Pooled analysis of all-cause and cause-specific mortality among Nordic military veterans following international deployment.

OBJECTIVES: To investigate all-cause and cause-specific mortality risks, including deaths from external, cardiovascular and cancer causes, among deployed Nordic military veterans in comparison to the general population in each country. DESIGN: Pooled analysis. SETTING: Denmark, Norway, Finland and Sweden. PARTICIPANTS: Military veterans deployed between 1990 and 2010 were followed via nationwide registers and compared with age-sex-calendar-year-specific rates in the general population using pooled standardised mortality ratios (SMRs). MAIN OUTCOMES: All-cause and cause-specific mortality retrieved from each country's Causes of Death Register, including deaths from external, cardiovascular and cancer causes. RESULTS: Among 83 584 veterans 1152 deaths occurred of which 343 were from external causes (including 203 suicides and 129 traffic/transport accidents), 134 from cardiovascular causes and 297 from neoplasms. Veterans had a lower risk of death from any cause (pooled SMR 0.58, 95% CI 0.52 to 0.64), external causes (0.71, 95% CI 0.64 to 0.79), suicide (0.77, 95% CI 0.67 to 0.89), cardiovascular causes (0.54, 95% CI 0.46 to 0.64) and neoplasms (0.78, 95% CI 0.70 to 0.88). There was no difference regarding traffic/transport accidents for the whole period (1.10, 95% CI 0.92 to 1.31) but the pooled point estimate was elevated, though not statistically significant, during the first 5 years (1.17, 95% CI 0.89 to 1.53) but not thereafter (1.01, 95% CI 0.77 to 1.34). For all other causes of death, except suicide, statistically significantly lower risk among veterans was observed both during the first 5 years and thereafter. For suicide, no difference was observed beyond 5 years. Judged from the country-specific SMR estimates, there was a high degree of consistency although statistically significant heterogeneity was found for all-cause mortality. CONCLUSIONS: Nordic military veterans had lower overall and cause-specific mortality than the general population for most outcomes, as expected given the predeployment selection process. Though uncommon, fatal traffic/transport accidents were an exception with no difference between deployed military veterans and the general population.

Violent crime among Swedish military veterans after deployment to Afghanistan: a population-based matched cohort study.

OBJECTIVE: To investigate the incidence of violent crime conviction among Swedish military veterans after deployment to Afghanistan versus non-deployed comparators. The main outcome was first conviction of a violent crime, retrieved from the Swedish National Council for Crime Prevention Register until December 31, 2013. METHODS: This was a cohort study of military veterans identified through personnel registers regarding deployment to Afghanistan between 2002 and 2013 (n = 5894). To each military veteran, up to five non-deployed comparators identified via the Military Service Conscription Register were matched by age, sex, conscription year, cognitive ability, psychological assessment, self-reported mental health, body mass index, antidepressants/anxiolytics prescriptions and self-harm (fully matched comparators; n = 28 895). Multivariable adjustment was made for substance abuse and previous health care visits with psychiatric diagnoses. An additional comparator group matched only for age, sex and conscription year was also used (age-sex-matched comparators; n = 29 410). RESULTS: During 21 898 person-years of follow-up (median = 3.6 years) there were 26 events among deployed military veterans compared with 98 in non-deployed fully matched comparators [12 vs 9 per 10 000 person-years, adjusted hazard ratio (aHR) 1.36; 95% confidence interval (CI) 0.88-2.10]. Among non-deployed age-sex-matched comparators there were 170 violent crime convictions (16 per 10 000 person-years; aHR 0.85; 95% CI 0.56-1.29). Factors associated with greater risk of violent crime convictions were younger age, lower scores on cognitive ability tests and psychological assessment, and convictions preceding deployment. CONCLUSION: The violent crime conviction rate after returning from military deployment to Afghanistan was not different compared with non-deployed comparators in individuals without history of violent crime convictions.

Marriage and divorce after military deployment to Afghanistan: A matched cohort study from Sweden.

AIM: To investigate the probability of marriage and divorce among Swedish military veterans deployed to Afghanistan relative to non-deployed matched comparators. STUDY DESIGN AND SETTING: Matched cohort study in Sweden. PARTICIPANTS: Military veterans were identified through Swedish military personnel registers regarding foreign deployments, and comparators from the Military Service Conscription Register (1969-2013). Of 1,882,411 eligible conscripts, 7041 had served in Afghanistan at some point in time between 2002 and 2013. To each military veteran, up to 5 non-deployed comparators who underwent conscription were matched by age, sex, psychological assessment, cognitive ability, psychiatric history and social characteristics. After matching there were 4896 (82%) unmarried and 1069 (18%) married deployed military veterans. The main outcome was marriage or divorce after deployment to Afghanistan. Data on marital status were retrieved from Statistics Sweden until December 31, 2014. RESULTS: During a median follow-up of 4.1 years after deployment of married individuals, 124 divorces were observed among deployed military veterans and 399 in the matched non-deployed comparator cohort (277 vs. 178 per 10,000 person-years; adjusted hazard ratio 1.61, 95%CI 1.31-1.97). During a median follow-up of 4.7 years after deployment in the unmarried cohort, 827 new marriages were observed among deployed military veterans and 4363 in the matched non-deployed comparators cohort (399 vs. 444 per 10,000 person-years; adjusted hazard ratio 0.89, 95%CI 0.83-0.96). CONCLUSION: Military veterans were more likely to divorce and less likely to marry after deployment compared with matched non-deployed comparators.

Suicide and all-cause mortality in Swedish deployed military veterans: a population-based matched cohort study.

OBJECTIVE: To investigate suicide and mortality risk in deployed military veterans versus non-deployed comparators who had gone through military conscription testing. DESIGN: Population-based matched cohort study. SETTING: Sweden. PARTICIPANTS: Participants were identified from the Military Service Conscription Register and deployment status from the Swedish Military Information Personnel Register. Of 1.9 million conscripts, 21 721 had deployed at some time between 1990 and 2013 (deployed military veterans). Non-deployed comparators were matched to deployed military veterans in two ways: (1) by cognitive ability, psychological assessment, mental health, body mass index, sex, birth-year and conscription-year (carefully matched), with further adjustment for exercise capacity and suicide attempt history; and (2) by sex, birth-year and conscription-year (age- and sex-matched). MAIN OUTCOME: Suicide retrieved from the Swedish National Patient and Causes of Death Register until 31 December 2013. RESULTS: During a median follow-up of 12 years, 39 and 211 deaths by suicide occurred in deployed military veterans (n=21 627) and carefully matched non-deployed comparators (n=107 284), respectively (15 vs 16/100 000 person-years; adjusted HR (aHR) 1.07; 95% CI 0.75 to 1.52; p=0.72) and 329 in age- and sex-matched non-deployed comparators (n=108 140; 25/100 000 person-years; aHR 0.59; 95% CI 0.42 to 0.82; p=0.002). There were 284 and 1444 deaths by suicide or attempted suicides in deployed military veterans and carefully matched non-deployed comparators, respectively (109 vs 112; aHR 0.99; 95% CI 0.88 to 1.13; p=0.93) and 2061 in age- and sex-matched non-deployed comparators (158; aHR 0.69; 95% CI 0.61 to 0.79; p<0.001). The corresponding figures for all-cause mortality for carefully matched non-deployed comparators were 159 and 820 (61 vs 63/100 000 person-years; aHR 0.97; 95% CI 0.82 to 1.15; p=0.71) and 1289 for age- and sex-matched non-deployed comparators (98/100 000 person-years; aHR 0.62; 95% CI 0.52 to 0.73; p<0.001). CONCLUSION: Deployed military veterans had similar suicide and mortality risk as non-deployed comparators after accounting for psychological, psychiatric and physical factors. Studies of mental health in deployed veterans need to adjust for more factors than age and sex for comparisons to be meaningful.

Health Care Utilization and Complications Rates among Users Of Hydrophilic-Coated Catheters.

This article presents results from an electronic survey completed by intermittent catheterization users who were registered members of a global web-based database. The results provide data on complication rates, health care utilization, and benefits from using hydrophilic-coated urinary catheters isotonic to urine.

Cost-Effectiveness of School-Based Prevention of Cannabis Use.

BACKGROUND: Cannabis is the most frequently used illicit drug globally. Despite increasing evidence that cannabis use is associated with adverse health effects, the knowledge on preventative strategies is still limited. This study stemmed from a systematic review of effective prevention in which school-based programmes were identified as promising. The primary objective was to evaluate the cost effectiveness of Project ALERT (Adolescent, Learning, Experiences, Resistance, and Training), compared with ordinary ATOD (Alcohol, Tobacco, and Other Drug) education, among Swedish students in the eighth grade of compulsory school. METHODS: The cost-effectiveness analysis was performed from the societal perspective with quality-adjusted life-years (QALYs) as an outcome (willingness-to-pay threshold €50,000) and follow-up periods from 1 year to a lifetime, considering a discounting rate of 3%, and with costs inflated to 2013 levels. A Markov model was constructed on the basis of the 'states' of single use, regular use, daily use and use of other illicit drugs, which were associated with 'complications' of psychosis, schizophrenia, traffic accidents, depression and amotivational syndrome. Health and cost consequences were linked to both states and complications. RESULTS: The programme was cost saving on the basis of evidence from the USA (ratio 1:1.1), and was cost effective (incremental cost-effectiveness ratio €22,384 per QALY) after reasonable adjustment for the Swedish context and with 20 years of follow-up. When the target group was restricted to boys who were neither studying nor working/doing work experience, the programme was cost effective after 9 years and cost saving (ratio 1:3.2) after 20 years. CONCLUSION: School-based prevention such as Project ALERT has the potential to be cost effective and to be cost saving if implemented in deprived areas. In the light of the shifting landscape regarding legalization of cannabis, it seems rational to continue the health economic analysis of prevention initiated here.

Trends in self-reported BMI and prevalence of obesity 2002-10 in Stockholm County, Sweden.

BACKGROUND: Trends in obesity have been reported to level off in several Western countries. The aim of this study was to investigate trends in body mass index (BMI) and prevalence of obesity between 2002 and 2010 in Stockholm County, Sweden. METHODS: Three cross-sectional questionnaires from the Stockholm Health Surveys were used for this study. A total of 31 182, 34 707 and 30 767 men and women aged between 18 and 64 years completed the questionnaire regarding sociodemographic factors, health parameters, physical activity, smoking habits and anthropometry in 2002, 2006 and 2010, respectively (response rate: 62.5, 61.3 and 55.6%, respectively). Linear regression was used to investigate changes in mean BMI. Relative risk regression models were used to investigate changes in prevalence of obesity, defined as BMI ≥ 30 kg/m(2). All analyses were stratified on age and further adjusted for smoking, education and socioeconomic position. RESULTS: Between 2002 and 2006, a stabilization was found in BMI and prevalence of obesity in both men and women. But from 2006 to 2010, BMI and prevalence of obesity had increased, also among the young. In 2010, the prevalence of obesity was 12.2% among men and 10.3% among women. CONCLUSION: After a period of stabilization in 2002-06, BMI and prevalence of obesity are increasing in Stockholm County, Sweden.

Lifetime productivity losses associated with obesity status in early adulthood: a population-based study of Swedish men.

BACKGROUND: Obesity is a well-known risk factor for sick leave, disability pension and premature death. Obesity is therefore presumably related to increased productivity losses. OBJECTIVE: The aim of this study was to estimate the lifetime productivity losses to society associated with obesity status. METHODS: This study was based on a 38-year follow-up of a nationwide cohort of 45 920 Swedish men performing mandatory military conscription tests at age 18.7 ± 0.5 years. Body mass index (BMI) based on measured height and weight at the time of military conscription tests was used to define underweight (<18.5 kg/m(2)), normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)) and obesity (≥30.0 kg/m(2)). Data on sick leave, disability pension and premature death were retrieved from national registers. The calculations were adjusted for socioeconomic index, smoking and muscular strength. RESULTS: Using the human capital approach, the lifetime productivity losses were calculated as 55.6 (95% CI 50.7, 62.0) × €1000 and 55.6 (95% CI 50.9, 61.4) × €1000 for underweight and normal weight, respectively, and 72.6 (95% CI 66.3, 80.7) × €1000 and 95.4 (95% CI 89.0, 102.9) × €1000 for overweight and obesity, respectively. If using the friction cost method instead, the estimated productivity losses were reduced by about 80%. CONCLUSION: Obesity is associated with almost twice as high productivity losses to society as for normal weight over a lifetime. These costs are important to include in health economic analyses of obesity intervention programmes in order to ensure an effective allocation of resources from a societal perspective.

Association between obesity status and sick-leave in Swedish men: nationwide cohort study.

BACKGROUND: Sick-leave is an important source of productivity losses to society. The objective of this study was to investigate the association between body mass index (BMI) status in young adulthood and future sick-leave. METHODS: A nation-wide cohort of 43,989 Swedish men (18.7 ± 0.5 years) performing military conscription tests in 1969-70 were followed between 1986 and 2005 regarding sick-leave. BMI was used to define underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9) and obesity (≥ 30.0). Relative risks of sick-leave were estimated with Cox proportional hazards models adjusted for smoking, socio-economic index and muscular strength, using normal weight as the reference. RESULTS: During 803,684 person-years of follow-up, 488,570 sick-leave episodes were recorded. On average, one short-term (≤ 7 days) episode occurred every eight person-months, one intermediate-term (8-30 days) every five person-years and one long-term (>30 days) episode every 15 person-years. Overweight was associated with 20% and obesity with >30% risk elevation for episodes ranging from 8 to 30 days [hazard ratio (HR) 1.20; 95% CI 1.15-1.24 and HR 1.35; 95% CI 1.24-1.47, respectively] as well as for episodes >30 days (HR 1.19; 95% CI 1.15-1.23 and HR 1.34; 95% CI 1.24-1.47, respectively) compared to normal weight. Obesity was also associated with an increased risk of sick-leave episodes ≤ 7 days (HR 1.13; 95% CI 1.09-1.16), but the corresponding risk increase for overweight was very small (HR 1.02; 95% CI 1.00-1.03). Underweight showed increased risk only for short-term episodes (HR 1.05; 95% CI 1.04-1.07). DISCUSSION: Overweight and obesity are associated with increased risk for sick-leave compared to normal weight, especially for sick-leave episodes of longer duration.

Cost-effectiveness analysis of palivizumab as respiratory syncytial virus prophylaxis in preterm infants in Sweden.

AIM: To investigate the cost-effectiveness of palivizumab vs. no prophylaxis for respiratory syncytial virus (RSV) infection in preterm infants in Sweden. METHODS: A probabilistic Markov model was populated using a nationwide register linkage and data from the literature. Cost-effectiveness was investigated from a societal perspective over a lifetime for infants born at <29 weeks of gestation. Palivizumab was modelled using assumptions for its direct effect on RSV hospitalization risk and an indirect effect (via decreased RSV hospitalization) on subsequent asthma and mortality during the epidemic. Costs and effects were discounted by 3%. RESULTS: In the base case, prophylaxis resulted in an additional 0.102 quality-adjusted life-year (QALY) at a cost of 20,000 SEK relative to no prophylaxis (incremental cost-effectiveness ratio [ICER] 195,000 SEK/QALY). The probability of prophylaxis being cost-effective was 99% at a willingness-to-pay of 500,000 SEK/QALY. Assumptions about a causal association between RSV infection and subsequent asthma had a moderate impact, while exclusion of the indirect prophylaxis effect on mortality increased the ICER to 492,000 SEK/QALY. When excluding both of these, prophylaxis was not cost-effective. CONCLUSION: Based on a willingness-to-pay of 500,000 SEK/QALY, palivizumab was found to be cost-effective compared with no prophylaxis for infants born at <29 weeks if severe RSV infection was assumed to increase subsequent asthma or mortality risk.

Including carbon emissions from deforestation in the carbon footprint of Brazilian beef.

Effects of land use changes are starting to be included in estimates of life-cycle greenhouse gas (GHG) emissions, so-called carbon footprints (CFs), from food production. Their omission can lead to serious underestimates, particularly for meat. Here we estimate emissions from the conversion of forest to pasture in the Legal Amazon Region (LAR) of Brazil and present a model to distribute the emissions from deforestation over products and time subsequent to the land use change. Expansion of cattle ranching for beef production is a major cause of deforestation in the LAR. The carbon footprint of beef produced on newly deforested land is estimated at more than 700 kg CO(2)-equivalents per kg carcass weight if direct land use emissions are annualized over 20 years. This is orders of magnitude larger than the figure for beef production on established pasture on non-deforested land. While Brazilian beef exports have originated mainly from areas outside the LAR, i.e. from regions not subject to recent deforestation, we argue that increased production for export has been the key driver of the pasture expansion and deforestation in the LAR during the past decade and this should be reflected in the carbon footprint attributed to beef exports. We conclude that carbon footprint standards must include the more extended effects of land use changes to avoid giving misleading information to policy makers, retailers, and consumers.

Forecast of future premature mortality as a result of trends in obesity and smoking: nationwide cohort simulation study.

In many countries obesity has increased dramatically during the last decades, while there has been a parallel decrease in smoking. The objective of the present study was to estimate the net effect on premature mortality of these trends. A simulation model was developed to estimate the expected number of deaths between ages 19-56 years for cohorts of young men (n = 50,000), depending on inputs of obesity and smoking prevalence. The model was populated with nationwide data of Swedish men performing mandatory military conscription tests between 1969 and 2005. Risk equations for all cause mortality with smoking and obesity status as predictors were developed based on the 1969-1970 conscription cohort (n = 45,920; 2,897 deaths, median follow-up 38 years). It was found that between 1969 and 2005, the prevalence of smoking decreased from 58.6 to 23.2%, while overweight increased from 5.7 to 15.6% and obesity from 0.8 to 5.5%. As a result of these trends, a 14% (CI95(%) 6, 21%) reduction of premature deaths between ages 19 and 56 years was forecasted for men aged 19 year in 2004-2005 compared to men aged 19 years in 1969-1970 (2,679 vs. 3,116 deaths). However, one-third of the survival benefit from reduced smoking during the period was offset due to the parallel increase in obesity. This study shows that despite large increases in overweight and obesity, a continued decline in premature deaths among Swedish males is expected due to reduced smoking during the last four decades.