Visit Experience and Fulfillment of Care Needs in Primary Care Differs for Video Visits Compared to In-person and Chat Visits

BACKGROUND

There is a lack of research comparing patient experience and to what extent patients' care needs are fulfilled in telemedicine compared to in-person care.

OBJECTIVE

To investigate if patient experience and fulfillment of care needs differ between video and chat visits with direct to consumer telemedicine providers compared to in-person visits.

DESIGN

Cross-sectional study.

PARTICIPANTS

Adults visiting a primary care physician in person or via chat or video in Region Stockholm, Sweden, October 2020-May 2021.

MAIN MEASURES

Patient-reported visit experience and fulfillment of care needs.

KEY RESULTS

The sample included 3315 patients who had an in-person (1950), video (844), or chat (521) visit. Response rates were 42% for in-person visitors and 41% for telemedicine visitors. Patients were 18-97 years old, mean age of 51 years, and 66% were female. In-person visitors reported the most positive patient experience ("To a very high degree" or "Yes, completely") for being listened to (64%), being treated with care (64%), and feeling trust and confidence in the health care professional (76%). Chat visitors reported the most positive patient experience for being given enough time (61%) and having care needs fulfilled during the care visit (76%). Video visitors had the largest proportion of respondents choosing "To a very low degree" or "No, not at all" for all visit experience measures. There were statistically significant differences in the distribution of visit experiences between in-person, video, and chat visits for all visit experience measures (P < 0.001).

CONCLUSIONS

Video visits were associated with a more negative visit experience and lower fulfillment of care needs than in-person visits. Chat visits were associated with a similar patient experience and fulfillment of care needs as in-person visits. Chat visits may be a viable alternative to in-person visits for selected patients.

Individual Patient Factors Associated with the Use of Physical or Digital Primary Care in Sweden

Introduction: Little is known about factors that influence patients' choice to use physical or digital primary care. This study aimed to compare self-rated health, internet habits, and what patients deem important when choosing health care between users of physical and digital primary health care. Methods: We recruited 2,716 adults visiting one of six physical or four digital primary health care providers in Stockholm, Sweden, October 2020 to May 2021. Participants answered a questionnaire with questions about sociodemography, self-rated health, internet habits, and what they considered important when seeking care. We used logistic regression and estimated odds ratios (ORs) for choosing digital care. Results: Digital users considered themselves healthier and used the internet more, compared with physical users (p < 0.001). Competence of health care staff was the most important factor when seeking care to both physical and digital users (90% and 78%, respectively). Patients considering it important to avoid leaving home were more likely to seek digital care (OR 29.55, 95% confidence interval [CI] 12.65-69.06), while patients valuing continuity were more likely to seek physical care (OR 0.25, 95% CI 0.19-0.32). These factors were significant also when adjusting for self-rated health and sociodemographic characteristics. Conclusion: What patients considered important when seeking health care was associated with what type of care they sought. Patient preferences should be considered when planning health care to optimize resource allocation.

The association of short and long sleep with mortality in men and women

Both short (< 6 hr) and long (> 8 hr) sleep are associated with increased mortality. We here investigated whether the association between sleep duration and all-cause, cardiovascular disease and cancer mortality differs between men and women. A cohort of 34,311 participants (mean age and standard deviation = 50.5 ± 15.5 years, 65% women), with detailed assessment of sleep at baseline and up to 20.5 years of follow-up (18 years for cause-specific mortality), was analysed using Cox proportional hazards model to estimate HRs with 95% confidence intervals. After adjustment for covariates, all-cause, cardiovascular disease and cancer mortalities were increased for both < 5 hr and ≥ 9 hr sleep durations (with 6 hr as reference). For all-cause mortality, women who slept < 5 hr had a hazard ratio = 1.54 (95% confidence interval = 1.32-1.80), while the corresponding hazard ratio was 1.05 (95% confidence interval = 0.88-1.27) for men, the interaction being significant (p < 0.05). For cardiovascular disease mortality, exclusion of the first 2 years of exposure, as well as competing risk analysis eliminated the originally significant interaction. Cancer mortality did not show any significant interaction. Survival analysis of the difference between the reference duration (6 hr) and the short duration (< 5 hr) during follow-up showed a gradually steeper reduction of survival time for women than for men for all-cause mortality. We also observed that the lowest cancer mortality appeared for the 5-hr sleep duration. In conclusion, the pattern of association between short sleep duration and all-cause mortality differed between women and men, and the difference between men and women increased with follow-up time.

A validation study comparing energy and nutrient intake between a web-based food frequency questionnaire and a 4-d dietary record

OBJECTIVE

Reliable assessments of dietary intake is crucial when examining associations between dietary factors and different outcomes. Today, web-based instead of paper-based food frequency questionnaires (FFQs) are common. A web-based FFQ implies a different experience (including design differences, the possibility only to show relevant questions, and automatic checks for completeness) and may capture dietary intake differently. The aim of this study was to validate a well-used paper-based FFQ transferred to a web-based version against a 4-d dietary record.

METHODS

Baseline data from a dietary intervention study comprising women and men with type 2 diabetes were used. Diet was assessed with the web-based FFQ and a 4-d dietary record. Energy intake and energy-adjusted nutrient intakes were assessed and compared using Spearman's rank correlation and Bland-Altman analysis. The analysis included 101 participants.

RESULTS

The average energy intake with the FFQ was 2068 kcal, 157 kcal higher than the average from the dietary record. Significant deattenuated correlations were found for intake of energy (r = 0.37; 95% confidence interval [CI],0.19-0.53), carbohydrates (r = 0.85; 95% CI, 0.78-0.89), protein (r = 0.53; 95% CI, 0.38-0.66) and fat (r = 0.59; 95% CI, 0.44-0.70). Significant deattenuated correlations (ranging r = 0.26-0.73) were found for intake of alcohol, whole grain, fiber, saturated fat, monounsaturated fat, polyunsaturated fat, cholesterol, vitamins A, B12, C, D, and E, folate, iron, potassium, magnesium, and calcium. Bland-Altman analyses showed no clear trends but wide limits of agreement.

CONCLUSION

Overall, the web-based FFQ performed well and is similar to the paper-based version. It can be a useful tool for dietary assessments.

Effectiveness of a Smartphone App to Promote Physical Activity Among Persons With Type 2 Diabetes: Randomized Controlled Trial

BACKGROUND

Physical activity is well known to have beneficial effects on glycemic control and to reduce risk factors for cardiovascular disease in persons with type 2 diabetes. Yet, successful implementation of lifestyle interventions targeting physical activity in primary care has shown to be difficult. Smartphone apps may provide useful tools to support physical activity. The DiaCert app was specifically designed for integration into primary care and is an automated mobile health (mHealth) solution promoting daily walking.

OBJECTIVE

This study aimed to investigate the effect of a 3-month-long intervention promoting physical activity through the use of the DiaCert app among persons with type 2 diabetes in Sweden. Our primary objective was to assess the effect on moderate to vigorous physical activity (MVPA) at 3 months of follow-up. Our secondary objective was to assess the effect on MVPA at 6 months of follow-up and on BMI, waist circumference, hemoglobin A1c, blood lipids, and blood pressure at 3 and 6 months of follow-up.

METHODS

We recruited men and women with type 2 diabetes from 5 primary health care centers and 1 specialized center. Participants were randomized 1:1 to the intervention or control group. The intervention group was administered standard care and access to the DiaCert app at baseline and 3 months onward. The control group received standard care only. Outcomes of objectively measured physical activity using accelerometers, BMI, waist circumference, biomarkers, and blood pressure were assessed at baseline and follow-ups. Linear mixed models were used to assess differences in outcomes between the groups.

RESULTS

A total of 181 study participants, 65.7% (119/181) men and 34.3% (62/181) women, were recruited into the study and randomized to the intervention (n=93) or control group (n=88). The participants' mean age and BMI were 60.0 (SD 11.4) years and 30.4 (SD 5.3) kg/m2, respectively. We found no significant effect of the intervention (group by time interaction) on MVPA at either the 3-month (β=1.51, 95% CI -5.53 to 8.55) or the 6-month (β=-3.53, 95% CI -10.97 to 3.92) follow-up. We found no effect on any of the secondary outcomes at follow-ups, except for a significant effect on BMI at 6 months (β=0.52, 95% CI 0.20 to 0.84). However, mean BMI did not differ between the groups at the 6-month follow-up.

CONCLUSIONS

We found no evidence that persons with type 2 diabetes being randomized to use an app promoting daily walking increased their levels of MVPA at 3 or 6 months' follow-up compared with controls receiving standard care. The effect of the app on BMI was unclear, and we found nothing to support an effect on secondary outcomes. Further research is needed to determine what type of mHealth intervention could be effective to increase physical activity among persons with type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03053336; https://clinicaltrials.gov/study/NCT03053336.

Ideal cardiovascular health and risk of death in a large Swedish cohort

BACKGROUND

Ideal cardiovascular health (CVH) can be assessed by 7 metrics: smoking, body mass index, physical activity, diet, hypertension, dyslipidemia and diabetes, proposed by the American Heart Association. We examined the association of ideal CVH metrics with risk of all-cause, CVD and non-CVD death in a large cohort.

METHODS

A total of 29,557 participants in the Swedish National March Cohort were included in this study. We ascertained 3,799 deaths during a median follow-up of 19 years. Cox regression models were used to estimate hazard ratios with 95% confidence intervals (95% CIs) of the association between CVH metrics with risk of death. Laplace regression was used to estimate 25th, 50th and 75th percentiles of age at death.

RESULTS

Compared with those having 6-7 ideal CVH metrics, participants with 0-2 ideal metrics had 107% (95% CI = 46-192%) excess risk of all-cause, 224% (95% CI = 72-509%) excess risk of CVD and 108% (31-231%) excess risk of non-CVD death. The median age at death among those with 6-7 vs. 0-2 ideal metrics was extended by 4.2 years for all-causes, 5.8 years for CVD and 2.9 years for non-CVD, respectively. The observed associations were stronger among females than males.

CONCLUSIONS

The strong inverse association between number of ideal CVH metrics and risk of death supports the application of the proposed seven metrics for individual risk assessment and general health promotion.

Risk of Death in Patients With Coronary Artery Disease Taking Nitrates and Phosphodiesterase-5 Inhibitors

BACKGROUND

Phosphodiesterase-5 inhibitor (PDE5i) treatment for erectile dysfunction is associated with lower mortality compared with no treatment for erectile dysfunction after myocardial infarction (MI). There are conflicting results regarding the impact of PDE5i treatment on mortality in conjunction with nitrate medication.

OBJECTIVES

The purpose of this study was to investigate the association between PDE5i treatment and cardiovascular outcomes in men with stable coronary artery disease treated with nitrate medication.

METHODS

Using the Swedish Patient Register and the Prescribed Drug Register we included men with previous MI or revascularization in 2006-2013 who had 2 dispensed nitrate prescriptions within 6 months. Exposure was defined as at least 2 filled prescriptions of any PDE5i. We performed multivariable Cox proportional hazard regression to estimate HRs with 95% CIs for all-cause, cardiovascular, and noncardiovascular mortality, MI, heart failure, cardiac revascularization, and major cardiovascular events (MACE).

RESULTS

In total, 55,777 men were treated with nitrates and 5,710 men with nitrates and a PDE5i. The combined use of PDE5i treatment with nitrates was associated with higher mortality (HR: 1.39; 95% CI: 1.28-1.51), cardiovascular mortality (HR: 1.34; 95% CI: 1.11-1.62), noncardiovascular mortality (HR: 1.40; 95% CI: 1.27-1.54), MI (HR: 1.72; 95% CI: 1.55-1.90), heart failure (HR: 1.67; 95% CI: 1.48-1.90), cardiac revascularization (HR: 1.95; 95% CI: 1.78-2.13), and MACE (HR: 1.70; 95% CI: 1.58-1.83).

CONCLUSIONS

The use of a PDE5i in combination with nitrate medication in men with stable coronary artery disease may pose an increased hazard for cardiovascular morbidity and mortality. Careful patient-centered consideration before prescribing PDE5is to patients with cardiovascular disease using nitrate medication is warranted.

Systematic Development of National Guidelines for Obesity Care: The Swedish Approach

INTRODUCTION

With the rapid development of treatment modalities for obesity management, there is an increasing demand for guidance to facilitate the prioritization of interventions. In 2020, the Swedish National Board of Health and Welfare started the process of producing the first national guidelines for obesity care directed to decision makers who allocate resources to the best knowledge-based care. The main aim of this paper was to describe the systematic development of these guidelines, designed to guarantee uniformly high standards of care throughout the whole country.

METHODS

The standardized procedures of the National Board of Health and Welfare were applied to construct guidelines in a systematic and transparent way, including priority setting of recommendations and quality indicators to evaluate the progress of implementation. The process involved independent expert committees including professionals and patient representatives, and the guidelines were reviewed through an open public consultation.

RESULTS

National guidelines were issued in 2023, encompassing a broad scope, from identification and diagnosis to multiple treatment modalities, embedded in a life-course perspective from pregnancy to the elderly, as well as highlighting the need for improved knowledge and competence of health care providers.

CONCLUSIONS

National guidelines for improved standard care and evidence-based and efficient use of health care resources for obesity treatment can be developed in a systematic way with professionals and patient representatives.

Wrist-worn accelerometers: Influence of decisions during data collection and processing: A cross-sectional study

Background and Aims

Accelerometers collect data in an objective way, however, a number of decisions must be done during data collection, processing and output-interpretation. The influence of those decisions is seldom investigated, reported, or discussed. Herein, we examined the influence of different decisions on the outcomes: daily minutes of moderate-to-vigorous physical activity (MVPA), inactivity and light physical activity (LPA).

Methods

In total, 156 participants wore an accelerometer (ActiGraph wGT3X-BT) on their nondominant wrist for 7 days. Data collection was conducted from February 2017 to June 2018. Data was processed using the R-package GGIR and default settings were compared to by-the-literature-suggested options. The output was examined using paired t-tests.

Results

When comparing two commonly used MVPA-cut-points, default and Hildebrand et al. we found a marginal difference (0.4 min, 1.0%, p < 0.001) in MVPA/day. When no bout criteria for MVPA/day was applied, MVPA/day was twice as high as bouted MVPA/day. Further, when we changed the epoch-length from 5 to 1 s, statistically significant changes were seen for MVPA/day (-6.6 min, 19%, p < 0.001), inactivity/day (-22 min, 3.0%, p < 0.001) and LPA/day (28 min, 81%, p < 0.001).

Conclusion

Decisions made during data processing of wrist-worn accelerometers has an influence on the output and thus, may influence the conclusions drawn. However, there may be situations when these settings are changed. If so, we recommend examining if the variables of interest are affected. We encourage researchers to report decisions made during data collection, processing and output-interpretation, to facilitate comparisons between different studies.

Discrepancy between Current, Desired, and Ideal Body Mass Index in Persons with Obesity: A Swedish Population-Based Study

INTRODUCTION

Body weight dissatisfaction, when current and desired body mass index (BMI) do not align, is common in persons with obesity. The aim of this cross-sectional study was to explore factors associated with the differences between current and desired BMI, and ideal BMI (defined in the present study as BMI 25 kg/m2), in persons with obesity.

METHODS

Swedish citizens aged 20-64 years residing in the Stockholm County were randomly selected from the population register at five different and evenly separated occasions in the study period 1998-2000 and invited to provide self-reported data about their current weight, height, desired weight, and other characteristics such as depressive symptoms and alcohol intake. Among the 10,441 participants with a mean BMI of 24 kg/m2, differences between desired BMI and ideal BMI were calculated to determine the discrepancy between desired BMI and ideal BMI in participants with obesity (n = 808). The discrepancy between current and desired BMI was also determined. Using linear regression, factors associated with BMI discrepancies were determined.

RESULTS

Persons with BMI <40 kg/m2 desired a lower BMI than those with BMI ≥40 kg/m2 (26 ± 3 vs. 36 ± 14 kg/m2, p < 0.001). Women with obesity (n = 425) had a larger discrepancy between current and desired BMI, 32% ± 16, than men with obesity (n = 380), 24% ± 21 (p < 0.001). Persons with obesity and major depression had a 6.9% (95% CI: 2.5-11.4) larger discrepancy between current and desired BMI than persons with obesity but without major depression. Being born abroad, having a university degree, or hazardous alcohol use were not associated with discrepancy between current and desired BMI or desired BMI and ideal BMI (all p > 0.05).

CONCLUSION

Desired BMI and discrepancies between current, desired, and ideal BMI vary according to current BMI, sex, and presence of major depression. This underscores the significance of a patient-centered approach in the management of obesity, where the goals and needs of each patient should be considered.

Appetite and its association with mortality in patients with advanced cancer - a Post-hoc Analysis from the Palliative D-study

BACKGROUND

Loss of appetite is a common nutrition symptom in patients with cancer. Understanding the trajectory of appetite could be of clinical use for prognostication in palliative cancer care. Our primary aim was to explore the association between self-assessed appetite and mortality in patients suffering from advanced cancer. Secondary aims included the relation between fatigue, albumin levels and CRP/albumin ratio and mortality. We also aimed to study potential sex-differences in the associations.

METHODS

Post-hoc analyses were performed using data from the Palliative D-study comprising 530 patients with cancer admitted to palliative care. Appetite and fatigue were assessed with the Edmonton Symptom Assessment System (ESAS). Cox proportional hazards models were used to calculate Hazard ratios (HR) with 95% confidence intervals (CI) for exposures of appetite, fatigue, albumin and CRP/albumin ratio, and time from study inclusion to death or censoring. Analyses were also performed stratified by sex.

RESULTS

The follow-up time ranged between 7 to 1420 days. Moderate and poor appetite were significantly associated with a higher mortality rate compared to reporting a good appetite; HR 1.44 (95%CI: 1.16-1.79) and HR 1.78 (95%CI: 1.39-2.29), respectively. A higher mortality rate was also seen among participants reporting severe fatigue compared to those reporting no fatigue; HR 1.84 (95%CI:1.43-2.36). Participants with low albumin levels (< 25 g/L) and those in the highest tertile of CRP/albumin ratio, had higher mortality rates, HR 5.35 (95%CI:3.75-7.63) and HR 2.66 (95%CI:212-3.35), compared to participants with high albumin levels (> 36 g/L) and those in lowest tertile of CRP/albumin ratio. These associations were more pronounced in men than in women.

CONCLUSION

Poor appetite, severe fatigue, low albumin level and a high CRP/albumin ratio were associated with increased mortality rates among patients with advanced cancer. All these variables might be clinically useful for prognostication in palliative cancer care.

TRIAL REGISTRATION

Clinicaltrial.gov. Identifier: NCT03038516;31, January 2017.

Vitamin E - a scoping review for Nordic Nutrition Recommendations 2023

Current evidence suggests that dietary vitamin E (as α-tocopherol) intake has a beneficial role in preventing certain chronic diseases. In contrast, there is no clear evidence for the benefit of α-tocopherol supplements in a generally healthy population. Deficiency symptoms are rare and mainly occur due to genetic or other factors affecting α-tocopherol absorption and/or metabolism, rather than a low α-tocopherol intake. No qualified systematic review was identified by the NNR2023 project for updating the dietary reference values (DRV).

The effect of an app-based dietary intervention on diet-related greenhouse gas emissions - results from a randomized controlled trial

BACKGROUND

Dietary change towards a diet low in greenhouse gas emissions (GHGEs) can reduce climate impact and improve individual-level health. However, there is a lack of understanding if diet interventions can achieve low-GHGE diets.

METHODS

A randomized controlled trial was conducted to assess the effects of an app-based intervention. The intervention was designed to improve dietary intake of people with Type 2 diabetes, and was delivered via an app over 12 weeks, with each week covering one diet-related topic. Dietary intake was assessed at baseline and 3-month follow up by a 95-item food frequency questionnaire and linked to GHGE values. A total of n = 93 participants (n = 46 and n = 47 for the intervention and control group, respectively) were included in the analysis. Changes to GHGEs within and between the groups were analysed with inferential statistics.

RESULTS

The majority (60%) of participants were male, with a mean age of 63.2 years and body mass index of 30 kg/m2. At baseline, diet-related GHGEs were 4.8 and 4.9 kg CO2-eq/day in the intervention and control group, respectively. At 3-month follow up the corresponding GHGEs were 4.7 and 4.9 kg CO2-eq/day. We found no statistically significant changes to diet-related GHGEs within or between groups, or within food categories, from baseline to 3-month follow up.

CONCLUSION

No evidence was found for the effectiveness of the app-based intervention to generate changes to diet-related GHGEs in a population of people with Type 2 diabetes. However, future interventions that target reducing meat consumption specifically may have the potential to result in a reduction of individual-level diet-related GHGEs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03784612. Registered 24 December 2018. www.

CLINICALTRIALS

gov/ct2/show/NCT03784612 .

Effect of a Smartphone Application on Physical Activity and Weight Loss After Bariatric Surgery-Results from a Randomized Controlled Trial

PURPOSE

Ways to motivate and support patients in being physically active after bariatric surgery are needed. This trial was aimed at evaluating the effect of using a smartphone application targeting physical activity during 12 weeks on moderate-to-vigorous physical activity (MVPA, primary outcome) and secondary outcomes of inactivity, light physical activity (LPA), body mass index (BMI), and percent total weight loss (%TWL) after bariatric surgery.

MATERIALS AND METHODS

Data from a randomized controlled trial comprising 146 patients (79.5% women) undergoing bariatric surgery was analyzed. Mean age and BMI pre-surgery were 40.9 years and 40.5 kg/m2, respectively. Participants were randomized 1:1 to an intervention or a control group. Physical activity and body weight were objectively measured at baseline pre-surgery and post-surgery follow-ups after 6 weeks (weight only), 18 weeks, 6 months, and 1 year. Linear mixed models were fitted to assess longitudinal differences in outcomes between the groups.

RESULTS

A significant effect of the intervention (group-by-time interaction 16.2, 95% CI 3.5 to 28.9) was seen for MVPA at 18 weeks; the intervention group had increased their MVPA since baseline, while the control group had decreased their MVPA. The control group had lowered their BMI approximately 1 kg/m2 more than the intervention group at follow-up after 18 weeks and 12 months, yet, mean BMI did not differ between the groups. No intervention effect was seen on inactivity, LPA, or %TWL.

CONCLUSION

Our results indicate that use of a smartphone application targeting physical activity may have the potential to promote short-term MVPA post bariatric surgery.

TRIAL REGISTRATION

Clinicaltrials.gov : NCT03480464.

Interactive association between insomnia symptoms and sleep duration for the risk of dementia-a prospective study in the Swedish National March Cohort

OBJECTIVE

Given the importance of sleep in maintaining neurocognitive health, both sleep duration and quality might be component causes of dementia. However, the possible role of insomnia symptoms as risk factors for dementia remain uncertain.

METHODS

We prospectively studied 22,078 participants in the Swedish National March Cohort who were free from dementia and stroke at baseline. Occurrence of dementia was documented by national registers during a median follow-up period of 19.2 years. Insomnia symptoms and sleep duration were ascertained by Karolinska Sleep Questionnaire. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Compared to participants without insomnia at baseline, those who reported any insomnia symptom experienced a greater incidence of dementia during follow-up (HR 1.08, 95% CI: 1.03, 1.35). Difficulty initiating sleep versus non-insomnia (HR 1.24, 95% CI: 1.02, 1.52), but not difficulty maintaining sleep or early morning awakening was associated with an increased risk of dementia. Short sleep duration was associated with increased risk of dementia (6 h vs. 8 h, HR 1.29, 95% CI: 1.11-1.51; 5 h vs. 8 h, HR 1.26, 95% CI: 1.00-1.57). Stratified analyses suggested that insomnia symptoms increased the risk of dementia only amongst participants with ≥7 h sleep (vs. non-insomnia HR 1.24, 95% CI: 1.00-1.54, P = 0.05), but not amongst short sleepers (<7 h). Short sleep duration also did not further inflate the risk of dementia amongst insomniacs.

CONCLUSION

Insomnia and short sleep duration increase the risk of dementia amongst middle-aged to older adults.

Patients' Perspectives on Dietary Patterns and Eating Behaviors During Weight Regain After Gastric Bypass Surgery

PURPOSE

Food quality, energy intake, and various eating-related problems have been highlighted as some of the components influencing weight after bariatric surgery. This study aimed to increase our knowledge of patients' perspectives on dietary patterns and eating behaviors during weight regain after bariatric surgery.

MATERIALS AND METHODS

We recruited 4 men and 12 women with obesity and the experience of weight regain after bariatric surgery at an obesity clinic in Stockholm, Sweden. Data were collected during 2018-2019. We conducted a qualitative study, carried out individual semi-structured interviews, and analyzed the recorded and transcribed interview data with thematic analysis.

RESULTS

Participants had regained 12 to 71% from their lowest weight after gastric bypass surgery performed 3 to 15 years before. They perceived their dietary challenges as overwhelming and had not expected weight management, meal patterns, increasing portion sizes, and appealing energy-dense foods to be problematic after surgery. In addition, difficulties with disordered eating patterns, emotional eating, and increased alcohol intake further contributed to the weight management hurdles. Insufficient nutritional knowledge and lack of support limited participants' ability to avoid weight regain, leading to restrictive eating and dieting without sustained weight loss.

CONCLUSION

Eating behavior and dietary factors such as lack of nutritional knowledge, emotional eating, or disorganized meal patterns contribute to difficulties with weight management after gastric bypass surgery. Improved counseling may help patients prepare for possible weight regain and remaining challenges with food and eating. The results highlight the importance of regular medical nutrition therapy after gastric bypass surgery.

The Swedish Youth with Obesity cohort: Profile of an ongoing prospective study

OBJECTIVE

As there is a lack of studies on adolescents and young adults with obesity, the Swedish Youth with Obesity cohort was set up to describe the long-term results of medical, as well as surgical, obesity interventions in youth. This article describes the study protocol.

METHODS

Since 2018, the study has continuously recruited patients aged between 16 and 25 years who have been admitted for obesity treatment at a specialist obesity clinic in Stockholm, Sweden. Participants provide data from blood tests, questionnaires, and anthropometric measurements. Data are collected longitudinally at enrollment and after 18 months and 3, 4, 5, and 10 years.

RESULTS

In the first 500 participants (76% female), the mean age was 21 (SD 3.0) years and the mean BMI was 41.3 (SD 6.1) kg/m² at enrollment. Almost half of the participants (44.4%) reported that both parents were born outside the Nordic countries. The proportion of participants who smoked at least sometimes was 28.4%.

CONCLUSIONS

The longitudinally collected data from the Swedish Youth with Obesity cohort will become a valuable source for answering various research questions regarding long-term results of medical and surgical obesity treatment in adolescents and young adults with obesity.

Prospective study of weight loss and all-cause-, cardiovascular-, and cancer mortality

Effects of repeated weight changes on mortality are not well established. In this prospective cohort study, we followed 34,346 individuals from 1997 to 2018 for all-cause mortality, and 2016 for cause-specific mortality. At baseline, participants self-reported amount and frequency of prior weight loss. During 20.6 (median) years of follow-up, we identified 5627 deaths; 1783 due to cancer and 1596 due to cardiovascular disease (CVD). We used Cox Proportional Hazards models to estimate multivariable-adjusted Hazard Ratios (HRs) and 95% confidence intervals (CI). Participants with a weight loss > 10 kg had higher rates of all-cause (HR 1.22; 95%CI 1.09-1.36) and CVD mortality (HR 1.27; 95%CI 1.01-1.59) compared to individuals with no weight loss. Men who had lost > 10 kg had higher all-cause (HR 1.55; 95%CI 1.31-1.84) and CVD mortality (HR 1.55; 95%CI 1.11-2.15) compared to men with no weight loss. Participants who had lost ≥ 5 kg three times or more prior to baseline had increased rates of all-cause (HR 1.16; 95%CI 1.03-1.30) and CVD mortality (HR 1.49; 95%CI 1.20-1.85) compared to participants with no weight loss. We found no association between weight loss and cancer mortality. We conclude that previous and repeated weight loss may increase all-cause and CVD mortality, especially in men.

A Digital Platform and Smartphone App to Increase Physical Activity in Patients With Type 2 Diabetes: Overview Of a Technical Solution

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-018-5026-4.

Dietary habits after a physical activity mHealth intervention: a randomized controlled trial

BACKGROUND

A healthy diet and a sufficient amount of physical activity are important factors to reduce complications of type 2 diabetes. Diet and physical activity are associated behaviours. Individuals who are physically active have also been shown to have healthier eating habits than sedentary individuals. We aimed to evaluate the indirect effect of a smartphone-based physical activity intervention on dietary habits in patients with type 2 diabetes.

METHODS

We performed analyses of secondary outcomes in a randomized controlled trial. The active intervention was use of a smartphone application to promote physical activity during 12 weeks. Dietary intake was assessed at baseline and after three months using a validated semi-quantitative food frequency questionnaire comprising 94 items. We analysed changes in the intake of fruit and vegetables, snacks, fibre, whole grains, vitamin C, saturated fat, unsaturated fat and total energy. We also assessed overall dietary habits using a dietary index developed by the Swedish National Board of Health and Welfare. Results were compared between the intervention and control group, as well as stratified by sex within the study groups. Paired t-tests and analysis of covariance were performed.

RESULTS

A total of 181 patients were recruited to the DiaCert-study, whereof 146 patients had complete dietary data and were included in the analyses. Women in the intervention group had a higher fruit and vegetable intake (p = 0.008) and a higher dietary index (p = 0.007), at three-months compared to women in the control group. They had increased their daily intake of fruit and vegetables by on average 87.4 g/day (p = 0.04) and improved their dietary index by on average 0.8 points (p = 0.01) from baseline to follow-up. No effect was found in men.

CONCLUSIONS

Women, but not men, receiving a smartphone-based physical activity intervention improved their total intake of fruit and vegetables. The transfer effect, i.e. an intervention aimed at promoting one health behavior that facilitates changes in other health behaviors, may differ between the sexes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03053336; 15/02/2017.

Weight loss history and its association with self-esteem and eating behaviors in adolescents and young adults with obesity

Introduction Previous weight loss attempts in young people with obesity may have influenced their beliefs about themselves and contributed to maladaptive eating behaviors. Therefore, we aimed to investigate the association between previous weight loss with self-esteem and different eating behaviors in adolescents and young adults with obesity seeking specialty obesity care. Methods We performed a cross-sectional study, where a total of 224 participants with obesity, aged 16-25, self-reported the amount and the frequency of previous weight loss of 5 kg or more. Self-esteem was assessed with Rosenberg's Self-Esteem Scale and eating behavior with the Three-Factor Eating Questionnaire-Revised21. Linear regression was used to analyze associations between the amount of weight loss (no weight loss, 5-10 kg, and >10 kg) and the frequency of weight loss >5 kg (0, 1, and >2 times) with self-esteem and eating behaviors. Results We found that both those who had lost 5-10 kg and those who had lost >5 kg twice or more, had statistically significantly higher cognitive restraint eating scores β=7.03 (95%CI: 0.004 to 14.05) and β=8.32 (95%CI: 1.20 to 15.43), respectively, compared to those who reported no previous weight loss. No other statistically significant associations were found. Discussion/Conclusion Previous weight loss in adolescents and young adults with obesity may be associated with a higher cognitive restraint eating behavior. Therefore, assessing weight loss history and eating behavior may be beneficial to better individualize obesity treatment.

Maternal Health, Pregnancy and Offspring Factors, and Maternal Thyroid Cancer Risk: A Nordic Population-Based Registry Study

Thyroid cancer incidence is higher in women than men, especially during the reproductive years, for reasons that remain poorly understood. Using population-based registry data from 4 Nordic countries through 2015, we examined associations of perinatal characteristics with risk of maternal thyroid cancer. Cases were women diagnosed with thyroid cancer ≥2 years after last birth (n = 7,425, 83% papillary). Cases were matched to controls (n = 67,903) by mother's birth year, country, and county of residence. Odds ratios (ORs) were estimated using conditional logistic regression models adjusting for parity. Older age at first pregnancy, postpartum hemorrhage (OR = 1.18, 95% (confidence interval) CI: 1.08, 1.29), and benign thyroid conditions (ORs ranging from 1.64 for hypothyroidism to 10.35 for thyroid neoplasms) were associated with increased thyroid cancer risk, as were higher offspring birth weight (per 1-kg increase, OR = 1.17, 95% CI: 1.12, 1.22) and higher likelihood of offspring being large for gestational age (OR = 1.26, 95% CI: 1.11, 1.43). Unmarried/noncohabiting status (OR = 0.91, 95% CI: 0.84, 0.98), maternal smoking (OR = 0.75, 95% CI: 0.67, 0.84), and preterm birth (OR = 0.90, 95% CI: 0.83, 0.98) were associated with reduced risk. Several factors (e.g., older age at first pregnancy, maternal smoking, goiter, benign neoplasms, postpartum hemorrhage, hyperemesis gravidarum, and neonatal jaundice) were associated with advanced thyroid cancer. These findings suggest that some perinatal exposures may influence maternal thyroid cancer risk.

The effect of the smartphone app DiaCert on health related quality of life in patients with type 2 diabetes: results from a randomized controlled trial

BACKGROUND

Type 2 diabetes mellitus is associated with an increased risk of impaired quality of life. Improving health related quality of life (HRQoL) is therefore an important goal in the multimodal management of diabetes. The aim of this study was to evaluate whether the use of the smartphone app DiaCert, that encourage physical activity by promoting daily steps, also impacts HRQoL in patients with type 2 diabetes.

METHODS

In this randomized controlled trial, a total of 181 participants with type 2 diabetes were recruited from six health care centers in Stockholm, Sweden. At baseline, participants were randomized 1:1 to the use of the smartphone app DiaCert for a 3 month physical activity intervention in addition to routine care, or to a control group with routine care only. HRQoL was measured using the RAND-36 questionnaire at baseline and at follow-up after 3 months and 6 months. We analysed the HRQoL scores within the intervention and the control groups, respectively, using the Wilcoxon signed-rank test. Between group differences including intervention effect after the 3 month long intervention and after 6 months of follow-up, were assessed using generalized estimating equation models.

RESULTS

In total, 166 participants, 108 men and 58 women, with complete baseline data on RAND-36 were included in analysis. The mean age was 60.2 (SD 11.4) years and the mean Body Mass Index 30.3 (SD 5.4) kg/m². The intervention effect, expressed in terms of the difference in change in HRQoL from baseline to follow-up after 3 months of intervention, showed improvement in the health concept role limitations due to physical health problems (- 16.9; 95% CI - 28.5 to - 5.4), role limitations due to emotional problems (- 13.9; 95% CI - 25.8 to - 2.1), and emotional well-being (- 5.7; 95% CI - 10.4 to - 1.0), in the intervention group compared to the control group. No intervention effect was seen at follow-up after 6 months.

CONCLUSIONS

Being randomized to use the smartphone app DiaCert promoting physical activity for 3 months, improved aspects of both physical and emotional HRQoL in patients with type 2 diabetes compared to routine care, but the effect did not last 3 months after the intervention ended. Trial Registration ClinicalTrials.gov Identifier: NCT03053336.

Characterization of data-driven clusters in diabetes-free adults and their utility for risk stratification of type 2 diabetes

BACKGROUND

The prevention of type 2 diabetes is challenging due to the variable effects of risk factors at an individual level. Data-driven methods could be useful to detect more homogeneous groups based on risk factor variability. The aim of this study was to derive characteristic phenotypes using cluster analysis of common risk factors and to assess their utility to stratify the risk of type 2 diabetes.

METHODS

Data on 7317 diabetes-free adults from Sweden were used in the main analysis and on 2332 diabetes-free adults from Mexico for external validation. Clusters were based on sex, family history of diabetes, educational attainment, fasting blood glucose and insulin levels, estimated insulin resistance and β-cell function, systolic and diastolic blood pressure, and BMI. The risk of type 2 diabetes was assessed using Cox proportional hazards models. The predictive accuracy and long-term stability of the clusters were then compared to different definitions of prediabetes.

RESULTS

Six risk phenotypes were identified independently in both cohorts: very low-risk (VLR), low-risk low β-cell function (LRLB), low-risk high β-cell function (LRHB), high-risk high blood pressure (HRHBP), high-risk β-cell failure (HRBF), and high-risk insulin-resistant (HRIR). Compared to the LRHB cluster, the VLR and LRLB clusters showed a lower risk, while the HRHBP, HRBF, and HRIR clusters showed a higher risk of developing type 2 diabetes. The high-risk clusters, as a group, had a better predictive accuracy than prediabetes and adequate stability after 20 years.

CONCLUSIONS

Phenotypes derived using cluster analysis were useful in stratifying the risk of type 2 diabetes among diabetes-free adults in two independent cohorts. These results could be used to develop more precise public health interventions.

Does eating behaviour among adolescents and young adults seeking obesity treatment differ depending on sex, body composition, and parental country of birth?

BACKGROUND

Adolescents and young adults around the world experience high rates of weight gain. The underlying eating behaviours that may lead to overconsumption of energy are complex and can depend on a number of factors. The aim of this study was to explore if eating behaviour among adolescents and young adults referred to specialized obesity treatment differed depending on sex, body composition, and parental country of birth.

METHODS

Adolescents and young adults aged 16-25 years, referred for obesity treatment in 2018-2021 were included in the study. Eating behaviour was assessed using the Three Factor Eating Questionnaire, comprising domains of uncontrolled-, emotional- and cognitive restraint eating. Student's t-test was used to compare differences in eating behaviour scores between males and females, and between those having at least one parent born in a Nordic country and those with both parents born outside the Nordic countries. Associations between BMI, waist circumference, and body fat percentage, and eating behaviour as the dependent variable, were examined using linear regression.

RESULTS

A total of 463 participants, mean age 21 years and mean BMI 41.3 kg/m², were included in the analysis. Females scored statistically significantly higher than males on emotional eating (45.8 vs. 35.4, p = 0.002) and cognitive restraint eating (45.4 vs. 39.2, p = 0.009). Participants with at least one parent born in a Nordic country reported a statistically significantly lower score of uncontrolled eating (45.7 vs. 51.3, p = 0.02) compared to participants with both parents born outside the Nordic countries. Further, there were statistically significant inverse associations between cognitive restraint eating scores and BMI (β=-0.64, 95%CI: -0.97 to -0.31), waist circumference (β=-0.44, 95%CI: -0.61 to -0.27) and body fat percentage (β=-0.57, 95%CI: -1.01 to -0.14) in models adjusted for age, sex, smoking, and civil status.

CONCLUSION

Our findings suggest that sex and parental country of birth may influence eating behaviours among adolescents and young adults referred for specialist obesity treatment. We also found that cognitive restraint eating decreased with increasing BMI, waist circumference, and body fat percentage. This indicates that there may be an inverse association between the ability to restrain oneself from eating and gaining weight, however, the direction of the association must be investigated further. Increased knowledge about eating behaviours may be valuable in the clinical setting.

A smartphone application to improve adherence to vitamin and mineral supplementation after bariatric surgery

OBJECTIVE

This trial evaluated a smartphone application's effectiveness in improving adherence to vitamin and mineral supplementation postoperatively.

METHODS

This study was a randomized controlled trial comprising 140 patients undergoing bariatric surgery (gastric bypass or sleeve gastrectomy). Participants were randomized 1:1 to the 12-week intervention, using the smartphone application PromMera, or to standard care. The primary end point was adherence to vitamin and mineral supplementation.

RESULTS

Initiation rate and overall adherence to supplementation were high in both groups. Change in objectively measured adherence rate from before the intervention to 1 year post surgery, measured with pharmacy refill data, did not differ between groups for vitamin B₁₂ (-9.6% [SD = 27%] vs. -9.3% [SD = 30%]; p = 0.48) or calcium/vitamin D (-12.3% [SD = 29%] vs. -11.5% [SD = 32%]; p = 0.44). A modest effect on the secondary end point (subjectively measured adherence, using the Medication Adherence Report Scale-5) was seen immediately after the intervention (intervention group 0.00 [SD = 1.3] vs. control group -1.2 [SD = 3.5]; p = 0.021), but this effect did not persist 1 year post surgery. No differences were detected in the prevalence of biochemical deficiencies.

CONCLUSIONS

The use of the smartphone application PromMera did not obtain a lasting improvement in adherence to vitamin and mineral supplementation 1 year post bariatric surgery.

Kidney Complications and Hospitalization in Patients With Chronic Hypoparathyroidism: A Cohort Study in Sweden

CONTEXT

Kidney complications may be considerably higher in patients with chronic hypoparathyroidism (hypoPT) treated with activated vitamin D and calcium supplementation.

OBJECTIVE

We aimed to investigate the risk of chronic kidney disease (CKD), urolithiasis, and hospitalization in patients with chronic hypoPT.

METHODS

In this population-based cohort study in Sweden, national registries (Swedish National Patient Register, Swedish Prescribed Drug Register, and Total Population Register, 1997-2018) were used to identify patients with chronic hypoPT and controls matched by sex, age, and county of residence. We determined time to CKD and urolithiasis diagnosis, and incidence rates of hospitalization.

RESULTS

A total of 1562 patients with chronic hypoPT without preexisting CKD and 15 620 controls were included. The risk of developing CKD was higher in patients with chronic hypoPT compared with controls (hazard ratio [HR] 4.45; 95% CI, 3.66-5.41). In people without prior urolithiasis (n = 1810 chronic hypoPT and n = 18 100 controls), the risk of developing urolithiasis was higher in patients with chronic hypoPT (HR 3.55; 95% CI, 2.84-4.44) compared with controls. Patients with chronic hypoPT had higher incidence rates for all-cause hospitalization (49.59; 95% CI, 48.50-50.70, per 100 person-years vs 28.43; 95% CI, 28.15-28.71, respectively) and for CKD (3.46; 95% CI, 3.18-3.76, per 100 person-years vs 0.72; 95% CI, 0.68-0.77, respectively), compared with controls. Men with hypoPT appear to have a higher risk of CKD than women.

CONCLUSION

Patients with chronic hypoPT had an increased risk of CKD, urolithiasis, and hospitalization compared with controls.

FC006: Sex Differences in the Recognition, Monitoring and Management of Chronic Kidney Disease in Health Care

BACKGROUND AND AIMS

Sex-specific differences exist in the population prevalence of chronic kidney disease (CKD), progression rates and health outcomes. Recognition, diagnosis and monitoring are central processes in the management of patients with CKD, but it is unknown whether these processes differ between men and women.

METHOD

This is an observational cohort study of all adult individuals (n = 227 847) with at least one eGFR (from serum creatinine) &lt;60 mL/min/1.73 m2 during outpatient routine care in Stockholm, Sweden, 2009–2017. Through logistic regression, we evaluated differences by sex in carrying an ICD-10 code for CKD and provision of recommended medications (renin–angiotensin system inhibitors [RASi] and statins) at inclusion. Through Cox regression, we evaluated potential sex differences in receiving a CKD diagnosis, referral to nephrology care and performance of laboratory monitoring (creatinine and albuminuria) in the next 18 months from inclusion. We also explored time-trends, comparing the above-mentioned nephrology care indicators among 70–80 000 unique eligible individuals per calendar year (in total 695 632 observations), thus allowing participants to contribute to different calendar year-cohorts.

RESULTS

We identified more women (55%) than men (45%) with probable CKD (eGFR &lt; 60 mL/min/1.73 m2). Women were generally older than men (median 77 versus 74 years), but eGFR was similar between sexes (51 mL/min/1.73 m2). More men than women had diabetes or myocardial infarction, but there was similar prevalence of hypertension. At inclusion and compared with men, women had lower risk of carrying an ICD-10 code for CKD (odds ratio [OR]: 0.47, 95% CI: 0.45–0.49) and were less likely to receive RASi (OR: 0.55; 0.50–0.61, among patient with albuminuria A3) or statins (OR: 0.64; 0.63–0.66, among patients ≥ 50 years), despite the presence of clear indications. In subsequent time-to-event analyses, women were less likely to receive a CKD diagnosis (hazard ratio [HR]: 0.43; 0.42–0.45) and visit a nephrologist (HR: 0.46; 0.43–0.48) regardless of CKD severity, presence of albuminuria or criteria for referral. Women were also less likely to undergo monitoring of creatinine or albuminuria, even among participants with diabetes (HR: 0.75; 0.74–0.76) or hypertension (HR: 0.76; 0.75–0.78). Multivariable adjustment including comorbidities, eGFR and indication for referral showed some attenuation of the effect, but a sex difference remained. Although in absolute terms there has been a gradual improvement in all nephrology care indicators over time, the observed sex gap persisted throughout.

CONCLUSION

We found profound sex differences in the detection, recognition, monitoring and management (including referrals) of CKD in healthcare, also across high-risk groups and indications.

Appetite in Palliative Cancer Patients and Its Association with Albumin, CRP and Quality of Life in Men and Women—Cross-Sectional Data from the Palliative D-Study

Albumin is an important biochemical marker in palliative cancer care, used for assessment of nutritional status, disease severity and prognosis. Our primary aim was to investigate sex differences in the association between appetite and albumin levels in palliative cancer patients. We also aimed to study associations between appetite and C-reactive protein (CRP), Quality of Life (QoL), pain and fatigue. In the Palliative D-cohort, consisting of 266 men and 264 women, we found a correlation between appetite and albumin; low appetite, measured with the Edmonton Symptom Assessment System, correlated significantly with low albumin in men: (r = −0.33, p < 0.001), but not in women (r = −0.03, p = 0.65). In a regression analysis adjusted for confounding factors, results were similar. Lower appetite was correlated with higher CRP in men (r = 0.27, p < 0.001), but not in women (r = 0.12, p = 0.05). Appetite was correlated with QoL, fatigue and pain in both men and women; those with a low appetite had a low QoL and high fatigue- and pain-scores (p < 0.001). In conclusion, our results indicated possible sex differences in the associations between appetite and albumin, and between appetite and CRP, in palliative care patients. Understanding these associations could provide additional value for clinical practice.

Clinical Outcomes Among Working Adults Using the Health Integrator Smartphone App: Analyses of Prespecified Secondary Outcomes in a Randomized Controlled Trial

Background

There is a need to find new methods that can enhance the individuals’ engagement in self-care and increase compliance to a healthy lifestyle for the prevention of noncommunicable diseases and improved quality of life. Mobile health (mHealth) apps could provide large-scale, cost-efficient digital solutions to implement lifestyle change, which as a corollary may enhance quality of life.

Objective

Here we evaluate if the use of a smartphone-based self-management system, the Health Integrator app, with or without telephone counseling by a health coach, had an effect on clinical variables (secondary outcomes) of importance for noncommunicable diseases.

Methods

The study was a 3-armed parallel randomized controlled trial. Participants were randomized to a control group or to 1 of 2 intervention groups using the Health Integrator app with or without additional telephone counseling for 3 months. Clinical variables were assessed before the start of the intervention (baseline) and after 3 months. Due to the nature of the intervention, targeting lifestyle changes, participants were not blinded to their allocation. Robust linear regression with complete case analysis was performed to study the intervention effect among the intervention groups, both in the entire sample and stratifying by type of work (office worker vs bus driver) and sex.

Results

Complete data at baseline and follow-up were obtained from 205 and 191 participants, respectively. The mean age of participants was 48.3 (SD 10) years; 61.5% (126/205) were men and 52.2% (107/205) were bus drivers. Improvements were observed at follow-up among participants in the intervention arms. There was a small statistically significant effect on waist circumference (β=–0.97, 95% CI –1.84 to –0.10) in the group receiving the app and additional coach support compared to the control group, but no other statistically significant differences were seen. However, participants receiving only the app had statistically significantly lower BMI (β=–0.35, 95% CI –0.61 to –0.09), body weight (β=–1.08, 95% CI –1.92 to –0.26), waist circumference (β=–1.35, 95% CI –2.24 to –0.45), and body fat percentage (β=–0.83, 95% CI –1.65 to –0.02) at follow-up compared to the controls. There was a statistically significant difference in systolic blood pressure between the two intervention groups at follow-up (β=–3.74, 95% CI –7.32 to –0.16); no other statistically significant differences in outcome variables were seen.

Conclusions

Participants randomized to use the Health Integrator smartphone app showed small but statistically significant differences in body weight, BMI, waist circumference, and body fat percentage compared to controls after a 3-month intervention. The effect of additional coaching together with use of the app is unclear.

Trial Registration

ClinicalTrials.gov NCT03579342; https://clinicaltrials.gov/ct2/show/NCT03579342

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-019-6595-6

Association between total and leisure time physical activity and risk of myocardial infarction and stroke - a Swedish cohort study

BACKGROUND

Physical inactivity is a known risk factor for cardiovascular disease, but it is unclear if total and leisure time activity have different impact on the risk of myocardial infarction and stroke. In this cohort, we aimed to investigate the associations between both total and leisure time physical activity in detail, and the risks of myocardial infarction and stroke, both overall and for men and women separately.

METHODS

We assessed the association between total and leisure time physical activity on the risk of myocardial infarction and stroke in a cohort of 31,580 men and women through record linkages from 1997-2016. We used Cox proportional hazards regression models to estimate hazard ratios (HR) with 95% confidence intervals (CI) based on detailed self-reported physical activity. In the adjusted analyses, we included age, sex, body mass index, level of education, cigarette smoking, alcohol consumption, diabetes, lipid disturbance and hypertension as potential confounders.

RESULTS

We identified 1,621 incident cases of myocardial infarction and 1,879 of stroke. Among men, there was an inverse association between leisure time activity and myocardial infarction in the third tertile compared to the first (HR: 0.78; 95% CI: 0.62-0.98; p for trend = 0.03). We also found an inverse association between leisure time activity and stroke in the third tertile compared to the first (HR: 0.78; 95% CI: 0.61-0.99; p for trend = 0.04), while the corresponding HR for stroke among women was 0.91; 95% CI: 0.74-1.13. We found no significant association between total physical activity and MI (HR: 1.12; 95% CI: 0.93-1.34) or stroke (HR: 1.14 95% CI: 0.94-1.39) comparing the highest to the lowest tertile in men. Women in the highest tertile of total physical activity had a 22% lower risk of myocardial infarction compared to the lowest tertile (HR: 0.78; 95% CI: 0.63-0.97; p for trend = 0.02) and an 8% (95% CI: 0.87-0.98) reduced risk of myocardial infarction with each 1 METh/day increase of leisure time physical activity.

CONCLUSION

Total physical activity was inversely associated with the risk of myocardial infarction in women, while leisure time physical activity was inversely associated with the risk of myocardial infarction and stroke in men.

Patients’ Experiences of Weight Regain After Bariatric Surgery

Purpose

Bariatric surgery is a successful obesity treatment; however, an estimated 1/5 of patients have regained more than 15% of their body weight 5 years post-surgery. To increase the understanding of patients who experienced weight regain after bariatric surgery, we conducted a qualitative study.

Materials and Methods

We recruited 16 adult participants (4 men, 12 women) at an obesity clinic in Stockholm, Sweden, 2018 to 2019, and performed semi-structured individual interviews. The transcribed recorded interview data was analyzed with thematic analysis.

Results

Participants had undergone gastric bypass surgery on average 10 years prior to study and regained 36% (range 12 to 71%) of their weight from their nadir. Participants experienced challenges such as eating in social settings, loneliness, family difficulties, increases in appetite, and physical and mental health problems, which distracted them from weight management. Participants responded to weight regain with emotional distress, particularly with hopelessness, discouragement, shame, and frustration (theme: loss of control and focus). Nonetheless, participants experienced remaining benefits from the surgery, despite weight regain. Social support, self-care, and behavioral strategies were perceived as facilitators for weight management (theme: reducing the burden of weight management).

Conclusions

Weight regain after bariatric surgery was perceived to be an unexpected and difficult experience that induced hopelessness, discouragement, shame, and frustration. Results indicate that internal and external circumstances such as psychosocial factors, changes in appetite, and physical and mental health problems may contribute to loss of control over weight. Social support, self-care, and behavioral strategies might facilitate long-term post-surgical weight management.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-05908-1.

A Self-help Tool to Facilitate Implementation of eHealth Initiatives in Health Care (E-Ready): Formative Evaluation

BACKGROUND

eHealth interventions have the potential to increase the efficiency and effectiveness of health care. However, research has shown that implementing eHealth in routine health care practice is difficult. Organizational readiness to change has been shown to be central to successful implementation. This paper describes the development and formative evaluation of a generic self-help tool, E-Ready, designed to be used by managers, project leaders, or others responsible for implementation in a broad range of health care settings.

OBJECTIVE

The aim of this study is to develop and evaluate a tool that could facilitate eHealth implementation in, for example, health care.

METHODS

A first version of the tool was generated based on implementation theory (E-Ready 1.0). A formative evaluation was undertaken through expert panels (n=15), cognitive interviews (n=17), and assessment of measurement properties on E-Ready items from 3 different workplaces (n=165) using Rasch analyses. E-Ready 1.0 was also field tested among the target population (n=29). Iterative revisions were conducted during the formative evaluation process, and E-Ready 2.0 was generated.

RESULTS

The E-Ready Tool consists of a readiness assessment survey and a hands-on manual. The survey measures perceived readiness for change (willingness and capability) at individual and collective levels: perceived conditions for change at the workplace, perceived individual conditions for change, perceived support and engagement among management, perceived readiness among colleagues, perceived consequences on status quo, and perceived workplace attitudes. The manual contains a brief introduction, instructions on how to use the tool, information on the themes of E-Ready, instructions on how to create an implementation plan, brief advice for success, and tips for further reading on implementation theory. Rasch analyses showed overall acceptable measurement properties in terms of fit validity. The subscale Individual conditions for change (3 items) had the lowest person reliability (0.56), whereas Perceived consequences on status quo (5 items) had the highest person reliability (0.87).

CONCLUSIONS

E-Ready 2.0 is a new self-help tool to guide implementation targeting health care provider readiness and engagement readiness ahead of eHealth initiatives in, for example, health care settings. E-Ready can be improved further to capture additional aspects of implementation; improvements can also be made by evaluating the tool in a larger sample.

Effects of alcohol consumption and smoking on risk for RA: results from a Swedish prospective cohort study

Objective

Several, but not all studies, have shown a dose-dependent inverse association with alcohol consumption and rheumatoid arthritis (RA), whereas smoking is an established risk factor for RA. We aimed to study the association between alcohol consumption and RA incidence and investigate a potential interaction between alcohol and smoking habits, regarding RA incidence.

Methods

We used a prospective cohort study, based on 41 068 participants with detailed assessment of alcohol intake, smoking and potential confounders at baseline in 1997. We ascertained a total of 577 incident cases of RA during a mean of 17.7 years of follow-up through linkage to nationwide and essentially complete databases. Multivariate Cox proportional hazards models were used to estimate HR with 95% CI. Interaction on the additive scale between alcohol and smoking was estimated by calculating the attributable proportion due to interaction (AP).

Results

Overall, alcohol consumption was associated with a 30% reduced incidence of RA (HR 0.69, 95% CI 0.55 to 0.86) with a dose–response relationship (p value for trend <0.001) which remained significant after stratification by age and smoking habits. The positive association between smoking and RA incidence was reduced with increasing alcohol consumption (p value for trend <0.001). A synergistic effect was observed between alcohol and smoking (AP 0.40, 95% CI 0.15 to 0.64), indicating that 40% of the cases among the double exposed are due to the interaction per se.

Conclusions

Our findings suggest an inverse association between alcohol consumption and RA incidence, and a synergistic effect between alcohol and smoking.

Screen time and physical activity in children and adolescents aged 10-15 years

Background

Previous research studies have demonstrated a relationship between low levels of physical activity and high amounts of screen time in children and adolescents. However, this is usually based on self-reported data. Therefore, the aim of this cross-sectional study was to investigate the association between objectively measured smartphone screen time and physical activity among children and adolescents aged 10–15 years.

Methods

During seven consecutive days, we objectively assessed smartphone screen time, using the SCRIIN smartphone application, and physical activity, using the SCRIIN activity tracker, in children and adolescents recruited from two schools in Stockholm County, Sweden. Moreover, the children/adolescents and their parents responded to a questionnaire, obtaining among other things: self-reported screen time, physical activity, sleep and health-related quality of life.

Results

A total of 121 children and adolescents (mean age: 12.1 ± 1.5) were included in the study. Objectively measured smartphone screen time was 161.2 ± 81.1 min/day. Mean physical activity, measured with the SCRIIN activity tracker, was 32.6 ± 16.5 active min/day. Minutes of screen time and physical activity did not differ between the children and adolescents from the two schools, despite located in different socioeconomic areas. Further, we found no association between smartphone screen time and physical activity. However, girls aged 14–15 years, had more smartphone screen time (p<0.01) and were significantly more physically active (p<0.01) than girls aged 10–12 years. In addition, boys reported more than five times more time spent on computer and video games than girls did.

Conclusion

Smartphone screen time was not associated with physical activity level among children and adolescents aged 10–15 years.

Swedish snus use is associated with mortality: a pooled analysis of eight prospective studies

BACKGROUND

The health consequences of the use of Swedish snus, including its relationship with mortality, have not been fully established. We investigated the relationship between snus use and all-cause and cause-specific mortality (death due to cardiovascular diseases, cancer diseases and all other reasons, respectively) in a nationwide collaborative pooling project.

METHODS

We followed 169 103 never-smoking men from eight Swedish cohort studies, recruited in 1978-2010. Shared frailty models with random effects at the study level were used in order to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of mortality associated with snus use.

RESULTS

Exclusive current snus users had an increased risk of all-cause mortality (aHR 1.28, 95% CI 1.20-1.35), cardiovascular mortality (aHR 1.27, 95% CI 1.15-1.41) and other cause mortality (aHR 1.37, 95% CI 1.24-1.52) compared with never-users of tobacco. The risk of cancer mortality was also increased (aHR 1.12, 95% CI 1.00-1.26). These mortality risks increased with duration of snus use, but not with weekly amount.

CONCLUSIONS

Snus use among men is associated with increased all-cause mortality, cardiovascular mortality, with death from other causes and possibly with increased cancer mortality.

Risk of Delayed Discharge and Reoperation of Gastric Bypass Patients with Psychiatric Comorbidity-a Nationwide Cohort Study

BACKGROUND

Gastric bypass (GBP) surgery is considered a safe and effective treatment for obesity. However, there is uncertainty regarding the impact of preexisting psychiatric comorbidity on GBP complications. We have investigated whether a psychiatric diagnosis before GBP surgery is associated with delayed discharge (the odds of being in the 90th percentile of length of stay) and rate of reoperation in a nationwide Swedish cohort.

METHODS

Patients undergoing GBP surgery during 2008-2012 were identified and followed up through the National Patient Register and the Prescribed Drug Register. Logistic regression models were fitted to the studied outcomes.

RESULTS

Among the 22,539 patients identified, a prior diagnosis of bipolar disorder, schizophrenia, depression, neurotic disorders, ADHD (attention deficit hyperactivity disorder), substance use disorder, eating disorder, personality disorder, or self-harm since 1997 (n = 9480) was found to be associated with delayed discharge after GBP surgery (odds ratio [OR] = 1.47, confidence interval [CI] 1.34-1.62), especially in patients with psychiatric hospitalization exceeding 1 week in the 2 years preceding GBP surgery (OR = 2.06, CI 1.30-3.28), compared with those not hospitalized within psychiatry. Likewise, patients with a prior psychiatric diagnosis were more likely to be reoperated within 30 days (OR = 1.25, CI 1.11-1.41), with twice the likelihood OR 2.23 (CI 1.26-3.92) for patients with psychiatric hospitalization of up to a week in the 2 years preceding GBP surgery, compared with patients who had not been hospitalized within psychiatry.

CONCLUSIONS

A psychiatric diagnosis before GBP surgery was associated with delayed discharge and increased likelihood of reoperation within 30 days. Patients with a prior psychiatric diagnosis may, therefore, need additional attention and support.

Association of Phosphodiesterase-5 Inhibitors Versus Alprostadil With Survival in Men With Coronary Artery Disease

BACKGROUND

Phosphodiesterase 5 inhibitor (PDE5i) treatment is associated with reduced mortality compared with no treatment for erectile dysfunction after myocardial infarction (MI).

OBJECTIVES

This study sought to investigate the association between treatment with PDE5i or alprostadil and outcomes in men with stable coronary artery disease.

METHODS

All Swedish men with a prior MI or revascularization who received PDE5i or alprostadil during 2006 through 2013 at >6 months after the event were included, using the Swedish Patient Register and the Swedish Prescribed Drug Register. Cox regression was used to estimate adjusted hazard ratios with 95% confidence intervals for all-cause mortality, MI, heart failure, cardiovascular mortality, noncardiovascular mortality, cardiac revascularization, peripheral arterial disease, and stroke in men treated with PDE5i versus alprostadil.

RESULTS

This study included 16,548 men treated with PDE5i and 1,994 treated with alprostadil. The mean follow-up was 5.8 years, with 2,261 deaths (14%) in the PDE5i group and 521 (26%) in the alprostadil group. PDE5i compared with alprostadil treatment was associated with lower mortality (hazard ratio: 0.88; 95% confidence interval: 0.79 to 0.98) and with similar associations for MI, heart failure, cardiovascular mortality, and revascularization. When quintiles (q) of filled PDE5i prescriptions were compared using q1 as reference, patients in q3, q4, and q5 had lower all-cause mortality. Among alprostadil users, those in q5 had a lower all-cause mortality compared to q1.

CONCLUSIONS

In men with stable coronary artery disease, treatment with PDE5i is associated with lower risks of death, MI, heart failure, and revascularization compared with alprostadil treatment. Although the decrease in all-cause mortality was PDE5i dose dependent, the data do not permit the inference of causality or any clinical benefits of PDE5i because of the observational study design.

Perspectives From Underserved African Americans and Their Health Care Providers on the Development of a Diabetes Self-Management Smartphone App: Qualitative Exploratory Study

Background

Type 2 diabetes mellitus (T2DM) affects approximately 10% of the US population, disproportionately afflicting African Americans. Smartphone apps have emerged as promising tools to improve diabetes self-management, yet little is known about the use of this approach in low-income minority communities.

Objective

The goal of the study was to explore which features of an app were prioritized for people with T2DM in a low-income African American community.

Methods

Between February 2016 and May 2018, we conducted formative qualitative research with 78 participants to explore how a smartphone app could be used to improve diabetes self-management. Information was gathered on desired features, and app mock-ups were presented to receive comments and suggestions of improvements from smartphone users with prediabetes and T2DM, their friends and family members, and health care providers; data were collected from six interactive forums, one focus group, and 15 in-depth interviews. We carried out thematic data analysis using an inductive approach.

Results

All three types of participants reported that difficulty with accessing health care was a main problem and suggested that an app could help address this. Participants also indicated that an app could provide information for diabetes education and self-management. Other suggestions included that the app should allow people with T2DM to log and track diabetes care–related behaviors and receive feedback on their progress in a way that would increase engagement in self-management among persons with T2DM.

Conclusions

We identified educational and tracking smartphone features that can guide development of diabetes self-management apps for a low-income African American population. Considering those features in combination gives rise to opportunities for more advanced support, such as determining self-management recommendations based on data in users’ logs.

Maternal health, in-utero, and perinatal exposures and risk of thyroid cancer in offspring: a Nordic population-based nested case-control study

BACKGROUND

Thyroid cancer tends to be diagnosed at a younger age (median age 51 years) compared with most other malignancies (such as breast cancer [62 years] or lung cancer [71 years]). The incidence of thyroid cancer is higher in women than men diagnosed from early adolescence. However, few in-utero and early life risk exposures associated with increased risk of thyroid cancer have been identified.

METHODS

In this population-based nested case-control study we used registry data from four Nordic countries to assess thyroid cancer risk in offspring in relation to maternal medical history, pregnancy complications, and birth characteristics. Patient with thyroid cancer (cases) were individuals born and subsequently diagnosed with first primary thyroid cancer from 1973 to 2013 in Denmark, 1987 to 2014 in Finland, 1967 to 2015 in Norway, or 1973 to 2014 in Sweden. Each case was matched with up to ten individuals without thyroid cancer (controls) based on birth year, sex, country, and county of birth. Cases and matched controls with a previous diagnosis of any cancer, other than non-melanoma skin cancer, at the time of thyroid cancer diagnosis were excluded. Cases and matched controls had to reside in the country of birth at the time of thyroid cancer diagnosis. Conditional logistic regression models were used to calculate odds ratios (ORs) with 95% CIs.

RESULTS

Of the 2437 cases, 1967 (81·4%) had papillary carcinomas, 1880 (77·1%) were women, and 1384 (56·7%) were diagnosed before age 30 years (range 0-48). Higher birth weight (OR per kg 1·14 [95% CI 1·05-1·23]) and congenital hypothyroidism (4·55 [1·58-13·08]); maternal diabetes before pregnancy (OR 1·69 [0·98-2·93]) and postpartum haemorrhage (OR 1·28 [1·06-1·55]); and (from registry data in Denmark) maternal hypothyroidism (18·12 [10·52-31·20]), hyperthyroidism (11·91 [6·77-20·94]), goiter (67·36 [39·89-113·76]), and benign thyroid neoplasms (22·50 [6·93-73·06]) were each associated with an increased risk of thyroid cancer in offspring.

INTERPRETATION

In-utero exposures, particularly those related to maternal thyroid disorders, might have a long-term influence on thyroid cancer risk in offspring.

FUNDING

Intramural Research Program of the National Cancer Institute (National Institutes of Health).

CKD Progression and Mortality Among Men and Women: A Nationwide Study in Sweden

RATIONALE & OBJECTIVE

Chronic kidney disease (CKD) is a global health problem with increasing prevalence. Several sex-specific differences have been reported for disease progression and mortality. Selection and survival bias might have influenced the results of previous cohort studies. The objective of this study was to investigate sex-specific differences of CKD progression and mortality among patients with CKD not receiving maintenance dialysis.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

Adult patients with incident CKD glomerular filtration rate categories 3b to 5 (G3b-G5) identified between 2010 and 2018 within the nationwide Swedish Renal Registry-CKD (SRR-CKD).

EXPOSURE

Sex.

OUTCOMES

Time to CKD progression (defined as a change of at least 1 CKD stage or initiation of kidney replacement therapy [KRT]) or death. Repeated assessments of estimated glomerular filtration rate (eGFR).

ANALYTICAL APPROACH

CKD progression and mortality before KRT were assessed by the cumulative incidence function methods and Fine and Gray models, with death handled as a competing event. Sex differences in eGFR slope were estimated using mixed effects linear regression models.

RESULTS

7,388 patients with incident CKD G3b, 18,282 with incident CKD G4, and 9,410 with incident CKD G5 were identified. Overall, 19.6 (95% CI, 19.2-20.0) patients per 100 patient-years progressed, and 10.1 (95% CI, 9.9-10.3) patients per 100 person-years died. Women had a lower risk of CKD progression (subhazard ratio [SHR], 0.88 [95% CI, 0.85-0.92]), and a lower all-cause (SHR, 0.90 [95% CI, 0.85-0.94]) and cardiovascular (SHR, 0.83 [95% CI, 0.76-0.90]) mortality risk. Risk factors related to a steeper decline in eGFR included age, sex, albuminuria, and type of primary kidney disease.

LIMITATIONS

Incomplete data for outpatient visits and laboratory measurements and regional differences in reporting.

CONCLUSIONS

Compared to women, men had a higher rate of all-cause and cardiovascular mortality, an increased risk of CKD progression, and a steeper decline in eGFR.

Dietary Antioxidants and the Risk of Parkinson Disease: The Swedish National March Cohort

OBJECTIVE

To determine whether high baseline dietary antioxidants and total nonenzymatic antioxidant capacity (NEAC) is associated with a lower risk of Parkinson disease (PD) in men and women, we prospectively studied 43,865 men and women from a large Swedish cohort.

METHODS

In the Swedish National March Cohort, 43,865 men and women aged 18-94 years were followed through record linkages to National Health Registries from 1997 until 2016. Baseline dietary vitamin E, vitamin C, and beta-carotene intake, as well as NEAC, were assessed by a validated food frequency questionnaire collected at baseline. All exposure variables were adjusted for energy intake and categorized into tertiles. Multivariable Cox proportional hazard regression models were fitted to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for PD.

RESULTS

After a mean follow-up time of 17.6 years, we detected 465 incidence cases of PD. In the multivariable adjusted model, dietary vitamin E (HR 0.68, 95% CI 0.52-0.90; p for trend 0.005) and vitamin C (HR 0.68, 95% CI 0.52-0.89; p for trend 0.004) were inversely associated with the risk of PD when comparing participants in the highest vs the lowest tertiles of exposure. No association was found with estimated intake of dietary beta-carotene or NEAC.

CONCLUSION

Our findings suggest that dietary vitamin E and C intake might be inversely associated with the risk of PD. No association was found with dietary beta-carotene or NEAC.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that dietary vitamin E and C intake are inversely associated with the risk of PD.

WITHDRAWN: The relationship between nightmares, depression and suicide

Objective

Methods

Results

Conclusions

•

No association observed between nightmares and suicide among non-depressed subjects.

•

Suicide incidence was similar among depressed subjects with and without nightmares.

•

Mediation analysis revealed no significant effects of nightmares on suicide incidence.

•

The incidence of depression was higher among nightmare sufferers.

•

Nightmares may reflect pre-existing depression.

Erratum: Withdrawal notice to "The relationship between nightmares, depression and suicide" [Sleep Med: X 2 (2020) 100016]

[This corrects the article DOI: 10.1016/j.sleepx.2020.100016.].

Digital Support for Healthier Eating Habits Among Patients With Type 2 Diabetes: Protocol for a Randomized Clinical Trial Within Primary Care (HAPPY Trial)

Background

Despite the large impact that dietary habits have in the management of diabetes, few tools for supporting healthy eating habits are available for persons with diabetes.

Objective

The aim of this randomized clinical trial is to evaluate the effect of a 12-week, mobile health (mHealth), app-based intervention promoting healthy eating habits among patients with type 2 diabetes.

Methods

The HAPPY (Healthy eating using APP technologY) trial is a randomized clinical trial with two arms aiming to include 200 patients, 18 years of age or older, with type 2 diabetes. Both women and men are eligible for inclusion. Study participants are randomized 1:1 to an intervention group, where they are instructed to use a smartphone app promoting healthy eating, or to a control group, where they receive standard primary care only, for a period of 12 weeks. Each week a new topic (eg, vegetable intake) is introduced via the app. After an introduction text, the user is given a topic-related activity to perform (eg, eat one additional serving of vegetables per day during that week). The app records daily progress and sends automatic reminders or feedback to the user. Dietary intake, body composition, clinical variables, and biomarkers are measured at baseline and at 3- and 6-month follow-ups. An extensive web-based questionnaire comprising several validated questionnaires assessing a number of lifestyle factors is distributed via email at baseline and at 3-, 6-, and 12-month follow-ups; lifestyle factors include, for example, sleep, physical activity, eating behavior, and health-related quality of life. The effect of the intervention on dietary intake (primary outcome) and on glycated hemoglobin and blood lipid levels, body composition, blood pressure, other lifestyle factors, and overall health (secondary outcomes) will be assessed.

Results

Data collection is ongoing. Recruitment of participants started in January 2019. Findings from the study are expected to be published by the end of 2021.

Conclusions

Technology development provides new ways to promote and support long-term adherence to healthier eating habits. mHealth-based approaches allow for real-time interaction and the delivery of an intervention at any time. Further, focusing on overall diet allows the user to apply new knowledge to current eating patterns, creating an individualized approach. In this study, we evaluate the effect of using a new smartphone app promoting healthy eating habits on dietary intake, clinical markers, and lifestyle factors among patients with type 2 diabetes.

Trial Registration

ClinicalTrials.gov NCT03784612; https://clinicaltrials.gov/ct2/show/NCT03784612

International Registered Report Identifier (IRRID)

DERR1-10.2196/24422

App Technology to Support Physical Activity and Intake of Vitamins and Minerals After Bariatric Surgery (the PromMera Study): Protocol of a Randomized Controlled Clinical Trial

Background

To optimize postoperative outcomes after bariatric surgery, lifestyle changes including increased physical activity are needed. Micronutrient deficiency after surgery is also common and daily supplementation is recommended.

Objective

The aim of the PromMera study is to evaluate the effects of a 12-week smartphone app intervention on promotion of physical activity (primary outcome) and adherence to postsurgery vitamin and mineral supplementation, as well as on other lifestyle factors and overall health in patients undergoing bariatric surgery.

Methods

The PromMera study is a two-arm, randomized controlled trial comprising patients undergoing bariatric surgery. Participants are randomized postsurgery 1:1 to either the intervention group (ie, use of the PromMera app for 12 weeks) or the control group receiving only standard care. Clinical and lifestyle variables are assessed pre- and postsurgery after 18 weeks (postintervention assessment), 6 months, 1 year, and 2 years. Assessments include body composition using Tanita or BOD POD analyzers, muscle function using handgrip, biomarkers in blood, and an extensive questionnaire on lifestyle factors. Physical activity is objectively measured using the ActiGraph wGT3X-BT triaxial accelerometer.

Results

A total of 154 participants have been enrolled in the study. The last study participant was recruited in May 2019. Data collection will be complete in May 2021.

Conclusions

Implementing lifestyle changes are crucial after bariatric surgery and new ways to reach patients and support such changes are needed. An app-based intervention is easily delivered at any time and can be a key factor in the adoption of healthier behavioral patterns in this rapidly growing group of patients.

Trial Registration

ClinicalTrials.gov NCT03480464; https://clinicaltrials.gov/ct2/show/NCT03480464

International Registered Report Identifier (IRRID)

DERR1-10.2196/19624