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Background: Impacted third molars are common and often require surgical removal, which can lead to postoperative complications, particularly pain. While pain has been extensively studied in specialist settings, data from general dental practice remains limited. This study evaluated postoperative pain over seven days following mandibular third molar surgery performed by general dental practitioners (GDPs), who conduct a significant number of these procedures.

Material and Methods: A prospective multi-center cohort study was conducted in three public dental clinics in Luleå, Sweden, from October 2022 to December 2023. Participants (≥18 years old) undergoing mandibular third molar surgery were included, while those requiring referral to an oral maxillofacial surgeon were excluded. Pain intensity was self-reported daily using a numerical rating scale (NRS) from 0–10. Statistical analyses included descriptive statistics, chi-square tests, and t-tests.

Results: Of 133 enrolled participants, 111 submitted valid pain assessments. Pain peaked on the day of surgery (Day 0), with 4% reporting the worst imaginable pain (NRS 10), 34% severe pain (NRS 7–9), and 35% moderate pain (NRS 4–6). Pain significantly declined by Day 1 (p<0.001) and continued to decrease throughout the week. Female participants reported higher pain scores (statistically significant on Days 2–4) and used more analgesics. Sedated patients also reported higher pain scores. Bilateral surgeries showed slightly higher pain levels, though not statistically significant. Postoperative complications were rare (one case of paraesthesia, two infections).

Conclusions: Postoperative pain after third molar surgery performed by GDPs was highest on the day of surgery and declined rapidly.

Background: The incidence of post-traumatic osteoarthritis (OA) following intraarticular knee fractures has been estimated to be relatively high but it varies substantially between different reports. In this study we sought to assess the prevalence of radiographic knee OA secondary to tibial plateau fractures (TPF). The second aim was to report medium- and long-term functional outcomes and investigate whether there were any risk factors associated with these outcomes.

Methods: We retrospectively reviewed documentation of patients who had TPF between 2001 and 2015. The radiographs, clinical characteristics and patient-reported outcome measures (PROMs) scores were evaluated. Presence of radiographic OA was the primary endpoint. The other endpoints were the relationship between OA and different potential predictors as well as the scores in PROMs.

Results: The study involved a total of 130 patients including 114 who were radiographically examined at mean follow-up time of 10 years (range 4.6–19.3 years). Radiographic OA was present in 50% of patients (34% in the injured knee and 16% in both knees). Having OA in the contralateral knee increased the odds to develop OA in the index knee (OR = 4.8; 95%CI 1.6–4.1 in the crude model and OR = 6.6; 95%CI 1.8–23.5 in the model adjusted for age, sex, BMI, fracture type and treatment method). The occurrence of OA was associated stronger with medial or bicondylar TPF than with lateral condyle TPF (OR = 2.8; 95%CI 1.2–6.1 in the crude model and OR = 3.4; 95%CI 1.4–8.6 in the adjusted model). The KOOS scores were significantly lower in patients with OA than in those without OA in the index knee in all the KOOS subscales (p < 0.007), except for the KOOS Symptoms (p = 0.362). The EQ-5D-5L index score was significantly higher in patients without OA in the index knee compared to those with OA (p = 0.015).

Conclusion: Radiographic OA following TPF occurred in 50% of knee joints. The odds for knee OA were highest after medial or bicondylar fractures. Patients with OA in the index knee had lower scores in both condition-specific and generic PROMs than subjects without OA, which indicates that TPF may contribute to the development of both OA disease and illness. Trial registration: The trial was registered retrospectively on June 4, 2024 on ClinicalTrials.gov (registration number: NCT06451510).

Objective: Endovascular aneurysm repair (EVAR) has a higher long term aneurysm related mortality rate compared with open surgery, mainly due to aneurysm rupture. Loss of stent graft to vessel apposition at the EVAR sealing zones is a potential cause of post-EVAR rupture. This study aimed to investigate sealing zone failure and its relationship with post-EVAR rupture.

Methods: This was a retrospective structured review of pre- and post-operative computed tomography (CT) scans of 399 consecutive patients treated with standard bifurcated EVAR. The primary outcome was total loss of seal at last post-operative CT. Secondary outcomes were partial loss of seal, standard follow up detection, post-EVAR rupture, aneurysm sac development, and endoleaks.

Results: During a median follow up of 5.3 years, total and partial loss of seal occurred in 85 (21.3%) and 78 (19.5%) patients, respectively. Initial mean sealing zone lengths were within current recommendations but decreased over time, mainly due to vessel dilatation. Mean proximal sealing length at the one month CT was 15.5 ± 10.5 mm (95% confidence interval [CI] 12.6 – 18.5 mm) in the group with total loss of seal, 14.3 ± 6.9 mm (95% CI 12.2 – 16.4 mm) with partial loss of seal, and 23.2 ± 7.4 mm (95% CI 22.3 – 24.0 mm) with preserved seal through follow up (p < .001). Mean iliac sealing lengths were 22.4 ± 12.1 mm (95% CI 18.9 – 25.8 mm) if total loss and 21.8 ± 10.0 mm (95% CI 19.6 – 24.0 mm) if partial loss of seal vs. 34.7 ± 12.4 mm (95% CI 33.8 – 35.7 mm) if preserved seal. Larger vessel diameters were associated with loss of seal in both the proximal and distal sealing zones. During the study period, 13 post-EVAR ruptures occurred, all preceded by CT findings of total (n = 7) or partial (n = 6) loss of seal. Aneurysm sac expansion was seen in 40% of patients with total loss of seal, 18% with partial loss of seal, and 6.6% with preserved seal.

Conclusion: Loss of seal after EVAR is frequent and associated with post-EVAR rupture. Increased recommended sealing zones lengths and focus on sealing zones in surveillance may reduce post-EVAR ruptures and aneurysm related death.

Background: Tularemia is a re-emerging disease in Sweden, frequently affecting working-age individuals and often resulting in prolonged recovery times. The disease-related economic impact has not previously been investigated outside bioterrorism scenarios. In this study we assess the economic burden associated with endemic tularemia in Sweden.  

Method: Data on primary care visits, hospital admissions, and sick leaves were collected from participants with serology-confirmed tularemia through questionnaires and electronic medical records in Northern Sweden from 2011 to 2021. The dataset was enhanced with national cost-of-care data for tularemia in primary and specialist care from NordDRG (Diagnosis Related Group; 2021-2023), and sickness benefit data from the Social Insurance Agency (2011-2023). Total direct and indirect costs were estimated by integrating these data sources and adjusted for inflation to 2025 levels. Average salary and labor productivity (Gross Domestic Product [GDP] per person employed) was assumed.

Results: Among participants (n=294), the mean age was 52 years; 68.1% were employed or job-seeking, with 71.3% of these reporting sick leave during illness. Healthcare costs were primarily driven by general practitioner visits (mean 1.74 visits; 5,125 SEK per participant [p.p.]) and hospital admissions (15.6% of participants; mean 4.7 days; 11,268 SEK p.p.) with relatively low complexity (mean DRG weight 0.8), while antibiotic treatment and diagnostics were less costly (figure 1). Indirect costs included sick pay (≤14 days; 70.0%; 4,106 SEK p.p.), sickness benefit (>14 days; 30.0%; 5,835 SEK p.p.), and lost GDP-based productivity, and made up 75.7% of total costs (78,503 SEK p.p.).

A mean of 394 (range 87-1,048) tularemia cases per year were reported to the Swedish Public Health Agency between 2011-2023. The estimated annual societal cost of human tularemia infection was 30.9 million SEK (range 6.8-82.3 million SEK). 

Conclusion: Tularemia imposes a significant socioeconomic burden on society primarily through morbidity and prolonged recovery. Regional outbreaks could have detrimental effects on local economy and public services. Further evaluation of the cost-effectiveness of primary and secondary preventive measures is required. 

Background: At the beginning of the COVID-19 pandemic, concerns arose about a possible rise in alcohol consumption. Early surveys, however, more commonly pointed towards a decrease of alcohol use. But studies based on self-reports may underestimate alcohol use. They also depend on the population sampled. Because of border closures and gastronomy restrictions, countries with centralised alcohol sales provided a unique opportunity to study total domestic consumption during the pandemic without influence of private import or reliance on self-reports.

Aims: We examined the correlation between alcohol sales and national COVID-19 restrictions in three such countries, Finland, Norway and Sweden.

Method: We conducted this study as a mirror image study, comparing alcohol sales during the first 2 years of the COVID-19 pandemic with the two preceding years. We explored hours of daylight/season as potential confounders.

Results: We found no relevant change in alcohol sales during the pandemic years for Finland or Sweden. For Norway, there was a level-change in sales, which could be explained by decreased imports. Sales followed a seasonal pattern. In all three countries, the initial pandemic increase in alcohol sales coincided with an underlying annually recurring seasonal variation.

Conclusions: The COVID-19 pandemic had less of an impact on alcohol consumption in the three Nordic countries than could intuitively be expected. The increase of alcohol sales at the beginning of the COVID-19 pandemic coincided with a seasonal rise following a pre-pandemic pattern. Therefore, caution should be exercised with drawing conclusions from data with a short time perspective to avoid attribution bias.

Background: Tularaemia is a geographically widespread disease affecting animals and humans. In Sweden, transmission patterns are complex, occurring mainly through mosquito vectors. We investigated human exposure and whether passive tularaemia surveillance (reported by the public) of deceased wild hares could be used to temporally and geographically predict outbreaks among humans. 

Methods: A survey was sent to the 830 cases of reported tularaemia in Norrbotten county, Sweden, between 2011-2021; and 313/415 (75.4%) respondents with laboratory-evidence of tularaemia were included. Geographic data from human infections in 2019 (n=54) and 2020 (n=77) was compared to data on deceased forest hares from the Swedish Veterinary Agency, matched by year and region.

Results: Respondents (n=313) rarely reported direct exposure to hares (8,6%) and/or other rodents (3.8%) during the 2-weeks prior to illness; while recreational activities (forest hiking 61.6%; mushroom/berry-picking 24.0%; fishing 11.5%; and hunting 3.8%) were more common. Peak incidence of reported deceased hares in 2019 and 2020 (n=84 and n=66; 11/15 [73.3%] and 19/21 [90.4%] PCR-positive for tularaemia, respectively) corresponded to peak incidence of symptom onset of human cases (median difference +6 days [2019] and -2 days [2020]; p=0.066 and p=0.695, respectively). Distribution of reported hares corresponded with municipalities with highest incidence of human tularaemia and location of self-reported suspected infection (Figure 1). Most reported their location of infection to be within their residential municipality (n=92/106, 86.8%).

Conclusion: Passive surveillance of tularaemia using deceased hares correlates with symptom onset in humans and could predict geographical outbreaks in the community. Surveillance of other affected/reservoir species should be considered. 

Introduction: Mood stabilisers and other psychotropic drugs can lead to serious adverse drug events (ADEs). However, the incidence remains unknown. We aimed to (a) determine the incidence of serious ADEs in patients with bipolar or schizoaffective disorders, (b) explore the role of lithium exposure, and (c) describe the aetiology.

Methods: This study is part of the LiSIE (Lithium—Study into Effects and Side Effects) retrospective cohort study. Between 2001 and 2017, patients in the Swedish region of Norrbotten, with a diagnosis of bipolar or schizoaffective disorder, were screened for serious ADEs to psychotropic drugs, having resulted in critical, post-anaesthesia, or intensive care. We determined the incidence rate of serious ADEs/1,000 person-years (PY).

Results: In 1,521 patients, we identified 41 serious ADEs, yielding an incidence rate of 1.9 events per 1,000 PY. The incidence rate ratio (IRR) between ADEs with lithium present and causally implicated and ADEs without lithium exposure was significant at 2.59 (95% CI 1.20–5.51; p = 0.0094). The IRR of ADEs in patients <65 and ≥65 years was significant at 3.36 (95% CI 1.63–6.63; p = 0.0007). The most common ADEs were chronic lithium intoxication, oversedation, and cardiac/blood pressure-related events.

Discussion: Serious ADEs related to treatment of bipolar (BD) or schizoaffective disorder (SZD) were uncommon but not rare. Older individuals were particularly at risk. The risk was higher in individuals exposed to lithium. Serum lithium concentration should always be checked when patients present with new or unclear somatic symptoms. However, severe ADEs also occurred with other mood stabilisers and other psychotropic drugs.

Background: Tularemia is an important re-emerging disease with a multimodal transmission-pattern. Treatment outcomes of current recommended antibiotic regimens (including ciprofloxacin and doxycycline) remain unclear. In this retrospective cohort study, we report clinical, laboratory, geographical, and treatment outcomes of laboratory-confirmed tularemia cases over an 11-year period in Northern Sweden.

Methods: Data from reported tularemia cases (aged >10 years at time of study) in Norrbotten county between 2011-2021 were collected through review of electronic medical records and participant questionnaires; with 415 out of 784 accepting participation (52.9%). Of these, 327 were laboratory-confirmed cases (serology and/or PCR). A multivariable logistic regression model was used to investigate variables associated with re-treatment.

Results: Median age of participants was 54 years (IQR 41.5-65) and 49.2% were female. While ulceroglandular tularemia was the predominant form (n=215, 65.7%), there were several cases of pulmonary tularemia (n=40; 12.2%). Inflammatory markers were largely non-specific, with monocytosis frequently observed (n=36/75; 48%). Tularemia was often misdiagnosed upon presentation (n=158, 48.3%), with 65 (19.9%) receiving initial inappropriate antibiotics, and 102 (31.2%) re-treated. Persistent lymphadenopathy was infrequent (n=22, 6.7%), with 10 undergoing surgical interventions. In multivariable analysis of variables associated with re-treatment, we highlight differences in time until receiving appropriate antibiotics (8 [IQR 3.25-20.75] vs. 7 [IQR 4-11.25] days; adjusted p=0.076), and doxycycline-based treatment regimen (vs. ciprofloxacin; adjusted p=0.084), although not significant after correction for multiple comparisons.

Conclusion: We comprehensively summarize clinical, laboratory, and treatment outcomes of type B tularemia. Targeting tularemia requires clinical awareness, early diagnosis and timely commencement of treatment for an appropriate duration.

Introduction: This study's aim was to calculate the incidence of first additional endodontic treatment or extraction as the result of an unfavorable endodontic outcome following orthograde root canal treatment (RCT) performed by general dental practitioners during a 10-year period and to identify possible predictors for outcomes.

Methods: A randomized cohort of 280 individuals (and as many teeth) with an orthograde RCT was followed for over 10 years. Dental records were reviewed, and individuals were recalled when data were missing. The following terminal events indicative of unfavorable endodontic treatment outcome were orthograde retreatment, surgical endodontics, and tooth extractions exclusively due to endodontic reasons. Selected variables related to individuals and treatment (pre-, intra-, and postoperative) were harvested to analyze possible associations with the terminal events. Unadjusted survival analysis and Cox regression analysis were performed and P < .05 was considered statistically significant.

Results: Terminal events were registered for 22 teeth/individuals and 17 of these were orthograde retreatments. The cumulative 10-year survival of RCTs was 92.7% (standard error 1.7%), with a higher yearly incidence during the first 2 years. The univariate analysis identified 5 factors associated with the outcome. There were too few events to perform a multivariate analysis.

Conclusions: The mean incidence of additional treatment indicative of unfavorable endodontic outcome was 0.7% per year during the first 10 years, but the mean incidence was greater during the first 2 years. Five factors were associated with an unfavorable outcome; however, confounders cannot be excluded from the associations.

Background: Lithium-associated hyperthyroidism is much rarer than lithium-associated hypothyroidism. Yet, it may be of substantial clinical significance for affected individuals. For instance, lithium-associated hyperthyroidism could destabilise mood, mimic manic episodes and impact physical health. Only few studies have explored incidence rates of lithium-associated hyperthyroidism. Even fewer studies have compared incidence rates according to lithium exposure history.

Objectives: To determine the impact of lithium treatment on the incidence rate of hyperthyroidism in patients with bipolar or schizoaffective disorder and assess its aetiology.

Design: This study is part of the LiSIE (Lithium - Study into Effects and Side Effects) retrospective cohort study.

Methods: Between 1997 and 2017, patients in the Swedish region of Norrbotten with a diagnosis of bipolar or schizoaffective disorder were screened for all episodes of overt hyperthyroidism in form of thyrotoxicosis or thyroiditis. Incidence rates of episodes of hyperthyroidism per 1000 person-years (PY) were compared in relation to lithium exposure; concurrent, previous, or no exposure ever (lithium-naïve patients).

Results: In 1562 patients, we identified 16 episodes of hyperthyroidism corresponding to an incidence rate of 0.88 episodes per 1000 PY. Ninety-four percent of episodes had occurred in women. Patients who had concurrently been exposed to lithium, had an incidence rate of 1.35 episodes per 1000 PY. Patients who had previously been exposed to lithium had an incidence rate of 0.79 per 1000 PY. Patients who had never been exposed to lithium had an incidence rate of 0.47 per 1000 PY. There were no significant differences in the risk ratios for patients with concurrent or previous exposure compared with lithium-naïve patients, neither for hyperthyroidism overall, thyrotoxicosis, or thyroiditis.

Conclusion: Lithium-associated hyperthyroidism seems uncommon. The risk of hyperthyroidism does not seem significantly higher in patients with current or previous lithium exposure than in lithium-naïve patients.