[Choosing Wisely in Sweden]. / Kloka kliniska val ­ att avstå det som inte gör nytta för patienten.

Overdiagnosis and overtreatment receive increasing attention. More than 20 percent of health expenditure is without patient benefit, so-called low-value care. Several national and international initiatives have been launched to minimize low-value care. Arguably, the most widely spread initiative is Choosing Wisely. First launched by the American Board of Internal Medicine in 2012, this campaign has spread to more than 20 countries. The Swedish Society of Medicine has identified low-value care as a significant problem in Swedish health care and  has established a working group to investigate if and how a campaign based on Choosing Wisely would be feasible in Sweden. Here, the working group reports on the history of Choosing Wisely, identifies potential challenges for deimplementation generally and in the Swedish context specifically.

[Cardiac implantable electronic device infections; risk factors, prevention and treatment]. / Ökning av infektioner relaterade till pacemaker och defibrillator.

The infection rate associated with cardiac implantable electronic devices has increased over the past decades. A recent study found the prevalence of infection after cardiac resynchronization therapy to be more than tenfold higher than reported to the national registry. Risk factors for infection can be host-, procedure-, or device-related, the most important being recent manipulation of the device. Perioperative contamination is the most frequent source, but leads can also be secondarily infected from bacteremia, most commonly with staphylococci. Patients with pocket infection often present with erythema and swelling over the pocket, whereas systemic infection usually produces fever and, in its most severe form, endocarditis. Parenteral empiric antimicrobial therapy should be initiated after drawing blood cultures and followed by transesophageal echocardiogram. Management also includes prompt device extraction, followed by a reevaluation of the indication before reimplantation. Education of operators, related personnel, and referring physicians, prevention of modifiable risk factors, and accurate reporting to national registries are critical actions to limit complications.