Publications by authors named "Tor Åge Myklebust"

68 Publications

The impact of the COVID-19 pandemic on cancer diagnosis based on pathology notifications: A comparison across the Nordic countries during 2020.

Int J Cancer 2022 Apr 13. Epub 2022 Apr 13.

Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.

The severity of the COVID-19 pandemic and subsequent mitigation strategies have varied across the Nordic countries. In a joint Nordic population-based effort, we compared patterns of new cancer cases and notifications between the Nordic countries during 2020. We used pathology notifications to cancer registries in Denmark, the Faroe Islands, Finland, Iceland, Norway and Sweden to determine monthly numbers of pathology notifications of malignant and in situ tumours from January to December 2020 compared to 2019 (2017-2019 for Iceland and the Faroe Islands). We compared new cancer cases per month based on unique individuals with pathology notifications. In April and May 2020, the numbers of new malignant cases declined in all Nordic countries, except the Faroe Islands, compared to previous year(s). The largest reduction was observed in Sweden (May: -31.2%, 95% CI -33.9, -28.3), followed by significant declines in Finland, Denmark and Norway, and a nonsignificant decline in Iceland. In Denmark, Norway, Sweden and Finland the reporting rates during the second half of 2020 rose to almost the same level as in 2019. However, in Sweden and Finland, the increase did not compensate for the spring decline (annual reduction -6.2% and -3.6%, respectively). Overall, similar patterns were observed for in situ tumours. The COVID-19 pandemic led to a decline in rates of new cancer cases in Sweden, Finland, Denmark and Norway, with the most pronounced reduction in Sweden. Possible explanations include the severity of the pandemic, temporary halting of screening activities and changes in healthcare seeking behaviour.
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http://dx.doi.org/10.1002/ijc.34029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9087674PMC
April 2022

Comparison of 3 Different Minimally Invasive Surgical Techniques for Lumbar Spinal Stenosis: A Randomized Clinical Trial.

JAMA Netw Open 2022 03 1;5(3):e224291. Epub 2022 Mar 1.

Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.

Importance: Operations for lumbar spinal stenosis is the most often performed surgical procedure in the adult lumbar spine. This study reports the clinical outcome of the 3 most commonly used minimally invasive posterior decompression techniques.

Objective: To compare the effectiveness of 3 minimally invasive posterior decompression techniques for lumbar spinal stenosis.

Design, Setting, And Participants: This randomized clinical trial used a parallel group design and included patients with symptomatic and radiologically verified lumbar spinal stenosis without degenerative spondylolisthesis. Patients were enrolled between February 2014 and October 2018 at the orthopedic and neurosurgical departments of 16 Norwegian public hospitals. Statistical analysis was performed in the period from May to June 2021.

Interventions: Patients were randomized to undergo 1 of the 3 minimally invasive posterior decompression techniques: unilateral laminotomy with crossover, bilateral laminotomy, and spinous process osteotomy.

Main Outcomes And Measures: Primary outcome was change in disability measured with Oswestry Disability Index (ODI; range 0-100), presented as mean change from baseline to 2-year follow-up and proportions of patients classified as success (>30% reduction in ODI). Secondary outcomes were mean change in quality of life, disease-specific symptom severity measured with Zurich Claudication Questionnaire (ZCQ), back pain and leg pain on a 10-point numeric rating score (NRS), patient perceived benefit of the surgical procedure, duration of the surgical procedure, blood loss, perioperative complications, number of reoperations, and length of hospital stay.

Results: In total, 437 patients were included with a median (IQR) age of 68 (62-73) years and 230 men (53%). Of the included patients, 146 were randomized to unilateral laminotomy with crossover, 142 to bilateral laminotomy, and 149 to spinous process osteotomy. The unilateral laminotomy with crossover group had a mean change of -17.9 ODI points (95% CI, -20.8 to -14.9), the bilateral laminotomy group had a mean change of -19.7 ODI points (95% CI, -22.7 to -16.8), and the spinous process osteotomy group had a mean change of -19.9 ODI points (95% CI, -22.8 to -17.0). There were no significant differences in primary or secondary outcomes among the 3 surgical procedures, except a longer duration of the surgical procedure in the bilateral laminotomy group.

Conclusions And Relevance: No differences in clinical outcomes or complication rates were found among the 3 minimally invasive posterior decompression techniques used to treat patients with lumbar spinal stenosis.

Trial Registration: ClinicalTrials.gov Identifier: NCT02007083.
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http://dx.doi.org/10.1001/jamanetworkopen.2022.4291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8961320PMC
March 2022

Treatment and survival of patients with pancreatic ductal adenocarcinoma: 15-year national cohort.

BJS Open 2022 03;6(2)

Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway.

Background: Improvement in survival from pancreatic ductal adenocarcinoma (PDAC) has been reported in trial settings but is less explored in unselected cohorts. The aim of this study was to assess trends in provision of treatments and survival in Norway over a 15-year period following the implementation of hepato-pancreato-biliary (HPB) multidisciplinary teams, centralization of surgery, and implementation of modern chemotherapy (CTx) regimens.

Methods: A population-based observational study was conducted by analysing all patients diagnosed with PDAC between 2004 and 2018 using coupled data from the Cancer Registry of Norway and the National Patient Registry.

Results: A total of 10 630 patients were identified, of whom 1492 (14.0 per cent) underwent surgical resection. The resection rate, median age of those resected, and provision of perioperative CTx all increased over time. Median overall survival after resection improved from 16.0 months in the period 2004 to 2008 to 25.1 months in the period 2014 to 2018 (P < 0.001). For non-resected patients there was a rise in the provision of palliative chemotherapy, but little survival gain over time (median overall survival for 2004 to 2008 was 3.2 months versus 4.2 months for 2014 to 2018; P < 0.001). The rate of patients who did not receive any tumour-directed treatment (neither CTx nor surgery) was 44.3 per cent (2481 of 5603 patients) and decreased from 52.9 per cent in 2010 to 37.9 per cent in 2018 (P < 0.001). The median overall survival for all patients with PDAC increased from 3.7 months for 2004 to 2008 to 5.8 months for 2014 to 2018 (P < 0.001).

Conclusion: Survival after resection increased substantially, as did national resection rates. Little development in the provision of CTx or survival was observed for non-resected patients.
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http://dx.doi.org/10.1093/bjsopen/zrac004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8902330PMC
March 2022

Lifestyle modification for weight loss: Effects on cardiorespiratory capacity in patients with class II and class III obesity.

Obes Sci Pract 2022 Feb 8;8(1):45-55. Epub 2021 Jul 8.

Department of Medicine Ålesund Hospital Møre & Romsdal Hospital Trust Ålesund Norway.

Background: The prevalence of obesity has increased worldwide. Obesity affects the lungs and airways, limits peak oxygen uptake, and hampers physical performance; however, objective data are scarce. Does lifestyle modification for weight loss (LM) have an impact on cardiorespiratory capacity (CRC) in patients with class II and class III obesity?

Method: This was a single-center prospective 2-year follow-up pilot study. Four separated stays in the inpatient specialized medical center Muritunet with an integrated approach to LM, including an individual plan on diet and physical activity (PA) goals. Furthermore, it included lectures and counseling on human anatomy and physiology, nutrition, physical exercise, and motivation, as well as daily PA. Cardiopulmonary and blood chemistry tests were conducted.

Results: Seventy-seven participants were included; however, 47% ( = 36) dropped out during follow-up. Forty-one participants completed the study. At baseline (BL), the mean age was 45.4 (SD 10.2, range 23-62) years, with a mean body mass index (BMI) of 41.3 (SD 5.4) kg/m, and 85% ( = 35) had one or more comorbidities, such as obstructive pulmonary disease ( = 15, 37%), obstructive sleep apnea ( = 19, 46%), type 2 diabetes ( = 20, 49%), and hypertension ( = 17, 41%). The mean functional residual capacity increased, significantly the second year ( = 0,037). CRC increased significantly the first year ( = 0.032). Weight and BMI declined, reaching statistical significance at 2 years for both males and females ( = 0.033 and  = 0.003, respectively). At BL, the participants reported lower health-related quality of life compared to the general Norwegian population. Across time the physical component summary score (quality of life) for both males and females ( = 0.011 and  = 0.049, respectively) increased significantly.

Conclusion: Lifestyle modification for weight loss improves CRC in patients with class II and class III obesity.
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http://dx.doi.org/10.1002/osp4.544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8804912PMC
February 2022

Five ways to improve international comparisons of cancer survival: lessons learned from ICBP SURVMARK-2.

Br J Cancer 2022 May 20;126(8):1224-1228. Epub 2022 Jan 20.

Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.

Background: Comparisons of population-based cancer survival between countries are important to benchmark the overall effectiveness of cancer management. The International Cancer Benchmarking Partnership (ICBP) Survmark-2 study aims to compare survival in seven high-income countries across eight cancer sites and explore reasons for the observed differences. A critical aspect in ensuring comparability in the reported survival estimates are similarities in practice across cancer registries. While ICBP Survmark-2 has shown these differences are unlikely to explain the observed differences in cancer-specific survival between countries, it is important to keep in mind potential biases linked to registry practice and understand their likely impact.

Methods: Based on experiences gained within ICBP Survmark-2, we have developed a set of recommendations that seek to optimally harmonise cancer registry datasets to improve future benchmarking exercises.

Results: Our recommendations stem from considering the impact on cancer survival estimates in five key areas: (1) the completeness of the registry and the availability of registration sources; (2) the inclusion of death certification as a source of identifying cases; (3) the specification of the date of incidence; (4) the approach to handling multiple primary tumours and (5) the quality of linkage of cases to the deaths register.

Conclusion: These recommendations seek to improve comparability whilst maintaining the opportunity to understand and act upon international variations in outcomes among cancer patients.
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http://dx.doi.org/10.1038/s41416-022-01701-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9023566PMC
May 2022

Reliability of preoperative MRI findings in patients with lumbar spinal stenosis.

BMC Musculoskelet Disord 2022 Jan 15;23(1):51. Epub 2022 Jan 15.

Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway.

Background: Magnetic Resonance Imaging (MRI) is an important tool in preoperative evaluation of patients with lumbar spinal stenosis (LSS). Reported reliability of various MRI findings in LSS varies from fair to excellent. There are inconsistencies in the evaluated parameters and the methodology of the studies. The purpose of this study was to evaluate the reliability of the preoperative MRI findings in patients with LSS between musculoskeletal radiologists and orthopaedic spine surgeons, using established evaluation methods and imaging data from a prospective trial.

Methods: Consecutive lumbar MRI examinations of candidates for surgical treatment of LSS from the Norwegian Spinal Stenosis and Degenerative Spondylolisthesis (NORDSTEN) study were independently evaluated by two musculoskeletal radiologists and two orthopaedic spine surgeons. The observers had a range of experience between six and 13 years and rated five categorical parameters (foraminal and central canal stenosis, facet joint osteoarthritis, redundant nerve roots and intraspinal synovial cysts) and one continuous parameter (dural sac cross-sectional area). All parameters were re-rated after 6 weeks by all the observers. Inter- and intraobserver agreement was assessed by Gwet's agreement coefficient (AC1) for categorical parameters and Intraclass Correlation Coefficient (ICC) for the dural sac cross-sectional area.

Results: MRI examinations of 102 patients (mean age 66 ± 8 years, 53 men) were evaluated. The overall interobserver agreement was substantial or almost perfect for all categorical parameters (AC1 range 0.67 to 0.98), except for facet joint osteoarthritis, where the agreement was moderate (AC1 0.39). For the dural sac cross-sectional area, the overall interobserver agreement was good or excellent (ICC range 0.86 to 0.96). The intraobserver agreement was substantial or almost perfect/ excellent for all parameters (AC1 range 0.63 to 1.0 and ICC range 0.93 to 1.0).

Conclusions: There is high inter- and intraobserver agreement between radiologists and spine surgeons for preoperative MRI findings of LSS. However, the interobserver agreement is not optimal for evaluation of facet joint osteoarthritis.

Trial Registration: www.ClinicalTrials.gov identifier: NCT02007083 , registered December 2013.
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http://dx.doi.org/10.1186/s12891-021-04949-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8760672PMC
January 2022

Non-parametric estimation of reference adjusted, standardised probabilities of all-cause death and death due to cancer for population group comparisons.

BMC Med Res Methodol 2022 01 6;22(1). Epub 2022 Jan 6.

Department of Health Sciences, University of Leicester, Leicester, UK.

Background: Ensuring fair comparisons of cancer survival statistics across population groups requires careful consideration of differential competing mortality due to other causes, and adjusting for imbalances over groups in other prognostic covariates (e.g. age). This has typically been achieved using comparisons of age-standardised net survival, with age standardisation addressing covariate imbalance, and the net estimates removing differences in competing mortality from other causes. However, these estimates lack ease of interpretability. In this paper, we motivate an alternative non-parametric approach that uses a common rate of other cause mortality across groups to give reference-adjusted estimates of the all-cause and cause-specific crude probability of death in contrast to solely reporting net survival estimates.

Methods: We develop the methodology for a non-parametric equivalent of standardised and reference adjusted crude probabilities of death, building on the estimation of non-parametric crude probabilities of death. We illustrate the approach using regional comparisons of survival following a diagnosis of rectal cancer for men in England. We standardise to the covariate distribution and other cause mortality of England as a whole to offer comparability, but with close approximation to the observed all-cause region-specific mortality.

Results: The approach gives comparable estimates to observed crude probabilities of death, but allows direct comparison across population groups with different covariate profiles and competing mortality patterns. In our illustrative example, we show that regional variations in survival following a diagnosis of rectal cancer persist even after accounting for the variation in deprivation, age at diagnosis and other cause mortality.

Conclusions: The methodological approach of using standardised and reference adjusted metrics offers an appealing approach for future cancer survival comparison studies and routinely published cancer statistics. Our non-parametric estimation approach through the use of weighting offers the ability to estimate comparable survival estimates without the need for statistical modelling.
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http://dx.doi.org/10.1186/s12874-021-01465-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8740504PMC
January 2022

Early referral to a palliative team improves end-of-life care among gynecological cancer patients: a retrospective, population-based study.

Int J Gynecol Cancer 2022 02 5;32(2):181-188. Epub 2022 Jan 5.

Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway.

Objective: To assess end-of-life care among patients with gynecological cancer, and to describe the association between timing of palliative care referral and patterns of care.

Methods: All women with residence in Oslo, Norway, who died of gynecological cancer between January 1, 2015 and December 30, 2017 (36 months), were identified. Patients were primarily treated at the Norwegian Radium Hospital and clinical data on end-of-life care were retrospectively extracted from the medical records.

Results: We identified 163 patients with median age 70.1 years at death (range 26-100) with the following diagnoses: ovarian (n=100), uterine (n=40), cervical (n=21), and vulvar cancer (n=2). 53 (33%) of patients died in a palliative care unit, 34 patients (21%) died in nursing homes without palliative care, and 48 (29%) patients died in hospital. Only 15 (9%) patients died at home. 25 (15%) patients received chemotherapy in the last 30 days before death, especially ovarian cancer patients (n=21, 21%). 103 patients (61%) were referred to a palliative team prior to death. Referral to a palliative team was associated with a significantly reduced risk of intensive care unit admission (OR 0.11, 95% CI 0.02 to 0.62) and higher likelihood of a structured end-of-life discussion (OR 2.91, 95% CI 1.03 to 8.25). Palliative care referral also seemed to be associated with other quality indicators of end-of-life care (less chemotherapy use, more home deaths).

Conclusions: End-of-life care in patients with gynecological cancer suffers from underuse of palliative care. Chemotherapy is still commonly used towards end-of-life. Early palliative care referral in the disease trajectory may be an important step towards improved end-of-life care.
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http://dx.doi.org/10.1136/ijgc-2021-002898DOI Listing
February 2022

A way to explore the existence of "immortals" in cancer registry data - An illustration using data from ICBP SURVMARK-2.

Cancer Epidemiol 2022 02 24;76:102085. Epub 2021 Dec 24.

Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Health Sciences, University of Leicester, Leicester, United Kingdom.

Background: Accurately recorded vital status of individuals is essential when estimating cancer patient survival. When deaths are ascertained by linkage with vital statistics registers, some may be missed, and such individuals will wrongly appear to be long-term survivors, and survival will be overestimated. Interval-specific relative survival that levels off above one indicates that the survival among the cancer patients is better than expected, which could be due to the presence of immortals.

Methods: We included colon cancer cases diagnosed in 1995-1999 within the 19 jurisdictions in seven countries participating in ICBP SURVMARK-2, with follow-up information available until end-2015. Interval-specific relative survival was estimated for each year following diagnosis, by country and age group at diagnosis.

Results: The interval-specific relative survival levels off at 1 for all countries and age groups, with two exceptions: for the age group diagnosed at age 75 years and above in Ireland, and, to a lesser extent, in New Zealand.

Conclusion: Overall, a subset of immortals are not apparent in the early years within the ICBP SURVMARK-2 study, except for possibly in Ireland. We suggest this approach as one strategy of exploring the existence of immortals, and to be part of routine checks of cancer registry data.
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http://dx.doi.org/10.1016/j.canep.2021.102085DOI Listing
February 2022

Survival Trends of Right- and Left-Sided Colon Cancer across Four Decades: A Norwegian Population-Based Study.

Cancer Epidemiol Biomarkers Prev 2022 02 1;31(2):342-351. Epub 2021 Dec 1.

Department of Oncology, Oslo University Hospital, Oslo, Norway.

Background: Patients with right-sided colon cancer (RCC) and left-sided colon cancer (LCC) differ clinically and molecularly. The main objective was to investigate stage-stratified survival and recurrence of RCC and LCC across four 10-year periods.

Methods: Patients diagnosed from 1977 to 2016 with colon adenocarcinoma were included from the Cancer Registry of Norway. Primary tumor location (PTL) was defined as RCC if proximal and LCC if distal to the splenic flexure. Multivariable regressions were used to estimate HRs for overall survival (OS), recurrence-free survival (RFS), survival after recurrence (SAR), and excess HRs (eHR) for relative survival (RS).

Results: 72,224 patients were eligible for analyses [55.1% ( = 39,769/72,224) had RCC]. In 1977 to 1986, there was no difference between LCC and RCC in OS [HR, 1.01; 95% confidence interval (CI), 0.97-1.06; = 0.581] or RS (eHR, 0.96; 95% CI, 0.90-1.02; = 0.179). In 2007 to 2016, LCC had significantly better OS (HR, 0.84; 95% CI, 0.80-0.87; < 0.001) and RS (eHR, 0.76; 95% CI, 0.72-0.81; < 0.001) compared with RCC. The gradually diverging and significantly favorable prognosis for LCC was evident for distant disease across all time periods and for regional disease from 2007 onward. There was no difference in RFS between LCC and RCC in patients less than 75 years during 2007 to 2016 (HR, 0.99; 95% CI, 0.91-1.08; = 0.819); however, SAR was significantly better for LCC (HR, 0.61; 95% CI, 0.53-0.71; < 0.001).

Conclusions: A gradually diverging and increasingly favorable prognosis was observed for patients with LCC with advanced disease over the past four decades.

Impact: Current PTL survival disparities stress the need for further exploring targetable molecular subgroups across and within different PTLs to further improve patient outcomes.
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http://dx.doi.org/10.1158/1055-9965.EPI-21-0555DOI Listing
February 2022

Clinical and MRI findings in lumbar spinal stenosis: baseline data from the NORDSTEN study.

Eur Spine J 2021 Nov 19. Epub 2021 Nov 19.

Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.

Purpose: The aim was to describe magnetic resonance imaging findings in patients planned for lumbar spinal stenosis surgery. Further, to describe possible associations between MRI findings and patient characteristics with patient reported disability or pain.

Methods: The NORDSTEN spinal stenosis trial included 437 patients planned for surgical decompression of LSS. The following MRI findings were evaluated before surgery: morphological (Schizas) and quantitative (cross-sectional area) grade of stenosis, disk degeneration (Pfirrmann), facet joint tropism and fatty infiltration of the multifidus muscle. Patients were dichotomized into a moderate or severe category for each radiological parameter classification. A multivariable linear regression analysis was performed to investigate the association between MRI findings and preoperative scores for Oswestry Disability Index, Zurich Claudication Questionnaire and Numeric rating scale for back and leg pain. The following patient characteristics were included in the analysis: gender, age, smoking and weight.

Results: The percentage of patients with severe scores was as follows: Schizas (C + D) 71.3%, cross-sectional area (< 75 mm) 86.8%, Pfirrmann (4 + 5) 58.1%, tropism (≥ 15°) 11.9%, degeneration of multifidus muscle (2-4) 83.7%. Regression coefficients indicated minimal changes in severity of symptoms when comparing the groups with moderate and severe MRI findings. Only gender had a significant and clinically relevant association with ODI score.

Conclusion: In this cross-sectional study, the majority of the patients had MRI findings classified as severe LSS changes, but the findings had no clinically relevant association with patient reported disability and pain at baseline. Patient characteristics have a larger impact on disability and pain than radiological findings.

Trial Registration: www.ClinicalTrials.gov identifier: NCT02007083, registered December 2013.
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http://dx.doi.org/10.1007/s00586-021-07051-4DOI Listing
November 2021

Regional variation in cancer survival in Norway.

Cancer Epidemiol 2021 12 24;75:102038. Epub 2021 Sep 24.

Department of Registration, Cancer Registry of Noikrway, Box 5313 Majorstuen, 0304 Oslo, Norway. Electronic address:

Background: Cancer services in Norway are intended to provide high quality services and equal access for all citizens. Still, regional variation in cancer survival has been reported. Currently, the public hospitals are organized in Health Trusts (HTs), respectively within one of four regional trusts (RHTs). We aimed to evaluate the extent and rank pattern of regional and intraregional variation in cancer survival systematically over the last three decades. We postulated that organizational reforms during this period might have modulated the variation.

Methods: Excess hazard ratios (EHR) of death from cancer were estimated for all individuals identified in The Cancer Registry of Norway as diagnosed with cancer from 1984 to 2018. The model covariates included continuous age at diagnosis, sex, cancer site, stage, 5-year time period of diagnosis and place of residence. In addition to analyses for all cancers combined, selected cohorts with predominantly centralized vs. not centralized primary surgery were evaluated.

Results: For all cancer sites combined and for the centralized surgery cohort, the range of variation in EHR among the four regions was in the order of 0.10. The ranks among the regions were fairly consistent over time. For the not centralized surgery cohort, the range of inter-regional EHR-variation was in the order of 0.10 - 0.15, with no consistent ranks. Intra-regionally, the ranges of EHR-variation were similar, but with more complex rank patterns.

Conclusions: The range of inter- and intra-regional variation in cancer survival was minor, as compared to the general improvement in cancer survival in the period, with no evidence of effect from organizational reforms on regional variation.
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http://dx.doi.org/10.1016/j.canep.2021.102038DOI Listing
December 2021

The validity of cancer information on death certificates in Norway and the impact of death certificate initiated cases on cancer incidence and survival.

Cancer Epidemiol 2021 12 22;75:102023. Epub 2021 Sep 22.

Department of Registration, Cancer Registry of Norway, Oslo, Norway; Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway.

Background: Death certificates are an important source of information for cancer registries. The aim of this study was to validate the cancer information on death certificates, and to investigate the effect of including death certificate initiated (DCI) cases in the Cancer Registry of Norway when estimating cancer incidence and survival.

Methods: All deaths in Norway in the period 2011-2015 with cancer mentioned on the death certificates were linked to the cancer registry. Notifications not registered from other sources were labelled death certificate notifications (DCNs), and considered as either cancer or not, based on available information in the registry or from trace-back to another source.

Results: From the total of 65 091 cancers mentioned on death certificates in the period 2011-2015, 58,425 (89.8%) were already in the registry. Of the remaining 6 666 notifications, 2 636 (2 129 with cancer as underlying cause) were not regarded to be new cancers, which constitutes 4.0% of all cancers mentioned on death certificates and 39.5% of the DCNs. Inclusion of the DCI cases increased the incidence of all cancers combined by 2.6%, with largest differences for cancers with poorer prognosis and for older age groups. Without validation, including the 2 129 disregarded death certificates would over-estimate the incidence by 1.3%. Including DCI cases decreased the five-year relative survival estimate for all cancer sites combined with 0.5% points.

Conclusion: In this study, almost 40% of the DCNs were regarded not to be a new cancer case, indicating unreliability of death certificate information for cancers that are not already registered from other sources. The majority of the DCNs where, however, registered as new cases that would have been missed without death certificates. Both including and excluding the DCI cases will potentially bias the survival estimates, but in different directions. This biases were shown to be small in the Cancer Registry of Norway.
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http://dx.doi.org/10.1016/j.canep.2021.102023DOI Listing
December 2021

Cardiopulmonary resuscitation retention training for hospital nurses by a self-learner skill station or the traditional instructor led course: A randomised controlled trial.

Resusc Plus 2021 Sep 19;7:100157. Epub 2021 Aug 19.

Department of Medicine, Ålesund Hospital, Møre & Romsdal Hospital Trust, Ålesund, Norway.

Introduction: Intrahospital cardiac arrest has a steep mortality and high-quality cardiopulmonary resuscitation (CPR) is essential for favourable outcome. Instructor led (IL) CPR training is resource demanding and instructor free, feedback providing CPR skill stations (SS) could provide a means to enable the needed frequent retraining. The main objective of this study was to test the hypothesis that there was no difference between IL and SS training.

Methods: A total of 129 hospital nurses were randomised to CPR retraining in three groups; skill station with retraining at 2 months (SS-R), skill station without retraining (SS) and instructor led training (IL). Participants were tested at baseline, 2 and 8 months. The skill station groups were combined (c-SS) for analysis at baseline and 2 months when comparing to IL.

Results: Baseline characteristics for the three groups differed significantly, however c-SS and IL groups performed equally at baseline and testing at 2 months. At 8 months the SS group performed 71% correct ventilations compared to 54% in the IL group (p = 0.04), but CPR quality was otherwise equal. Longitudinal analysis showed SS-R performed 3.4 mm deeper compressions at final evaluation compared to baseline (p = 0.02) and 2.8 mm deeper compared to 2-month test (p = 0.02). No effects of retraining at 2 months could be detected at final comparison of SS-R and SS groups.

Conclusion: CPR training using a skill station led to equal performance at 2 and 8 months compared to instructor led training. Feedback-providing skill stations could be a feasible tool for required frequent retraining.
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http://dx.doi.org/10.1016/j.resplu.2021.100157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8384897PMC
September 2021

Persisting symptoms three to eight months after non-hospitalized COVID-19, a prospective cohort study.

PLoS One 2021 26;16(8):e0256142. Epub 2021 Aug 26.

Cancer Registry of Norway, Oslo, Norway.

Long-COVID-19 is a proposed syndrome negatively affecting the health of COVID-19 patients. We present data on self-rated health three to eight months after laboratory confirmed COVID-19 disease compared to a control group of SARS-CoV-2 negative patients. We followed a cohort of 8786 non-hospitalized patients who were invited after SARS-CoV-2 testing between February 1 and April 15, 2020 (794 positive, 7229 negative). Participants answered online surveys at baseline and follow-up including questions on demographics, symptoms, risk factors for SARS-CoV-2, and self-rated health compared to one year ago. Determinants for a worsening of self-rated health as compared to one year ago among the SARS-CoV-2 positive group were analyzed using multivariate logistic regression and also compared to the population norm. The follow-up questionnaire was completed by 85% of the SARS-CoV-2 positive and 75% of the SARS-CoV-2 negative participants on average 132 days after the SARS-CoV-2 test. At follow-up, 36% of the SARS-CoV-2 positive participants rated their health "somewhat" or "much" worse than one year ago. In contrast, 18% of the SARS-CoV-2 negative participants reported a similar deterioration of health while the population norm is 12%. Sore throat and cough were more frequently reported by the control group at follow-up. Neither gender nor follow-up time was associated with the multivariate odds of worsening of self-reported health compared to one year ago. Age had an inverted-U formed association with a worsening of health while being fit and being a health professional were associated with lower multivariate odds. A significant proportion of non-hospitalized COVID-19 patients, regardless of age, have not returned to their usual health three to eight months after infection.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0256142PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8389372PMC
September 2021

Testicular Cancer in the Cisplatin Era: Causes of Death and Mortality Rates in a Population-Based Cohort.

J Clin Oncol 2021 11 13;39(32):3561-3573. Epub 2021 Aug 13.

Department of Oncology, University Hospital of North Norway, Tromsø, Norway.

Purpose: Using complete information regarding testicular cancer (TC) treatment burden, this study aimed to investigate cause-specific non-TC mortality with impact on previous treatment with platinum-based chemotherapy (PBCT) or radiotherapy (RT).

Methods: Overall, 5,707 men identified by the Cancer Registry of Norway diagnosed with TC from 1980 to 2009 were included in this population-based cohort study. By linking data with the Norwegian Cause of Death Registry, standardized mortality ratios (SMRs), absolute excess risks (AERs; [(observed number of deaths - expected number of deaths)/person-years of observation] ×10,000), and adjusted hazard ratios (HRs) were calculated.

Results: Median follow-up was 18.7 years, during which non-TC death was registered for 665 (12%) men. Overall excess non-TC mortality was 23% (SMR, 1.23; 95% CI, 1.14 to 1.33; AER, 11.14) compared with the general population, with increased risks after PBCT (SMR, 1.23; 95% CI, 1.07 to 1.43; AER, 7.68) and RT (SMR, 1.28; 95% CI, 1.15 to 1.43; AER, 19.55). The highest non-TC mortality was observed in those < 20 years at TC diagnosis (SMR, 2.27; 95% CI, 1.32 to 3.90; AER, 14.42). The most important cause of death was non-TC second cancer with an overall SMR of 1.53 (95% CI, 1.35 to 1.73; AER, 7.94), with increased risks after PBCT and RT. Overall noncancer mortality was increased by 15% (SMR, 1.15; 95% CI, 1.04 to 1.27; AER, 4.71). Excess suicides appeared after PBCT (SMR, 1.65; 95% CI, 1.01 to 2.69; AER, 1.39). Compared with surgery, increased non-TC mortality appeared after 3 (HR, 1.47; 95% CI, 0.91 to 2.39), 4 (HR, 1.41; 95% CI, 1.01 to 1.99), and more than four (HR, 2.04; 95% CI, 1.25 to 3.35) cisplatin-based chemotherapy cycles after > 10 years of follow-up.

Conclusion: TC treatment with PBCT or RT is associated with a significant excess risk of non-TC mortality, and increased risks emerged after more than two cisplatin-based chemotherapy cycles after > 10 years of follow-up.
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http://dx.doi.org/10.1200/JCO.21.00637DOI Listing
November 2021

Comparative Survival Outcomes of High-risk Prostate Cancer Treated with Radical Prostatectomy or Definitive Radiotherapy Regimens.

Eur Urol Open Sci 2021 Apr 24;26:55-63. Epub 2021 Feb 24.

Cancer Registry of Norway, Oslo, Norway.

Background: Observational data has indicated improved survival after radical prostatectomy (RP) compared with definitive radiotherapy (RT) in men with high-risk prostate cancer (PCa).

Objective: To compare PCa-specific mortality (PCSM) and overall mortality (OM) in men with high-risk PCa treated with RP or RT, providing information on target doses and fractionations.

Design Setting And Participants: This is an observational study from the Cancer Registry of Norway. Patients were diagnosed with high-risk PCa during 2006-2015, treated with RP ≤12 mo or RT ≤15 mo after diagnosis, and stratified according to RP or RT modality; external beam radiotherapy (EBRT; 70-<74, 74-<78, or 78 Gy), hypofractionated RT or EBRT combined with brachytherapy (BT-RT).

Outcome Measurements And Statistical Analysis: Competing risk and Kaplan-Meier methods estimated PCSM and OM, respectively. Multivariable Cox regression models evaluated hazard ratios (HRs) for PCSM and OM.

Results And Limitations: In total, 9254 patients were included (RP 47%, RT 53%). RT patients were older, had poorer performance status and more unfavorable disease characteristics. With a median follow-up time of seven and eight yrs, the overall 10-yr PCSM was 7.2% (95% confidence interval [CI] 6.4-8.0) and OM was 22.9% (95% CI 21.8-24.1). Compared with RP, EBRT 70-<74 Gy was associated with increased (HR 1.88, 95% CI 1.33-2.65, < 0.001) and BT-RT with decreased (HR 0.49, 95% CI 0.24-0.96, = 0.039) 10-yr PCSM. Patients treated with EBRT 70-78 Gy had higher adjusted 10-yr OM than those treated with RP.

Conclusions: In men with high-risk PCa, treatment with EBRT <74 Gy was associated with increased adjusted 10-yr PCSM and OM, and BT-RT with decreased 10-yr PCSM, compared with RP.

Patient Summary: In this study, we compared mortality after radical prostatectomy (RP) and radiotherapy (RT) in men with high-risk prostate cancer (PCa); the results suggest that men receiving lower-dose RT have higher, and patients receiving brachytherapy may have lower, risk of death from PCa than patients treated with prostatectomy.
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http://dx.doi.org/10.1016/j.euros.2021.01.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8317873PMC
April 2021

Fear of Recurrence in Prostate Cancer Patients: A Cross-sectional Study After Radical Prostatectomy or Active Surveillance.

Eur Urol Open Sci 2021 Mar 3;25:44-51. Epub 2021 Feb 3.

Department of Urology, Vestfold Hospital Trust, Tønsberg, Norway.

Background: Fear of recurrence (FoR) is a distressing consequence of cancer. Little is known about the prevalence of FoR in different treatment groups and factors associated with FoR among prostate cancer (PCa) survivors.

Objective: To investigate the prevalence of high FoR among PCa survivors after radical prostatectomy (RP) or under active surveillance (AS) and to explore clinical and psychological factors potentially associated with FoR.

Design Setting And Participants: This is a retrospective cross-sectional study of 606 patients with PCa, treated with either RP ( = 442) or AS ( = 164) at two Norwegian regional hospitals. The 440 patients (73%) who gave consent to participate were invited in 2017 to complete a questionnaire measuring FoR, self-rated health, adverse effects, and psychological factors at a mean of 4.1 yr (standard deviation 1.7) after their treatment decision. Clinical data were retrieved from medical records.

Outcome Measurements And Statistical Analysis: FoR was measured using the Concerns About Recurrence Questionnaire, with high FoR defined as a sum score of =12 points (range 0-40). Using multivariable logistic regression analyses, factors associated with high FoR were identified.

Results And Limitations: One-third of the participants had high FoR; scores were higher in the AS group and in the RP group with treatment failure. Younger age was significantly associated with high FoR in the AS group, while high prostate-specific antigen at diagnosis, biochemical recurrence, positive surgical margin, higher fatigue, and a type D personality were significantly associated with high FoR in the RP group.

Conclusions: At 4 yr after a diagnosis of PCa, high FoR was common, especially among AS patients and among RP patients with treatment failure.

Patient Summary: In this study, we examined fear that their disease will return or progress among prostate cancer survivors. We found that such fear was common, especially among young patients under active surveillance and among radical prostatectomy patients with treatment failure or with certain psychological features.
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http://dx.doi.org/10.1016/j.euros.2021.01.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8317872PMC
March 2021

Increased Mortality in Young-Onset Parkinson's Disease.

J Mov Disord 2021 Sep 29;14(3):214-220. Epub 2021 Jul 29.

Department of Neuromedicine and Movement Science (INB), NTNU, Faculty of Medicine and Health Sciences, Trondheim, Norway.

Objective: Few studies have followed Parkinson's disease (PD) patients from the time of diagnosis to the date of death. This study compared mortality in the Trondheim PD cohort to the general population, investigated causes of death and analyzed the associations between mortality and age at disease onset (AAO) and cognitive decline defined as Montreal Cognitive Assessment (MoCA) score below 26.

Methods: The cohort was followed longitudinally from 1997. By the end of January 2020, 587 patients had died. Comparisons to the Norwegian population were performed by calculating standardized mortality ratios (SMRs). Survival curves were estimated using the standard Kaplan-Meier estimator, and multivariable Cox proportional hazard models were estimated to investigate associations.

Results: SMR was 2.28 [95% confidence interval (CI): 2.13-2.44] for the whole cohort. For participants with AAO 20-39 years, the SMR was 5.55 (95% CI: 3.38-8.61). Median survival was 15 years (95% CI: 14.2-15.5) for the whole cohort. Early-onset PD (EOPD) patients (AAO < 50 years) had the longest median survival time. For all groups, there was a significant shortening in median survival time and an almost 3-fold higher age- and sex-adjusted hazard ratio for death when the MoCA score decreased below 26.

Conclusion: PD patients with an AAO before 40 years had a more than fivefold higher mortality rate compared to a similar general population. EOPD patients had the longest median survival; however, their life expectancy was reduced to a greater degree than that of late-onset PD patients. Cognitive impairment was strongly associated with mortality in PD.
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http://dx.doi.org/10.14802/jmd.21029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8490197PMC
September 2021

Is T2 mapping reliable in evaluation of native and repair cartilage tissue of the knee?

J Exp Orthop 2021 Apr 28;8(1):34. Epub 2021 Apr 28.

Department of Orthopaedic Surgery, Akershus University Hospital, 1478 Lørenskog, Norway.

Purpose: To evaluate the effect of imaging plane and experience of observers on the reliability of T2 mapping of native and repair cartilage tissue of the knee.

Methods: Fifteen consecutive patients from two randomised controlled trials (RCTs) were included in this cross-sectional study. Patients with an isolated knee cartilage lesion were randomised to receive either debridement or microfracture (RCT 1) or debridement or autologous chondrocyte implantation (RCT 2). T2 mapping was performed in coronal and sagittal planes two years postoperatively. A musculoskeletal radiologist, a resident of radiology and two orthopaedic surgeons measured the T2 values independently. Intraclass Correlation Coefficient (ICC) with 95% Confidence Intervals was used to calculate the inter- and intraobserver agreement.

Results: Mean age for the patients was 36.8 ± 11 years, 8 (53%) were men. The overall interobserver agreement varied from poor to good with ICCs in the range of 0.27- 0.76 for native cartilage and 0.00 - 0.90 for repair tissue. The lowest agreement was achieved for evaluations of repair cartilage tissue. The estimated ICCs suggested higher inter- and intraobserver agreement for radiologists. On medial femoral condyles, T2 values were higher for native cartilage on coronal images (p < 0.001) and for repair tissue on sagittal images (p < 0.001).

Conclusions: The reliability of T2 mapping of articular cartilage is influenced by the imaging plane and the experience of the observers. This influence may be more profound for repair cartilage tissue. This is important to consider when using T2 mapping to measure outcomes after cartilage repair surgery.

Trial Registration: ClinicalTrials.gov, NCT02637505 and NCT02636881 , registered December 2015.

Level Of Evidence: II, based on prospective data from two RCTs.
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http://dx.doi.org/10.1186/s40634-021-00350-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081777PMC
April 2021

Does a history of cardiovascular disease or cancer affect mortality after SARS-CoV-2 infection?

Tidsskr Nor Laegeforen 2021 02 29;140(2). Epub 2020 Dec 29.

Background: Cardiovascular disease and cancer have been described as possible risk factors for COVID-19 mortality. The purpose of this study was to investigate whether a history of cardiovascular disease or cancer affects the risk of dying after a COVID-19 diagnosis in Norway.

Material And Method: Data were compiled from the Norwegian Surveillance System for Communicable Diseases, the Norwegian Cardiovascular Disease Registry and the Cancer Registry of Norway. Univariable and multivariable regression models were used to calculate both relative and absolute risk.

Results: In the first half of 2020, 8 809 people tested positive for SARS-CoV-2 and 260 COVID-19-associated deaths were registered. Increasing age, male sex (relative risk (RR): 1.5; confidence interval (CI): 1.2-2.0), prior stroke (RR: 1.5; CI: 1.0-2.1) and cancer with distant metastasis at the time of diagnosis (RR: 3.0; CI: 1.1-8.2) were independent risk factors for death after a diagnosis of COVID-19. After adjusting for age and sex, myocardial infarction, atrial fibrillation, heart failure, hypertension, and non-metastatic cancer were no longer statistically significant risk factors for death.

Interpretation: The leading risk factor for death among individuals who tested positive for SARS-CoV-2 was age. Male sex, and a previous diagnosis of stroke or cancer with distant metastasis were also associated with an increased risk of death after a COVID-19 diagnosis.
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http://dx.doi.org/10.4045/tidsskr.20.0956DOI Listing
February 2021

The impact of excluding or including Death Certificate Initiated (DCI) cases on estimated cancer survival: A simulation study.

Cancer Epidemiol 2021 04 10;71(Pt A):101881. Epub 2021 Jan 10.

Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Health Sciences, University of Leicester, Leicester, United Kingdom.

Background: Population-based cancer registries strive to cover all cancer cases diagnosed within the population, but some cases will always be missed and no register is 100 % complete. Many cancer registries use death certificates to identify additional cases not captured through other routine sources, to hopefully add a large proportion of the missed cases. Cases notified through this route, who would not have been captured without death certificate information, are referred to as Death Certificate Initiated (DCI) cases. Inclusion of DCI cases in cancer registries increases completeness and is important for estimating cancer incidence. However, inclusion of DCI cases will generally lead to biased estimates of cancer survival, but the same is often also true if excluding DCI cases. Missed cases are probably not a random sample of all cancer cases, but rather cases with poor prognosis. Further, DCI cases have poorer prognosis than missed cases in general, since they have all died with cancer mentioned on the death certificates.

Methods: We performed a simulation study to estimate the impact of including or excluding DCI cases on cancer survival estimates, under different scenarios.

Results: We demonstrated that including DCI cases underestimates survival. The exclusion of DCI cases gives unbiased survival estimates if missed cases are a random sample of all cancer cases, while survival is overestimated if these have poorer prognosis.

Conclusion: In our most extreme scenarios, with 25 % of cases initially missed, the usual practice of including DCI cases underestimated 5-year survival by at most 3 percentage points.
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http://dx.doi.org/10.1016/j.canep.2020.101881DOI Listing
April 2021

Metachronous Contralateral Testicular Cancer in the Cisplatin Era: A Population-Based Cohort Study.

J Clin Oncol 2021 02 23;39(4):308-318. Epub 2020 Dec 23.

Department of Oncology, University Hospital of North Norway, Tromsø, Norway.

Purpose: It is hypothesized that cisplatin-based chemotherapy (CBCT) reduces the occurrence of metachronous contralateral (second) germ cell testicular cancer (TC). However, studies including treatment details are lacking. The aim of this study was to assess the second TC risk, emphasizing the impact of previous TC treatment.

Patients And Methods: Based on the Cancer Registry of Norway, 5,620 men were diagnosed with first TC between 1980 and 2009. Treatment data regarding TC were retrieved from medical records. Cumulative incidences of second TC were estimated, and standardized incidence ratios were calculated. The effect of treatment intensity was investigated using Cox proportional hazard regression.

Results: Median follow-up was 18.0 years, during which 218 men were diagnosed with a second TC after median 6.2 years. Overall, the 20-year crude cumulative incidence was 4.0% (95% CI, 3.5 to 4.6), with lower incidence after chemotherapy (CT) (3.2%; 95% CI, 2.5 to 4.0) than after surgery only (5.4%; 95% CI, 4.2 to 6.8). The second TC incidence was also lower for those age ≥ 30 years (2.8%; 95% CI, 2.3 to 3.4) at first TC diagnosis than those age < 30 years (6.0%; 95% CI, 5.0 to 7.1). Overall, the second TC risk was 13-fold higher compared with the risk of developing TC in the general male population (standardized incidence ratio, 13.1; 95% CI, 11.5 to 15.0). With surgery only as reference, treatment with CT significantly reduced the second TC risk (hazard ratio [HR], 0.55). For each additional CBCT cycle administered, the second TC risk decreased significantly after three, four, and more than four cycles (HRs, 0.53, 0.41, and 0.21, respectively).

Conclusion: Age at first TC diagnosis and treatment intensity influenced the second TC risk, with significantly reduced risks after more than two CBCT cycles.
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http://dx.doi.org/10.1200/JCO.20.02713DOI Listing
February 2021

Epidemiology and Antimicrobial Susceptibility of Invasive Bacterial Infections in Children-A Population-Based Study From Norway.

Pediatr Infect Dis J 2021 05;40(5):403-410

From the Department of Clinical Science, University of Bergen.

Objective: To describe epidemiology and antimicrobial susceptibility testing (AST) data of bacteria causing invasive infections in Norwegian children (0-18 years).

Methods: Population-based observational study using prospectively collected AST data from the Norwegian Surveillance System of Antimicrobial Resistance from 2013 to 2017. We included all clinically relevant bacterial isolates (blood and cerebrospinal fluid), and compared incidence of invasive infections and AST data in isolates from children and adults.

Results: We included 1173 isolates from children and 44,561 isolates from adults. Staphylococcus aureus accounted for 220/477 (46.2%, 95% CI: 41.6-50.7) of all isolates in schoolchildren (6-18 years). Compared with Streptococcus pneumonia isolates from adults (N = 2674), we observed higher nonsusceptibility rates to penicillin in isolates from children (N = 151), 11.9% versus 5.8%, P < 0.01; also higher resistance rates to erythromycin (11.3% vs. 4.9%, P < 0.01), clindamycin (9.3% vs. 3.6%, P < 0.001), and trimethoprim/sulfamethoxazole (17.9% vs. 6.4%, P < 0.001). Compared with Escherichia coli isolates in adults (N = 9073), we found lower rates of ESBL in isolates from children (N = 212), 2.4% versus 6.4%, P < 0.05.

Conclusion: The study indicates the importance of microbiologic surveillance strategies in children and highlights the need for pediatric AST data. The high rates of nonsusceptibility to commonly used antibiotics among S. pneumoniae in children and the high burden of invasive S. aureus infections in schoolchildren calls for modifications of Norwegian guidelines.
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http://dx.doi.org/10.1097/INF.0000000000003013DOI Listing
May 2021

Exploring the impact of cancer registry completeness on international cancer survival differences: a simulation study.

Br J Cancer 2021 03 9;124(5):1026-1032. Epub 2020 Dec 9.

Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.

Background: Data from population-based cancer registries are often used to compare cancer survival between countries or regions. The ICBP SURVMARK-2 study is an international partnership aiming to quantify and explore the reasons behind survival differences across high-income countries. However, the magnitude and relevance of differences in cancer survival between countries have been questioned, as it is argued that observed survival variations may be explained, at least in part, by differences in cancer registration practice, completeness and the availability and quality of the respective data sources.

Methods: As part of the ICBP SURVMARK-2 study, we used a simulation approach to better understand how differences in completeness, the characteristics of those missed and inclusion of cases found from death certificates can impact on cancer survival estimates.

Results: Bias in 1- and 5-year net survival estimates for 216 simulated scenarios is presented. Out of the investigated factors, the proportion of cases not registered through sources other than death certificates, had the largest impact on survival estimates.

Conclusion: Our results show that the differences in registration practice between participating countries could in our most extreme scenarios explain only a part of the largest observed differences in cancer survival.
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http://dx.doi.org/10.1038/s41416-020-01196-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7921088PMC
March 2021

The outcome at follow-up after inpatient eating disorder treatment: a naturalistic study.

J Eat Disord 2020 Dec 2;8(1):67. Epub 2020 Dec 2.

Regional Eating Disorder Service, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway.

Background: Patients with eating disorders may experience a severe and enduring course of illness. Treatment outcome for patients provided with inpatient treatment is reported as poor. Research to date has not provided consistent results for predictors of treatment outcome. The aims of the study were to investigate rates of remission at follow-up after inpatient treatment, symptom change from admission to follow-up, and predictors of treatment outcome.

Methods: The follow-up sample consisted of 150 female adult former patients (69.4% of all eligible female patients) with eating disorders. Mean age at admission was 21.7 (SD = 4.9) years. Diagnostic distribution: 66% (n = 99) anorexia nervosa, 21.3% (n = 32) bulimia nervosa and 12.7% (n = 19) other specified feeding or eating disorder, including binge eating. Data were collected at admission, discharge and follow-up (mean 2.7 (SD = 1.9) years). Definition of remission was based on the EDE-Q Global score, body mass index and binge/purge behavior. Paired T-tests were performed to investigate change over time. Univariate and multivariate logistic regressions were estimated to investigate predictors of remission.

Results: At follow-up, 35.2% of the participants were classified as in remission. Significant symptom reduction (in all patients) (p <  0.001) and significant increase in body mass index (BMI) (in underweight participants at admission) (p <  0.001) was found. Increased BMI (p <  0.05), the level of core eating disorder symptoms at admission (p <  0.01) and reduced core eating disorder symptoms (p <  0.01) during inpatient treatment were found significant predictors of outcome in the multivariate model.

Conclusions: All participants had an eating disorder requiring inpatient treatment. Approximately one-third of all participants could be classified as in remission at follow-up. However, most participants experienced significant symptom improvement during inpatient treatment and the improvements were sustained at follow-up. Increased probability of remission at follow-up was indicated by lower core ED symptoms at admission for all patients, raised BMI during admission for patients with AN, and reduced core ED symptoms during inpatient treatment for all patients. This finding contributes important information and highlights the importance of targeting these core symptoms in transdiagnostic treatment programs.
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http://dx.doi.org/10.1186/s40337-020-00349-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709321PMC
December 2020

Education, income and risk of cancer: results from a Norwegian registry-based study.

Acta Oncol 2020 Nov 14;59(11):1300-1307. Epub 2020 Sep 14.

Cancer Registry of Norway, Oslo, Norway.

Introduction: Several studies have shown an association between socioeconomic status and incidence of cancer. In this study, we have examined the association between socioeconomic factors, using income and education as proxies, and cancer incidence in Norway, a country known to be egalitarian, with universal access to health care and scoring high on the human development index.

Methods: We linked individual data for the total Norwegian population with information on all cancer patients registered in the Cancer Registry of Norway (CRN) with any cancer diagnosed between 2012 and 2016. Data on education, and individual income, were provided from Statistics Norway. We used Poisson regression to obtain incidence rate ratios (IRR) across education and income levels for 23 cancer sites.

Results: A total of 9 cancers among men and 13 cancers among women were observed to have significantly higher incidence rates in cases with the lowest level of education. Melanoma for both sexes, testis and prostate cancer in men, and breast cancer in women were found to have a higher incidence rate among those with the highest level of education. The largest differences in IRR were found for lung cancer, where men and women with college or university education as their highest completed education had a two- to threefold decreased risk, compared to those with primary school (IRR men; 0.40 [0.37-0.43], women 0.34 [0.31-0.37]). The results for income mirrored the results for education among men, while for women we did not observe many differences in cancer risk across income groups.

Conclusion: Our findings were consistent with findings from other studies showing that the incidence rate of cancer differs across levels of socioeconomic status. We may need behavioral change campaigns focused on lifestyle changes that lower the risk of cancer and target perhaps to those with lower socioeconomic status.
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http://dx.doi.org/10.1080/0284186X.2020.1817548DOI Listing
November 2020

Neonatal transitional support with intact umbilical cord in assisted vaginal deliveries: a quality-improvement cohort study.

BMC Pregnancy Childbirth 2020 Aug 27;20(1):496. Epub 2020 Aug 27.

Department of Pediatrics, Møre and Romsdal Hospital Trust, Ålesund Hospital, Ålesund, Norway.

Background: Deferring cord clamping has proven benefits for both term and preterm infants, and recent studies have demonstrated better cardio-respiratory stability if clamping is based on the infant's physiology, and whether the infant has breathed. Nevertheless, current guidelines for neonatal resuscitation still recommend early cord clamping (ECC) for compromised babies, unless equipment and competent personnel to resuscitate the baby are available at the mother's bedside. The objective of this quality improvement cohort study was to evaluate whether implementing a new delivery room protocol involving mobile resuscitation equipment (LifeStart™) reduced the prevalence of ECC in assisted vaginal deliveries.

Methods: Data on cord clamping and transitional care were collected 8 months before and 8 months after implementing the new protocol. The Model for Improvement was applied to identify drivers and obstacles to practice change. Statistical Process Control analysis was used to demonstrate signals of improvement, and whether these changes were sustainable. Multivariate logistic regression was used to evaluate the impact of the new protocol on the primary outcome, adjusted for possible confounders.

Results: Overall prevalence of ECC dropped from 13 to 1% (P < 0.01), with a 98% relative risk reduction for infants needing transitional support on a resuscitation table (adjusted OR 0.02, P < 0.001). Mean cord clamping time increased by 43% (p < 0.001). Although fewer infants were placed directly on mothers' chest (n = 43 [42%] vs n = 69 [75.0%], P < 0.001), there were no significant differences in needs for immediate transitional care or transfers to Neonatal Intensive Care Unit. A pattern of improvement was seen already before the intervention, especially after mandatory educational sessions and cross-professional simulation training.

Conclusions: A new delivery-room protocol involving mobile resuscitation equipment successfully eliminated early cord clamping in assisted vaginal deliveries of term and near-term infants. A systematic approach, like the Model for Improvement, seemed crucial for both achieving and sustaining the desired results.

Trial Registration: The study was approved as a service evaluation as defined by the Regional Committee for Medical and Health Research Ethics ( 2018/1755/REK midt ).
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http://dx.doi.org/10.1186/s12884-020-03188-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457264PMC
August 2020

Reference-adjusted and standardized all-cause and crude probabilities as an alternative to net survival in population-based cancer studies.

Int J Epidemiol 2020 10;49(5):1614-1623

Department of Registration, Cancer Registry of Norway, Oslo, Norway.

Background: In population-based cancer survival studies, the most common measure to compare population groups is age-standardized marginal relative survival, which under assumptions can be interpreted as marginal net survival; the probability of surviving if it was not possible to die of causes other than the cancer under study (if the age distribution was that of a common reference population). The hypothetical nature of this definition has led to confusion and incorrect interpretation. For any measure to be fair in terms of comparing cancer survival, then differences between population groups should depend only on differences in excess mortality rates due to the cancer and not differences in other-cause mortality rates or differences in the age distribution.

Methods: We propose using crude probabilities of death and all-cause survival which incorporate reference expected mortality rates. This makes it possible to obtain marginal crude probabilities and all-cause probability of death that only differ between population groups due to excess mortality rate differences. Choices have to be made regarding what reference mortality rates to use and what age distribution to standardize to.

Results: We illustrate the method and some potential choices using data from England for men diagnosed with melanoma. Various marginal measures are presented and compared.

Conclusions: The new measures help enhance understanding of cancer survival and are a complement to the more commonly used measures.
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http://dx.doi.org/10.1093/ije/dyaa112DOI Listing
October 2020
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