Objectives The objective of this study was to evaluate and update the evidence on pharmacologic and interventional treatments for major organ involvement in Behçet syndrome (BS), in order to inform the 2025 update of the European Alliance of Associations for Rheumatology recommendations. Methods A systematic literature review was conducted using 2 distinct search strategies for pharmacologic and surgical/interventional therapies, covering major databases from October 2015 to November 2024. Controlled studies comparing active interventions with placebo or another active treatment were included. If no controlled trials were available for a specific research question, uncontrolled studies or case series with at least 10 patients with BS were included. Results Of 7128 citations, 69 studies on major organ involvement and tapering/withdrawal of immunosuppressives were included. Only 5 were randomised controlled trials (RCTs), 4 of them included patients with eye involvement, and 1 included patients with vascular or nervous system involvement. RCTs and comparative observational studies for eye involvement supported the use of monoclonal tumour necrosis factor alfa inhibitors and interferon alfa. The RCT that included patients with vascular or nervous system involvement favoured infliximab over cyclophosphamide based on complete response rates and safety. Observational data additionally supported the use of interferon alfa for venous thrombosis, whereas the role of adjunctive anticoagulation remains unclear. Noncomparative observational studies showed benefit with monoclonal tumour necrosis factor alfa inhibitors in patients with gastrointestinal involvement. Conclusions This systematic literature review provided evidence on the management of major organ involvement to inform the task force for developing the 2025 update of the European Alliance of Associations for Rheumatology recommendations for the management of BS.

BACKGROUND:Trauma-associated sleep disorder is a proposed sleep disorder characterized by trauma-related nightmares, hyperarousal during sleep, and disruptive nocturnal behaviors following exposure to a traumatic event. Sleep problems are common after trauma, yet little is known about their prevalence among women in the general population. We aimed to estimate the prevalence of trauma-associated sleep disturbances (TASD) and identify associated factors in a large nationally representative cohort. METHODS:We used data from a population-based cohort of Icelandic women aged 18 to 69 years. Of the 30,403 women who provided informed consent, 27,938 women were included in the analysis. Participants completed assessments of trauma history, TASD, and other mental health outcomes. Past month TASD were identified using established symptom criteria. Prevalence ratios were estimated using modified Poisson regression adjusted for demographic, socioeconomic, behavioral, and trauma-related factors. RESULTS:Here we show that 6.9% of women in the cohort report TASD. Prevalence was highest among young women and those exposed to physical or sexual violence. Experiencing the worst life stressor more than once and close temporal proximity to the worst life stressor was also associated with higher TASD prevalence. TASD are strongly associated with symptoms of posttraumatic stress disorder (PTSD), depression, anxiety, and general sleep problems. CONCLUSIONS:Results indicate that TASD affect a substantial number of women in the general population and are most prevalent among women exposed to interpersonal violence and among those with repeated or recent traumatic experiences. These findings underscore the importance of early identification of TASD and targeted interventions in healthcare.

Objectives We aimed to update the evidence for the management of mucocutaneous and joint involvement of Behçet’s syndrome (BS) to inform the 2025 update of European Alliance of Associations for Rheumatology (EULAR) recommendations. Methods A systematic literature review was conducted to evaluate the benefits and harms of therapeutic interventions in patients with BS. All comparative studies were included, and in the absence of controlled studies for a specific intervention, noncomparative studies were also considered. We presented here the summary of the outcomes for mucocutaneous and joint involvement, overall disease activity and health-related quality of life (HRQoL). Results Among the 7128 articles, 16 studies (7 randomised controlled trials [RCTs]) reported on mucocutaneous involvement, joint involvement, overall disease activity, or HRQoL. Apremilast was superior to placebo for oral ulcers in an RCT with low risk of bias (RoB). Few patients experienced genital ulcers, skin lesions, or arthritis during the 12 weeks. In the first head-to-head RCT with low RoB comparing adalimumab with infliximab, both drugs provided similar response rates for mucocutaneous manifestations, with a more rapid response observed with adalimumab. In other head-to-head RCTs, all with low RoB except for 1 with some concerns, the efficacy of immunosuppressive agents was confounded by concomitant glucocorticoid use for major organ involvement and by the small number of patients with active mucocutaneous manifestations. Conclusions This systematic review supported the use of apremilast and tumour necrosis factor alpha inhibitors in patients with refractory mucocutaneous involvement and provided evidence for updating the 2025 EULAR Recommendations for the management of mucocutaneous and joint involvement of BS.

Abstract Background Cognitive dysfunction (“brain fog”) is a commonly reported post-COVID-19 symptom. Leveraging data from five general population cohorts across four European countries (Estonia, Iceland, Norway, and Sweden), we assessed long-term prevalence of impaired subjective cognitive function among individuals diagnosed with COVID-19 by acute illness severity. Methods The included cohorts consisted of adult participants recruited from March 2020 and followed with self-report measures of cognitive function and past COVID-19 infection (except one cohort consisting of clinically confirmed COVID-19 cases) through February 2023. In a cross-sectional analysis we contrasted the prevalence of impaired cognitive function among individuals with and without a COVID-19 diagnosis, overall and by illness severity up to 32 months post-diagnosis. We adjusted for age, gender, education, relationship status, binge drinking, body mass index, previous psychiatric diagnosis, number of chronic medical conditions, and response period. In a longitudinal analysis, we assessed potential changes in cognitive function scores before and after COVID-19 diagnosis. Results The study population consisted of 153,841 participants (71% women), with 31,359 (20.4%) reporting a positive COVID-19 test. Overall, a COVID-19 diagnosis was not statistically significantly associated with increased prevalence ratio (PR) of impaired cognitive function (PR 1.30 [95% CI: 0.98–1.71]). Individuals bedridden due to COVID-19 for 1–6 days (PR 1.38 [95% CI 0.96–1.99]) or ≥ 7 days (2.59 [1.55–4.33]) had higher prevalence of impaired cognitive function compared to those never diagnosed, while individuals never bedridden had a lower prevalence to those never diagnosed with COVID-19 (0.89 [0.80–1.00]). These findings were corroborated in the longitudinal analysis where a pre- to post diagnosis decline in cognitive function was observed among individuals bedridden due to COVID-19 (p < 0.0001). Conclusions The data indicates that a severe COVID-19 acute illness course is associated with impaired cognitive function up to 18–32 months after COVID-19 diagnosis.

Background and aim Validation of Food Frequency Questionnaires (FFQ) is an important part of quality assurance, particularly when the FFQ is applied to populations with distinct regional dietary patterns. The purpose of this study was to investigate the validity of the FFQ used in the Icelandic SAGA cohort pilot study with special focus on fish consumption. Methods Data from the SAGA cohort pilot study was used, where 922 participants answered an electronic questionnaire, including FFQ (FFQ1) and had a blood sample taken. The FFQ included questions about 78 different food variables, supplements, and meals consumed over the past 12 months. Mean age of participants was 49.6 (SD 12.6) and 56% were women. A randomized sample from the pilot study (N=200) was invited to participate in the validation study. In total, 88 participants then answered the questionnaire again (FFQ2). Moreover, 37 of these participants also completed a four-day food record (FDFR). Questions on fish consumption and long-chain n-3 fatty acid supplements were validated against long-chain n-3 fatty acids measured in plasma. Spearman´s R, cross-classification and weighted-Kappa were calculated. A significant correlation of r s >0.25 was considered moderate, enabling ranking of individuals according to their food intake. Results There were no significant differences in background characteristics between participants at baseline and participants in the validation study. Reproducibility of the questionnaire, i.e comparison of FFQ1 with FFQ2, was acceptable for 75 out of 78 food variables, with mean correlation coefficient of 0.53 (p<0.05). When comparing FFQ2 and the FDFR, a positive association between the two methods was observed, especially for food items commonly consumed (47 out of 74 variables). The mean correlation coefficient was 0.34 (p<0.01). A significant correlation was observed for total fish consumption reported in the FFQ and long-chain plasma n-3 levels (r=0.36; p<0.01). Fish consumption was common among participants, with 78% consuming fish once a week or more often and 61% reported taking fish oil supplements. Conclusion: The study shows favorable reproducibility and validity of the SAGA FFQ and that it can be used for assessing dietary intake among adults in the Nordic regions.

Objectives This study aims to update the European Alliance of Associations for Rheumatology (EULAR) recommendations for the management of Behçet’s syndrome according to the updated EULAR standard operating procedures. Methods The task force comprised 29 members from 11 countries, including 19 rheumatologists, 2 ophthalmologists, 1 dermatologist, 1 gastroenterologist, 1 neurologist, 1 health professional, 2 patient research partners, and 2 Emerging EUlar NETwork members. Research questions were proposed by the task force through a Delphi survey and formulated into patients, interventions, comparison, and outcomes (PICO) questions for the systematic literature review. The results of the systematic literature review were discussed among the task force members. Previous recommendations and overarching principles were modified, and new recommendations were developed as needed. The updated recommendations were voted, and the levels of evidence and levels of agreement were determined. Results The updated recommendations consist of 5 overarching principles and 12 recommendations that were tabulated according to organ involvement. Among the 12 recommendations, 1 was a new recommendation, 7 recommendations were modified, and only the wording was changed in 4 recommendations. The overarching principles focus on the importance of recognising the relapsing and remitting disease course and individualising treatment according to disease activity and prognostic risk factors, and emphasise the importance of a multidisciplinary approach, patient education, and shared decision making for optimal care. For mucocutaneous and joint involvement, colchicine is recommended as the first-line treatment modality. Apremilast and immunosuppressives such as tumour necrosis factor alpha (TNFα) inhibitors are recommended for refractory patients. For patients with organ involvement, more aggressive treatment with glucocorticoids and immunosuppressives is recommended for rapid induction of remission. Early use of monoclonal antibodies against TNFα is encouraged in patients with organ or life-threatening manifestations. Conclusions These recommendations, which were updated based on new evidence and expert opinion, provide guidance for all stakeholders involved in the management of patients with Behçet’s syndrome to improve the quality of care of these patients.

We aimed to examine the association between adverse childhood experiences (ACEs) and type 2 diabetes in a nationwide cohort of Icelandic women, and to assess the mechanisms through which it is mediated. We used cross-sectional data from the nationwide-representative Stress-And-Gene-Analysis cohort, including 26 952 Icelandic women aged 18–69 years who self-reported exposure to 13 types of ACEs and adult diagnosis of type 2 diabetes. Modified Poisson regression was used to quantify the association between ACEs and type 2 diabetes, adjusting for age and childhood deprivation. We used causal mediation analysis to test whether adult body mass index (BMI), smoking, and socioeconomic factors mediated the association. Among a sample with a mean age of 44.2 (13.6), 780 (2.9%) women reported a diagnosis of type 2 diabetes. We observed a dose–response relationship between the number of ACEs and type 2 diabetes, of which women with five or more ACEs had almost double the prevalence compared to those with no ACEs (2.0% vs. 3.9%; prevalence ratio 1.90 [1.50–2.42]). Mediation analysis suggested adult BMI, smoking, and socioeconomic factors collectively explained 35.3% (16.5–53.6%) of the association but ACEs remained directly associated with type 2 diabetes (natural direct effect odds ratio 1.64 [1.25–2.26]). Bullying and sexual abuse were independently associated with a higher prevalence of type 2 diabetes. These findings suggest that adverse childhood experiences are associated with type 2 diabetes in adult women, partially mediated through adult BMI, smoking, and socioeconomic factors.

BACKGROUND:Knowledge of the impact of perimenopause on women with attention-deficit/hyperactivity disorder (ADHD) is lacking. We compared levels of perimenopausal symptoms and prevalence of severe perimenopausal symptoms among women with and without ADHD across age groups. METHODS:In this cohort study, we used data from the population-based Stress-and-Gene-Analysis cohort study. ADHD diagnosis was self-reported at baseline and 5-year follow-up. At follow-up, we assessed ADHD symptoms using the Adult ADHD Self-Report Scale, perimenopausal symptoms (psychological, somatic, and urogenital) using Menopause Rating Scale (MRS), and general physical symptoms using Patient Health Questionnaire. We described mean scores and mean difference on MRS among women with and without ADHD with linear regression models and contrasted the prevalence of severe perimenopausal symptoms among women with and without ADHD, calculating prevalence ratios (PRs) with 95% confidence intervals (CIs) using modified Poisson regression models. RESULTS:Women with ADHD (n = 535) had higher total perimenopausal symptom scores (18.0 vs. 13.0, p < 0.01) than women without ADHD (n = 4,857). The difference was most pronounced among women aged 35-39 years (19.0 vs. 12.5, p < 0.01). The prevalence of severe perimenopausal symptoms was significantly higher among women with ADHD compared to those without, both overall (54.2% vs. 30.1%, PR = 1.80, 95% CI = 1.64-1.98) and on all subdimensions (psychological: 58.6% vs. 36.0%, PR = 1.63, 95% CI = 1.51-1.76; somatic: 30.4% vs. 13.9%, PR = 2.20, 95% CI = 1.88-2.57; uro-genital: 43.2% vs. 27.5%, PR = 1.57, 95% CI = 1.40-1.77). CONCLUSION:Women with ADHD have higher prevalence of severe perimenopausal symptoms. These symptoms present at an earlier age than among women without ADHD, indicating an earlier onset age of perimenopause in ADHD.

Background This study examined psychological reactions to perceived threats, viewed within the context of human evolutionary history. We compared the relative weight of perceived threat to life or physical harm versus social threat, i.e., humiliation and/or rejection, in symptoms of posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD). Methods Participants were 50 women with clinically significant posttraumatic stress symptoms (PTSS) and 59 women with little or no PTSS (control group) selected from a large, population-based cohort of women in Iceland, the SAGA Cohort. Participants rated (1) life threat, (2) physical threat, (3) humiliation, and (4) rejection during their worst trauma or stressor. Results Rates of both life and social threats were higher in the PTSS than control group. Among the PTSS participants, 4% (n = 2) reported primarily life threats (vs. 6.8%, n = 4 in controls), 36% (n = 18) reported primarily social threats (vs. 33.9%, n = 20 in controls), and 60% (n = 30) reported both types of threats (vs. 15.3%, n = 9 in controls). Those who reported dual life and social threats exhibited elevated PTSS compared to those who experienced a single type of threat. The highest levels of life or physical threat, along with humiliation, predicted PTSS severity, but rejection did not. Nearly half of the PTSS group (approximately 50%, n = 25) also met criteria for SAD compared to roughly 14% (n = 8) in the control group, and humiliation predicted SAD symptom severity. Notably, 18% of the PTSS group (n = 9) linked the onset of their SAD and PTSS to a singular trauma or stressor involving a social threat. Conclusions The findings underscore the role of social threat in PTSD and SAD, with implications for theoretical models of both disorders.

Purpose: We aimed to investigate the association between sexual orientation and multiple types of adverse childhood experiences (ACEs) and to what extent ACEs mediate the association between sexual orientation and symptoms of depression and anxiety among sexual minority women (SMW). Methods: This was a cross-sectional analysis nested within the nationally representative Icelandic Stress-And-Gene-Analysis cohort. Data were collected from March 2018 to June 2019. Participants included 11,007 women, aged 18-69, with data on sexual orientation and ACEs. Self-reported data were obtained on 13 different ACEs, and current symptoms of depression and anxiety. Results: Overall, 724 (6.6%) identified as sexual minority. The mean age of SMW was 34.0 years (standard deviation [SD] 14.0) and 44.7 years (SD 14.0) for heterosexual women. SMW were more likely to report six or more ACEs than heterosexual women (21.7% vs. 11.3%, respectively), yielding an adjusted odds ratio (aOR) of 2.26 (95% confidence interval [CI] 1.76-2.91). SMW were more likely than heterosexual women to report four types of ACEs: specifically bullying, emotional abuse, sexual abuse, and mental illness in the household (aOR ranging from 1.36 to 1.71). SMW reported higher odds of current symptoms of depression (aOR = 2.10, 95% CI 1.77-2.49) and anxiety (aOR = 1.69, 95% CI 1.41-2.02). The total number of ACEs mediated 32.6% of the association between sexual orientation and depression, and 43.2% of the association between sexual orientation and anxiety. Conclusion: These findings suggest that ACEs are a major contributor to the mental health disparities observed among SMW.

Identifying specific factors affecting psychological resilience could be instrumental in developing new therapeutic strategies for improving and maintaining mental and physical health. To achieve this, an adequate measure of psychological resilience is essential. We studied the psychometric properties of the 10-item Connor-Davidson Resilience Scale (CD-RISC-10) across three population-based cohorts. The study included adult Danish individuals in the Danish Blood Donor Study (DBDS, N = 57,031), and the Icelandic cohorts Stress-And-Gene Analysis cohort (SAGA, N = 27,236), and COVID-19 National Resilience cohort (C19-Resilience, N = 20,373). Exploratory factor analysis revealed a consistent one-factor fit across cohorts. The scale demonstrated good internal consistency (Cronbach's alpha: 0.88–0.90) and longitudinal stability (Spearman correlation coefficients in DBDS: 0.71 across 1.5 years, 0.66 across two years). Mean CD-RISC-10 scores were consistent with previously reported scores in European populations. Lower scores were observed among participants with probable major depressive disorder, and higher scores were found with increasing age. Further evidence for construct validity was revealed as CD-RISC-10 scores moderated the association between financial trouble and depressive symptoms across all cohorts. Psychometric properties of the CD-RISC-10 were similar among women and men. Our findings support the use of the CD-RISC-10 as a reliable and valid unidimensional measure of psychological resilience in Danish and Icelandic populations.

BACKGROUND:Adverse childhood experiences (ACEs) have consistently been associated with adult health complications, including adverse mental and physical health during pregnancy. The aim of this study was to assess the relationship between ACEs and women's birthing experiences leveraging data from a large population-representative cohort of Icelandic women. METHODS:In this retrospective cohort study, we used data from 22,293 births among 10,759 women (8588 primipara, 13,705 multipara) in the Stress-And-Gene-Analysis (SAGA) with a record in the Icelandic Medical Birth Register. At baseline 2018-19, women responded to the ACE-International Questionnaire (ACE-IQ) and then in 2024 to questions on birth experiences in a follow-up questionnaire. Objective markers on birth complications were obtained from the Medical Birth Register. We used Poisson regression to assess the association between ACEs and a negative birth experience, calculating crude and adjusted prevalence ratios (PR) and 95 % confidence intervals (CI). FINDINGS:The prevalence of a negative birth experience was 22.5 % (n = 1717) and 8.5 % (1021) among primipara and multipara, respectively. Exposure to ACEs was associated with an increased prevalence of a negative birth experience in a dose-dependent manner: exposure to ≥4 ACEs was associated with a 2.1-fold higher prevalence of a negative birth experience (PR = 2.08, 95 %CI 1.81-2.40), with an elevated PR among women experiencing an uncomplicated birth, 3.62 (2.62-4.99), vs uncomplicated birth, 1.66 (1.42-1.95). CONCLUSION:Women who experienced four or more ACEs had a two-fold increased prevalence of a negative birth experience compared with women with no ACEs. CLINICAL IMPLICATIONS:Women with ACEs are a vulnerable group that may benefit from screening and trauma informed antenatal care.

BACKGROUND:Adverse childhood experiences (ACEs) have been associated with increased risks of autoimmune diseases. However, data are scarce on the role of specific ACEs as well as the potential mediating role of adverse mental health symptoms in this association. METHODS:A cohort study using the nationwide Icelandic Stress-And-Gene-Analysis (SAGA, 22,423 women) cohort and the UK Biobank (UKB, 86,492 women) was conducted. Participants self-reported on five ACEs. Twelve autoimmune diseases were self-reported in SAGA and identified via hospital records in UKB. Poisson regression was used to assess the cross-sectional association between ACEs and autoimmune diseases in both cohorts. Using longitudinal data on self-reported mental health symptoms in the UKB, we used causal mediation analyses to study potential mediation by depressive, anxiety, and PTSD symptoms in the association between ACEs and autoimmune diseases. RESULTS:The prevalence of ACEs was 50% in SAGA and 35% in UKB, while the prevalence of autoimmune diseases was 29% (self-reported) and 14% (clinically confirmed), respectively. In both cohorts, ACEs were associated with an increased prevalence ratio (PR) of any studied autoimmune disease in a dose-response manner (PR = 1.10 (95%CI = 1.08-1.12) per ACE), particularly for Sjögrens (PR = 1.34), polymyalgia rheumatica (PR = 1.20), rheumatoid arthritis (PR = 1.14), systemic lupus erythematosus (PR = 1.13), and thyroid disease (PR = 1.11). Sexual abuse and physical and emotional neglect were consistently associated with an elevated prevalence of autoimmune diseases when including all ACEs in the model. Approximately one fourth of the association was mediated through depression, anxiety, and PTSD. CONCLUSIONS:These findings based on two large cohorts indicate a role of ACEs and corresponding mental health distress in autoimmune diseases among adult women.

OBJECTIVE:The OMERACT Composite Working Group hosted a workshop at OMERACT 2023 to explore the complexities of weighting components in the development of composite outcomes. This study presents the methodology and findings of this workshop, exploring the complexities of weighting the individual components of composite outcome measures. METHODS:The workshop featured a multifaceted program, beginning with a plenary session that introduced the concept of composite outcomes, shared a patient's journey with rheumatic disease through a narrative, illustrated a composite outcome for Osteoarthritis Flares, and outlined the five domains selected for this composite outcome. A breakout exercise engaged participants in ranking and assigning weights to these domains, followed by group discussions to reach a consensus on weights. The workshop concluded with another plenary session that discussed various weighting approaches, including discrete choice and conjoint analysis from the ANCA-Associated Vasculitis working group, and outlined future directions for research on composite outcome methods. RESULTS:The breakout exercise revealed the challenges in assigning relative importance to different domains, highlighting the variability in participant perspectives. Consensus discussions highlighted the diversity in approaches to weighting, the need for appropriate methods to determine domain weights and the impact of such weights on the interpretation of composite scores. CONCLUSION:The OMERACT 2023 workshop underscored the significance of a systematic approach to weighting components in composite outcome development. It highlighted the complexity of achieving consensus on the importance of domains and the role of incorporating the perspectives of patient research partners in this process. Future research directions include refining weighting methodologies, moving composites through the OMERACT Filter and enhancing understanding of their implications for clinical trials. The findings contribute to the ongoing discourse on optimizing composite outcome measures in rheumatology and beyond, advocating for a balanced integration of scientific rigour and patient-centeredness in their development.

BACKGROUND:Adverse childhood experiences (ACEs) are well-known risk factors for schizophrenia and bipolar disorder.AIMS:The aim was to study the associations between specific ACEs and psychological functioning in women with schizophrenia or bipolar disorder.METHOD:Among 29 367 women (mean age 44 years) from the Icelandic Stress-And-Gene-Analysis (SAGA) study, 534 (1.8%, mean age 40) reported having been diagnosed with schizophrenia or bipolar disorder, which were combined to 'severe mental disorders'. Participants reported on 13 types of ACEs, childhood deprivation and psychological functioning (defined as coping ability and current symptoms of depression, anxiety and sleep disturbances). Adjusted Poisson regression calculated prevalence ratios (PRs) between ACEs and severe mental disorders. Linear regression assessed the association between ACEs and psychological functioning among women with a severe mental disorder.RESULTS:Women with a severe mental disorder reported more ACEs (mean 4.57, s.d. = 2.82) than women without (mean 2.51, s.d. = 2.34) in a dose-dependent manner (fully-adjusted PR = 1.23 per ACE, 95% CI 1.20-1.27). After mutual adjustment for other ACEs, emotional abuse, sexual abuse, mental illness of a household member, emotional neglect, bullying and collective violence were associated with severe mental disorders. Among women with severe mental disorders, a higher number of ACEs was associated with increased symptom burden of depression (β = 2.79, 95% CI = 1.19-4.38) and anxiety (β = 2.04, 95% CI = 0.99-3.09) including poorer sleep quality (β = 0.83, 95% CI = 0.07-1.59). Findings were similar for schizophrenia and bipolar disorder separately.CONCLUSION:Women with schizophrenia or bipolar disorder show a strong history of ACEs, which may interfere with their psychological functioning and, therefore, need to be addressed as part of their treatment, for example, with trauma-focused psychotherapy.

Background Since the publication of the EULAR recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in 2016, several randomised clinical trials have been published that have the potential to change clinical care and support the need for an update. Methods Using EULAR standardised operating procedures, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 16 countries. We modified existing recommendations and created new recommendations. Results Four overarching principles and 17 recommendations were formulated. We recommend biopsies and ANCA testing to assist in establishing a diagnosis of AAV. For remission induction in life-threatening or organ-threatening AAV, we recommend a combination of high-dose glucocorticoids (GCs) in combination with either rituximab or cyclophosphamide. We recommend tapering of the GC dose to a target of 5 mg prednisolone equivalent/day within 4–5 months. Avacopan may be considered as part of a strategy to reduce exposure to GC in granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Plasma exchange may be considered in patients with rapidly progressive glomerulonephritis. For remission maintenance of GPA/MPA, we recommend rituximab. In patients with relapsing or refractory eosinophilic GPA, we recommend the use of mepolizumab. Azathioprine and methotrexate are alternatives to biologics for remission maintenance in AAV. Conclusions In the light of recent advancements, these recommendations provide updated guidance on AAV management. As substantial data gaps still exist, informed decision-making between physicians and patients remains of key relevance.

Individuals with mental illness are at higher risk of severe COVID-19 outcomes. However, previous studies on the uptake of COVID-19 vaccination in this population have reported conflicting results. Using data from seven cohort studies (N = 325,298) included in the multinational COVIDMENT consortium, and the Swedish registers (N = 8,080,234), this study investigates the association between mental illness (defined using self-report measures, clinical diagnosis and prescription data) and COVID-19 vaccination uptake. Results from the COVIDMENT cohort studies were pooled using meta-analyses, the majority of which showed no significant association between mental illness and vaccination uptake. In the Swedish register study population, we observed a very small reduction in the uptake of both the first and second dose of a COVID-19 vaccine among individuals with vs. without mental illness; the reduction was however greater among those not using psychiatric medication. Here we show that uptake of the COVID-19 vaccine is generally high among individuals both with and without mental illness, however the lower levels of vaccination uptake observed among subgroups of individuals with unmedicated mental illness warrants further attention. Monitoring COVID-19 vaccine uptake in those at risk of severe disease, such as people with mental illness, is important. Here, the authors use cohort and/or health registry data from five countries in northern Europe and investigate vaccine uptake by mental illness and treatment status.

IntroductionWhile changes in the prevalence of depressive symptoms during the COVID-19 pandemic have been described across populations, few studies have incorporated multidimensional variables to characterise the varying effects of the pandemic on the population’s mental health.MethodsThis cohort study included 6423 participants aged ≥18 years from the Icelandic COVID-19 National Resilience Cohort. Data on depressive symptoms and pandemic-related and non-pandemic-related factors were obtained during three pandemic assessment periods (baseline, follow-up wave 1 and follow-up wave 2; April 2020–December 2021), while health outcomes were obtained during the post-pandemic assessment period (follow-up wave 3; September 2022–February 2023). We used latent growth mixture models to identify variation in depressive symptom trajectories during the pandemic. We then used XGBoost models with 37 pandemic-related and non-pandemic-related factors to characterise these trajectories. Moreover, we performed linear regression to assess the association between the identified trajectories and post-pandemic health outcomes.ResultsOf the included participants, we identified four depressive symptom trajectories, including consistently low (83.7%), consistently high (5.3%), initially high (5.1%) and late-onset high (5.9%) symptom trajectories. Individuals who exercised frequently (≥3 days/week) and enjoyed social and family support were more likely to experience a consistently low symptom trajectory. In contrast, individuals with a history of psychiatric disorders, women and young adults (18–39 years) were less likely to follow the consistently low symptom trajectory. Moreover, compared with the consistently low symptom trajectory, the other trajectories were associated with significantly higher levels of depressive, anxiety and somatic symptoms and cognitive problems during the post-pandemic period.ConclusionsOur results underscore the long-lasting impact of the COVID-19 pandemic on population mental health. Interventions focusing on exercise, social support and family support may mitigate the adverse mental health effects of future pandemics.

BACKGROUND:Workplace sexual violence against women is a pressing global issue with scarce knowledge on its health implications. Existing research is largely limited to specific occupations, which calls for comprehensive, population-based studies. This study aimed to examine the associations between self-labelled workplace sexual violence and a variety of health outcomes in a nationally representative sample of Icelandic women aged 18-69 years. METHODS:Participants in this cross-sectional study were women in the Stress-And-Gene-Analysis (SAGA) cohort who answered the question regarding workplace sexual violence, defined in our study as encompassing all work sectors, academic settings, and other school environments. Eligible participants were women, aged 18-69 years, residing in Iceland, who spoke Icelandic and were listed in the Icelandic Population Register or had a contact number registered with the online 1819 service. Poisson and binomial regressions were used to assess the associations between workplace sexual violence and validated measures of current mental and physical health outcomes (eg, probable depression, general anxiety, and severe sleep problems). Multiple imputation was performed to account for missing values in the dataset. FINDINGS:The study was conducted from March 1, 2018, to July 1, 2019. Of the 113 814 women deemed eligible for study inclusion, 104 197 were invited to take part in the online survey. Of those invited, 30 403 women completed the survey and were included in the SAGA cohort. Among these participants, 15 812 provided answers to the question regarding exposure to workplace sexual harassment or violence. Exposure to sexual violence was associated with an increased prevalence of probable depression (prevalence ratio [PR] 1·50 [95% CI 1·41-1·60]), general anxiety (PR 1·49 [1·40-1·59]), social phobia (PR 1·62 [1·48-1·78]), self-harm (PR 1·86 [1·53-2·28]), suicidal ideation (PR 1·68 [1·44-1·68]), suicide attempts (PR 1·99 [1·62-2·44]), binge drinking (PR 1·10 [1·01-1·20]), sleep problems (PR 1·41 [1·48-1·91]), physical symptoms (PR 1·59 [1·48-1·70]), and sick leave (PR 1·20 [1·12-1·28]). The prevalence of the health outcomes among those exposed show age-related differences: younger women report anxiety or depression more frequently, while older women report sleep problems after experiencing workplace sexual violence. INTERPRETATION:In this cross-sectional study self-reported experiences of sexual violence in the workplace were associated with several self-reported health outcomes. The findings suggest a need for targeted interventions to promote workplace safety and to mitigate adverse health implications among people who have experienced workplace sexual violence. Future research should explore factors such as the frequency, duration, and relationship dynamics of workplace sexual violence, as well as the effect on different genders and sexual orientations, to deepen our understanding of these experiences and inform effective prevention strategies. FUNDING:Reykjavík Energy Research Fund, The Icelandic Gender Equality Fund, European Research Council, and Icelandic Center for Research.

Importance Comprehensive data on the prevalence of various life stressors and their role in posttraumatic stress disorder (PTSD) among women are lacking. Objective To determine the prevalence of a broad range of life stressors and their association with PTSD in a large nationally representative cohort of women. Design, Setting, and Participants This cross-sectional analysis used data from the population-based Stress-And-Gene-Analysis, which invited women in Iceland to complete an online survey from March 1, 2018, to July 1, 2019. Participants were a nationally representative sample of women 18 to 69 years of age. This analysis was conducted from January 21, 2022, to September 13, 2024. Exposures History of 23 life stressors assessed with the Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) and additional survey questions. Main Outcomes and Measures The main outcome was probable PTSD during the past month assessed for the worst life stressor experienced as evaluated with the PTSD Checklist for DSM-5. Modified Poisson log-linear models were used to assess prevalence ratios (PRs) of PTSD by type of life stressor, adjusting for multiple covariates, including number of life stressors and time since the worst life stressor. Results Overall, 28 199 women participated in the study (mean [SD] age, 43.8 [13.7] years). The prevalence of life stressors varied substantially, ranging from 3.3% for war or armed conflict-related events to 66.4% for unwanted sexual experiences. The overall prevalence of probable PTSD was 15.9% and varied substantially across life stressor types. The highest prevalence of probable PTSD was for sexual assault (1427 of 3872 [36.9%]) and lowest for natural disasters (15 of 456 [3.3%]). Interpersonal trauma, specifically sexual assault (adjusted PR [APR], 6.66 [95% CI, 4.01-11.04]), other unwanted sexual experience (APR, 4.33 [95% CI, 2.53-7.42]), and physical assault (APR, 4.44 [95% CI, 2.63-7.49]) were associated with the highest prevalence increase of probable PTSD compared with natural disasters as the reference category. Conclusions and Relevance This cross-sectional study of 28 199 women in Iceland, which ranks highest globally in gender equality, found that sexual and physical assaults were among the most common life stressors reported and were associated with the highest prevalence of probable PTSD. The propensity of such trauma to result in PTSD calls for widespread societal efforts to prevent sexual and physical violence and reduce gender-based disparities in mental health.