Background: Observational studies have shown that selective serotonin reuptake inhibitors are associated with an increased risk of bone fractures, but the association can be confounded by indication and other sources of systematic bias that can be minimized in randomized controlled trials (RCTs). Aim: Our aim was to report the rate, site, context, and predictors of fractures after stroke, and whether the fractures modified the effect of fluoxetine on modified Rankin scale (mRS) at 6 months in an individual patient data meta-analysis of 5907 patients enrolled in three RCTs of fluoxetine (20 mg for 6 months) for stroke recovery. Methods: We classified fractures by treatment allocation, site (and thus likelihood of osteoporosis), and context, then performed multivariable analyses to explore the independent predictors of fractures. We explored whether the trend toward a poorer mRS at 6 months was explained by a fracture excess. Risk of bias was assessed using GRADE. Results: Among 5907 patients randomized at a mean of 6.6 days (SD 3.6) post-stroke onset and followed for 6 months, the number of fractures at 6 months was 93 (3.15%) in the fluoxetine group versus 41 (1.39%) in the control group (difference 1.76, 95% CI 0.10-2.51). However, 128 patients with fractures were suitable for further analyses. Of these, 102 (80%) were in sites typically affected by osteoporosis; 115 (90%) were associated with falls and 1 (1%) with a seizure. Independent fracture risk factors were female sex (hazard ratio (HR) 1.96; 95% CI 1.37-2.81, p = 0.0002), age > 70 years (HR 2.30, 95% CI 1.52-3.49, p < 0.001), previous fractures (HR 0.63 for no previous fractures, 95% CI 0.42-0.94, p = 0.0227), and randomized treatment (fluoxetine) (HR 2.39; 95% CI 1.64-3.49, p < 0.001). The common odds ratio for the effect of fluoxetine on mRS at 6 months was unchanged after excluding fracture patients. Risk of bias was high for imprecision. Conclusion: Fractures were more common in the fluoxetine group but the absolute risk of fractures was small and risk estimates were imprecise. Most fractures occurred with a fall, and in osteoporotic locations. Fractures did not modify the effect of fluoxetine on functional outcome.

The aim of this study was to describe gender-related differences in characteristics and mortality in heart failure (HF) patients managed in primary care (PC). We included 1802 hF patients aged 77.5 ± 8.8 years (47% women) with ejection fraction (EF) ≥ 40% from the Swedish Heart Failure (SwedeHF) registry. The patients were divided by gender, and by heart failure with mildly reduced ejection fraction (HFmrEF; EF 40–49%) or heart failure with preserved ejection fraction (HFpEF; EF ≥ 50%). Men included in the study were younger (mean-age 76.4 vs 78.7 years, p < 0.0001) and showed a higher age-adjusted mortality (p < 0.0001). Men more often showed ischemic heart disease, 49% vs. 38% (p < 0.0001), atrial fibrillation, 56% vs. 50%, and diabetes, 25% vs. 17% (both p < 0.01). Women had higher blood pressure compared to men (p < 0.01), more commonly had kidney dysfunction (p < 0.01), and a worse functional capacity (p < 0.01). Cardiovascular diseases were the dominating causes of death in men and women (60% and 56%) but were less dominating in individuals with EF ≥ 50%, especially among women (56% in men vs. 46% in women). Among women with EF ≥ 50%, the mortality was dominated of mixed and unspecified diseases. Other important causes of death were cancer (15%) and chronic obstructive pulmonary disease (13%). Men managed in PC with HF and EF ≥ 40% have a higher age-adjusted mortality than women. Cardiovascular disease is the dominating cause of death in both genders. Other frequent causes of death were malignant tumors and respiratory diseases, illustrating the need to carefully diagnose and treat all associated comorbidities.

This article aims to compare the pattern of responses obtained by a web-based anda paper-based survey used to investigate the transit safety of travellers in railwaystations in Sweden. This aim is achieved by evaluating whether the response andthe completion rates change as the surveys progress, assessing the effect of the surveymode on respondents’ answers (after controlling for the surveys’ internal consistencyand differences in the samples), and the potential impact of the order ofalternatives in multiple-choice questions on the responses. To carry out the study, asample of 500 responses was taken from each population and later compared usinga series of statistical tests. Findings indicate that despite the surveys’ high internalconsistency, the prevalence of victimisation, fear of crime, and precautions detectedin the web survey was higher than those found in the paper survey. The web surveyshows a major drop just after the initial questions, while the paper survey showsa more stable pattern of responses, but was also affected by a single compulsoryquestion that pushed the completion rate down. Finally, the order of alternatives inmultiple-choice questions (fixed or random) did not affect the answers given by therespondents, providing a solid base for safety interventions in transit environments,regardless of survey mode. The article concludes by making suggestions for bothresearch and practice.

Att investera i ett tryggt kollektivtrafiksystem innebär att främja tillgänglighet som en grundlägganderättighet för alla. Ljusförhållanden är avgörande för att göra kollektivtrafik tillgänglig, eftersom depåverkar en individernas syn och upplevelse av trygghet. Dock saknar vi fortfarande en djupareförståelse för hur ljusförhållanden, dvs belysningen på en plats, påverkar individuell trygghet påoffentliga platser som tunnelbanestationer. Denna studie undersöker belysningens påverkan påindividuell uppfattning av trygghet på två olika stationstyper: plattformar och passager. Studien fokuserarpå förändringar i ljusförhållanden (intensitet och färg) genom experiment vid Fridhemsplanstunnelbanestation i Stockholm samt i virtuella verklighetsscenarier (VR-scenarier) som speglar denverkliga stationen. Basscenarier jämförs med två alternativa ljusscenarier, och 92 deltagare deltog iexperimentet—67 universitetsstudenter och 25 äldre personer med synnedsättning—i både stationsochVR-miljöerna. Resultaten visar att ljusets färg påverkar trygghetsupplevelsen negativt, där blått ochorange ljus resulterade i lägre upplevd trygghet jämfört med Basscenarierna där ljuset var vitt. Någotintressant är att dämpat ljus (reducerat med 39%) på plattformen inte hade någon signifikant påverkanpå trygghetsupplevelsen i stationsexperimentet. Deltagarna tenderade att associera högre värden tillordet ’trygghet’ än till ’säkerhet’ vid frågorna under identiska ljusförhållanden. I kontrast bedömdestrygghet och säkerhet i passager generellt lägre än på plattformarna. Trygghet och säkerhet relateradesoftare till faktorer som komfort, bekvämlighet, ljusstyrka och öppenhet, snarare än till färg eller värme ibåde stations- och VR-experimenten. I VR-modellen påverkades upplevelsen av trygghet mer avindividuella faktorer (t.ex. synnedsättning eller tidigare erfarenheter som brottsoffer) än istationsexperimentet. Trots dessa skillnader var resultaten från både VR- och fältexperiment överlagöverensstämmande, där deltagarna noterade större skillnader mellan ljusscenarierna i VR än påstationen. Plattformens trygghet bedömdes som högre i VR än i stationen, medan passager upplevdessom tryggare i stationen än i VR-miljön. Ytterligare analyser krävs för att bättre förstå de potentiellasambanden mellan VR-resultaten och resultaten från fältexperimentet. Ett viktigt resultat är att personermed synnedsättning rapporterade lägre trygghetsupplevelse i alla scenarier än de utan synnedsättning,vilket understryker vikten av att beakta belysning som en central tillgänglighetsfråga för personer medsynnedsättning i tunnelbana. Ett annat viktigt fynd är att dämpat ljus på plattformen inte påverkadedeltagarnas uppfattning om trygghet. Detta tyder på att lägre belysningsnivåer (i vårt fall: 110 lux pågolvet, med en max luminans på 600 cd/m2, i neutralt vitt ljus på 4000 Kelvin1) kan användas för attspara energi på stationer med liknande plattformdesign utan att avsevärt påverka resenärernasupplevda trygghet. Det är nödvändigt att i framtida studier undersöka tröskelnivåerna för belysningtillsammans ljusfördelning (kontrast, reflektivitet, perspektiv) för att säkerställa att ljusförhållandenafungerar för alla typer av resenärer, inklusive de med synnedsättning. Rapporten avslutas medytterligare rekommendationer för forskning och praktisk tillämpning, inklusive med användning av VRscenarier.

Investing in a safe public transport system means promoting accessibility as a fundamental right for allcity users. Lighting conditions are crucial in making public transportation accessible to everyone, as theyimpact an individual’s vision and safety perceptions. However, a deeper understanding of how lightingconditions (illumination in a particular place) affect an individual’s safety perceptions in subway stationsis still lacking. This study examines the effect of lighting on passengers' safety perceptions in two distinctstation environments: platforms and passages. The research focuses on changes in lighting conditions(intensity and colour) through experiments conducted at Fridhemsplan station in Stockholm, Sweden,and in virtual reality (VR) scenarios that mirrored the actual station. Baseline scenarios are comparedwith two alternative lighting scenarios, with 92 participants involved in the experiment—67 universitystudents and 25 elderly individuals with visual impairments—participating in the station and VRenvironments. The results show that the colour of the light negatively affects the perception of safety,with blue and orange light resulting in lower perceived safety compared to the baseline scenarios. Moreinterestingly, dimmed light (reduced by 39%) on the platform did not significantly impact safetyperception in the station experiment. Participants generally associated higher scores with the word'safety' than 'security' when prompted with questions under identical lighting conditions. In contrast,safety and security in passages were generally rated lower scores than in platform scenarios. Safetyand security were more frequently linked to factors such as comfort, convenience, brightness, andopenness rather than colour or warmth in the station and VR experiments. In the VR model, safetyperception was more influenced by individual factors (e.g., visual impairments or prior experiences ascrime victims) than in the station experiment. Despite these differences, the results from VR and fieldexperiments in the station were generally aligned, showing a strong correlation. Participants noted morepronounced differences in the lighting scenarios within the VR environment compared to the station.Platform safety was rated higher in VR than in the station, whereas passages were perceived as saferin the station than in the VR environment. Further analysis is needed to better understand the potentialconnections between the VR results and those from the field experiment. An important finding is thatpeople with visual impairments reported lower safety perceptions across all scenarios than those withoutimpairments (including in the VR experiment), emphasizing the need to consider lighting as a keyaccessibility issue for individuals with visual impairments in public transport. Another key finding is thatdimmed light on the platform did not significantly affect participants' safety perceptions compared to thebaseline lighting conditions. This suggests that lower lighting levels (in our case: 110 lux on the floor,with max luminance of 600 cd/m2, in neutral white light of 4000 K2) could be used in similar platforms tosave energy in stations without significantly affecting passengers’ safety perceptions. Future studiesmust examine lighting threshold levels together with distribution (contrast, reflection, view angle) toensure lighting conditions work for all passengers, including those with visual impairments. The reportconcludes with further recommendations for research and practice, including pilot tests in VR.

Background: Females are generally less prone to cardiovascular (CV) events than males, but this protection is trumped by diabetes. The mechanism behind the increased relative risk in females with diabetes is not fully understood. Insulin resistance (IR) is suggested to be a more important contributor to CV morbidity in females than in males. We aim to investigate differences in the association between IR indexes (Homeostatic Model Assessment of IR - HOMA-IR, visceral adiposity index – VAI, and triglycerides/high-density lipoprotein-cholesterol - TG/HDL-C index), and a first non-fatal myocardial infarction (MI) across different glycaemic states. Methods: IR indexes were calculated in a population with (n = 696) and without (n = 707) a first non-fatal MI, free from known diabetes. MI cases were investigated at least six weeks after the event. All participants were categorized by an oral glucose tolerance test as having normal glucose tolerance, impaired fasting glucose, impaired glucose tolerance, or newly diagnosed diabetes. Comparison of proportion of glycaemic states by sex was tested by chi-square test. The associations between sex, a first non-fatal MI, IR indexes, and traditional CV risk factors were analysed by multivariate logistic regression models. Continuous variables were logarithmically transformed. Results: Of the total population 19% were females and 81% males, out of whom 47% and 50% had a first non-fatal MI, respectively. Compared with males, females were older, less often smokers, with lower body mass index and higher total cholesterol and high-density lipoprotein cholesterol levels. The proportion of glycaemic states did not differ between the sexes (p = 0.06). Females were less insulin resistant than males, especially among cases and with normal glucose tolerance. In logistic regression models adjusted for major CV risk factors including sex, the associations between VAI and TG/HDL-C index and a first non-fatal MI remained significant only in females (odds ratios and 95% confidence intervals: 1.7, 1.0-2.9, and 1.9, 1.1–3.4 respectively). Conclusions: These results support the assumption that IR indexes based on anthropometrics and lipid panel, i.e., VAI and TG/HDL-C, could be a better measure of IR and CV-predictor for non-fatal MI in females, even without glycaemic perturbations.

The safety perception of the built environment, rather than the sheer number of crimes and incivility behavior, is a fundamental driver of public policies intended to improve urban safety. Traditional surveys often capture neighborhood residents’ perceived safety, but may not fully reflect the perceptions of people who are unfamiliar with the area. In this study, focused on the city of Stockholm, Sweden, we develop a geospatial artificial intelligence (GeoAI) approach using street view images and recruiting locals to create a measure of citywide residents’ safety perceptions. We compare the measures from the survey based on neighborhood residents’ responses with those from the GeoAI approach to better understand the relationship between these safety measures. We model the two forms of safety perceptions and their disparities (i.e., perception bias) as a function of the city’s land use and its socio-demographics. Results confirm that while the GeoAI-based measures better capture people’s instant impressions of the built environment across the city, the survey-based measures reflect their overall daily experiences of specific areas. Regions that appear to be economically vibrant and have inner-city streetscapes are perceived as safe places from visual appearance but are not always perceived as such by residents. Older adults tend to overestimate their likelihood of being victimized by crime, which may enlarge perception bias. The study concludes by critically assessing the potential ethical issues (e.g., spatial bias, population bias) in the proposed methodology and making suggestions for future research.

BACKGROUND: Empagliflozin reduces the risk of cardiovascular disease (CVD) in patients with type 2 diabetes (T2DM) and high cardiovascular risk via mechanisms which have not been fully explained. The mechanisms of such benefit have not been fully understood, and whether empagliflozin can be safely administered as first-line treatment in patients with CVD at the initial stages of glycaemic perturbations remains to be established. We investigated the effects of empagliflozin on insulin resistance, insulin sensitivity and β-cell function indexes in patients with a recent acute coronary event and newly detected dysglycaemia, i.e., impaired glucose tolerance (IGT) or T2DM. METHODS: Forty-two patients (mean age 67.5 years, 19% females) with a recent myocardial infarction (n = 36) or unstable angina (n = 6) and newly detected dysglycaemia were randomized to either empagliflozin 25 mg daily (n = 20) or placebo (n = 22). Patients were investigated with stress-perfusion cardiac magnetic resonance imaging before randomization, 7 months after the start of study drug and 3 months following its cessation. Indexes of insulin resistance, sensitivity and β-cell function were calculated based on glucose and insulin values from 2-hour oral glucose tolerance tests (OGTT) and fasting C-peptide. The differences in glucose, insulin, C-peptide, mannose levels and indexes between the two groups were computed by repeated measures ANOVA including an interaction term between the treatment allocation and the time of visit. RESULTS: After 7 months, empagliflozin significantly decreased glucose and insulin values during the OGTT, whereas C-peptide, mannose and HbA1c did not differ. Empagliflozin significantly improved insulin sensitivity indexes but did not impact insulin resistance and β-cell function. After cessation of the drug, all indexes returned to initial levels. Insulin sensitivity indexes were inversely correlated with left ventricular mass at baseline. CONCLUSIONS: Empagliflozin improved insulin sensitivity indexes in patients with a recent coronary event and drug naïve dysglycaemia. These findings support the safe use of empagliflozin as first-line glucose-lowering treatment in patients at very high cardiovascular risk with newly diagnosed dysglycaemia. TRIAL REGISTRATION NUMBER: EudraCT number 2015-004571-73.