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  • 1.
    Alaie, Iman
    et al.
    Department of Neuroscience, Child and Adolescent Psychiatry, Uppsala University, Uppsala, Sweden.
    Philipsson, Anna
    Örebro University, School of Health Sciences. University Health Care Research Centre.
    Ssegonja, Richard
    Department of Public Health and Caring Sciences, Child Health and Parenting (CHAP), Uppsala University, Uppsala, Sweden.
    Hagberg, Lars
    Örebro University, School of Health Sciences. Örebro University Hospital. University Health Care Research Centre.
    Feldman, Inna
    Department of Public Health and Caring Sciences, Child Health and Parenting (CHAP), Uppsala University, Uppsala, Sweden.
    Sampaio, Filipa
    Department of Public Health and Caring Sciences, Child Health and Parenting (CHAP), Uppsala University, Uppsala, Sweden.
    Möller, Margareta
    Örebro University, School of Health Sciences. University Health Care Research Centre.
    Arinell, Hans
    Department of Neuroscience, Child and Adolescent Psychiatry, Uppsala University, Uppsala, Sweden; Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
    Ramklint, Mia
    Department of Neuroscience, Child and Adolescent Psychiatry, Uppsala University, Uppsala, Sweden; Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
    Päären, Aivar
    Department of Neuroscience, Child and Adolescent Psychiatry, Uppsala University, Uppsala, Sweden.
    von Knorring, Lars
    Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
    Olsson, Gunilla
    Department of Neuroscience, Child and Adolescent Psychiatry, Uppsala University, Uppsala, Sweden.
    von Knorring, Anne-Liis
    Department of Neuroscience, Child and Adolescent Psychiatry, Uppsala University, Uppsala, Sweden.
    Bohman, Hannes
    Department of Neuroscience, Child and Adolescent Psychiatry, Uppsala University, Uppsala, Sweden.
    Jonsson, Ulf
    Department of Neuroscience, Child and Adolescent Psychiatry, Uppsala University, Uppsala, Sweden; Center of Neurodevelopmental Disorders at Karolinska Institutet (KIND), Pediatric Neuropsychiatry Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.
    Uppsala Longitudinal Adolescent Depression Study (ULADS)2019In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 3, article id e024939Article in journal (Refereed)
    Abstract [en]

    Purpose: To present the Uppsala Longitudinal Adolescent Depression Study, initiated in Uppsala, Sweden, in the early 1990s. The initial aim of this epidemiological investigation was to study the prevalence, characteristics and correlates of adolescent depression, and has subsequently expanded to include a broad range of social, economic and health-related long-term outcomes and cost-of-illness analyses.

    Participants: The source population was first-year students (aged 16-17) in upper-secondary schools in Uppsala during 1991-1992, of which 2300 (93%) were screened for depression. Adolescents with positive screening and sex/age-matched peers were invited to a comprehensive assessment. A total of 631 adolescents (78% females) completed this assessment, and 409 subsequently completed a 15year follow-up assessment. At both occasions, extensive information was collected on mental disorders, personality and psychosocial situation. Detailed social, economic and health-related data from 1993 onwards have recently been obtained from the Swedish national registries for 576 of the original participants and an age-matched reference population (N=200 000).

    Findings to date: The adolescent lifetime prevalence of a major depressive episode was estimated to be 11.4%. Recurrence in young adulthood was reported by the majority, with a particularly poor prognosis for those with a persistent depressive disorder or multiple somatic symptoms. Adolescent depression was also associated with an increased risk of other adversities in adulthood, including additional mental health conditions, low educational attainment and problems related to intimate relationships.

    Future plans: Longitudinal studies of adolescent depression are rare and must be responsibly managed and utilised. We therefore intend to follow the cohort continuously by means of registries. Currently, the participants are approaching mid-adulthood. At this stage, we are focusing on the overall long-term burden of adolescent depression. For this purpose, the research group has incorporated expertise in health economics. We would also welcome extended collaboration with researchers managing similar datasets.

  • 2.
    Angelhoff, Charlotte
    et al.
    Department of Social and Welfare Studies, Division of Nursing Science, Linköping University, Norrköping, Sweden; Department of Clinical and Experimental Medicine, Department of Paediatrics, Linköping University, Linköping, Sweden.
    Blomqvist, Ylva Thernström
    Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
    Helmer, Charlotte Sahlén
    Department of Social and Welfare Studies, Division of Nursing Science, Linköping University, Norrköping, Sweden; Department of Clinical and Experimental Medicine, Department of Paediatrics, Linköping University, Linköping, Sweden.
    Olsson, Emma
    Örebro University, School of Health Sciences. Örebro University Hospital. Department of Pediatrics.
    Shorey, Shefaly
    Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.
    Frostell, Anneli
    Division of Psychology, Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden.
    Morelius, Evalotte
    Department of Social and Welfare Studies, Division of Nursing Science, Linköping University, Norrköping, Sweden.
    Effect of skin-to-skin contact on parents' sleep quality, mood, parent-infant interaction and cortisol concentrations in neonatal care units: study protocol of a randomised controlled trial2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 7, article id e021606Article in journal (Refereed)
    Abstract [en]

    Introduction: Separation after preterm birth is a major stressor for infants and parents. Skin-to-skin contact (SSC) is a method of care suitable to use in the neonatal intensive care unit (NICU) to minimise separation between parents and infants. Less separation leads to increased possibilities for parent-infant interaction, provided that the parents' sleep quality is satisfactory. We aimed to evaluate the effect of continuous SSC on sleep quality and mood in parents of preterm infants born <33 weeks of gestation as well as the quality of parent-infant interaction and salivary cortisol concentrations at the time of discharge.

    Methods and analysis: A randomised intervention study with two arms-intervention versus standard care. Data will be collected from 50 families. Eligible families will be randomly allocated to intervention or standard care when transferred from the intensive care room to the family-room in the NICU. The intervention consists of continuous SSC for four consecutive days and nights in the family-room. Data will be collected every day during the intervention and again at the time of discharge from the hospital. Outcome measures comprise activity tracker (Actigraph); validated self-rated questionnaires concerning sleep, mood and bonding; observed scorings of parental sensitivity and emotional availability and salivary cortisol. Data will be analysed with pairwise, repeated measures, Mann Whitney U-test will be used to compare groups and analysis of variance will be used to adjust for different hospitals and parents' gender.

    Ethics and dissemination: The study is approved by the Regional Research Ethics Board at an appropriate university (2016/89-31). The results will be published in scientific journals. We will also use conferences and social media to disseminate our findings.

  • 3.
    Berglund, Annika
    et al.
    Karolinska Institutet Stroke Research Network at Södersjukhuset, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Section of Neurology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden; Karolinska Institutet, Center for Gender Medicine, Stockholm, Sweden.
    von Euler, Mia
    Karolinska Institutet Stroke Research Network at Södersjukhuset, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Section of Neurology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden Karolinska Institutet, Center for Gender Medicine, Stockholm, Sweden.
    Schenck-Gustafsson, Karin
    Karolinska Institutet, Center for Gender Medicine, Stockholm, Sweden; Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
    Castrén, Maaret
    Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
    Bohm, Katarina
    Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Section of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Identification of stroke during the emergency call: a descriptive study of callers' presentation of stroke2015In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, no 4, article id e007661Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To evaluate symptoms presented by the caller during emergency calls regarding stroke, and to assess if symptoms in the Face-Arm-Speech-Time Test (FAST) are related to identification of stroke.

    SETTING: Emergency calls to the Emergency Medical Communication Center (EMCC) concerning patients discharged with stroke diagnosis in a large teaching hospital in Stockholm, Sweden, in January-June 2011.

    PARTICIPANTS: The emergency calls of 179 patients who arrived at hospital by ambulance, and who were discharged with a stroke diagnosis and consented to participate were included in the study.

    OUTCOME MEASURES: Frequencies of stroke symptoms presented and a comparison of symptoms presented in calls with dispatch code stroke or other dispatch code.

    RESULTS: Of the 179 emergency calls analysed, 64% were dispatched as 'Stroke'. FAST symptoms, that is, facial or arm weakness or speech disturbances, were presented in 64% of the calls and were spontaneously revealed in 90%. Speech disturbance was the most common problem (54%) in all calls, followed by fall/lying position (38%) and altered mental status (27%). For patients with dispatch codes other than stroke, the dominating problem presented was a fall or being in a lying position (66%), followed by speech disturbance (31%) and altered mental status (25%). Stroke-specific symptoms were more common in patients dispatched as stroke. FAST symptoms were reported in 80% of patients dispatched as stroke compared with 35% in those dispatched as something else.

    CONCLUSIONS: This study implicates that fall/lying position and altered mental status could be considered as possible symptoms of stroke during an emergency call. Checking for FAST symptoms in these patients might uncover stroke symptoms. Future studies are needed to evaluate if actively asking for FAST symptoms in emergency calls presenting falls or a lying position can improve the identification of stroke.

    TRIAL REGISTRATION NUMBER: Stroke2010/703-31/2.

  • 4.
    Biswas, Animesh
    et al.
    Örebro University, School of Health Sciences. Centre for Injury Prevention and Research, Dhaka, Bangladesh.
    Rahman, Fazlur
    Centre for Injury Prevention and Research, Dhaka, Bangladesh.
    Eriksson, Charli
    Örebro University, School of Health Sciences.
    Halim, Abdul
    Centre for Injury Prevention and Research, Dhaka, Bangladesh.
    Dalal, Koustuv
    Örebro University, School of Health Sciences.
    Social Autopsy of maternal, neonatal deaths and stillbirths in rural Bangladesh: qualitative exploration of its effect and community acceptance2016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 8, article id e010490Article in journal (Refereed)
    Abstract [en]

    Objectives: Social Autopsy (SA) is an innovative strategy where a trained facilitator leads community groups through a structured, standardised analysis of the physical, environmental, cultural and social factors contributing to a serious, non-fatal health event or death. The discussion stimulated by the formal process of SA determines the causes and suggests preventative measures that are appropriate and achievable in the community. Here we explored individual experiences of SA, including acceptance and participant learning, and its effect on rural communities in Bangladesh. The present study had explored the experiences gained while undertaking SA of maternal and neonatal deaths and stillbirths in rural Bangladesh.

    Design: Qualitative assessment of documents, observations, focus group discussions, group discussions and in-depth interviews by content and thematic analyses.

    Results: Each community's maternal and neonatal death was a unique, sad story. SA undertaken by government field-level health workers were well accepted by rural communities. SA had the capability to explore the social reasons behind the medical cause of the death without apportioning blame to any individual or group. SA was a useful instrument to raise awareness and encourage community responses to errors within the society that contributed to the death. People participating in SA showed commitment to future preventative measures and devised their own solutions for the future prevention of maternal and neonatal deaths.

    Conclusions: SA highlights societal errors and promotes discussion around maternal or newborn death. SA is an effective means to deliver important preventative messages and to sensitise the community to death issues. Importantly, the community itself is enabled to devise future strategies to avert future maternal and neonatal deaths in Bangladesh.

    Download full text (pdf)
    Social Autopsy of maternal, neonatal deaths and stillbirths in rural Bangladesh: qualitative exploration of its effect and community acceptance
  • 5.
    Björk, Tabita
    et al.
    Psychiatric Research Centre, Örebro County Council, Örebro, Sweden; Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
    Brus, Ole
    Örebro University Hospital, Örebro, Sweden.
    Osika, Walter
    Stress Research Institute, Stockholm University, Stockholm, Sweden.
    Montgomery, Scott M.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden; Department of Primary Care and Public Health, Charing Cross Hospital, Imperial College, London, UK.
    Laterality, hand control and scholastic performance: a British birth cohort study2012In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 2, no 2, article id e000314Article in journal (Refereed)
    Abstract [en]

    Objectives: To use simple measures of laterality and hand control that can identify a greater risk of poorer scholastic ability, potentially signalling suboptimal hemispheric lateralisation.

    Design: Analysis of material from a birth cohort study.

    Setting: Members of the National Child Development Study, a British birth cohort study following people born in 1958.

    Participants: 10 612 children who undertook tests at age 11 years.

    Primary outcome measures: Teacher-administered tests of non-verbal general ability, verbal general ability, reading comprehension and mathematics.

    Results: Linear regression produced associations (and 95% CIs) with tests of verbal general ability, non-verbal general ability, reading comprehension and mathematics scores for the lowest third (compared with highest) of a left-hand control test involving picking up matches of -1.21 (-1.73 to -0.68; p<0.001), -0.72 (-1.14 to -0.29; p=0.001), -0.70 (-1.06 to -0.35; p<0.001) and -1.32 (-1.90 to -0.73; p<0.001). Among those in the lowest third of the right-hand control test score, mixed-handedness compared with right-handedness was associated with poorer scholastic performance, with regression coefficients (and 95% CIs; p values) of 1.90 (-3.01 to -0.80; p=0.001), -1.25 (-2.15 to -0.35; p=0.007), -1.28 (2.04 to -0.53; p=0.001) and -1.33 (-2.53 to -0.13; p=0.030). The estimates are for a point change in the scholastic test scores, after adjustment for sex, left-hand motor function and social class. Statistically significant associations with mixed-handedness were only observed for the lowest third of right-hand motor function.

    Conclusions: Measures involving poorer left-hand motor function may represent useful markers of reduced cognitive function possibly reflecting suboptimal hemispheric lateralisation. Crude measures of laterality such as reported non-right-handedness may be more useful for research when combined with measures of motor function.

  • 6.
    Dahlgren, Cecilia
    et al.
    Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Solna, Sweden; Stockholms Läns Landsting, Center for Health Economics, Informatics and Healthcare Research, Stockholm, Sweden.
    Geary, Lukas
    Unit of Medicine, Capio S:t Görans Sjukhus, Stockholm, Sweden; Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Solna, Sweden.
    Hasselström, Jan
    Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Solna, Sweden; Stockholms Läns Landsting, Academic Primary Care Center, Stockholm, Sweden.
    Rehnberg, Clas
    Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Solna, Sweden.
    Schenck-Gustafsson, Karin
    Department of Medicine, Cardiac Unit, Center for Gender Medicine, Karolinska Institutet, Solna, Sweden.
    Wändell, Per
    Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Solna, Sweden.
    von Euler, Mia
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Medicine, Clinical Pharmacology Unit Solna, Karolinska Institutet, Solna, Sweden .
    Recording a diagnosis of stroke, transient ischaemic attack or myocardial infarction in primary healthcare and the association with dispensation of secondary preventive medication: a registry-based prospective cohort study2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 9, article id e015723Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The aim of this study was to explore whether recording in primary care of a previously recorded hospital diagnosis was associated with increased patient utilisation of recommended medications.

    DESIGN: Registry-based prospective cohort study.

    SETTING AND PARTICIPANTS: 19 072 patients with a hospital discharge diagnosis of transient ischaemic attack (TIA), stroke or acute coronary syndrome from hospitals in Stockholm County 2010-2013 were included in the study.

    MAIN OUTCOME MEASURE: The outcome of the study was medication dispensation as a marker of adherence to recommended medications. Adherence was defined as having had at least two filled prescriptions in the third year following hospital discharge.

    RESULTS: Recording a diagnosis was associated with higher utilisation of all recommended medications with the exception of antihypertensives in patients with TIA. The differences between the groups with and without a recorded diagnosis remained after adjusting for age, sex, index year and visits to private practitioners. Dispensation of antithrombotics was high overall, 80%-90% in patients without a recorded diagnosis and 90%-94% for those with a diagnosis. Women with recorded ischaemic stroke/TIA/acute coronary syndrome were dispensed more statins (56%-71%) than those with no recorded diagnosis (46%-59%). Similarly, 68%-83% of men with a recorded diagnosis were dispensed statins (57%-77% in men with no recorded diagnosis). The rate of diagnosis recording spanned from 15% to 47% and was especially low in TIA (men 15%, women 16%).

    CONCLUSION: Recording a diagnosis of TIA/stroke or acute coronary syndrome in primary care was found to be associated with higher dispensation of recommended secondary preventive medications. Further study is necessary in order to determine the mechanisms underlying our results and to establish the utility of our findings.

  • 7.
    Dalal, Koustuv
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Dahlström, Örjan
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden; Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Timpka, Toomas
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Interactions between microfinance programmes and non-economic empowerment of women associated with intimate partner violence in Bangladesh: a cross-sectional study2013In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, no 12, article id e002941Article in journal (Refereed)
    Abstract [en]

    Objective: This study aims to examine the associations between microfinance programme membership and intimate partner violence (IPV) in different socioeconomic strata of a nationally representative sample of women in Bangladesh. Methods: The cross-sectional study was based on a nationally representative interview survey of 11 178 ever-married women of reproductive age (15-49 years). A total of 4465 women who answered the IPV-related questions were analysed separately using chi(2) tests and Cramer's V as a measure of effect size to identify the differences in proportions of exposure to IPV with regard to microfinance programme membership, and demographic variables and interactions between microfinance programme membership and factors related to non-economic empowerment were considered. Results: Only 39% of women were members of microfinance programmes. The prevalence of a history of IPV was 48% for moderate physical violence, 16% for severe physical violence and 16% for sexual violence. For women with secondary or higher education, and women at the two wealthiest levels of the wealth index, microfinance programme membership increased the exposure to IPV two and three times, respectively. The least educated and poorest groups showed no change in exposure to IPV associated with microfinance programmes. The educated women who were more equal with their spouses in their family relationships by participating in decision-making increased their exposure to IPV by membership in microfinance programmes. Conclusions: Microfinance plans are associated with an increased exposure to IPV among educated and empowered women in Bangladesh. Microfinance firms should consider providing information about the associations between microfinance and IPV to the women belonging to the risk groups.

  • 8.
    Ericson, Jenny
    et al.
    Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden; Centre for Clinical Research Dalarna, Falun, Sweden; Department of Pediatrics, Falun Hospital, Falun, Sweden.
    Flacking, Renée
    School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
    Hellström-Westas, Lena
    Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
    Eriksson, Mats
    Örebro University, School of Health Sciences.
    Changes in the prevalence of breast feeding in preterm infants discharged from neonatal units: a register study over 10 years2016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 12, article id e012900Article in journal (Refereed)
    Abstract [en]

    Objective: There are indications that the prevalence of exclusively breastfed preterm infants is decreasing in Sweden. The objective was to investigate trends in exclusive breast feeding at discharge from Swedish neonatal units and associated factors in preterm infants.

    Design, setting and participants: This is a register study with data from the Swedish Neonatal Quality Register. Data from 29 445 preterm infants (gestational age (GA) <37 weeks) who were born during the period 2004–2013 were retrieved. Data included maternal, perinatal and neonatal characteristics. Data were analysed for the whole population as well as for 3 GA groups.

    Results: From 2004 to 2013, the prevalence of exclusive breast feeding decreased, in extremely preterm (GA 22–27 weeks) from 55% to 16%, in very preterm (GA 28–31 weeks) from 41% to 34% and in moderately preterm infants (GA 32–36 weeks) from 64% to 49%. The decline was statistically significant (p<0.001) in all 3 GA groups. This decline remained significant when adjustments were made for factors negatively associated with exclusive breast feeding andwhich became more prevalent during the study period, that is, small for GA (all groups) and maternal mental illness (very preterm and moderately preterm infants).

    Conclusions: In the past 10 years, Sweden has experienced a lower rate of exclusive breast feeding in preterm infants, especially in extremely preterm infants. The factors analysed in this study explain only a small proportion of this decline. The decline in exclusive breast feeding at discharge from neonatal units raises concern and present challenges to the units to support and promote breast feeding.

  • 9.
    Eriksen, Jaran
    et al.
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden.
    Gustafsson, Lars L
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden.
    Ateva, Kristina
    Stockholm Drug and Therapeutics Committee, Public Healthcare Services Committee, Stockholm, Sweden.
    Bastholm-Rahmner, Pia
    Medical Management Centre, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden.
    Ovesjö, Marie-Louise
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Quality and Development, Södersjukhuset, Stockholm, Sweden.
    Jirlow, Malena
    Public Healthcare Services Committee, Stockholm, Sweden.
    Juhasz-Haverinen, Maria
    Public Healthcare Services Committee, Stockholm, Sweden.
    Lärfars, Gerd
    Department of Clinical Science and Education, Södersjukhuset, Internal Medicine, Karolinska Institutet, Stockholm, Sweden.
    Malmström, Rickard E.
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
    Wettermark, Björn
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.
    Andersén-Karlsson, Eva
    Department of Clinical Science and Education, Södersjukhuset, Internal Medicine, Karolinska Institutet, Stockholm, Sweden.
    DTC, Stockholm
    High adherence to the 'Wise List' treatment recommendations in Stockholm: a 15-year retrospective review of a multifaceted approach promoting rational use of medicines2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 4, article id e014345Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To present the 'Wise List' (a formulary of essential medicines for primary and specialised care in Stockholm Healthcare Region) and assess adherence to the recommendations over a 15-year period.

    DESIGN: Retrospective analysis of all prescription data in the Stockholm Healthcare Region between 2000 and 2015 in relation to the Wise List recommendations during the same time period.

    SETTING: All outpatient care in the Stockholm Healthcare Region.

    PARTICIPANTS: All prescribers in the Stockholm Healthcare Region.

    MAIN OUTCOME MEASURES: The number of core and complementary substances included in the Wise List, the adherence to recommendations by Anatomic Therapeutic Chemical (ATC) 1st level using defined daily doses (DDDs) adjusted to the DDD for 2015, adherence to recommendations over time measured by dispensed prescriptions yearly between 2002 and 2015.

    RESULTS: The number of recommended core substances was stable (175-212). Overall adherence to the recommendations for core medicines for all prescribers increased from 75% to 84% (2000 to 2015). The adherence to recommendations in primary care for core medicines increased from 80% to 90% (2005 to 2015) with decreasing range in practice variation (32% to 13%). Hospital prescriber adherence to core medicine recommendations was stable but increased for the combination core and complementary medicines from 77% to 88% (2007 to 2015). Adherence varied between the 4 therapeutic areas studied.

    CONCLUSIONS: High and increasing adherence to the Wise List recommendations was seen for all prescriber categories. The transparent process for developing recommendations involving respected experts and clinicians using strict criteria for handling potential conflicts of interests, feedback to prescribers, continuous medical education and financial incentives are possible contributing factors. High-quality evidence-based recommendations to prescribers, such as the Wise List, disseminated through a multifaceted approach, will become increasingly important and should be developed further to include recommendations and introduction protocols for new expensive medicines.

  • 10.
    Fang, Xin
    et al.
    Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Li, Runkui
    College of Resources and Environment, University of Chinese Academy of Sciences, Beijing, China; State Key Laboratory of Resources and Environmental Information System, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing, China.
    Kan, Haidong
    Key Laboratory of Public Health Safety of the Ministry of Education, Fudan University, Shanghai, China; Key Laboratory of Health Technology Assessment of the Ministry of Health, School of Public Health, Fudan University, Shanghai, China; Shanghai Key Laboratory of Atmospheric Particle Pollution and Prevention (LAP), Fudan University, Shanghai, China.
    Bottai, Matteo
    Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Fang, Fang
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Bayesian model averaging method for evaluating associations between air pollution and respiratory mortality: a time-series study2016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 8, article id e011487Article in journal (Refereed)
    Abstract [en]

    Objective: To demonstrate an application of Bayesian model averaging (BMA) with generalised additive mixed models (GAMM) and provide a novel modelling technique to assess the association between inhalable coarse particles (PM10) and respiratory mortality in time-series studies.

    Design: A time-series study using regional death registry between 2009 and 2010.

    Setting: 8 districts in a large metropolitan area in Northern China.

    Participants: 9559 permanent residents of the 8 districts who died of respiratory diseases between 2009 and 2010.

    Main outcome measures: Per cent increase in daily respiratory mortality rate (MR) per interquartile range (IQR) increase of PM10 concentration and corresponding 95% confidence interval (CI) in single-pollutant and multipollutant (including NOx, CO) models.

    Results: The Bayesian model averaged GAMM (GAMM+ BMA) and the optimal GAMM of PM10, multipollutants and principal components (PCs) of multipollutants showed comparable results for the effect of PM10 on daily respiratory MR, that is, one IQR increase in PM10 concentration corresponded to 1.38% vs 1.39%, 1.81% vs 1.83% and 0.87% vs 0.88% increase, respectively, in daily respiratory MR. However, GAMM+ BMA gave slightly but noticeable wider CIs for the single-pollutant model (-1.09 to 4.28 vs -1.08 to 3.93) and the PCs-based model (-2.23 to 4.07 vs -2.03 vs 3.88). The CIs of the multiple-pollutant model from two methods are similar, that is, -1.12 to 4.85 versus -1.11 versus 4.83.

    Conclusions: The BMA method may represent a useful tool for modelling uncertainty in time-series studies when evaluating the effect of air pollution on fatal health outcomes.

  • 11.
    Geijer, Håkan
    et al.
    Örebro University, School of Medical Sciences. Centre for Assessment of Medical Technology in Örebro, Region Örebro County, Örebro, Sweden; Department of Radiology, Örebro University Hospital, Örebro, Sweden.
    Udumyan, Ruzan
    Örebro University, School of Medical Sciences. Örebro University Hospital, Örebro, Sweden.
    Lohse, Georg
    Centre for Assessment of Medical Technology in Örebro, Region Örebro County, Örebro, Sweden; Örebro Rehab Center, Örebro, Sweden.
    Nilsagård, Ylva
    Örebro University, School of Health Sciences. Centre for Assessment of Medical Technology in Örebro, Region Örebro County, Örebro, Sweden; Department of Medicine, Örebro University Hospital, Örebro, Sweden.
    Temperature measurements with a temporal scanner: systematic review and meta-analysis2016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 3, article id e009509Article in journal (Refereed)
    Abstract [en]

    Objectives: Systematic review and meta-analysis on the diagnostic accuracy of temporal artery thermometers (TAT).

    Design: Systematic review and meta-analysis. The index test consisted of temperature measurement with TAT. The reference test consisted of an estimation of core temperature.

    Participants: Clinical patients as well as healthy participants, with or without fever.

    Interventions: Literature search in PubMed, Embase, Cinahl and Web of Science. Three reviewers selected articles for full-text reading after which a further selection was made. Risk of bias was assessed with QUADAS-2. Pooled difference and limits of agreement (LoA) were estimated with an inverse variance weighted approach. Subgroup and sensitivity analyses were performed. Sensitivity and specificity were estimated using hierarchical models. Quality of evidence was assessed according to the GRADE system.

    Primary and secondary outcome measures: The primary outcome was measurement accuracy expressed as mean difference ±95% LoA. A secondary outcome was sensitivity and specificity to detect fever. If tympanic thermometers were assessed in the same population as TAT, these results were recorded as well.

    Results: 37 articles comprising 5026 participants were selected. Pooled difference was -0.19°C (95% LoA -1.16 to 0.77°C), with moderate quality of evidence. Pooled sensitivity was 0.72 (95% CI 0.61 to 0.81) with a specificity of 0.94 (95% CI 0.87 to 0.97). The subgroup analysis revealed a trend towards underestimation of the temperature for febrile patients. There was a large heterogeneity among included studies with wide LoA which reduced the quality of evidence.

    Conclusions: TAT is not sufficiently accurate to replace one of the reference methods such as rectal, bladder or more invasive temperature measurement methods. The results are, however, similar to those with tympanic thermometers, both in our meta-analysis and when compared with others. Thus, it seems that TAT could replace tympanic thermometers with the caveat that both methods are inaccurate.

    Trial registration number: CRD42014008832.

  • 12.
    Göras, Camilla
    et al.
    Örebro University, School of Health Sciences. Department of Anesthesia, Intensive Care Unit, Falu Lasarett, Falun, Sweden; Centre for Clinical Research, Falun, Sweden.
    Maria, Unbeck
    Department of Orthopedics, Danderyd Hospital, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Nilsson, Ulrica
    Örebro University, School of Health Sciences.
    Ehrenberg, Anna
    Örebro University, School of Health Sciences. School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
    Interprofessional team assessments of the patient safety climate in Swedish operating rooms: a cross-sectional survey2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 9, article id e015607Article, review/survey (Refereed)
    Abstract [en]

    Background: A positive patient safety climate within teams has been associated with higher safety performance. The aim of this study was to describe and compare attitudes to patient safety among the various professionals in surgical teams in Swedish operating room (OR) departments. A further aim was to study nurse managers in the OR and medical directors’ estimations of their staffs’ attitudes to patient safety.

    Methods: A cross-sectional survey with the Safety Attitudes Questionnaire (SAQ) was used to elicit estimations from surgical teams. To evoke estimations from nurse managers and medical directors about staff attitudes to patient safety, a short questionnaire, based on SAQ, was used. Three OR departments at three different hospitals in Sweden participated. All licensed practical nurses (n=124), perioperative nurses (n=233), physicians (n=184) and their respective manager (n=22) were invited to participate.

    Results: Mean percentage positive scores for the six SAQ factors and the three professional groups varied, and most factors (safety climate, teamwork climate, stress recognition, working conditions and perceptions of management), except job satisfaction, were below 60%. Significantly lower mean values were found for perioperative nurses compared with physicians for perceptions of management (56.4 vs 61.4, p=0.013) and working conditions (63.7 vs 69.8, p=0.007). Nurse managers and medical directors’ estimations of their staffs’ ratings of the safety climate cohered fairly well.

    Conclusions: This study shows variations and some weak areas for patient safety climate in the studied ORs as reported by front-line staff and acknowledged by nurse managers and medical directors. This finding is a concern because a weak patient safety climate has been associated with poor patient outcomes. To raise awareness, managers need to support patient safety work in the OR.

  • 13.
    Göras, Camilla
    et al.
    Örebro University, School of Health Sciences. Department of Anaesthesia and Intensive Care Unit, Falu Hospital, Falun, Sweden; Centre for Clinical Research, Falun, Dalarna, Sweden.
    Olin, Karolina
    Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden; Development Centre, Turku University Hospital, Turku, Finland.
    Unbeck, Maria
    Trauma and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Pukk-Härenstam, Karin
    Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden; Paediatric Emergency Department, Karolinska University Hospital, Stockholm, Sweden.
    Ehrenberg, Anna
    School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
    Tessma, Mesfin Kassaye
    Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
    Nilsson, Ulrica
    Department of Neurobiology, Care Sciences and Society, Karolinska Institutet Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden.
    Ekstedt, Mirjam
    Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden; School of Health and Caring Sciences, Linneuniversitet, Kalmar, Sweden.
    Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study2019In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 5, article id e026410Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR.

    DESIGN: Prospective observational study using the Work Observation Method By Activity Timing tool.

    SETTING: An OR department at a county hospital in Sweden.

    PARTICIPANTS: OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9).

    RESULTS: The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons' and ORNs' intraoperative time, while in RNAs' work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs' and surgeons' work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication.

    CONCLUSIONS: The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system.

    TRIAL REGISTRATION NUMBER: 2016/264.

  • 14.
    Helldén, Anders
    et al.
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Odar-Cederlöf, Ingegerd
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Nilsson, Göran
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Sjöviker, Susanne
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Söderström, Anders
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    von Euler, Mia
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Ohlén, Gunnar
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Bergman, Ulf
    Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Renal function estimations and dose recommendations for dabigatran, gabapentin and valaciclovir: a data simulation study focused on the elderly2013In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, no 4, article id e002686Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The thrombin inhibitor dabigatran is mainly excreted by the kidneys. We investigated whether the recommended method for estimation of renal function used in the clinical trials, the Cockcroft-Gault (CGold) equation and the estimated glomerular filtration rate (eGFR) modification of diet in renal disease equation 4 (MDRD4), differ in elderly participants, resulting in erroneously higher dose recommendations of dabigatran, which might explain the serious, even fatal, bleeding reported. The renally excreted drugs gabapentin and valaciclovir were also included for comparison.

    DESIGN: A retrospective data simulation study.

    PARTICIPANTS: Participants 65 years and older included in six different studies.

    MAIN OUTCOME MEASURE: Estimated renal function by CG based on uncompensated ('old Jaffe' method) creatinine (CGold) or by MDRD4 based on standardised compensated P-creatinine traceable to isotope-dilution mass spectrometry, and the resulting doses.

    RESULTS: 790 participants (432 females), mean age (±SD) 77.6±5.7 years. Mean estimated creatinine clearance (eCrCl) by the CGold equation was 44.2±14.8 ml/min, versus eGFR 59.6±20.7 ml/min/1.73 m(2) with MDRD4 (p<0.001), absolute median difference 13.5, 95% CI 12.9 to 14.2. MDRD4 gave a significantly higher mean dose (valaciclovir +21%, dabigatran +25% and gabapentin +37%) of all drugs (p<0.001). With MDRD4 58% of the women would be recommended a full dose of dabigatran compared with 18% if CGold is used.

    CONCLUSIONS: MDRD4 would result in higher recommended doses of the three studied drugs to elderly participants compared with CG, particularly in women, and thus increased the risk of dose and concentration-dependent adverse reactions. It is important to know which method of estimation of renal function the Summary of Products Characteristics was based on, and use only that one when prescribing renally excreted drugs with narrow safety window. Doses based on recently developed methods for estimation of renal function may be associated with considerable risk of overtreatment in the elderly.

  • 15.
    Jaensson, Maria
    et al.
    Örebro University, School of Health Sciences.
    Dahlberg, Karuna
    Örebro University, School of Health Sciences.
    Nilsson, Ulrica
    Division of Nursing, Department of Neurobiology, Care Sciences, and Society, Karolinska Institute, Stockholm, Sweden; Perioperative Medicine & Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
    Stenberg, Erik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    The impact of self-efficacy and health literacy on outcome after bariatric surgery in Sweden: a protocol for a prospective, longitudinal mixed methods study2019In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 5, article id e027272Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: A person-centred approach, to know about a person's individual weaknesses and strengths, is warranted in today's healthcare in Sweden. When a person suffers from obesity, there are not only risks for comorbidities but also increased risk for decreased health-related quality of life (HRQoL). After bariatric surgery, there are also risks for complications; however, healthcare service expects the person to have sufficient ability to handle recovery after surgery. The need is to investigate how a person's self-efficacy and health literacy(HL) skills are important to determine their effect on recovery as well as HRQoL after bariatric surgery. It can, involve the person in the care, improve shared decision-making, and perhaps decrease complications and readmissions.

    METHOD AND ANALYSIS: This is a prospective, longitudinal mixed-methods study with the intent of including 700 patients from three bariatric centres in Sweden (phase 1); 20 patients will be included in a qualitative study (phase 2). Inclusion criteria will be age >17 years, scheduled primary bariatric surgery and ability to read and understand the Swedish language in speech and in writing. Inclusion criteria for the qualitative study will be patients who reported a low self-efficacy, with a selection to ensure maximum variation regarding age and gender. Before bariatric surgery patients will answer a questionnaire including 20 items. Valid and reliable instruments will be used to investigate general self-efficacy (10 items) and functional and communicative and critical HL (10 items). This data collection will then be merged with data from the Scandinavian Obesity Surgery Registry. Analysis will be performed 30 days, 1 year and 2 years after bariatric surgery. One year after bariatric surgery the qualitative study will be performed. The main outcomes are the impact of a person's self-efficacy and HL on recovery after bariatric surgery.

    ETHICS AND DISSEMINATION: The study has received approval from the ethical review board in Uppsala, Sweden (number 2018/256). The study results will be disseminated through peer-reviewed publications and conference presentations to the scientific community and social media.

  • 16.
    Johansson, R.
    et al.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Ljótsson, B.
    Division of Psychology, Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Frederick, R. J.
    Center for Courageous Living, Beverly Hills, California, USA.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; Psychiatry Section, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Transdiagnostic, affect-focused, psychodynamic, guided self-help for depression and anxiety through the internet: Study protocol for a randomised controlled trial2012In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 2, no 6, article id e002167Article in journal (Refereed)
    Abstract [en]

    Introduction: Cognitive behaviour therapy delivered in the format of guided self-help via the internet has been found to be effective for a range of conditions, including depression and anxiety disorders. Recent results indicate that guided self-help via the internet is a promising treatment format also for psychodynamic therapy. However, to date and to our knowledge, no study has evaluated internet-delivered psychodynamic therapy as a transdiagnostic treatment. The affect-phobia model of psychopathology by McCullough et al provides a psychodynamic conceptualisation of a range of psychiatric disorders. The aim of this study will be to test the effects of a transdiagnostic guided self-help treatment based on the affect-phobia model in a sample of clients with depression and anxiety.

    Methods and analysis: This study will be a randomised controlled trial with a total sample size of 100 participants. The treatment group receives a 10-week, psychodynamic, guided self-help treatment based on the transdiagnostic affect-phobia model of psychopathology. The treatment consists of eight text-based treatment modules and includes therapist contact in a secure online environment. Participants in the control group receive similar online therapist support without any treatment modules. Outcome measures are the 9-item Patient Health Questionnaire Depression Scale and the 7-item Generalised Anxiety Disorder Scale (GAD-7). Process measures that concerns emotional processing and mindfulness are included. All outcome and process measures will be administered weekly via the internet and at 6-month follow-up.

    Discussion: This trial will add to the body of knowledge on internet-delivered psychological treatments in general and to psychodynamic treatments in particular. We also hope to provide new insights in the effectiveness and working mechanisms of psychodynamic therapy based on the affect-phobia model.

  • 17.
    Kostulas, Nikolaos
    et al.
    Depatment of Clinical Science and Education, Karolinska Institutet, Solna, Sweden.
    Larsson, Martin
    Depatment of Clinical Science and Education, Karolinska Institutet, Solna, Sweden.
    Kall, Tor-Bjorn
    Depatment of Clinical Science and Education, Karolinska Institutet, Solna, Sweden.
    von Euler, Mia
    Depatment of Clinical Science and Education, Karolinska Institutet, Solna, Sweden; Karolinska Institutet Stroke Research Network, Stockholm, Sweden.
    Nathanson, David
    Depatment of Clinical Science and Education, Karolinska Institutet, Solna, Sweden.
    Safety of thrombolysis in stroke mimics: an observational cohort study from an urban teaching hospital in Sweden2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 10, article id e016311Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Acute stroke management has changed dramatically over the recent years, where a timely assessment is driven by the expanding treatment options of acute ischaemic stroke. This increases the risk in treating non-stroke patients (stroke mimics) with a possibly hazardous intravenous thrombolysis treatment (IVT).

    SETTING: Patients of the thrombolysis registry of Södersjukhuset AB, a secondary health centre in Stockholm, were retrospectively studied to determine complications and outcome after IVT in strokes and stroke mimics.

    PARTICIPANTS: Consecutively, 674 recruited patients from 1 January 2008 to 1 December 2013 were analysed regarding demographics and outcome at 3 months after onset of symptoms.

    RESULTS: Ischaemic stroke was confirmed in 625 patients (93%), and 48 patients (7%) were stroke mimics. Patients with strokes were older than stroke mimics 72 (IQR: 64-81) vs 54 years (IQR 40-67), p<0.0001. Antihypertensive and antithrombotic treatment were more common in patients with stroke (p<0.0001 and p=0.006, respectively). National Institute of Health Stroke Scale did not differ at time of presentation. Excellent outcome defined as modified Rankin Scale score 0-1, at 3 months, was less common in stroke than in stroke mimics (50% vs 87.5%, p<0.0001). No stroke mimic had a symptomatic intracerebral haemorrhage. Age of less than 40 years may be a predictor for a patient to be a stroke mimic (OR: 8.7, 95% CI: 3.2 to 24.0, p<0.0001).

    CONCLUSIONS: Stroke mimics receiving IVT had a more favourable outcome compared with patients with stroke, and showed no haemorrhagic complications. Age below 40 years may be a predictor for stroke mimics.

  • 18.
    Kwakkenbos, Linda
    et al.
    Behavioural Science Institute, Clinical Psychology, Radboud University, Nijmegen, Gelderland, Netherlands.
    Imran, Mahrukh
    Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal QC, Canada.
    McCord, Kimberly A.
    Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.
    Sampson, Margaret
    Library Services, Children's Hospital of Eastern Ontario, Ottawa ON, Canada.
    Fröbert, Ole
    Örebro University, School of Medical Sciences. Department of Cardiology.
    Gale, Chris
    Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, United Kingdom.
    Hemkens, Lars G.
    Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.
    Langan, Sinead M.
    Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
    Moher, David
    Centre for Journalology, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa ON, Canada.
    Relton, Clare
    Centre for Clinical Trials and Methodology, Barts Institute of Population Health Science, Queen Mary University, London, United Kingdom.
    Zwarenstein, Merrick
    Department of Family Medicine, Western University, London, United Kingdom; Institute for Clinical Evaluative Sciences, Toronto ON, Canada.
    Benchimol, Eric I.
    Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa ON, Canada; Institute for Clinical Evaluative Sciences, Ottawa ON, Canada; Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa ON, Canada.
    Boutron, Isabelle
    Sorbonne Paris Cité Epidemiology and Statistics Research Center, INSERM, UMR1153, Paris, France; Centre d'Épidémiologie Clinique, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
    Campbell, Marion K.
    Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom.
    Erlinge, David
    Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden.
    Jawad, Sena
    Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, United Kingdom.
    Ravaud, Philippe
    Sorbonne Paris Cité Epidemiology and Statistics Research Center, INSERM, UMR1153, Paris, France; Centre d'Épidémiologie Clinique, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
    Rice, Danielle B.
    Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal QC, Canada; Department of Psychology, McGill University, Montréal QC, Canada.
    Sauve, Maureen
    Scleroderma Society of Ontario, Hamilton, ON, Canada; Scleroderma Canada, Hamilton ON, Canada.
    van Staa, Tjeerd P.
    Health E-Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Utrecht, Netherlands.
    Thabane, Lehana
    Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ON, Canada.
    Uher, Rudolf
    Department of Psychiatry, Dalhousie University, Halifax NS, Canada.
    Verkooijen, Helena M.
    Department of Epidemiology, University Medical Center Utrecht, Utrecht, Netherlands; Department of Epidemiology, University of Utrecht, Utrecht, Netherlands.
    Juszczak, Edmund
    NPEU Clinical Trials Unit, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
    Thombs, Brett D.
    Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal QC, Canada; Department of Psychology, McGill University, Montréal QC, Canada; Department of Psychiatry, McGill University, Montreal QC, Canada; Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal QC, Canada; Department of Medicine, McGill University, Montreal QC, Canada; Departments of Educational and Counselling Psychology, McGill University, Montreal QC, Canada.
    Protocol for a scoping review to support development of a CONSORT extension for randomised controlled trials using cohorts and routinely collected health data2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 8, article id e025266Article, review/survey (Refereed)
    Abstract [en]

    Introduction: Randomised controlled trials (RCTs) conducted using cohorts and routinely collected health data, including registries, electronic health records and administrative databases, are increasingly used in healthcare intervention research. The development of an extension of the CONsolidated Standards of Reporting Trials (CONSORT) statement for RCTs using cohorts and routinely collected health data is being undertaken with the goal of improving reporting quality by setting standards early in the process of uptake of these designs. To develop this extension to the CONSORT statement, a scoping review will be conducted to identify potential modifications or clarifications of existing reporting guideline items, as well as additional items needed for reporting RCTs using cohorts and routinely collected health data.

    Methods and analysis: In separate searches, we will seek publications on methods or reporting or that describe protocols or results from RCTs using cohorts, registries, electronic health records and administrative databases. Data sources will include Medline and the Cochrane Methodology Register. For each of the four main types of RCTs using cohorts and routinely collected health data, separately, two investigators will independently review included publications to extract potential checklist items. A potential item will either modify an existing CONSORT 2010, Strengthening the Reporting of Observational Studies in Epidemiology or REporting of studies Conducted using Observational Routinely collected health Data item or will be proposed as a new item. Additionally, we will identify examples of good reporting in RCTs using cohorts and routinely collected health data.

    Ethics and dissemination: The proposed scoping review will help guide the development of the CONSORT extension statement for RCTs conducted using cohorts and routinely collected health data.

  • 19.
    Lekander, Ingrid
    et al.
    Ivbar Institute AB and Medical Management Center, LIME, Karolinska Institutet, Solna, Sweden.
    Willers, Carl
    Ivbar Institute AB and Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Ekstrand, Elisabeth
    Department of Health Sciences, Lund University, Lund, Sweden.
    von Euler, Mia
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet and Karolinska Institutet Stroke research Network at Södersjukhuset, Stockholm, Sweden.
    Fagervall-Yttling, Birgitta
    Sweden Occupational Unions, Luleå, Sweden.
    Henricson, Lena
    Swedish Association of Speech and Language Pathologists, Stockholm, Sweden.
    Kostulas, Konstantinos
    Department of Neurology, Huddinge Unit, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Neuro-Angiological Research Center, Karolinska Institutet, Solna, Sweden.
    Lilja, Mikael
    Department of Public Health and Clinical Medicine, Family Medicine, Östersund, Umeå University, Östersund, Sweden.
    Sunnerhagen, Katharina S.
    Institute of Neuroscience and Physiology, Rehabilitation medicine, University of Gothenburg, Gothenburg, Sweden.
    Teichert, Jörg
    Department of Medicine, Landstinget Dalarna, Mora lasarett, Mora, Sweden.
    Pessah-Rasmussen, Hélène
    Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden.
    Hospital comparison of stroke care in Sweden: a register-based study2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 9, article id e015244Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: The objective of this study was to estimate the level of health outcomes and resource use at a hospital level during the first year after a stroke, and to identify any potential differences between hospitals after adjusting for patient characteristics (case mix).

    METHOD: Data from several registries were linked on individual level: seven regional patient administrative systems, Swedish Stroke Register, Statistics Sweden, National Board of Health and Welfare and Swedish Social Insurance Agency. The study population consisted of 14 125 patients presenting with a stroke during 2010. Case-mix adjusted analysis of hospital differences was made on five aspects of health outcomes and resource use, 1 year post-stroke.

    RESULTS: The results indicated that 26% of patients had died within a year of their stroke. Among those who survived, almost 5% had a recurrent stroke and 40% were left with a disability. On average, the patients had 22 inpatient days and 23 outpatient visits, and 13% had moved into special housing. There were significant variations between hospitals in levels of health outcomes achieved and resources used after adjusting for case mix.

    CONCLUSION: Differences in health outcomes and resource use between hospitals were substantial and not entirely explained by differences in patient mix, indicating tendencies of unequal stroke care in Sweden. Healthcare organisation of regions and other structural features could potentially explain parts of the differences identified.

  • 20.
    Lendaro, Eva
    et al.
    Biomechatronics and Neurorehabilitation Laboratory, Department of Electrical Engineering, Chalmers University of Technology, Goteborg, Sweden.
    Hermansson, Liselotte
    Örebro University, School of Health Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics.
    Burger, Helena
    University Rehabilitation Institute, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
    van der Sluis, Corry K
    Department of Rehabilitation Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
    McGuire, Brian E.
    School of Psychology & Centre for Pain Research, National University of Ireland, Galway, Ireland.
    Pilch, Monika
    School of Psychology & Centre for Pain Research, National University of Ireland, Galway, Ireland.
    Bunketorp-Käll, Lina
    Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Kulbacka-Ortiz, Katarzyna
    Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Rignér, Ingrid
    Gåskolan/Ortopedteknik, Sahlgrenska Universitetssjukhuset, Göteborg, Sweden.
    Stockselius, Anita
    Rehabcenter Sfären, Bräcke Diakoni, Stockholm, Sweden.
    Widehammar, Cathrine
    Örebro University, School of Health Sciences.
    Hill, Wendy
    Institute of Biomedical Engineering, University of New Brunswick, Fredericton, New Brunswick, Canada.
    Geers, Sybille
    Fysische Geneeskunde en Revalidatie, University Hospital Gent, Gent, Belgium.
    Ortiz-Catalan, Max
    Biomechatronics and Neurorehabilitation Laboratory, Department of Electrical Engineering, Chalmers University of Technology, Göteborg, Sweden; Integrum AB, Mölndal, Sweden.
    Phantom motor execution as a treatment for phantom limb pain: protocol of an international, double-blind, randomised controlled clinical trial2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 7, article id e021039Article in journal (Refereed)
    Abstract [en]

    Introduction: Phantom limb pain (PLP) is a chronic condition that can greatly diminish quality of life. Control over the phantom limb and exercise of such control have been hypothesised to reverse maladaptive brain changes correlated to PLP. Preliminary investigations have shown that decoding motor volition using myoelectric pattern recognition, while providing real-time feedback via virtual and augmented reality (VR-AR), facilitates phantom motor execution (PME) and reduces PLP. Here we present the study protocol for an international (seven countries), multicentre (nine clinics), double-blind, randomised controlled clinical trial to assess the effectiveness of PME in alleviating PLP.

    Methods and analysis: Sixty-seven subjects suffering from PLP in upper or lower limbs are randomly assigned to PME or phantom motor imagery (PMI) interventions. Subjects allocated to either treatment receive 15 interventions and are exposed to the same VR-AR environments using the same device. The only difference between interventions is whether phantom movements are actually performed (PME) or just imagined (PMI). Complete evaluations are conducted at baseline and at intervention completion, as well as 1, 3 and 6 months later using an intention-to-treat (ITT) approach. Changes in PLP measured using the Pain Rating Index between the first and last session are the primary measure of efficacy. Secondary outcomes include: frequency, duration, quality of pain, intrusion of pain in activities of daily living and sleep, disability associated to pain, pain self-efficacy, frequency of depressed mood, presence of catastrophising thinking, health-related quality of life and clinically significant change as patient’s own impression. Follow-up interviews are conducted up to 6 months after the treatment.

    Ethics and dissemination: The study is performed in agreement with the Declaration of Helsinki and under approval by the governing ethical committees of each participating clinic. The results will be published according to the Consolidated Standards of Reporting Trials guidelines in a peer-reviewed journal.

    Trial registration number: NCT03112928; Pre-results.

  • 21.
    Liakopoulos, Vasileios
    et al.
    Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Medical Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Franzen, Stefan
    National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden; Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Svensson, Ann-Marie
    Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden.
    Miftaraj, Mervete
    National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Gudbjörnsdottir, Soffia
    Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden.
    Eliasson, Björn
    Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Medical Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Pros and cons of gastric bypass surgery in individuals with obesity and type 2 diabetes: nationwide, matched, observational cohort study2019In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 1, article id e023882Article in journal (Refereed)
    Abstract [en]

    Objectives: Long-term effects of gastric bypass (GBP) surgery have been presented in observational and randomised studies, but there are only limited data for persons with obesity and type 2 diabetes mellitus (T2DM) regarding postoperative complications.

    Design: This is a nationwide observational study based on two quality registers in Sweden (National Diabetes Register, NDR and Scandinavian Obesity Surgery Register, SOReg) and other national databases.

    Setting: After merging the data, we matched individuals with T2DM who had undergone GBP with those not surgically treated for obesity on propensity score, based on sex, age, body mass index (BMI) and calendar time. The risks of postoperative outcomes (rehospitalisations) were assessed using Cox regression models.

    Participants: We identified 5321 patients with T2DM in the SOReg and 5321 matched controls in the NDR, aged 18-65 years, with BMI > 27.5 kg/m(2) and followed for up to 9 years.

    Primary and secondary outcome measures: We assessed risks for all-cause mortality and hospitalisations for cardiovascular disease, severe kidney disease, along with surgical and other medical conditions.

    Results: The results agree with the previously suggested lower risks of all-cause mortality (49%) and cardiovascular disease (34%), and we also found positive effects for severe kidney disease but significantly increased risks (twofold to ninefold) of several short-term complications after GBP, such as abdominal pain and gastrointestinal conditions, frequently requiring surgical procedures, apart from reconstructive plastic surgery. Long-term, the risk of anaemia was 92% higher, malnutrition developed approximately three times as often, psychiatric diagnoses were 33% more frequent and alcohol abuse was three times as great as in the control group.

    Conclusions: This nationwide study confirms the benefits and describes the panorama of adverse events after bariatric surgery in persons with obesity and T2DM. Long-term postoperative monitoring and support, as better selection of patients by appropriate specialists in interdisciplinary settings, should be provided to optimise the outcomes.

  • 22.
    Loikas, Desirée
    et al.
    Department of Medicine, Centre for Pharmacoepidemiology (CPE), Solna Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden; Department of Healthcare Development, Public Healthcare Services Committee, Stockholm County Council, Stockholm, Sweden.
    Wettermark, Björn
    Department of Medicine, Centre for Pharmacoepidemiology (CPE), Solna Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden; Department of Healthcare Development, Public Healthcare Services Committee, Stockholm County Council, Stockholm, Sweden; Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    von Euler, Mia
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Bergman, Ulf
    Department of Medicine, Centre for Pharmacoepidemiology (CPE), Solna Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden; Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Schenck-Gustafsson, Karin
    Department of Medicine, Cardiac Unit and Centre for Gender Medicine, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden.
    Differences in drug utilisation between men and women: a cross-sectional analysis of all dispensed drugs in Sweden2013In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, no 5, article id e002378Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Ascertain the extent of differences between men and women in dispensed drugs since there is a lack of comprehensive overviews on sex differences in the use of prescription drugs.

    DESIGN: Cross-sectional population database analysis.

    METHODS: Data on all dispensed drugs in 2010 to the entire Swedish population (9.3 million inhabitants) were obtained from the Swedish Prescribed Drug Register. All pharmacological groups with ambulatory care prescribing accounting for >75% of the total volume in Defined Daily Doses and a prevalence of >1% were included in the analysis. Crude and age-adjusted differences in prevalence and incidence were calculated as risk ratios (RRs) of women/men.

    RESULTS: In all, 2.8 million men (59%) and 3.6 million women (76%) were dispensed at least one prescribed drug during 2010. Women were dispensed more drugs in all age groups except among children under the age of 10. The largest sex difference in prevalence in absolute numbers was found for antibiotics that were more common in women, 265.5 patients (PAT)/1000 women and 191.3 PAT/1000 men, respectively. This was followed by thyroid therapy (65.7 PAT/1000 women and 13.1 PAT/1000 men) and antidepressants (106.6 PAT/1000 women and 55.4 PAT/1000 men). Age-adjusted relative sex differences in prevalence were found in 48 of the 50 identified pharmacological groups. The pharmacological groups with the largest relative differences of dispensed drugs were systemic antimycotics (RR 6.6 CI 6.4 to 6.7), drugs for osteoporosis (RR 4.9 CI 4.9 to 5.0) and thyroid therapy (RR 4.5 CI 4.4 to 4.5), which were dispensed to women to a higher degree. Antigout agents (RR 0.4 CI 0.4 to 0.4), psychostimulants (RR 0.6 CI 0.6 to 0.6) and ACE inhibitors (RR 0.7 CI 0.7 to 0.7) were dispensed to men to a larger proportion.

    CONCLUSIONS: Substantial differences in the prevalence and incidence of dispensed drugs were found between men and women. Some differences may be rational and desirable and related to differences between the sexes in the incidence or prevalence of disease or by biological differences. Other differences are more difficult to explain on medical grounds and may indicate unequal treatment.

  • 23.
    Melinder, Carren
    et al.
    Örebro University, School of Medical Sciences.
    Hiyoshi, Ayako
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Fall, Katja
    Örebro University, School of Medical Sciences.
    Halfvarson, Jonas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Gastroenterology, Örebro University Hospital, Örebro, Sweden.
    Montgomery, Scott
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Stress resilience and the risk of inflammatory bowel disease: a cohort study of men living in Sweden2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 1, article id e014315Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To determine if low psychosocial stress resilience in adolescence (increasing chronic stress arousal throughout life) is associated with an increased inflammatory bowel disease (IBD) risk in adulthood. Subclinical Crohn's disease (CD) and ulcerative colitis (UC) can exist over many years and we hypothesise that psychosocial stress may result in conversion to symptomatic disease through its proinflammatory or barrier function effects.

    DESIGN: National register-based cohort study of men followed from late adolescence to middle age.

    SETTING: A general population cohort of men in Sweden.

    PARTICIPANTS: Swedish population-based registers provided information on all men born between 1952 and 1956 who underwent mandatory Swedish military conscription assessment (n=239 591). Men with any gastrointestinal diagnoses (except appendicitis) prior to follow-up were excluded.

    PRIMARY OUTCOME MEASURES: An inpatient or outpatient diagnosis of CD or UC recorded in the Swedish Patient Register (1970-2009).

    RESULTS: A total of 938 men received a diagnosis of CD and 1799 UC. Lower stress resilience in adolescence was associated with increased IBD risk, with unadjusted HRs (95% CIs) of 1.54 (1.26 to 1.88) and 1.24 (1.08 to 1.42), for CD and UC, respectively. After adjustment for potential confounding factors, including markers of subclinical disease activity in adolescence, they are 1.39 (1.13 to 1.71) and 1.19 (1.03 to 1.37).

    CONCLUSIONS: Lower stress resilience may increase the risk of diagnosis of IBD in adulthood, possibly through an influence on inflammation or barrier function.

  • 24.
    Montgomery, Scott
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Clinical Epidemiology Unit, Karolinska Inst, Stockholm, Sweden ; Dept Epidemiology & Publ Health, University College London (UCL), London, England .
    Bahmanyar, Shahram
    Clinical & Epidemiological Unit, Karolinska Inst, Stockholm, Sweden; Center of Pharmacoepidemiology, Karolinska Institute, Stockholm, Sweden .
    Brus, Ole
    Örebro University Hospital, Örebro, Sweden.
    Hussein, Oula
    Örebro University Hospital, Örebro, Sweden.
    Kosma, Paraskevi
    Dept Woman & Child Health, Karolinska Institute, Stockholm, Sweden; Division of Neonatology, Karolinska Hosp, Stockholm, Sweden.
    Palme-Kilander, Charlotte
    Dept Woman & Child Health, Karolinska Institute, Stockholm, Sweden.
    Respiratory infections in preterm infants and subsequent asthma: a cohort study2013In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, no 10, article id e004034Article in journal (Refereed)
    Abstract [en]

    Objectives: To investigate whether gestational age modifies the association of airway infections that result in hospital admission during the first year after birth, with subsequent asthma risk after age 5years.

    Setting: Hospital inpatients and a general population comparison group in Sweden followed for subsequent diagnoses in primary and secondary care.

    Participants: National registers identified 42334 children admitted to hospital for respiratory infection in their first year after birth during 1981-1995, individually matched with 211594 children not admitted to hospital for infection during their first year.

    Primary outcome Asthma diagnoses and prescribed asthma treatments after the age of 5years identified through registers.

    Results: Cox regression was used to identify a HR (and 95% CI) of 1.51 (1.47 to 1.51) for the association of respiratory infection before 1year of age with asthma after age 5years, after adjustment for sex, gestational age, chronic lung disease, maternal asthma and maternal smoking. When stratified by gestational age (and with additional adjustment for birth weight), there is statistically significant effect modification by gestational age, with the highest magnitude asthma risk among those born with a gestational age of less than 28 weeks, producing an adjusted HR of 2.22 (1.59 to 3.09). This higher magnitude asthma risk persisted until after age 10years, but differences in risk by gestational age were less pronounced for asthma after age 16years.

    Conclusions: Extremely preterm infants are most likely to have chronic respiratory sequelae following respiratory infections in early life.

  • 25.
    Montgomery, Scott
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Karolinska Institutet, Stockholm, Sweden .
    Hassan, Ahmad
    School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Bahmanyar, Shahram
    Karolinska Institutet, Stockholm, Sweden; Golestan University of Medical Sciences, Gorgan, Iran .
    Brus, Ole
    Örebro University Hospital, Örebro, Sweden.
    Hussein, Oula
    Örebro University Hospital, Örebro, Sweden.
    Hiyoshi, Ayako
    Örebro University Hospital.
    Hillert, Jan
    Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden .
    Olsson, Tomas
    Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden .
    Fall, Katja
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital, Örebro, Sweden.
    Mortality following a brain tumour diagnosis in patients with multiple sclerosis2013In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, no 11, article id e003622Article in journal (Refereed)
    Abstract [en]

    Objectives: As brain tumours and their treatment may theoretically have a poorer prognosis in inflammatory central nervous system diseases such as multiple sclerosis (MS), all-cause mortality following a brain tumour diagnosis was compared between patients with and without MS. The potential role of age at tumour diagnosis was also examined.

    Setting: Hospital inpatients in Sweden with assessment of mortality in hospital or following discharge.

    Participants: Swedish national registers identified 20 543 patients with an MS diagnosis (1969–2005) and they were matched individually to produce a comparison cohort of 204 163 members of the general population without MS. Everyone with a primary brain tumour diagnosis was selected for this study: 111 with MS and 907 without MS.

    Primary and secondary outcome measures: 5-year mortality risk following brain tumour diagnosis and age at brain tumour diagnosis.

    Results: A non-statistically significant lower mortality risk among patients with MS (lower for those with tumours of high-grade and uncertain-grade malignancy and no notable difference for low-grade tumours) produced an unadjusted HR (and 95% CI) of 0.75 (0.56 to 1.02). After adjustment for age at diagnosis, grade of malignancy, sex, region of residence and socioeconomic index, the HR is 0.91 (0.67–1.24). The change in estimate was largely due to adjustment for age at brain tumour diagnosis, as patients with MS were on average 4.7 years younger at brain tumour diagnosis than those in the comparison cohort (p<0.001).

    Conclusions: Younger age at tumour diagnosis may contribute to mortality reduction in those with highgrade and uncertain-grade brain tumours. Survival following a brain tumour is not worse in patients with MS; even after age at brain tumour diagnosis and grade of malignancy are taken into account.

  • 26.
    Montgomery, Scott
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Karolinska Institutet, Stockholm, Sweden .
    Udumyan, Ruzan
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital, Örebro, Sweden.
    Magnuson, Anders
    Örebro University Hospital, Örebro, Sweden.
    Osika, Walter
    Stockholm University, Stockholm, Sweden.
    Sundin, Per-Ola
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital, Örebro, Sweden.
    Blane, David
    School of Public Health, Imperial College London, London, UK .
    Mortality following unemployment during an economic downturn: Swedish register-based cohort study2013In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, no 7, p. e003031-Article in journal (Refereed)
  • 27.
    Nilsson, Ulrica
    et al.
    Örebro University, School of Health Sciences.
    Jaensson, Maria
    Örebro University, School of Health Sciences.
    Dahlberg, Karuna
    Örebro University, School of Health Sciences.
    Odencrants, Sigrid
    Örebro University, School of Health Sciences.
    Grönlund, Åke
    Örebro University, Örebro University School of Business.
    Hagberg, Lars
    Örebro University, School of Health Sciences. Centre for Health Care Sciences, Örebro University Hospital, Örebro, Sweden.
    Eriksson, Mats
    Örebro University, School of Health Sciences.
    RAPP, a systematic e-assessment of postoperative recovery in patients undergoing day surgery: study protocol for a mixed-methods study design including a multicentre, two-group, parallel, single-blind randomised controlled trial and qualitative interview studies2016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 1, article id e009901Article in journal (Refereed)
    Abstract [en]

    Introduction: Day surgery is a well-established practice in many European countries, but only limited information is available regarding postoperative recovery at home though there is a current lack of a standard procedure regarding postoperative follow-up. Furthermore, there is also a need for improvement of modern technology in assessing patient-related outcomes such as mobile applications. This article describes the Recovery Assessment by Phone Points (RAPP) study protocol, a mixed-methods study to evaluate if a systematic e-assessment follow-up in patients undergoing day surgery is cost-effective and improves postoperative recovery, health and quality of life.

    Methods and analysis: This study has a mixed-methods study design that includes a multicentre, two-group, parallel, single-blind randomised controlled trial and qualitative interview studies. 1000 patients >17 years of age who are undergoing day surgery will be randomly assigned to either eassessed postoperative recovery follow-up daily in 14 days measured via smartphone app including the Swedish web-version of Quality of Recovery (SwQoR) or to standard care (ie, no follow-up). The primary aim is cost-effectiveness. Secondary aims are (A) to explore whether a systematic e-assessment follow-up after day surgery has a positive effect on postoperative recovery, health-related quality of life (QoL) and overall health; (B) to determine whether differences in postoperative recovery have an association with patient characteristic, type of surgery and anaesthesia; (C) to determine whether differences in health literacy have a substantial and distinct effect on postoperative recovery, health and QoL; and (D) to describe day surgery patient and staff experiences with a systematic e-assessment follow-up after day surgery.

    The primary aim will be measured at 2 weeks postoperatively and secondary outcomes (A–C) at 1 and 2 weeks and (D) at 1 and 4 months.

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  • 28.
    Olsen, Birgitta
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Månsson, Fredrik
    Infectious Diseases Research Unit, Department of Clinical Sciences, Lund, University, Malmö, Sweden.
    Camara, Cidia
    National Public Health Laboratory (LNSP), Bissau, Guinea-Bissau.
    Monteiro, Mario
    National Public Health Laboratory (LNSP), Bissau, Guinea-Bissau.
    Biai, Ansu
    National Public Health Laboratory (LNSP), Bissau, Guinea-Bissau.
    Alves, Alfredo
    Department of Obstetrics and Gynaecology, Simaõ Mendes National Hospital, Bissau, Guinea-Bissau.
    Andersson, Sören
    WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Örebro University Hospital, Örebro, Sweden .
    Norrgren, Hans
    Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden.
    Unemo, Magnus
    WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Örebro University Hospital, Örebro, Sweden.
    Phenotypic and genetic characterisation of bacterial sexually transmitted infections in Bissau, Guinea-Bissau, West Africa: a prospective cohort study2012In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 20, no 2, article id e000636Article in journal (Refereed)
    Abstract [en]

    Background: Knowledge regarding characteristics and transmission of Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium and antibiotic resistance in N gonorrhoeae in Guinea-Bissau, West Africa, is entirely lacking.

    Objectives: To characterise N gonorrhoeae, C trachomatis and M genitalium samples from Guinea-Bissau and to define bacterial populations, possible transmission chains and for N gonorrhoeae spread of antibiotic-resistant isolates.

    Design: Prospective cohort study.

    Setting: Two sexual health and family planning clinics, Bissau, Guinea-Bissau.

    Participants: Positive samples from 711 women and 27 men.

    Material and methods: Positive samples for N gonorrhoeae (n=31), C trachomatis (n=60) and M genitalium (n=30) were examined. The gonococcal isolates were characterised with antibiograms, serovar determination and N gonorrhoeae multiantigen sequence typing (NG-MAST). The C trachomatis ompA gene and the M genitalium mgpB gene were sequenced, and phylogenetic analyses were performed.

    Results: For N gonorrhoeae, the levels of resistance (intermediate susceptibility) to ciprofloxacin, erythromycin, rifampicin, ampicillin, tetracycline, penicillin G and cefuroxime were 10% (0%), 6% (10%), 13% (10%), 68% (0%), 74% (0%), 68% (16%) and 0% (84%), respectively. All isolates were susceptible to cefixime, ceftriaxone, spectinomycin and azithromycin, and the minimum inhibitory concentrations of kanamycin (range: 8-32 mg/l) and gentamicin (range: 0.75-6 mg/l) were low (no resistance breakpoints exist for these antimicrobials). 19 NG-MAST sequence types (STs) (84% novel STs) were identified. Phylogenetic analysis of the C trachomatis ompA gene revealed genovar G as most prevalent (37%), followed by genovar D (19%). 23 mgpB STs were found among the M genitalium isolates, and 67% of isolates had unique STs.

    Conclusions: The diversity among the sexually transmitted infection (STI) pathogens may be associated with suboptimal diagnostics, contact tracing, case reporting and epidemiological surveillance. In Guinea-Bissau, additional STI studies are vital to estimate the STI burden and form the basis for a national sexual health strategy for prevention, diagnosis and surveillance of STIs.

  • 29.
    Persson, Martina
    et al.
    Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
    Pasupathy, Dharmintra
    Division of Women’s Health, NIHR Biomedical Research Centre, Kings Health’s Partners, King’s College London, London, UK.
    Hanson, Ulf
    Department of Woman and Child Health, Uppsala University, Uppsala, Sweden.
    Westgren, Magnus
    Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
    Norman, Mikael
    Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
    Pre-pregnancy body mass index and the risk of adverse outcome in type 1 diabetic pregnancies: a population-based cohort study2012In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 2, no 1, article id e000601Article in journal (Refereed)
    Abstract [en]

    Objective: To assess the risk of perinatal complications in overweight and obese women with and without type 1 diabetes (T1DM).

    Design: Prospective population-based cohort study.

    Setting: This study was based on data from the Swedish Medical Birth Registry from 1998 to 2007.

    Participants: 3457 T1DM and 764 498 non-diabetic pregnancies were included. T1DM was identified based on ICD code O24.0. Mothers were categorised according to pre-pregnancy body mass index (BMI: weight in kilograms per height in square metres) as normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9) or obese (BMI ≥30). Only women with singleton pregnancies and with data on BMI were included. PRIMARY/SECONDARY OUTCOMES: The primary outcome was large for gestational age (LGA: birth weight >90th percentile) infants. Secondary outcomes were major malformations, pre-eclampsia (PE), preterm delivery, perinatal mortality, delivery by Caesarean section and neonatal overweight. Logistic regression analysis was performed with normal weight non-diabetic women as the reference category and also within the diabetic cohort with normal weight type 1 diabetic women as the reference. The ORs were adjusted for ethnicity, maternal age, height, parity, smoking and chronic hypertension.

    Results: 35% of women with T1DM were overweight and 18% were obese, as compared with 26% and 11%, respectively, in non-diabetic pregnancies. The incidences of adverse outcome increased with greater BMI category. As compared with non-diabetic normal weight women, the adjusted OR for obese T1DM for LGA was 13.26 (95% CI 11.27 to 15.59), major malformations 4.11 (95% CI 2.99 to 5.65) and PE 14.19 (95% CI 11.50 to 17.50). T1DM was a significant effect modifier of the association between BMI and LGA, major malformations and PE (p<0.001).

    Conclusion: High pre-pregnancy BMI is an important risk factor for adverse outcome in type 1 diabetic pregnancies. The combined effect of both T1DM and overweight or obesity constitutes the greatest risk. It seems prudent to strive towards normal pre-pregnancy BMI in women with T1DM.

  • 30.
    Pettersen, Gunn
    et al.
    Department of Health and Care Science, University of Tromsø-The Artic University of Norway, Tromsø, Norway.
    Wallin, Karin
    Department of Clinical Science Lund, Child and Adolescent Psychiatry, Lund University, Lund, Sweden.
    Björk, Tabita
    Örebro University, School of Medical Sciences.
    How do males recover from eating disorders?: An interview study2016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 8, article id e010760Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim of the current study is to investigate what males experience as helpful in their recovery process from eating disorders (ED).

    Methods: Qualitative in-depth interviews within a phenomenological approach, and using content analysis to excavate overarching text themes.

    Setting: Norway and Sweden.

    Participants: Included were 15 males with an age range from 19 to 52 years. Duration of illness varied between 3 and 25 years of experience with anorexia nervosa (n=10), bulimia nervosa (n=4) or ED not otherwise specified (n=1).

    Results: The content analysis revealed four main categories, that is, 'the need for a change', 'a commitment to leave the eating disorder behind', 'interpersonal changes' and 'searching for a life without an eating disorder'. These categories comprise features like motivation to change, gaining structure in eating situations, a re-learning of personal and interpersonal skills as well as accepting losses and starting a reorientation of identity and meaning. We noted a rather goal-oriented approach to help seeking and a variation in how the males engaged their social network in resolving the challenges associated with the recovery process. Still, the overall nature of the recovery process highly accords with what has been reported for women.

    Discussion: A clinical implication from our findings is that symptom relief is important to facilitate good circles of improvement, but that the nature of the recovery process would require a wider perspective in treatment. Clinicians may also be informed about challenges related to an instrumental approach to help seeking reported in this study.

  • 31.
    Prenkert, Malin
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Ehnfors, Margareta
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Growth data of underprivileged children living in rural areas of Chin State, Burma/Myanmar, compared to the WHO reference growth standards: an observational study2016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 1, article id e009119Article in journal (Refereed)
    Abstract [en]

    Objectives: To explore growth data (height-for-age, weight-for-age and BMI-for-age) of children living in poor socioeconomic conditions in rural areas of Chin State, Burma/Myanmar; and to compare these data with the growth and development z-score (GDZ) values for school-aged children and adolescents, provided by the WHO.

    Setting: A support and educational programme, run by the Swedish association Chin Development and Research Society (CDRS), was carried out among underprivileged school-aged children, unable to attend school without economic and practical support, living in villages and remote areas in Chin State.

    Participants: Community leaders who were well familiar with the citizens in the community identified children in need of this support. Other community members could also suggest or apply for this. The sample includes all participating children in the CDRS programme at the time of the data collection in six townships. The children were placed in host families, close to a suitable school. Two samples with a total of 639 children from 144 villages and remote areas were obtained:

    1. Children in the CDRS Chin Programme (CCP) (20072010) comprised 558 children: 50% girls and boys.

    2. Children in the Chin Society (CCS) (2010) comprised 81 children: 44% girls and 56% boys.

    Primary outcome measures: Growth data.

    Results: All growth data from both groups deviated significantly from the WHO standard references (p=0.001). The prevalence of stunting (height-for-age <=-2SD) was 52% among girls and 68% among boys. High levels of wasting (weight-for-age <=-2SD) were found among girls 29% and boys 36% aged 5-10 years. In addition, severe thinness (BMI-for-age <=-2SD) was found among girls 31% and boys 44%, all results to be compared to the expected 2.27%.

    Conclusions: Many more than expected-according to the WHO reference values-in CCP and CCS suffered from stunting, wasting and thinness.

  • 32.
    Strömbom, Ylva
    et al.
    Centre for Research and Development, Region Gävleborg, Gävle, Sweden; Department of Psychology, Uppsala Universitet, Uppsala, Sweden.
    Magnusson, Peter
    Centre for Research and Development, Region Gävleborg, Gävle, Sweden; Cardiology Research Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
    Karlsson, Jan
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Center.
    Fredrikson, Mats
    Department of Psychology, Uppsala Universitet, Uppsala, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Health-related quality of life among frequent attenders in Swedish primary care: a cross-sectional observational study2019In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 7, article id e026855Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The aim was to examine health-related quality of life (HRQoL), patient characteristics and reasons for visits to general practitioners (GPs) by frequent attenders (FAs) and a comparison group (CG) in primary care.

    METHODS: Patients aged 18-64 years were eligible for the study. Medical records were scrutinised concerning reasons for visits. Questionnaires including short-form health survey (SF-36) were mailed to 331 FAs (≥5 visits at GPs during 2000) and 371 patients in a CG randomly selected from two healthcare centres and returned by 49% and 57%, respectively. FAs' SF-36 health profiles were compared both to CG and general Swedish population norms.

    RESULTS: FAs report lower HRQoL than CG and below the general Swedish population norms in all eight SF-36 domains including both mental and physical component summary scores (MCS and PCS). Effect sizes (ESs) for differences between FAs and norms ranged from 0.79 to 1.08 for specific domains and was 0.94 for PCS and 0.71 for MCS. ESs of FAs versus CG ranged between 0.60 and 0.95 for the domains and was 0.76 for PCS and 0.49 for MCS. There were no significant differences between the FAs and CG with regard to sex, being married or cohabiting, number of children in household or educational level. FAs were more often unemployed, obese, slightly older and used complementary medicine more frequently. Except for injuries, all health complaints as classified in 10 categories were more common among FAs than CG, particularly musculoskeletal pain and psychosocial distress related to compromised HRQoL.

    CONCLUSION: The HRQoL is compromised in FAs, both when compared with patients who do not often seek care and to general Swedish population norms. Commonly reported reasons for visiting GPs among FAs were musculoskeletal pain and psychosocial distress. Thus, perceived ill health, particularly pain and distress, seems important for high utilisation of healthcare resources.

  • 33.
    Sultan, Alyshah Abdul
    et al.
    Div Epidemiol & Publ Hlth, Univ Nottingham, Nottingham, England; Dept Med Epidemiol & Biostat, Karolinska Inst, Stockholm, Sweden; Queens Med Ctr, Nottingham Digest Dis Biomed Res Unit, Univ Nottingham, Nottingham, England.
    West, Joe
    Div Epidemiol & Publ Hlth, Univ Nottingham, Nottingham, England.
    Stephansson, Olof
    Dept Med, Clin Epidemiol Unit, Karolinska Inst, Stockholm, Sweden; Dept Womens & Childrens Hlth, Karolinska Inst, Stockholm, Sweden.
    Grainge, Matthew J.
    Div Epidemiol & Publ Hlth, Univ Nottingham, Nottingham, England.
    Tata, Laila J.
    Div Epidemiol & Publ Hlth, Univ Nottingham, Nottingham, England.
    Fleming, Kate M.
    Div Epidemiol & Publ Hlth, Univ Nottingham, Nottingham, England.
    Humes, David
    Div Epidemiol & Publ Hlth, Univ Nottingham, Nottingham, England.
    Ludvigsson, Jonas F.
    Örebro University Hospital. Dept Med Epidemiol & Biostat, Karolinska Inst, Stockholm, Sweden; Department of Paediatrics, Örebro University Hospital, Örebro, Sweden.
    Defining venous thromboembolism and measuring its incidence using Swedish health registries: a nationwide pregnancy cohort study2015In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, no 11, article id e008864Article in journal (Refereed)
    Abstract [en]

    Objective: To accurately define venous thromboembolism (VTE) in the routinely collected Swedish health registers and quantify its incidence in and around pregnancy. Study design: Cohort study using data from the Swedish Medical Birth Registry (MBR) linked to the National Patient Registry (NPR) and the Swedish Prescribed Drug Register (PDR). Setting: Secondary care centres, Sweden. Participant: 509 198 women aged 15-44 years who had one or more pregnancies resulting in a live birth or stillbirth between 2005 and 2011. Main outcome measure: To estimate the incidence rate (IR) of VTE in and around pregnancy using various VTE definitions allowing direct comparison with other countries. Results: The rate of VTE varied based on the VTE definition. We found that 43% of cases first recorded as outpatient were not accompanied by anticoagulant prescriptions, whereas this proportion was much lower than those cases first recorded in the inpatient register (9%). Using our most inclusive VTE definition, we observed higher rates of VTE compared with previously published data using similar methodology. These reduced by 31% (IR=142/100 000 person-years; 95% CI 132 to 153) and 22% (IR=331/100 000 person-years; 95% CI 304 to 361) during the antepartum and postpartum periods, respectively, using a restrictive VTE definition that required anticoagulant prescriptions associated with diagnosis, which were more in line with the existing literature. Conclusions: We found that including VTE codes without treatment confirmation risks the inclusion of false-positive cases. When defining VTE using the NPR, anticoagulant prescription information should therefore be considered particularly for cases recorded in an outpatient setting.

  • 34.
    Sundh, Josefin
    et al.
    Örebro University, School of Medical Sciences. Department of Respiratory Medicine, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Ekström, Magnus
    Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden.
    Dyspnoea-12: a translation and linguistic validation study in a Swedish setting2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 5, article id e014490Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Dyspnoea consists of multiple dimensions including the intensity, unpleasantness, sensory qualities and emotional responses which may differ between patient groups, settings and in relation to treatment. The Dyspnoea-12 is a validated and convenient instrument for multidimensional measurement in English. We aimed to take forward a Swedish version of the Dyspnoea-12.

    METHODS: The linguistic validation of the Dyspnoea-12 was performed (Mapi Language Services, Lyon, France). The standardised procedure involved forward and backward translations by three independent certified translators and revisions after feedback from an in-country linguistic consultant, the developerand three native physicians. The understanding and convenience of the translated version was evaluated using qualitative in-depth interviews with five patients with dyspnoea.

    RESULTS: A Swedish version of the Dyspnoea-12 was elaborated and evaluated carefully according to international guidelines. The Swedish version, 'Dyspné-12', has the same layout as the original version, including 12 items distributed on seven physical and five affective items. The Dyspnoea-12 is copyrighted by the developer but can be used free of charge after permission for not industry-funded research.

    CONCLUSION: A Swedish version of the Dyspnoea-12 is now available for clinical validation and multidimensional measurement across diseases and settings with the aim of improved evaluation and management of dyspnoea.

  • 35.
    Svantesson, Mia
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Carlsson, Eva
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Prenkert, Malin
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Anderzen-Carlsson, Agneta
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    'Just so you know, the patient is staff': healthcare professionals' perceptions of caring for healthcare professional-patients2016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 1, article id e008507Article in journal (Refereed)
    Abstract [en]

    Objective: To explore healthcare professionals' conceptions of the care of patients who are also healthcare professionals.

    Design: Explorative, with a qualitative, phenomenographic approach.

    Participants and setting: 16 healthcare personnel within different professions (doctors, nurses, assistant nurses, physiotherapists, occupational therapists) were interviewed about the care of 32 patients who were themselves members of different healthcare professions, in one healthcare organisation in Sweden.

    Results: The care of patients who are healthcare professionals was conceived in five different ways, as: usual, dutiful, prioritised and secure, insecure and responsive. An initial conception was that their care was usual, just as for any other patient, and also a perceived duty to treat them and to protect their right to be a patient-as any other patient. Exploring further, informants described that these patients did receive secure and prioritised care, as the informants experienced making a greater commitment, especially doctors giving privileges to doctor-patients. A conception of insecure care infused the informants' descriptions. This comprised of them feeling intimidated in their professional role, feeling affected by colleagues' stressful behaviour and ambiguity whether the healthcare professional-patient could be regarded as a competent professional. The deepest way of understanding care seemed to be responsive care, such as acknowledging and respecting the patient's identity and responding to their wishes of how treatment was to be met.

    Conclusions: Caring for healthcare professionals seems to trigger different ethical approaches, such as deontology and ethics of care. According to ethics of care, the findings may indeed suggest that these patients should be cared for just as any other patients would be, but only if this means that they are cared for as persons, that is, they are given 'person-centred care'. This would imply balancing between acknowledging the vulnerable patient in the colleague and acknowledging the identity of the colleague in the patient.

  • 36.
    Viegas, Edna Omar
    et al.
    Instituto Nacional de Saúde, Maputo, Mozambique; Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Sweden; Eduardo Mondlane University, Maputo, Mozambique; .
    Augusto, Orvalho
    Eduardo Mondlane University, Maputo, Mozambique.
    Ismael, Nália
    Instituto Nacional de Saúde, Maputo, Mozambique.
    Kaliff, Malin
    Örebro University, School of Medical Sciences. Department of Laboratory Medicine, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Lillsunde-Larsson, Gabriella
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Laboratory Medicine, Örebro University Hospital, Örebro, Sweden.
    Ramqvist, Torbjörn
    Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.
    Nilsson, Charlotta
    Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Sweden; Department of Microbiology, Public Health Agency of Sweden, Stockholm, Sweden; Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.
    Falk, Kerstin
    Department of Microbiology, Public Health Agency of Sweden, Stockholm, Sweden; Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.
    Osman, Nafissa
    Eduardo Mondlane University, Maputo, Mozambique; Hospital Central de Maputo, Maputo, Mozambique.
    Jani, Ilesh Vindorai
    Instituto Nacional de Saúde, Maputo, Mozambique.
    Andersson, Sören
    Örebro University, School of Medical Sciences. Department of Laboratory Medicine.
    Human papillomavirus prevalence and genotype distribution among young women and men in Maputo city, Mozambique2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 7, article id e015653Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Human papillomavirus (HPV) is a well-known cause of cervical cancer, the second most frequent cancer in female African populations. This study aimed at determining the prevalence of HPV infections and the genotype distribution in young adults aged 18-24, in Maputo city, Mozambique, and to assess the suitability of commercially available HPV vaccines.

    METHODS: This cross-sectional study was conducted between 2009 and 2011 at a youth clinic in Maputo Central Hospital. Cervical and urethral samples were obtained from 236 women and 176 men, respectively. Demographic and behavioural data were collected using structured questionnaires. HPV genotyping was performed for 35 different high, probably or possibly high-risk and low-risk HPV types using the CLART Human Papillomavirus 2.

    RESULTS: HPV prevalence was 168/412 (40.8%; 95% CI 36.0 to 45.5) and was significantly higher in women than in men (63.6%vs10.2%). HPV52 was the most frequent type found in women, followed by HPV35, -16,-53, -58,-6 and -51. In men, HPV51 ranked the highest, followed by HPV6, -11,-52, -59 and -70. HIV infection and sexual debut before 18 years of age were associated with multiple HPV infections (OR 3.03; 95% CI 1.49 to 6.25 and OR 6.03; 95% CI 1.73 to 21.02, respectively). Women had a significantly higher HPV infection prevalence than men (p<0.001). The 9-valent HPV vaccine would cover 36.8% of the high-risk genotypes circulating in women in this study, compared with 26.3% and 15.8% coverage by the bivalent and quadrivalent vaccines, respectively.

    CONCLUSION: This study confirmed the high burden of HPV infections in young women in Maputo city, Mozambique. The HPV prevalence was associated with high-risk sexual behaviour. Sex education and sexually transmitted infection prevention interventions should be intensified in Mozambique. Only a proportion of the high-risk HPV genotypes (37%) were covered by currently available vaccines.

  • 37.
    Vihlborg, Per
    et al.
    Örebro University, School of Medical Sciences. Department of Occupational and Environmental Medicine.
    Bryngelsson, Ing-Liss
    Faculty of Medicine and Health, Department of Occupational and Environmental Medicine, Örebro University, Örebro, Sweden.
    Andersson, Lena
    Faculty of Medicine and Health, Department of Occupational and Environmental Medicine, Örebro University, Örebro, Sweden.
    Graff, Pål
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Occupational and Environmental Medicine, Örebro University Hospital, Örebro, Sweden.
    Risk of sarcoidosis and seropositive rheumatoid arthritis from occupational silica exposure in Swedish iron foundries: a retrospective cohort study2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 7, article id e016839Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To study the impact of occupational silica exposure on the incidence rates of sarcoidosis and rheumatoid arthritis (RA) in a cohort of exposed workers in Swedish iron foundries.

    DESIGN: The prevalence of sarcoidosis and RA in a cohort of silica exposed workers was compared with the prevalence in the general Swedish population in this register study. A mixed model was used to calculate silica exposure, and individual silica exposures were used to compute dose responses.

    SETTING: Personnel records from 10 iron foundries were used to identify workers whose employment began before 2005 which was then linked to the national non-primary outpatient visits register.

    PARTICIPANTS: The final cohort consisted of 2187 silica-exposed male workers who had been employed for at least 1 year and were still alive without having emigrated when the follow-up study began. The cohort's employment period covers 23 807 person-years at risk.

    MAIN OUTCOME: The presented results indicate that moderate to high levels of silica exposure increase risks for sarcoidosis and seropositive RA.

    RESULTS: Mean levels of airborne silica dust in the foundries decreased significantly between the 1970s and 2000s. Incidence rates of sarcoidosis (3.94; 95% CI 1.07 to 10.08) and seropositive RA (2.59; 95% CI 1.24 to 4.76) were significantly higher among highly exposed individuals.

    CONCLUSION: Our results reveal increased risks for sarcoidosis and seropositive RA among individuals with high exposure to silica dust (>0.048 mg/m(3)) compared with non-exposed and less-exposed groups.

  • 38.
    Wallden, Albin
    et al.
    Department of Occupational and Environmental Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Graff, Pal
    Department of Chemical and Biological Work Environment, National Institute of Occupational Health (STAMI), Oslo, Norway.
    Bryngelsson, Ing-Liss
    Department of Occupational and Environmental Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Fornander, Louise
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Occupational and Environmental Medicine.
    Wiebert, Pernilla
    Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden.
    Vihlborg, Per
    Örebro University, School of Medical Sciences. Department of Occupational and Environmental Medicine.
    Risks of developing ulcerative colitis and Crohn's disease in relation to silica dust exposure in Sweden: a case-control study2020In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 10, no 2, article id e034752Article in journal (Refereed)
    Abstract [en]

    Objective: To determine whether occupational exposure to silica dust causes an increased risk of developing Crohn's disease (CD) and ulcerative colitis (UC).

    Design: Case-control study of CD (K50) and UC (K51) from 2007 through 2016. Controls were matched to cases (2:1) based on age, sex and county at the time of diagnosis. A job exposure matrix was used to estimate the occupational silica exposure of all cases and controls.

    Setting: Medical and occupational data from the National Outpatient Register were used to implement a case-control analysis, while the two controls used for each case were selected from the National Register of the Total Population.

    Participants: All men and women aged 20-65 years old who were diagnosed with CD (K50) and UC (K51) during the years of study were included and assigned two controls, resulting in 58 136 cases and 116 272 controls.

    Main outcomes: Silica dust exposure correlates with an increased risk of developing UC in men and CD in women.

    Results: The prevalence of UC was significantly higher in the group exposed to silica dust (OR 1.13, 95% CI 1.06 to 1.21) than in controls, particularly in individuals with over 5 years exposure. When stratified by sex, a significantly increased OR was detected for men (OR 1.33, 95% CI 1.05 to 1.22). This trend was also consistent with longer exposure times. The prevalence of UC was not increased in exposed women. The prevalence of CD was significantly increased among exposed women (OR 1.29, 95% CI 1.01 to 1.65), but not for exposed men.

    Conclusions: Silica dust exposure correlates with an increased risk of developing UC, especially in men, and the risk seems to increase with the duration and degree of exposure. Conversely, silica dust exposure correlates positively with the risk of developing CD in women.

  • 39.
    Wångdahl, Josefin
    et al.
    Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; Department of Neurobiology, Care Sciences, and Society, Karolinska Institute, Stockholm, Sweden.
    Dahlberg, Karuna
    Örebro University, School of Health Sciences.
    Jaensson, Maria
    Örebro University, School of Health Sciences.
    Nilsson, Ulrica
    Department of Neurobiology, Care Sciences, and Society, Karolinska Institute, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
    Psychometric validation of Swedish and Arabic versions of two Health literacy questionnaires, eHEALS and HLS-EU-Q16, for use in a Swedish context: A study protocol2019In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 9, article id e029668Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Equity in health and access to healthcare regardless of gender, ethnicity or social position is a major political issue worldwide. Regardless of an individual's knowledge, motivation and competence, individuals are expected to be engaged and take responsibility of their own care. Migrants have been identified as a vulnerable population in healthcare, and an explanation for the inequity in health and in healthcare is limited health literacy. Furthermore, with increasing digitalisation in healthcare, it also puts demand on the individual to have digital or electronic health (eHealth) literacy.

    The overall aim of this study is to conduct a psychometric evaluation of the Swedish and Arabic versions of HLS-EU-Q16 and eHEALS and to compare Arabic and Swedish speakers' Health literacy and eHealth literacy levels in Sweden.

    METHODS AND ANALYSIS: This is a prospective, psychometric evaluation study with the intent of including 300 Arabic-speaking and 300 Swedish-speaking participants. Questionnaires: The Health Literacy Survey European Questionnaire (HLS-EU-Q16) includes 16 items measuring perceived personal skills of finding, understanding, judging and applying health information to maintain and improve their health. The eHealth literacy scale (eHEALS) is an 8-item scale measuring health literacy skills in relation to online information and applications.

    This study will be conducted in four phases. Phase 1: Translation of HLS-EU-Q16 and eHEALS from English to Swedish and Arabic versions following the principles of translation of questionnaires. Phase 2: Content validity testing of eHEALS, including face validity and interpretability, conducted with five Arabic and five Swedish-speaking participants. Phase 3: Psychometric testing including construct validity, reliability, feasibility and floor ceiling effects. Phase 4: Distribution and comparison of eHealth and HLS-EU-Q16 analysed with χ2 and Fisher's exact test as appropriate. To assess associations between HLS-EU-Q16, eHEALS and demographic variables, binary logistic regression analyses will be performed.

    ETHICS AND DISSEMINATION: The project has been approved by the regional ethical review board in Stockholm, Sweden (2019/5:1) and will follow the principles outlined in the 1964 Helsinki Declaration and its later amendments. Results from this study will be disseminated in peer-reviewed journals, scientific conferences and social media.

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