height. (b) Assess risk factors for short stature at the age of 6–7 years. (c) Evaluate the impact of clinical and socioeconomic factors on linear growth from birth to the age of 6–7 years. This was a retrospective cohort study. Anonymized anthropometric data measured at the first grade of school during 2015–2019 were collected from the Ministry of Health records. The participants were stratified into sectors according to the affiliation of their school. Retrospective growth and sociodemographic data were extracted for each child from the national birth registry and Maternal Child Health Clinics files. The cohort included 368,088 children, with a median age of 6.7 years (IQR 6.3,7.0). Short stature was more prevalent in ultraorthodox Jewish boys (3.8%) and girls (3.2%), and least prevalent in Arab boys (0.8%) and girls (0.7%) compared with all other sectors (P < 0.001). The rate of stunting in Bedouin children was similar to that in the general population (1.6%). In a logistic regression model, the variables that predicted short stature at the age of 6–7 years were female sex, longer gestation, lower height z-score at 2 months of age, birth weight < 90th percentile, being in the ultraorthodox Jewish sector, and a smaller change in height z-score until 2 years of age. Growth gaps between different sectors of school-aged Israeli children emerge during the first 2 years of life. The most vulnerable population for stunting is the ultraorthodox population. Public health services, including Maternal Child Health clinics and primary caregivers, should prioritize this group and closely monitor for growth faltering during the first and second years of life.

Haematological malignancies during pregnancy: a systematic review of necessary services in the Australian context.

Haematological malignancies diagnosed during pregnancy are rare, with increasing incidence, presenting unique therapeutic, social and ethical challenges for treating teams, patients and their family. There are no national guidelines regarding appropriate referral pathways, resources and services for the management of these patients. To conduct a systematic review of the literature to identify the multidisciplinary team members required for optimal care of pregnant patients with haematological malignancies. These data will be used to evaluate the capabilities of Australian health networks to provide coordinated care. A systematic review of the literature in MEDLINE and SCOPUS databases was conducted. Eligible studies focused on pregnant Australian patients with haematological malignancies, exploring care models, specialist teams and services utilised. This was then used to generate a map of Australian hospitals that can service this patient demographic. Essential team members include haematologists, maternal-fetal medicine specialists, anaesthetists, midwives, intensive care specialists, psychologists and social workers. Services utilised include haematology, maternity, intensive care, tertiary imaging, operating theatre, pharmacy and perinatal mental health services. Utilising these data, 25 hospitals can manage these patients. This study identified the necessary healthcare practitioners, services and hospitals available that can manage this patient cohort. Future research should focus on determining ideal treatment regimens, timing of therapy throughout gestation, establishing a national patient registry and implementing a cancer care plan and frameworks for best practice care. A centralised referral pathway leveraging telehealth will allow expedient, multidisciplinary action and equity in access to all women across Australia.

Autoimmune Thyroid Diseases and Microscopic Colitis: A Nationwide Matched Case-Control Study in Sweden.

Microscopic colitis (MC), comprising collagenous colitis (CC) and lymphocytic colitis (LC), is an inflammatory condition of the colon, characterized by watery diarrhoea. Previous studies suggest an association between autoimmune thyroid diseases (AITDs) (Hashimoto's thyroiditis and Graves' disease) and MC; however, large-scale histology studies are lacking. We conducted a nationwide, matched case-control study. Patients with biopsy-confirmed MC diagnosed between 2006 and 2017 were identified through the population-based histopathology cohort ESPRESSO. Data on AITDs and covariates were retrieved from Swedish national healthcare registers. Odds ratios (ORs) for MC associated with prior AITDs were estimated using conditional logistic regression. Sibling comparisons were performed to minimize shared genetic and environmental confounding. Among 10,301 MC cases and 48,712 controls, AITDs were significantly more prevalent in MC patients (12.0%) than in controls (7.8%), yielding an adjusted OR of 1.65 (95% confidence interval (CI): 1.54-1.77). This association was attenuated but remained significant in sibling analyses (OR: 1.26; 95%CI: 1.11-1.43) The association was stronger in patients diagnosed with MC before age 50 (OR: 2.41; 95%CI: 2.02-2.89). Subgroup analyses revealed no difference between CC and LC or between sexes. Individuals with AITDs are at an increased risk of developing MC. That this association was robust across various subgroups may be indicative of shared underlying mechanisms. Our findings highlight the importance of being vigilant of gastrointestinal symptoms in patients with AITDs and that patients with persistent symptoms despite achieving euthyroidism should be evaluated for MC.

Adolescents Health Indicators in the Occupied Palestine Territory: Focus on Sexual and Reproductive Health

Abstract Adolescents face many barriers to health services, especially in humanitarian crises. Health indicators and their sources collected during humanitarian crises will help identify gaps in the data to inform policy and practice. This study aims to determine the available indicators of adolescents’ health, and reproductive health, in humanitarian crises. Secondary data analysis. An extensive document search was conducted to collect adolescent health indicators in Palestine. Our search included surveys, reports, assessments done by humanitarian organizations, and peer-reviewed journal articles. Population health surveys were the primary source for adolescent health indicators, specifically the Demographic Health Survey and the Multiple Indicator Cluster Surveys. Two-thirds of the indicators covered the childbearing process (antenatal care, postnatal care, and delivery), 19% were about the knowledge of HIV/AIDs, and 16% were about early marriage. Almost all indicators targeted females, and only 9% targeted both males and females. The Reproductive health indicators mainly were married females aged (15–19) and, nothing was reported for those between 10 and 14 years. Although the available indicators identified are of good quality, they are missing adolescent males and younger groups. Reliable data-based indicators are needed, which can be achieved by creating a national registry for adolescent health indicators or implementing longitudinal surveys to track trends over time..

Disproportionately raised risk of adverse outcomes in patients with COPD and comorbid type 2 diabetes or depression: Swedish register-based cohort study

BackgroundWe aimed to examine if patients with COPD and comorbid type 2 diabetes, or COPD with comorbid depression or anxiety, had disproportionally raised excess risks of subsequent cardiovascular disease and mortality.MethodsThis general population-based cohort study used data from Swedish national registers, with follow-up during 2005–2018. Cox regression estimated risks of cardiovascular disease or mortality, producing hazard ratios (HR) with (95% confidence intervals). Interaction testing quantified disproportionally increased excess risks.ResultsAmong 5,624,306 individuals, 332,549 had a COPD diagnosis. Compared with individuals who did not have COPD or type 2 diabetes, all-cause mortality risk was higher for individuals who had either COPD or type 2 diabetes, with HR 2.68 (2.66–2.69) and 1.70 (1.69–1.71), respectively. Having both conditions produced an HR of 3.72 (3.68–3.76). Among cardiovascular outcomes, the highest risks were found for chronic heart failure: COPD only, HR 2.87 (2.84–2.90); type 2 diabetes only, 1.86 (1.84–1.88); and both, 4.55 (4.46–4.64). Having both COPD and type 2 diabetes was associated with disproportionally higher excess risks than expected from the sum of the individual diseases, except for cerebrovascular disease or ischemic heart disease. For COPD and depression/anxiety, all-cause mortality risk was associated with COPD only, HR 2.74 (2.72–2.76); depression/anxiety only, 2.39 (2.38–2.40); and both 4.72 (4.68–4.75). Chronic heart failure was associated with COPD only, HR 2.74 (2.71–2.78); depression/anxiety only, 1.31 (1.30–1.32); and both, 3.45 (3.40–3.50). This disease combination was associated with disproportionally higher excess risks than expected, except for atrial fibrillation.ConclusionsType 2 diabetes or depression/anxiety in COPD patients were associated with disproportionally excess risks for cardiovascular disease and mortality. It is important for clinicians to be aware of these greater than expected risks, to prevent further cardiovascular morbidity and mortality.

Semen quality and lifespan: a study of 78284 men followed for up to 50years.

Is semen quality associated with the lifespan of men? Men with a total motile sperm count of >120 million could expect to live 2.7 years longer than men with total motile sperm count of >0-5 million. Male infertility and semen quality have been suggested to be markers of morbidity and thus mortality, but the role of underlying disease present at time of semen quality evaluation has not been thoroughly assessed. The aim of this study was to determine the association between semen quality and mortality, and to assess the impact of the health of the man prior to semen quality assessment. The study was based on 78284 men who had their semen quality assessed between 1965 and 2015 at the public semen analysis laboratory in the Copenhagen area, Denmark, due to reported couple infertility. Thus, the included men covered a wide range of semen quality. Semen quality assessment included semen volume, sperm concentration, and the proportion of motile and morphologically normal sperm, from which the total sperm count and the total motile sperm count were calculated. Utilizing the unique Danish national registers, follow-up of the men regarding all-cause mortality was performed with a median follow-up of 23 years (5-95th percentile: 8-45 years) during which 8600 deaths occurred, accounting for 11.0% of the total population. Life expectancy was calculated according to semen quality. Furthermore, the relative differences in mortality were estimated using Cox regression analyses and presented as hazard ratios (HRs) with 95% CIs. A more recent subpopulation of 59657 men delivered semen samples between 1987 and 2015, a period in which information on educational level and diseases prior to semen sampling was available and adjusted for in Cox regression analyses. Men with a total motile count of >120 million could expect to live 80.3 years, compared to 77.6 years among men with total motile count of >0-5 million. In Cox regression analyses, all semen parameters were negatively associated with mortality in a dose-response manner both in the total population and the more recent subpopulation (P-trend for all semen parameters <0.001), and adjustment for educational levels and prior diagnoses did not change the estimates in the latter. Looking at total motile sperm count as an example, men with a total motile sperm count >120 million served as the reference, and the adjusted HRs for all-cause mortality in the more recent subpopulation were: azoospermia: 1.39, >0-5 million: 1.61, >5-10 million: 1.38, >10-40 million: 1.27, >40-80 million: 1.16, >80-120 million: 1.19, P-trend < 0.001. The study was well-powered and included a unique database of results from semen analyses combined with register follow-up. However, we did not have information on health behaviours, and assessment of the health of men prior to semen sampling was limited to diagnoses obtained from the National Patient Register, and only applied to a subpopulation of men. A further limitation is that the group of men with azoospermia represents a heterogeneous group regarding testicular function as they could not be stratified into those having obstructive azoospermia and those having non-obstructive azoospermia. We observed clear negative dose-response associations between all semen parameters and all-cause mortality. The associations were not explained by educational levels or diseases registered at the time of semen evaluation. Thus, some men with impaired semen quality may experience less healthy ageing than men with better semen quality and could benefit from being identified at the time of semen quality evaluation. However, finding relevant biomarkers to identify the subgroups of men at increased risk will be key to initiating relevant prevention strategies. Funding for this study was received from Johan and Hanne Weimann, F. Seedorff's grant (F-24230-01), and the Research Fund of the Capital Region of Denmark (R-153-A6176). None of the funders had any role in the study design, collection, analysis or interpretation of data, writing of the article, or publication decisions. The authors declare they have no competing interests. N/A.

The VASA (historical and environmental evaluation) multitemporal approach for the analysis and assessment of rural landscape transformations

ContextThe study of landscape over different years through the analysis of different sources (cadasters, aerophotos, orthophotos, satellite images) is commonly used in landscape planning and in researches focusing on landscape and land use changes and transformations. Most of these studies, despite the scale and the period analyzed, tend to apply different methodologies, making it difficult to compare results and trends among different landscapes. The aim of the paper is to present the details of the Historical and Environmental Evaluation (VASA) methodology, highlighting the possible applications for landscape changes assessment, by presenting a specific study case as well as its use across different situations. VASA has been developed within the Department of Agricultural, Food, Environmental and Forestry Science and Technology (DAGRI) of the University of Florence to create a standard methodology for the monitoring of landscape transformations, and it was initially applied for the Regional Government of Tuscany (Italy). In 2012, VASA has been chosen by the Italian Ministry of Agriculture, Food Sovereignty and Forests for the assessment of the rural landscapes to be included in the official list of the National Register of Rural Landscapes of Historical Interest often representing the first step for rural landscapes to be proposed for the recognition by international programmes such as the UNESCO WHL (cultural landscapes) and the FAO GIAHS (Globally Important Agricultural Heritage Systems).ResultsThis methodology is based on the photointerpretation of the same area in different years through the Geographic Information Systems (GIS) software, for creating detailed maps and databases of land uses. In addition, various metrics are calculated for evaluating the structure of the landscape mosaic and its transformations.ConclusionsCompared to other multitemporal analyses, the VASA methodology is capable of providing reliable, measurable, and comparable data regarding land use characteristics, land use changes, landscape mosaic structure, main vulnerabilities, landscape trends, linear features presence and changes. This approach can be applied to different geographical contexts and for different aims, allowing to compare the results more accurately in different environmental and cultural situations, or for establishing landscape monitoring systems.

Can the use of a next generation partograph based on WHO's latest intrapartum care recommendations improve neonatal outcomes? (PICRINO) Study protocol for a stepped-wedge cluster randomized trial.

Monitoring labor and childbirth, early recognition, and treatment of complications are critical for preventing adverse birth outcomes. However excessive use of interventions during labor has not been demonstrated to enhance subsequent birth outcomes and may, in fact, pose a risk of harm. The World Health Organization has recently synthesized research from the last decade concerning labor progress and patient-centered care into a new recommendation: the Labour Care Guide (LCG). No trial has, however, compared the LCG with standard care regarding adverse neonatal outcomes or the degree of safety associated with implementing this recommendation within a high-resource setting, and its potential to enhance birth outcomes remains undetermined. This trial aims to evaluate the impacts of using two different guidelines for monitoring labor with respect to neonatal and maternal outcomes, the LCG and the currently used standard care guideline. The hypothesis is that use of the LCG will reduce the number of adverse neonatal outcomes and decrease the rate of intrapartum cesarean sections, as compared with standard care. A national, multicenter, stepped-wedge cluster randomized controlled trial that includes 24 Swedish maternity wards randomized to six clusters. The trial is planned to run during a 22 month period in 2023-2025 and the intervention LCG will be implemented in the six clusters, with three months intervals. The recruited wards will together have approximatively 100,000 births during the study period. Outcome data will be extracted from the Swedish national pregnancy, neonatal, and patient registers. Two safety analyses will be performed at one-third and two-thirds of the way through the trial. The LCG offers a promising new approach, but its effectiveness and safety in high resource settings remain unexplored and must be studied further before LCG can be fully implemented in settings with similar health care. The trial has been registered at www.clinicaltrials.gov: NCT05560802.