Paul Blomqvist’s research while affiliated with Karolinska Institutet and other places

Context: There are no published data on drug prescription in patients with Addison's disease (AD). Objective: Our objective was to describe the drug prescription patterns in Swedish AD patients before and after diagnosis compared with population controls. Design and setting: We conducted a population-based cohort study in Sweden. Patients: Through the Swedish National Patient Register and the Swedish Prescribed Drug Register, we identified 1305 patients with both a diagnosis of AD and on combination treatment with hydrocortisone/cortisone acetate and fludrocortisone. Direct evidence of the AD diagnosis from patient charts was not available. We identified 11 996 matched controls by the Register of Population. Main outcome measure: We determined the ratio of observed to expected number of patients treated with prescribed drugs. Results: Overall, Swedish AD patients received more prescribed drugs than controls, and 59.3% of the AD patients had medications indicating concomitant autoimmune disease. Interestingly, both before and after the diagnosis of AD, patients used more gastrointestinal medications, antianemic preparations, lipid-modifying agents, antibiotics for systemic use, hypnotics and sedatives, and drugs for obstructive airway disease (all P values < .05). Notably, an increased prescription of several antihypertensive drugs and high-ceiling diuretics was observed after the diagnosis of AD. Conclusion: Gastrointestinal symptoms and anemia, especially in conjunction with autoimmune disorders, should alert the physician about the possibility of AD. The higher use of drugs for cardiovascular disorders after diagnosis in patients with AD raises concerns about the replacement therapy.

Objectives To investigate gender and age differences in sociodemographic risk factors and their relationship with femur shaft fractures and injury mechanisms in children. Methods Population based case-control study. Swedish children (N=1,874), aged 0–14 years, with a femur shaft fracture diagnostic code between 1987–2005 were compared to matched controls (N=18,740). Data were based on record linkage between six Swedish registers. Adjusted Odds Ratios were calculated. Results Parental age < 25 years old increased the risk (25%) for fracture, compared to parents with an average age of 25–37 years. When stratifying for gender and age group, the risk (40%) was only seen in older boys, 7–14 years of age. If parents’ total income was among the 25th percentile, the risk (20%) increased, compared to parents with an income in the 50th percentile. The risk (50%) was only seen in older girls living in low-income households. Children with at least one university-educated parent reduced their fracture risk (15%), compared to children whose parents had 10–12 years of education, but this decrease could not be linked to gender and age group. Family composition, number of siblings, birth order or receiving social welfare did not influence the fracture risk. Regarding the cause of injury none of the sociodemographic variables influenced the risk equal for boys and girls. Conclusions Sociodemographic differences related to femur shaft fracture rate and cause of injury differ between boys and girls in different age groups. This have implications for parental counselling.

Background & aims: It is unclear whether colectomy restores the ability of patients with ulcerative colitis (UC) to work to precolectomy levels. We estimated the burden of sick leave and disability pension in a population-based cohort of patients with UC and the effects of colectomy. Methods: We performed a register-based cohort study using the Swedish National Patient Register and identified working-age patients with UC in 2005 (n = 19,714) and patients who underwent colectomies between 1998 and 2002 (n = 807). Sick leave and disability pension data were retrieved from Statistics Sweden (1995-2005). Data from each patient in the study were compared with those from 5 age-, sex-, education-, and county-matched individuals from the general population. Results: In 2005, 15% of patients with prevalent UC received a disability pension, compared with 11% of the general population, and 21% vs 13% had ≥1 sick leave episode (P < .001 for each comparison). The annual median work days lost was 0 in both groups, but patients with UC had higher mean (65 vs 45 days; difference, 20; 95% confidence interval [CI], 18-22 days) and 75th percentile work days lost (37 vs 0 days; difference, 37; 95% CI, 36-38 days). Among patients who underwent colectomies, annual days lost increased from a mean of 40 (median, 0) days 3 years before surgery to 141 (median, 99) days during the year of surgery (P < .001). The number then decreased to a mean of 85 days 3 years after surgery (median, 0). The corresponding 75th percentile days were 17, 207, and 130, respectively. Three years after colectomy, 12% did not work at all compared with 7.2% of the general population (risk difference, 5.2%; 95% CI, 2.7%-7.7%) and compared with 5.9% 3 years before colectomy (P < .001). Conclusions: Patients with UC miss more work days than the general population in Sweden. Although most patients had no registered work loss 3 years after colectomy, work loss was not restored to presurgery or general population levels in the group that underwent colectomy during several years of follow-up.

Background Healthcare information provided by telephone service and internet sources is growing but has not been shown to reduce inappropriate emergency department (ED) visits. Objective To describe the use of advice or healthcare information among patients with non-urgent illnesses seeking care before attendance at an ED, or primary care (PC) centres in an urban region in Sweden. Design Patients with non-urgent illnesses seeking care at an ED or patients attending the PC were followed up with a combination of patient interviews, a questionnaire to the treating physician and a prospective follow-up of healthcare use through a population-based registry. Results Half of the non-urgent patients attending the ED had used healthcare information or advice before the visit, mainly from a healthcare professional source. In PC, men were more likely to have used information or advice compared with women (OR 2.5 95% CI 1.3 to 5.0), whereas the situation was reversed among ED patients (OR=0.4 95% CI 0.2 to 0.9). Men with no previous healthcare experience attending the ED had the lowest use of healthcare information (p<0.01). Very few in both groups had utilised healthcare information on the internet in a case of perceived emergency. Conclusion ED patients rated as non-urgent by the triage nurse used more advice and healthcare information than PC patients, irrespective of the physician-rated urgency of the symptoms. The problem seems not to be lack of information about appropriate ED use, but to find ways to direct the information to the right target group.

The overall completeness of the Swedish Cancer Register is high, although underreporting for certain sites must be acknowledged. The aims of the present study were twofold. Firstly to assess the completeness of reporting of pancreatic cancer to the Swedish Cancer Register, and secondly to identify and characterise long-term survivors based on information from two separate population-based register resources. To assess the completeness of the Cancer Register, pancreatic cancer cases registered in the National Patient Register between 1987 and 1999 were compared to cases reported to the Cancer Register. For estimations of long-term survival, the study population was restricted to 4321 cases identified both in the Cancer Register and the Patient Register with a histopathologically confirmed diagnosis of pancreatic ductal adenocarcinoma. A complete follow-up of survival in this group was performed till December 31, 2004. There was a considerable underreporting of pancreatic cancer to the Cancer Register. During the period under study, a total of 19 745 patients were identified with a diagnosis of pancreatic cancer. Of these, only 73% had been reported to the Cancer Register. The underreporting increased markedly with age at diagnosis and was more pronounced during the second period under study. Only 2.8% of patients with a histopathologically confirmed diagnosis of pancreatic ductal adenocarcinoma survived five years or longer. The likelihood of long-term survival was strongly associated with younger age and surgery. Pancreatic resection was reported in 20.4% of all patients. Median survival among those operated on was 12 months compared to 4.6 months in all patients. Underreporting of pancreatic cancer to the Swedish Cancer Register was pronounced and increased with older age. Less than 3% of patients with a record of pancreatic cancer both in the Cancer Register and the Patient Register survived five years or longer.

The surgical treatment of femur shaft fractures in children is changing, and the time spent in hospital is shorter than before. The purpose of this nationwide epidemiology study is to report incidence of pediatric femur shaft fractures in Sweden during 1987 to 2005 by age, sex, cause of injury, severity of injury, and seasonal variation, and to analyze the change in incidence, treatment modalities, and length of hospital stay over time. Children (N = 4984) with a diagnostic code for femur shaft fracture in Sweden 1987 to 2005 were selected from the Swedish National Hospital Discharge Registry. The overall annual incidence per 100,000 children was 22.9 in boys and 9.5 in girls. The incidence declined by 42%, on average 3% per year, from 19.4 to 11.8 between 1987 and 2005 (P < 0.001). The most common cause of injury in children younger than 4 years of age was fall of < 1 m; in children 4 to 12 years of age, sports accidents were the most frequent cause of injury; and in children 13 to 14 years of age, traffic accidents. The month of occurrence for femur shaft fractures had a bimodal seasonal variation with a peak in March and in August. Treatment modalities were changing during the study period from the use of traction to an increased use of external fixation and elastic intramedullary nailing. The length of hospital stay decreased by 81%, from 26 days in 1987 to 5 days in 2005 (P < 0.001), but had no correlation to the introduction of new surgical treatment methods. The present nationwide study of femur shaft fractures shows a decrease of fracture incidence, a shift in the treatment modalities, and shorter length of hospital stay. Level III, retrospective comparative study.

Survivors of aneurysmal subarachnoid hemorrhage (SAH) may have an increased risk of cardiovascular events because of shared risk factors. We compared incidences of vascular diseases, vascular death, and all-cause death after SAH with those in the general population. From the Swedish Hospital Discharge and Cause of Death registries, we identified patients with SAH between January 1987 and January 2003. Conditional on survival of 3 months after SAH, we calculated standardized mortality and incidence ratios with corresponding 95% CIs for vascular death, all-cause death, and fatal or nonfatal vascular diseases. Cumulative risks were estimated with survival analysis. Of 17,705 patients with SAH (mean age, 59.7 years; 59.5% women), 11,374 survived at least 3 months after SAH. During follow-up (mean, 6.8 years), 2152 (18.9%) died. The risk of death was 12.9% within 5 years, 23.6% within 10 years, and 35.4% within 15 years after SAH. The overall standardized mortality ratio was 1.57 (95% CI, 1.44 to 1.70) for vascular death and 1.61 (95% CI, 1.52 to 1.70) for all-cause death. The standardized mortality ratios were particularly high in younger individuals, ranging from 2.1 to 3.7 for vascular death and from 2.1 to 2.6 for all-cause death for patients between 50 and 65 years of age. The standardized incidence ratio for fatal or nonfatal vascular diseases was 1.51 (95% CI, 1.45 to 1.56). Mortality and risk of vascular diseases are increased in survivors of SAH. Prevention of new vascular diseases after SAH by management of risk factors seems important.

Unscheduled visits to an emergency department (ED) or to primary care (PC) are often followed by further healthcare contacts. Present knowledge about predisposing factors and differences between healthcare levels is sparse. The objectives of this study were to describe and to analyze factors influencing subsequent healthcare contacts within 30 days following a non-urgent ED visit or an unscheduled visit in PC. In this prospective cohort study, subjects were identified and interviewed at the time of a non-urgent ED visit or unscheduled visits to PC. Data of all healthcare contacts during 1 month were collected. The probability of reattendance was analyzed regarding socio-demographic factors, previous and present health care utilization, the physicians' perceptions of the urgency of the visit, and appropriateness of its level of care. More than half of the patients in both settings had at least one contact with healthcare the following month. In 16% of the ED patients and 9% of PC patients, these contacts were to an ED. In the multivariate analysis, patients with regular monitoring of chronic disease were associated with an increased probability of having one or more physician visit the following month (OR 1.97 CI 95% 1.15-3.36). In conclusion, previous health care utilization was associated with an increased probability of one or more further physician visits the following month, regardless of the setting for the index visit or other patients characteristics. Physicians' perception of urgency did not influence the probability of further contacts.