Co-morbidity associated with development of severe COVID-19 before vaccine availability: a retrospective cohort study in the first pandemic year among the middle-aged and elderly in Jönköping county, Sweden.

BACKGROUND: In preparation of future pandemics, it is important to recognise population-level determinants associated with development of severe illness before efficient vaccines and evidence-based therapeutic measures are available. The aim of this study was to identify pre-pandemic diagnoses recorded in a middle-aged and elderly population that were associated with development of severe COVID-19 during the first pandemic year. METHODS: A cohort study design was used. Severe COVID-19 was defined as a course of illness that resulted in hospital admission or death. A retrospective analysis was performed that comprised all individuals aged 39 years and older (N = 189,951) living in Jönköping County, Sweden. All diagnosed morbidity recorded in contacts with health care during the pre-pandemic year 2019 was used to identify which diagnoses that were associated with development of severe COVID-19 in the first pandemic year 2020. The analyses were performed separately for each diagnosis using binary logistic regression with adjustment for sex and age. RESULTS: Severe COVID-19 was suffered by 0.67% (N = 1,280) of the middle-aged and elderly population in the first pandemic year. Individuals previously diagnosed with dementia, cerebral palsy, kidney failure, type 2 diabetes mellitus, hypertension, and obesity were at higher risk of developing severe COVID-19. For patients with Type 2 diabetes mellitus, the odds ratio (OR) was 2.18 (95% confidence interval, 1.92-2.48). Type 1 diabetes mellitus was not associated with increased risk. CONCLUSION: Diagnoses suggesting service provision at long-term healthcare facilities and co-morbidity with components of the metabolic syndrome were associated with an increased risk of developing severe COVID-19 in a middle-aged and elderly population before vaccines were available.

Effectiveness of the BNT162b2 mRNA Vaccine Compared with Hybrid Immunity in Populations Prioritized and Non-Prioritized for COVID-19 Vaccination in 2021-2022: A Naturalistic Case-Control Study in Sweden.

The term hybrid immunity is used to denote the immunological status of vaccinated individuals with a history of natural infection. Reports of new SARS-CoV-2 variants of concern motivate continuous rethought and renewal of COVID-19 vaccination programs. We used a naturalistic case-control study design to compare the effectiveness of the BNT162b2 mRNA vaccine to hybrid immunity 180 days post-vaccination in prioritized and non-prioritized populations vaccinated before 31 July 2021 in three Swedish counties (total population 1,760,000). Subjects with a positive SARS-CoV-2 test recorded within 6 months before vaccination (n = 36,247; 6%) were matched to vaccinated-only controls. In the prioritized population exposed to the SARS-CoV-2 Alpha and Delta variants post-vaccination, the odds ratio (OR) for breakthrough infection was 2.2 (95% CI, 1.6−2.8; p < 0.001) in the vaccinated-only group compared with the hybrid immunity group, while in the later vaccinated non-prioritized population, the OR decreased from 4.3 (95% CI, 2.2−8.6; p < 0.001) during circulation of the Delta variant to 1.9 (95% CI, 1.7−2.1; p < 0.001) with the introduction of the Omicron variant (B.1.617.2). We conclude that hybrid immunity provides gains in protection, but that the benefits are smaller for risk groups and with circulation of the Omicron variant and its sublineages.

Oral health among older adults in nursing homes: A survey in a national quality register, the Senior Alert.

AIM: To investigate the extent to which the Revised Oral Assessment Guide-Jönköping (ROAG-J) is used by nursing staff routinely in nursing homes in Sweden and to describe oral health status of the residents. DESIGN: An observational, retrospective register-based study. METHODS: Data from different validated health assessments instruments, including ROAG-J, for the period 2011-2016 were obtained from the Web-based national quality register Senior Alert. The basis for the analyses was 190,016 assessments. RESULTS: About half of all residents had underwent at least one annual ROAG-J assessment (2014-2016). During the period 2011-2016, 42% of the residents (n = 92,827) were registered to have oral health problems. Significantly more oral health problems were found for men and for those with younger age, poorer physical condition, neurophysiological problems, underweight, impaired mobility and many medications. In conclusion, poorer oral health was found for more care-dependent individuals, which shows a need of preventive actions.

Assessment of hormonal levels as prognostic markers and of their optimal cut-offs in small intestinal neuroendocrine tumours grade 2.

PURPOSE: Small intestinal neuroendocrine tumours (siNETs) with a Ki-67 proliferation index between 3 and 20% belong to WHO grade 2. Response to treatment may be monitored by blood chromogranin A (CgA) and urine 5-hydroxyindoleacetic acid (5HIAA). The aim of this retrospective study was to investigate the prognostic value of baseline CgA and 5HIAA and of the early biochemical response to treatment, and to compare different cut-off values used in the literature. METHODS: A retrospective cohort study of 184 patients with siNET Grade 2 treated with somatostatin analogues (SSA), interferon-alpha (IFN) or peptide receptor radionuclide therapy (PRRT). RESULTS: Baseline CgA was a statistically significant prognostic marker for both cancer-specific survival (CSS) and progression-free survival (PFS). A cut-off of 5 × ULN (upper limit of normal) was best discriminative in most cases, but 2 × ULN discriminated better for SSA. Baseline 5HIAA was a prognostic marker for CSS in treatment with IFN and PRRT, but not for single SSA. Early changes of CgA and 5HIAA correlated well with CSS (HR 3.18, 95% CI 1.82-5.56 and HR 1.47, 95% CI 1.16-1.86) and PFS (HR 3.08, 95% CI 1.86-5.10 and HR 1.37, 95% CI 1.11-1.68) for SSA, but not for PRRT. CONCLUSIONS: Baseline CgA and to a lesser extent 5HIAA are associated with CSS irrespective of treatment used, and with PFS after PRRT, and 5 × ULN provides best discrimination in many, but not all, cases. Early reductions of CgA and 5HIAA are prognostic for treatment with SSA, but not PRRT.

[Personal physician continuity in primary care associated with fewer emergency room visits]. / Hög personlig läkar­kontinuitet i primärvård förenad med färre besök på akutmottagning - En populationsbaserad studie i Jönköpings sjukvårdsregion.

Overloading of the emergency departments in hospitals is, in Sweden, a common problem that is often blamed on lack of access to primary care.  We have conducted a cross-sectional study comprising more than 40% of the 347 837  inhabitants of Region Jönköping with access to complete individual data on healthcare consumption, personal doctor continuity, socio-economics, and accessibility data for all of the region's health centres. Individuals with high personal continuity at their own health centre had significantly fewer emergency room visits compared to those with the lowest continuity: for younger adults 55% and for elderly 34% fewer emergency room visits. Access to doctor consultations or to counselling nurses in primary care was not associated with a lower number of emergency room visits. Our results show the importance of personal doctor continuity also for the group of younger adults.

Surgical Treatment of Degenerative Disk Disease in Three Scandinavian Countries: An International Register Study Based on Three Merged National Spine Registers.

STUDY DESIGN: Observational study of prospectively collected data. OBJECTIVES: Patients with chronic low back pain resistant to nonoperative treatment often face a poor prognosis for recovery. The aim of the current study was to compare the variation and outcome of surgical treatment of degenerative disc disease in the Scandinavian countries based on The International Consortium for Health Outcomes Measurement core spine data sets. METHODS: Anonymized individual level data from 3 national registers were pooled into 1 database. At the time of surgery, the patient reports data on demographics, lifestyle topics, comorbidity, and data on health-related quality of life such as Oswestry Disability Index, Euro-Qol-5D, and back and leg pain scores. The surgeon records diagnosis, type of surgery performed, and complications. One-year follow-ups are obtained with questionnaires. Baseline and 1-year follow-up data were analyzed to expose any differences between the countries. RESULTS: A total of 1893 patients were included. At 1-year follow-up, 1315 (72%) patients responded. There were statistically significant baseline differences in age, smoking, comorbidity, frequency of previous surgery and intensity of back and leg pain. Isolated fusion was the primary procedure in all the countries ranging from 84% in Denmark to 76% in Sweden. There was clinically relevant improvement in all outcome measures except leg pain. CONCLUSIONS: In homogenous populations with similar health care systems the treatment traditions can vary considerably. Despite variations in preoperative variables, patient reported outcomes improve significantly and clinically relevant with surgical treatment.

Lumbar spinal stenosis: comparison of surgical practice variation and clinical outcome in three national spine registries.

BACKGROUND CONTEXT: Decompression surgery for lumbar spinal stenosis (LSS) is the most common spinal procedure in the elderly. To avoid persisting low back pain, adding arthrodesis has been recommended, especially if there is a coexisting degenerative spondylolisthesis. However, this strategy remains controversial, resulting in practice-based variation. PURPOSE: The present study aimed to evaluate in a pragmatic study if surgical selection criteria and variation in use of arthrodesis in three Scandinavian countries can be linked to variation in treatment effectiveness. STUDY DESIGN: This is an observational study based on a combined cohort from the national spine registries of Norway, Sweden, and Denmark. PATIENT SAMPLE: Patients aged 50 and older operated during 2011-2013 for LSS were included. OUTCOME MEASURES: Patient-Reported Outcome Measures (PROMs): Oswestry Disability Index (ODI) (primary outcome), Numeric Rating Scale (NRS) for leg pain and back pain, and health-related quality of life (Euro-Qol-5D) were reported. Analysis included case-mix adjustment. In addition, we report differences in hospital stay. METHODS: Analyses of baseline data were done by analysis of variance (ANOVA), chi-square, or logistic regression tests. The comparisons of the mean changes of PROMs at 1-year follow-up between the countries were done by ANOVA (crude) and analysis of covariance (case-mix adjustment). RESULTS: Out of 14,223 included patients, 10,890 (77%) responded at 1-year follow-up. Apart from fewer smokers in Sweden and higher comorbidity rate in Norway, baseline characteristics were similar. The rate of additional fusion surgery (patients without or with spondylolisthesis) was 11% (4%, 47%) in Norway, 21% (9%, 56%) in Sweden, and 28% (15%, 88%) in Denmark. At 1-year follow-up, the mean improvement for ODI (95% confidence interval) was 18 (17-18) in Norway, 17 (17-18) in Sweden, and 18 (17-19) in Denmark. Patients operated with arthrodesis had prolonged hospital stay. CONCLUSIONS: Real-life data from three national spine registers showed similar indications for decompression surgery but significant differences in the use of concomitant arthrodesis in Scandinavia. Additional arthrodesis was not associated with better treatment effectiveness.

Effectiveness of surgery for sciatica with disc herniation is not substantially affected by differences in surgical incidences among three countries: results from the Danish, Swedish and Norwegian spine registries.

PURPOSE: Yearly incidence of surgery for symptomatic lumbar disc herniation varies and is 29/100,000 in Sweden, 46/100,000 in Denmark and 58/100,000 in Norway. This variation was used to study whether differences in surgical incidence were associated with differences in preoperative patient characteristics as well as patient-reported outcomes. METHODS: Data from the national spine registers in Sweden, Denmark and Norway during 2011-2013 were pooled, and 9965 individuals, aged 18-65 years, of which 6468 had one-year follow-up data, were included in the study. Both absolute and case-mix-adjusted comparisons of the primary outcome Oswestry Disability Index (ODI) and the secondary outcomes EQ-5D-3L, and Numerical Rating Scale (NRS) for leg and back pain were performed. Case-mix adjustment was done for baseline age, sex, BMI, smoking, co-morbidity, duration of leg pain and preoperative value of the dependent variable. RESULTS: Mean improvement in the outcome variables exceeded previously described minimal clinical important change in all countries. Mean (95% CI) final scores of ODI were 18 (17-18), 19 (18-20) and 15 (15-16) in Sweden, Denmark and Norway, respectively. Corresponding results of EQ-5D-3L were 0.74 (0.73-0.75), 0.73 (0.72-0.75) and 0.75 (0.74-0.76). Results of NRS leg and back pain behaved similarly. Case-mix adjustment did not alter the findings substantially. CONCLUSION: We found no clear association between incidence of surgery for lumbar disc herniation and preoperative patient characteristics as well as outcome, and the differences between the countries were lower than the minimal clinical important difference in all outcomes. These slides can be retrieved under Electronic Supplementary Material.