Standardized Incidence Rate Ratio Research Articles

Risk of malignant disease in 1-year sepsis survivors, a registry-based nationwide follow-up study

BackgroundCancer and sepsis share risk factors, and sepsis patients may have impaired immune response and increased morbidity long after intensive care. This study aimed to assess whether sepsis survivors are at increased risk for cancer. Our objective was to assess the incidence of new cancer in 1-year sepsis survivors and test the hypothesis that it is higher than that of the general population.MethodsWe obtained data on ICU admissions of adult patients from Swedish Intensive care registry (SICR) from 2005 to 2017. We included patients with an explicit ICD-10 code for sepsis for the primary ICU admission. We obtained data on cancer diagnoses (2001–2018), death (2005–2018) and emigration (2005–2018) from Cancer and Cause of death and National Patient Registry databases of the National Board of Health and Welfare; age and sex-specific cancer incidence rates in Sweden from NORDCAN registry from 2006 to 2018. One-year survivors formed the final cohort, that was followed for new cancer diagnoses until death, emigration, or end of 2018, whichever came first. The main outcome measure was standardized incidence rate ratio (SIR) to compare the incidence of cancer in 1-year sepsis survivors to that in the general population (NORDCAN). We also performed several sensitivity analyses.ResultsIn a cohort of 18,550 1-year survivors, 75,427 person years accumulated during a median follow-up (FU) of 3.36 years (IQR 1.72–5.86), 6366 (34.3%) patients died, and 1625 (8.8%) patients were diagnosed with a new cancer after a median FU of 2.51 (IQR 1.09–4.48) years. The incidence ratio of any new cancer over the whole FU was 1.31 (95% CI 1.23–1.40) for men and 1.74 (95% CI 1.61–1.88) for women. The difference in incidence rates persisted in several sensitivity analyses. The SIRs were highest in cancers of gastrointestinal tract, genital organs, and skin.Conclusion and relevanceCompared to general population, incidence of cancer is increased in 1-year sepsis survivors. Variation in the findings depending on follow-up time suggests that factors other than sepsis alone are involved. Surveillance for malignant disease may be warranted in sepsis survivors.Graphical abstract

Can deep learning on retinal images augment known risk factors for cardiovascular disease prediction in diabetes? A prospective cohort study from the national screening programme in Scotland

AimsThis study’s objective was to evaluate whether deep learning (DL) on retinal photographs from a diabetic retinopathy screening programme improve prediction of incident cardiovascular disease (CVD). MethodsDL models were trained to jointly predict future CVD risk and CVD risk factors and used to output a DL score. Poisson regression models including clinical risk factors with and without a DL score were fitted to study cohorts with 2,072 and 38,730 incident CVD events in type 1 (T1DM) and type 2 diabetes (T2DM) respectively. ResultsDL scores were independently associated with incident CVD with adjusted standardised incidence rate ratios of 1.14 (P = 3 × 10−04 95 % CI (1.06, 1.23)) and 1.16 (P = 4 × 10−33 95 % CI (1.13, 1.18)) in T1DM and T2DM cohorts respectively. The differences in predictive performance between models with and without a DL score were statistically significant (differences in test log-likelihood 6.7 and 51.1 natural log units) but the increments in C-statistics from 0.820 to 0.822 and from 0.709 to 0.711 for T1DM and T2DM respectively, were small. ConclusionsThese results show that in people with diabetes, retinal photographs contain information on future CVD risk. However for this to contribute appreciably to clinical prediction of CVD further approaches, including exploitation of serial images, need to be evaluated.

Contextualising adverse events of special interest to characterise the baseline incidence rates in 24 million patients with COVID-19 across 26 databases: a multinational retrospective cohort study

Adverse events of special interest (AESIs) were pre-specified to be monitored for the COVID-19 vaccines. Some AESIs are not only associated with the vaccines, but with COVID-19. Our aim was to characterise the incidence rates of AESIs following SARS-CoV-2 infection in patients and compare these to historical rates in the general population. A multi-national cohort study with data from primary care, electronic health records, and insurance claims mapped to a common data model. This study's evidence was collected between Jan 1, 2017 and the conclusion of each database (which ranged from Jul 2020 to May 2022). The 16 pre-specified prevalent AESIs were: acute myocardial infarction, anaphylaxis, appendicitis, Bell's palsy, deep vein thrombosis, disseminated intravascular coagulation, encephalomyelitis, Guillain- Barré syndrome, haemorrhagic stroke, non-haemorrhagic stroke, immune thrombocytopenia, myocarditis/pericarditis, narcolepsy, pulmonary embolism, transverse myelitis, and thrombosis with thrombocytopenia. Age-sex standardised incidence rate ratios (SIR) were estimated to compare post-COVID-19 to pre-pandemic rates in each of the databases. Substantial heterogeneity by age was seen for AESI rates, with some clearly increasing with age but others following the opposite trend. Similarly, differences were also observed across databases for same health outcome and age-sex strata. All studied AESIs appeared consistently more common in the post-COVID-19 compared to the historical cohorts, with related meta-analytic SIRs ranging from 1.32 (1.05 to 1.66) for narcolepsy to 11.70 (10.10 to 13.70) for pulmonary embolism. Our findings suggest all AESIs are more common after COVID-19 than in the general population. Thromboembolic events were particularly common, and over 10-fold more so. More research is needed to contextualise post-COVID-19 complications in the longer term. None.

Dva roky pandemie covidu-19 v populaci českých pacientů s idiopatickými střevními záněty léčenými bio­logickou léčbou – zkušenosti terciárního IBD centra

Summary: Background: Inflammatory bowel disease (IBD) may be associated with a more severe course of infections and a different response to vaccination, especially in complicated IBD course and in association with immune-modifying IBD treatment. The aim of this study was to describe COVID-19 pandemic during years 2020–2022 in IBD patients with long-term bio­logical therapy. Methods: A retrospective analysis of SARS-CoV-2 infection incidence in the population of 1,177 IBD (Crohn’s disease or ulcerative colitis) patients with long-term bio­logical therapy (IBD cohort) was performed. The incidence rate, crude incidence rate and standardized incidence ratio of COVID-19 in the IBD cohort, the odds ratio of infection depending on the type of bio­logic therapy administered, the dynamics of COVID-19 incidence depending on the predominant SARS-CoV-2 variant in the population and the current vaccination coverage of the IBD cohort were calculated. Results: From January 2020 to April 2022, 548 confirmed cases of COVID-19 (46.6%) were reported in the IBD cohort, with 39% share of PCR positivity in vaccinated individuals and with 95% occurrence of infection in unvaccinated part of the IBD cohort. Standardized incidence rate ratio of COVID-19 was 27% higher in the IBD cohort compared to the general Czech population. The dynamics of the development of the number of positive cases of COVID-19 in the IBD cohort was identical to the situation in the entire country. A higher odds ratio of the chances of infection was demonstrated in patients treated with tumor necrosis factor inhibitors, but not in patients treated with anti-integrins or monoclonal antibodies against interleukins. In the IBD cohort, 85.2% of patients were properly vaccinated, which was significantly more than the vaccination rate of the entire Czech population. Discussion and conclusion: During the two pandemic years, the incidence of COVID-19 in patients with severe IBD and long-term bio­logical treatment was higher compared to the general Czech population, despite the favorable vaccination coverage of this high-risk patients’ group. A higher risk was associated with tumor necrosis factor inhibitor therapy. Key words: inflammatory bowel disease – Crohn’s disease – ulcerative colitis – COVID-19 – SARS-CoV-2 – vaccination – bio­logical therapy

Filling the gaps in the research about second primary malignancies after bladder cancer: Focus on race and histology.

Previous research has shown that bladder cancer has one of the highest incidences of developing a second primary malignancy. So, we designed this study to further examine this risk in light of race and histology. Using the surveillance, epidemiology, and end results (SEER) 18 registry, we retrospectively screened patients who had been diagnosed with bladder cancer between 2000 and 2018. We then tracked these survivors until a second primary cancer diagnosis, the conclusion of the trial, or their deaths. In addition to doing a competing risk analysis, we derived standardized incidence ratios (SIRs) and incidence rate ratios (IRRs) for SPMs by race and histology. A total of 162,335 patients with bladder cancer were included, and during follow-ups, a second primary cancer diagnosis was made in 31,746 of these patients. When the data were stratified by race, SIRs and IRRs for SPMs showed a significant difference: Asian/Pacific Islanders (APIs) had a more pronounced increase in SPMs (SIR: 2.15; p 0.05) than White and Black individuals who had an SIRs of 1.69 and 1.94, respectively; p 0.05. In terms of histology, the epithelial type was associated with an increase in SPMs across all three races, but more so in APIs (IRR: 3.51; 95% CI: 2.11-5.85; p 0.001). We found that race had an impact on both the type and risk of SPMs. Additionally, the likelihood of an SPM increases with the length of time between the two malignancies and the stage of the index malignancy.

Behavioral economics indices predict alcohol use and consequences in young men at 4-year follow-up.

The alcohol purchase task (APT), which presents a scenario and asks participants how many drinks they would purchase and consume at different prices, generates indices of alcohol reward value that have shown robust associations with alcohol-related outcomes in numerous studies. The aim was to test its prospective validity at 4-year follow-up. Prospective cohort study. General population sample of young Swiss men. A total of 4594 Swiss young men (median age = 21, 25th - 75th quartiles = 20.5 - 21.5) completed baseline questionnaires; among those, 4214 (91.7%) were successfully followed-up 4years later. Alcohol reward value parameters (i.e. intensity, the planned consumption when drinks are free; breakpoint, the price at which consumption would be suppressed; Omax , the maximum alcohol expenditure; Pmax , the price associated with Omax ; and elasticity, the relative change in alcohol consumption as a function of the relative change in price) were derived from the APT at baseline and used to predict self-reported weekly drinking amount, monthly binge drinking, alcohol-related consequences and DSM-5 alcohol use disorder criteria. Regression analyses, adjusting for the baseline alcohol measure, age, linguistic region and socio-economic indicators showed that intensity, breakpoint, Omax and elasticity significantly predicted all tested outcomes in the expected direction (e.g. standardized incidence rate ratio [95% confidence interval] = 1.11 [1.07-1.15], 1.07 [1.03-1.10], 1.08 [1.04-1.11], and 0.92 [0.89-0.95], respectively, for weekly drinking amount, all P < 0.001). Pmax did not significantly predict any outcomes. Non-adjusted correlations, baseline adjusted regression and ancillary analyses using (1) latent alcohol variables, (2) multiple imputation for missing data and (3) replications in training and testing subsamples to evaluate predictive accuracy provided consistent findings. The alcohol purchase task demand curve measures of alcohol reward value are useful in characterizing alcohol-related risk in young men and have long-term predictive utility.

Autoimmune conditions following mRNA (BNT162b2) and inactivated (CoronaVac) COVID-19 vaccination: A descriptive cohort study among 1.1 million vaccinated people in Hong Kong

BackgroundConcerns regarding the autoimmune safety of COVID-19 vaccines may negatively impact vaccine uptake. We aimed to describe the incidence of autoimmune conditions following BNT162b2 and CoronaVac vaccination and compare these with age-standardized incidence rates in non-vaccinated individuals. MethodsThis is a descriptive cohort study conducted in public healthcare service settings. Territory-wide longitudinal electronic medical records of Hong Kong Hospital Authority users (≥16 years) were linked with COVID-19 vaccination records between February 23, 2021 and June 30, 2021. We classified participants into first/second dose BNT162b2 groups, first/second dose CoronaVac groups and non-vaccinated individuals for incidence comparison. The study outcomes include hospitalized autoimmune diseases (16 types of immune-mediated diseases across six body systems) within 28 days after first and second dose of vaccination. Age-standardized incidence rate ratios (IRRs) with exact 95% confidence intervals (CIs) were estimated using Poisson distribution. ResultsThis study included around 3.9 million Hong Kong residents, of which 1,122,793 received at least one dose of vaccine (BNT162b2: 579,998; CoronaVac: 542,795), and 721,588 completed two doses (BNT162b2: 388,881; CoronaVac: 332,707). Within 28 days following vaccination, cumulative incidences for all autoimmune conditions were below 9 per 100,000 persons, for both vaccines and both doses. None of the age-standardized incidence rates were significantly higher than the non-vaccinated individuals, except for an observed increased incidence of hypersomnia following the first dose of BNT162b2 (standardized IRR: 1.47; 95% CI: 1.10–1.94). ConclusionsAutoimmune conditions requiring hospital care are rare following mRNA and inactivated COVID-19 vaccination with similar incidence to non-vaccinated individuals. The association between first dose BNT162b2 vaccination and immune-related sleeping disorders requires further research. Population-based robust safety surveillance is essential to detect rare and unexpected vaccine safety events.

Smoking and risk of fractures requiring hospitalization in haemodialysis patients: a nationwide cohort study in Japan.

Smoking is a well-established lifestyle risk factor for fractures in the general population, but evidence specific to haemodialysis populations is lacking. This nationwide cohort study used data from the Japanese Society for Dialysis Therapy Renal Data Registry to examine the association between smoking status and fractures. A total of 154 077 patients (64.2% men; mean age 68 years) aged≥20 years undergoing maintenance haemodialysis thrice weekly at the end of 2016 were followed for 1 year. Among these, 19 004 (12.3%) patients were current smokers. Standardized incidence rate ratios of hospitalization due to any fracture were calculated and analysed by multivariable logistic regression analysis, controlling for potential confounders. Propensity score (PS) matching and subgroup analyses were also performed as sensitivity analyses. During the 1-year follow-up period, 3337 fractures requiring hospitalization (1201 hip, 479 vertebral and 1657 other fractures) occurred in 3291 patients. The age- and sex-standardized incidence ratio for current smokers was 1.24 (95% confidence interval 1.12-1.39) relative to non-smokers. Standardized incidence ratios were similar after stratification by age group and sex. Multivariable logistic regression analysis revealed a 1.25-fold higher risk of any fracture requiring hospitalization (95% confidence interval 1.10-1.42) in current smokers relative to non-smokers in a fully adjusted model. PS matching showed similar results (odds ratio 1.25; 95% confidence interval 1.05-1.48). Subgroup analyses for baseline covariates revealed no significant interactions. Smoking is a significant risk factor for any fracture requiring hospitalization in haemodialysis patients.

All-cause and cause-specific mortality during and following incarceration in Brazil: A retrospective cohort study.

Mortality during and after incarceration is poorly understood in low- and middle-income countries (LMICs). The need to address this knowledge gap is especially urgent in South America, which has the fastest growing prison population in the world. In Brazil, insufficient data have precluded our understanding of all-cause and cause-specific mortality during and after incarceration. We linked incarceration and mortality databases for the Brazilian state of Mato Grosso do Sul to obtain a retrospective cohort of 114,751 individuals with recent incarceration. Between January 1, 2009 and December 31, 2018, we identified 3,127 deaths of individuals with recent incarceration (705 in detention and 2,422 following release). We analyzed age-standardized, all-cause, and cause-specific mortality rates among individuals detained in different facility types and following release, compared to non-incarcerated residents. We additionally modeled mortality rates over time during and after incarceration for all causes of death, violence, or suicide. Deaths in custody were 2.2 times the number reported by the national prison administration (n = 317). Incarcerated men and boys experienced elevated mortality, compared with the non-incarcerated population, due to increased risk of death from violence, suicide, and communicable diseases, with the highest standardized incidence rate ratio (IRR) in semi-open prisons (2.4; 95% confidence interval [CI]: 2.0 to 2.8), police stations (3.1; 95% CI: 2.5 to 3.9), and youth detention (8.1; 95% CI: 5.9 to 10.8). Incarcerated women experienced increased mortality from suicide (IRR = 6.0, 95% CI: 1.2 to 17.7) and communicable diseases (IRR = 2.5, 95% CI: 1.1 to 5.0). Following release from prison, mortality was markedly elevated for men (IRR = 3.0; 95% CI: 2.8 to 3.1) and women (IRR = 2.4; 95% CI: 2.1 to 2.9). The risk of violent death and suicide was highest immediately post-release and declined over time; however, all-cause mortality remained elevated 8 years post-release. The limitations of this study include inability to establish causality, uncertain reliability of data during incarceration, and underestimation of mortality rates due to imperfect database linkage. Incarcerated individuals in Brazil experienced increased mortality from violence, suicide, and communicable diseases. Mortality was heightened following release for all leading causes of death, with particularly high risk of early violent death and elevated all-cause mortality up to 8 years post-release. These disparities may have been underrecognized in Brazil due to underreporting and insufficient data.

Second primary malignancies (SPM) in African American (AA) and white patients with multiple myeloma in the National Veterans Affairs (VA) healthcare system.

10507 Background: In the recent decade, novel therapies have led to significant improvements in overall survival (OS) in symptomatic multiple myeloma (MM). With this increase in OS, there is an increase in the incidence of second primary malignancies (SPM) in patients with MM. This is related to multiple factors; we hypothesize that racial disparities also play a role. There is a paucity of studies with large, high quality datasets evaluating racial disparities in SPMs in MM. Our goal is to explore patterns of incidence of SPMs in US Veterans with MM, focusing on racial disparities. Methods: We conducted a retrospective cohort study based on electronic health record (EHR) and cancer registry data recorded in the VA’s Corporate Data Warehouse (CDW) between January 1, 1999 and January 1, 2018. We compared incidence of SPMs (defined as malignancies occurring after the diagnosis and treatment initiation of MM) using the standardized incidence rate ratio (IRR). Univariate and multivariable analyses were performed, using a Cox model adjusting for age, race, gender, treatment era, smoking status, and stage at MM diagnosis. Results: There were 8467 Veterans (97.4% male) with MM identified with self-reported race: White, 5029 (59.4%); AA, 2178 (25.7%); and other or unknown, 1260 (14.9%). At 7.5 years of follow up, 430 (5.1%) MM patients developed SPM while 8037 did not. 982 had received HSCT (Hematopoietic Stem cell transplant) of whom 65 (6.62%), a significantly higher proportion developed SPM versus those without HSCT (n = 7485) of whom 365 (4.87%) developed SPM (p = 0.024). Among those Veterans who had SPM 380 (88.3%) had solid tumors, 50 (11.6 %) had hematological malignancies. Of 88.3% with solid SPM the distribution was: prostate cancer, 113 (29.7%); digestive tract cancers, 63 (16.6%); lung cancer, 55 (14.4%); and GU (bladder/renal/testicular), 48(12.6%). The cumulative incidence of developing SPM increased steadily over time for the duration of this study period of 7.5 years from diagnosis. The median age of diagnosis for Whites was 68.2 years and for AA was 64.3 years, (p &lt; 0.001) demonstrating that MM occurred earlier in AA. The hazard ratio for AA versus whites to develop SPMs was 1.21 (0.975-1.505) (p = 0.0823). However, the risk of prostate cancer was significantly higher in AA with an adjusted hazard ratio of 1.81 (1.196-2.739) (p = 0.005). No racial disparities were observed in the incidence of other types of SPMs. Conclusions: Our study suggests that the risk of SPMs does not plateau over a patient’s lifetime. HSCT was found to be an independent predictor of SPM, while smoking and agent orange were not. Our cohort is one of the largest groups of AA with MM in published literature. AA did not have a higher incidence of SPMs overall; but had a significantly higher incidence of prostate cancer than whites. We hope to develop an individualized predictive model for SPM in patients with MM.

Risk of Stroke in Systemic Necrotizing Vasculitis: A Nationwide Study Using the National Claims Database.

ObjectiveEvidences indicate that the risk of stroke is increased in autoimmune rheumatic diseases. This study aimed to investigate the incidence of stroke in patients with systemic necrotizing vasculitis (SNV) using the national health database.MethodsData were obtained from the Korean National Claims database between 2010 and 2018 to identify incident SNV [anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) and polyarteritis nodosa (PAN)] cases. The standardized incidence ratio (SIR) and incidence rate ratio (IRR) were calculated to estimate the risk of stroke in patients with SNV compared to the general population and among disease subgroups. Time-dependent Cox’s regression analysis was performed to identify risk factors for stroke.ResultsAmong 2644 incident SNV cases, 159 patients (6.0%) were affected by stroke. The overall risk of stroke was significantly higher in patients with SNV compared to the general population (SIR 8.42). Stroke event rates were the highest within the first year of SNV diagnosis (67.3%). Among disease subgroups, patients with microscopic polyangiitis (MPA) exhibited higher IRR compared to PAN (adjusted IRR 1.98). In Cox’s hazard analysis, older age and MPA were associated with higher risk of stroke [hazard ratio (HR) 1.05 and 1.88], whereas the administration of cyclophosphamide, azathioprine/mizoribine, methotrexate, and statins were protective in stroke (HR 0.26, 0.34, 0.49, and 0.50, respectively).ConclusionA considerable number of SNV patients experienced stroke, especially in the early phase of disease. Older age and MPA diagnosis were associated with elevated risk of stroke, while the administration of immunosuppressive agents and statins was beneficial in preventing stroke.

Stomach Cancer Incidence and Mortality Trends among Circumpolar Nations.

Stomach cancer incidence and mortality rates are declining across circumpolar nations, but the burden may not be distributed equally across subpopulations, including Indigenous peoples. Our objective was to examine stomach cancer incidence and mortality trends across circumpolar populations. Cancer incidence and mortality data from 1999-2016 were obtained from the Canadian Cancer Registry, Canadian Vital Statistics, CDC WONDER, NORDCAN, Northwestern Russian cancer registries, and National Cancer Reports. The direct method was used to calculate 10-year rolling age-standardized incidence and mortality rates to the world (WHO 2000-2025) and 2011 Canadian standard populations. Standardized incidence rate ratios (SRR) were calculated. Data were stratified by sex, year, and region. U.S. data were broken down by race [White; American Indian/Alaska Native (AIAN)]. Race data were not available from non-U.S. cancer registries. Most populations showed declining incidence and mortality rates over time. Incidence rates among Greenland males and females, Alaska AIAN males and females, and Northern Canadian both sexes were elevated compared with regional counterparts and remained stable. The largest male SRR was observed among Alaska AIAN versus Alaska Whites [SRR = 3.82; 95% confidence interval (95% CI), 2.71-5.37]. The largest female SRR was observed among Alaska AIAN versus Alaska Whites (SRR = 4.10; 95% CI, 2.62-6.43). Despite stomach cancer incidence and mortality rates declining overall, some northern and Indigenous populations experience elevated and stable incidence and mortality rates. There is a need to address disparities observed among circumpolar subpopulations. Given similarities in incidence, mortality, and risk factor prevalence across circumpolar regions, addressing disparities could benefit from coordinated international action.

Association Between Implementation Of Novel Therapies And Improved Survival In Patients Starting Hemodialysis: The Swedish Renal Registry 2006-2015.

BackgroundThe recent years have witnessed significant therapeutic advances for patients on haemodialysis (HD). We evaluated temporal changes in treatments practices and survival rates among incident HD patients.MethodsThis was an observational study of patients initiating HD in Sweden in 2006–15. Trends of HD-related practices, medications and routine laboratory biomarkers were evaluated. The incidence of death and major cardiovascular events (MACEs) across calendar years were compared against the age- and sex-matched general population. Via Cox regression, we explored whether adjustment for implementation of therapeutic advances modified observed survival and MACE risks.ResultsAmong 6612 patients, age and sex were similar, but the burden of comorbidities increased over time. The proportion of patients receiving treatment by haemodiafiltration, ≥3 sessions/week, lower ultrafiltration rate and working fistulas increased progressively, as did use of non-calcium phosphate binders, cinacalcet and vitamin D3. The standardized 1-year mortality decreased from 13.2% in 2006–07 to 11.1% in 2014–15. The risk of death decreased by 6% [hazard ratio (HR) = 0.94, 95% confidence interval (CI) 0.90–0.99] every 2 years, and the risk of MACE by 4% (HR = 0.96, 95% CI 0.92–1.00). Adjustment for changes in treatment characteristics abrogated these associations (HR = 1.00, 95% CI 0.92–1.09 for death and 1.00, 0.94–1.06 for MACE). Compared with the general population, the risk of death declined from 6 times higher in 2006–07 [standardized incidence rate ratio (sIRR) = 6.0, 95% CI 5.3–6.9] to 5.6 higher in 2014–15 (sIRR = 5.57, 95% CI 4.8–6.4).ConclusionsGradual implementation of therapeutic advances over the last decade was associated with a parallel reduction in short-term risk of death and MACE among HD patients.

Changes in Drug Prescribing Practices Are Associated With Improved Outcomes in Patients With Dementia in Sweden: Experience from the Swedish Dementia Registry 2008–2017

ObjectivesEvidence is lacking on how treatment of comorbidities improves outcomes in patients with dementia. In this study, we evaluated temporal changes in the management of comorbidities in relation to survival rates in incident dementia over a 10-year period in Sweden. DesignObservational cohort study. Setting and ParticipantsA total of 40,219 patients with recently diagnosed dementia in memory clinics from the Swedish Dementia Registry (SveDem) from 2008 to 2017. MethodsIn 1-year blocks, pharmacological treatment of dementia and comorbidities in relationship to risk for fractures, major cardiovascular events (MACE), and death were analyzed using Cox models. Standardized Incidence Ratios (SIR) of death are presented. ResultsAfter standardization for demographics and comorbidities, the risk of fracture, MACE, and mortality decreased by 16%, 23%, and 28%, respectively, between 2008 and 2016. Each year decreased the risk of fracture by 3% (hazard ratio 0.97, 95% confidence interval 0.96–0.99), MACE by 4% (0.96, 0.95–0.97), and death by 5% (0.95, 0.93–0.97). Adjustment for changes in medication use attenuated these associations. Compared with the general population, the risk of death declined by 11%, corresponding to standardized incidence rate ratio, between 2008 and 2016. Conclusions and ImplicationsOver 10 years, a reduction in the short-term risks of fracture, MACE, and death in patients with dementia was associated with changes in drug prescribing practices. These improvements seem to be partly explained by progressive implementation of dementia diagnostic, treatment guidelines, and general management of comorbidities.

Increased cancer risk in male hunters in Northern Sweden after the Chernobyl Nuclear Power Plant accident?

Background: Hunters have higher internal radiation exposure due to consumption of game in Swedish counties with high fallout of 137Cs after the Chernobyl accident compared with the general population. Methods: Cancer incidence was studied in nine counties with three deposition categories of 137Cs fallout after the Chernobyl accident in 1986. A total of 9,267 cancer cases occurred in male hunters and 138,909 cancer cases in male non-hunters to 31 December 2015. Directly age standardized cancer incidence and Incidence Rate Ratios (IRR) with 95% Confidence Intervals (CI) were calculated for total cancer and radiation associated cancers, respectively. IRR was calculated between hunters, using the lowest deposition counties as reference, and within counties using non-hunters as reference. Hence, cancer risks of internal radiation exposure and the hunting lifestyle, respectively, could be studied. Results: An increasing trend in total cancer incidence was seen in non-hunters. For hunters this trend was significantly lower up to 2001 when the total cancer incidence crossed over the weaker non-hunter trend and remained higher the following 15 years. A weak exposure response trend for radiation associated cancers was found both within hunter and non-hunter category, respectively. No clear exposure response pattern was seen in IRRs for total cancer in hunters versus non-hunters between counties with increasing 137Cs deposition. IRRs for hunters compared with non-hunters were higher regardless of rural/non-rural status with slightly higher risk estimates in rural areas. The overall IRR for hunters was 1.06 (95% CI 1.04 - 1.08) 1986 - 2015, representing an excess of 531 cancer cases in hunters. No confounding effect from tobacco smoking or education level could be identified. Conclusion: Total cancer incidence was increased for hunters versus non-hunters. However, exposure classification was too crude to exclude an association between cancer and 137Cs. Detailed dosimetry is needed to analyse and interpret any trend.

Ethnic differences in incidence and mortality of stroke in Denmark

Abstract Background Stroke is a leading cause of disability and mortality worldwide. However, studies on incidence and mortality of stroke hereof among ethnic minorities compared with local born are still limited. Methods We conducted a Danish nationwide register-based cohort study between 2004 and 2018. All cases of first ever stroke aged 18-95 years were included. Country of birth was used to construct ethnic groups. Age standardized incidence rate ratio (IRR) of stroke stratified by country of birth and sex were estimated with the Danish born as a reference group. Ethnic minorities were grouped as Western and Non-western for mortality hazard ratio (HR) estimates. Results In overall, ethnic minorities had a higher risk of stroke compared with Danish born. Particularly, the IRR of all stroke was estimated to be 8.3 times higher among Polish men compared to Danish born men (IRR, 8.32; 95% CI, 6.89-10.05). Compared with Danish born women, Pakistan women had the highest risk of all stroke (IRR, 2.89; 95% CI, 2.46-3.39). By contrast, Swedish women had reduced risk of hemorrhagic stroke (IRR, 0.40; 95% CI, 0.18-0.89) and Norwegian women had reduced risk of ischemic stroke (IRR, 0.87; 95% CI, 0.72-1.06). Compared with Danish born men, all-cause 1-year mortality hazard for Non-western men was (HR, 1.61; 95% CI, 1.13-2.29) while for Western men was (HR, 1.07; 95% CI, 0.90-1.29) among ischemic stroke patients. Among hemorrhagic stroke patients, 1-year mortality hazard for Non-western men was (HR, 0.75; 95% CI, 0.39-1.47) whereas Western men had (HR, 1.48; 95% CI, 1.04-2.10). Among women, we observed reduced all cause 1-year mortality hazard in Non-western (HR, 0.32; 95% CI, 0.13-0.80) for hemorrhagic stroke whereas no difference in mortality hazard was observed for ischemic stroke. Conclusions Incidence and post stroke mortality appear to vary among ethnic minorities in comparison to Danish born. It may depend on the type of stroke and sex. Key messages The study contributes knowledge in migration and health. With good quality registers, we are in unique position to establish findings in Denmark, which has a growing migrant population.

Clinical characteristics, risk factors, and incidence of symptomatic coronavirus disease 2019 in a large cohort of adults living with HIV: a single-center, prospective observational study.

It is unclear how characteristics, risk factors, and incidence of coronavirus disease 2019 (COVID-19) in people living with HIV (PLWH) differ from the general population. Prospective observational single-center cohort study of adult PLWH reporting symptoms of COVID-19. We assessed clinical characteristics, risk factors for COVID-19 diagnosis and severity, and standardized incidence rate ratio for COVID-19 cases in PLWH cohort and in Barcelona. From 1 March 2020 to 10 May 2020, 53 out of 5683 (0.9% confidence interval 0.7-1.2%) PLWH were diagnosed with COVID-19. Median age was 44 years, CD4 T cells were 618/μl and CD4/CD8 was 0.90. All but two individuals were virologically suppressed. Cough (87%) and fever (82%) were the most common symptoms. Twenty-six (49%) were admitted, six (14%) had severe disease, four (8%) required ICU admission, and two (4%) died. Several laboratory markers (lower O2 saturation and platelets, and higher leukocytes, creatinine, lactate dehydrogenase, C reactive protein, procalcitonin, and ferritin) were associated with COVID-19 severity. No HIV or antiretroviral-related factors were associated with COVID-19 diagnosis or severity. Standardized incidence rate ratios of confirmed or confirmed/probable COVID-19 in PLWH were 38% (95% confidence interval 27-52%, P < 0.0001) and 33% (95% confidence interval 21-50%, P < 0.0001), respectively relative to the general population. PLWH with COVID-19 did not differ from the rest of the HIV cohort. Clinical presentation, severity rate, and mortality were not dependent on any HIV-related or antiretroviral-related factor. COVID-19 standardized incidence rate was lower in PLWH than in the general population. These findings should be confirmed in larger multicenter cohort studies.

P1437RELATIONS BETWEEN IMPLEMENTATIONS OF EVIDENCE-BASED TREATMENTS AND IMPROVED OUTCOMES IN PATIENTS STARTING HEMODIALYSIS DURING THE LAST 10 YEARS: EXPERIENCES FROM THE SWEDISH RENAL REGISTRY 2006-2015

Abstract Background and Aims Although few randomized controlled trials have been able to demonstrate benefits of single treatments in improving outcomes of patients undergoing hemodialysis (HD), the last decades have witnessed significant therapeutic advances. This relates both to the HD treatment itself and to the management of patient complications. We here evaluated temporal changes in the use of evidence-based treatments and survival rates in incident HD patients. Method We included all patients initiating HD in Sweden between 2006-2015 and followed them until the end of 2017. Data were linked to national registries to retrieve information on date of death, cardiovascular events, comorbidity, and drug prescriptions. We first evaluated trends in the use of different HD related therapies and selected key therapeutic targets and medications in 2-year blocks. We then evaluated the incidence of death and major cardiovascular events (MACE) within one and two years from start of dialysis through standardized incidence rates via logistic regression models to account for differences in patient characteristics over time. Via Cox regression models, we explored whether adjustment for implementation of evidence-based treatments (e.g. hemodiafiltration (HDF), frequent HD, working fistula, drugs to control CKD-MBD, anemia) modified the observed survival and MACE risks. Finally, survival trends were also compared against an age-sex-calendar year-matched general Swedish population using standardized incidence ratios. Results We identified 6,612 patients starting HD in Sweden during the study period. There was no difference in mean age or proportion of women over time, but body mass index, serum parathyroid hormone levels and the proportion of patients with cerebrovascular disease, atrial fibrillation and cancer increased. Conversely, mean serum hemoglobin, phosphate and albumin values decreased over time. The proportion of patients who underwent HDF, had more than three HD sessions/week, and had a working fistula increased progressively, as well as the use of phosphate binders (particularly non-calcium), cinacalcet, and vitamin D3. After standardization for differences in demography and comorbidities, the one-year risk of mortality or MACE risk decreased by 7% and 16%, respectively, in 2014/15 compared to 2006/07. Similarly, the two-year risk of death or MACE decreased by 16 and 21%. In multivariable Cox models, we explored the linear association between calendar year blocks and study outcomes. Per 2-year period, the risk of death within one year decreased by 6% (HR 0.94, 95% CI 0.92-1.00), and of MACE by 5% (0.94, 95% CI 0.92-0.98). Adjustment for changes in the evidence-based treatments over time abrogated these associations (HR 1.00, 95% CI 0.91-1.09 for death and 1.00, 95% CI 0.94-1.06 for MACE). Similar results were obtained for 2-year outcomes. Compared with the general population, the one-year risk of death for a HD patient was 6 times higher in 2006/2007 [standardized incidence rate ratio, SIR 6.05 (5.30–6.91)], but decreased to 5.5 times higher in 2014/15 [SIR 5.57 (4.82–6.44)], corresponding to a SIR reduction of 8%. Conclusion In patients initiating HD therapy in Sweden, there has been a gradual implementation of new and established evidence-based treatments during the last 10 years, which was associated with a parallel reduction in the risk of death and MACE.

Cancer and risk of Alzheimer's disease: Small association in a nationwide cohort study.

Small observational studies with short-term follow-up suggest that cancer patients are at reduced risk of Alzheimer's disease (AD) compared to the general population. A nationwide cohort study using Danish population-based health registries (1980-2013) with cancer patients (n = 949,309) to identify incident diagnoses of AD. We computed absolute reductions in risk attributed to cancer and standardized incidence rate ratios (SIRs) accounting for survival time, comparing the observed to expected number of AD cases. During up to 34 years of follow-up of cancer survivors, the attributable risk reduction was 1.3 per 10,000 person-years, SIR = 0.94 (95% confidence interval 0.92-0.96). SIRs were similar after stratification by sex, age, and cancer stage, and approached that of the general population for those surviving >10 years. Inverse associations between cancer and AD were small and diminished over time. Incidence rates in cancer survivors approached those of the general population, suggesting limited association between cancer and AD risk.

Myocardial infarction after noncardiac surgery in Sweden: a national, retrospective observational cohort study

BackgroundThe precise incidence of perioperative myocardial infarction (MI) after noncardiac surgery remains unclear. We determined the incidence and risk factors for perioperative MI after noncardiac surgery and the risk of MI and mortality compared with matched non-surgical patients. MethodsPatients >18 yr undergoing noncardiac surgery in 23 Swedish hospitals from 2007 to 2014 were included in this national observational retrospective cohort study. We combined national surgical and outcome databases with Swedeheart, a national quality registry capturing data from patients with acute MI. The primary outcome was incidence of MI within 30 days of surgery. Multivariable logistic regression identified preoperative risk factors associated with MI, including ASA grade, diabetes mellitus, and cardiovascular pathology including previous MI. Standardised incidence rate ratios were calculated. Mortality rates were estimated using Cox proportional hazards. ResultsA total of 1605/400 742 (0.41%) patients (median age: 64 [49–75] yr) had an MI after surgery, which was independently associated with increasing age, comorbidities and higher risk (vascular, thoracic), emergency surgery, or all. The incidence of perioperative MI (per 1000 surgeries) varied from 0.064 (95% confidence interval [CI], 0.02–012) in low-risk patients (ASA physical status 1) to 15.8 (95% CI, 14.9–16.8) among higher risk patients (ASA physical status ≥3, age ≥80 yr, high-risk surgery). Perioperative MI was associated with higher 30-day mortality (adjusted odds ratio: 5.49 [95% 4.76–6.32]). Compared with the non-surgical Swedish population, the perioperative standardised incidence rate ratio was five-fold higher (odds ratio: 5.35 [95% CI: 5.09–5.61]). ConclusionsIn a large Swedish surgical cohort, the incidence of MI within 30 days of noncardiac surgery was 0.41%, chiefly occurring in a small subset of higher risk patients.