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Publications (10 of 37) Show all publications
Granberg Sandlund, M., Diamant, A., Granåsen, G. & Salzer, J. (2019). Effectiveness of care in acute dizziness presentations. European Archives of Oto-Rhino-Laryngology, 276(9), 2389-2396
Open this publication in new window or tab >>Effectiveness of care in acute dizziness presentations
2019 (English)In: European Archives of Oto-Rhino-Laryngology, ISSN 0937-4477, E-ISSN 1434-4726, Vol. 276, no 9, p. 2389-2396Article in journal (Refereed) Published
Abstract [en]

Purpose: This study aims to evaluate whether a management algorithm has improved the effectiveness of care for dizzy patients at Umea University Hospital.

Methods: This was an interventional study using medical records to collect data for acute dizziness presentations before (period 1, 2012-2014) and after (period 2, 2016-2017) the implementation of a management algorithm. Outcomes were changes in a set of pre-defined effectiveness markers and health economic effects.

Results: Total n = 2126 and n = 1487 acute dizziness presentations were identified in period 1 and 2, respectively. Baseline characteristics were similar. The proportion of patients undergoing Dix-Hallpike testing increased, 20.8% [95% confidence interval (CI) 18.8-23.0%] vs. 37.7% (95% CI 35.2-40.2%), as did BPPV diagnoses, 7.6% (95% CI 6.6-8.8%) vs. 15.3% (95% CI 13.6-17.3%). Hospitalization became less common, 61.5% (95% CI 59.4-63.6%) vs. 47.6% (95% CI 45.1-50.2%). The proportion undergoing any neuroradiological investigation decreased, 44.8% (95% CI 42.7-47.0%) vs. 36.3% (95% CI 33.8-38.7%) with a shift from CT to MRI, with unchanged sensitivity for diagnosing cerebrovascular causes. The average cost for the care of one dizzy patient decreased from $2561 during period 1 to $1808 during period 2.

Conclusions: This study shows that the implementation of a management algorithm for dizzy patients was associated with improved effectiveness of care.

Place, publisher, year, edition, pages
Springer, 2019
Keywords
Dizziness, Vertigo, Health economics, Management algorithms, Effectiveness of care
National Category
Otorhinolaryngology
Identifiers
urn:nbn:se:umu:diva-162655 (URN)10.1007/s00405-019-05470-0 (DOI)000478901700003 ()31098875 (PubMedID)
Available from: 2019-09-05 Created: 2019-09-05 Last updated: 2019-11-19Bibliographically approved
Boremalm, M., Juto, A., Axelsson, M., Novakova, L., Frisell, T., Svenningsson, A., . . . Salzer, J. (2019). Natalizumab, rituximab and fingolimod as escalation therapy in multiple sclerosis. European Journal of Neurology, 26(8), 1060-1067
Open this publication in new window or tab >>Natalizumab, rituximab and fingolimod as escalation therapy in multiple sclerosis
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2019 (English)In: European Journal of Neurology, ISSN 1351-5101, E-ISSN 1468-1331, Vol. 26, no 8, p. 1060-1067Article in journal (Refereed) Published
Abstract [en]

Background and purpose: Breakthrough disease on first-line injectables in relapsing-remitting multiple sclerosis (RRMS) is a common clinical situation where comparative studies between different escalation therapies are lacking. The aim of this study was to compare the efficacy, safety and medication persistence of natalizumab (NTZ), rituximab (RTX) and fingolimod (FGL) as escalation therapy in RRMS.

Methods: Patients switching from interferon or glatiramer acetate to NTZ, RTX or FGL due to breakthrough disease were identified through the Swedish multiple sclerosis (MS) registry at four large MS centers in this retrospective observational study. Data were collected from the MS registry and medical charts. Hazard ratios (HRs) for relapses, adverse events and drug discontinuation with 95% confidence interval (CI) were calculated using multivariable confounder-adjusted Cox proportional hazard models.

Results: A total of 241 patients were included. The annualized relapse rates were 0.02 for NTZ, 0.03 for RTX and 0.07 for FGL. Compared with NTZ, the adjusted HR for relapse was 1.0 (95% CI, 0.2-5.6) for RTX and 3.4 (95% CI, 1.3-9.2) for FGL. The annualized drug discontinuation rates were 0.15, 0.01 and 0.15 for NTZ, RTX and FGL, respectively. The adjusted HR for drug discontinuation was 0.05 (95% CI, 0.01-0.38) for RTX and 1.0 (95% CI, 0.6-1.7) for FGL vs. NTZ.

Conclusions: In patients with RRMS on interferon/glatiramer acetate with breakthrough disease, switching to NTZ or RTX was associated with less disease activity compared with FGL. RTX displayed superior medication persistence compared with both NTZ and FGL.

Keywords
escalation therapy, fingolimod, natalizumab, relapsing-remitting multiple sclerosis, rituximab
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-161811 (URN)10.1111/ene.13936 (DOI)000474697500006 ()30762259 (PubMedID)
Available from: 2019-08-13 Created: 2019-08-13 Last updated: 2019-11-25Bibliographically approved
Granberg Sandlund, M., Diamant, A., Granåsen, G. & Salzer, J. (2019). Quality of care in acute dizziness presentations. Paper presented at 5th Congress of the European Academy of Neurology, Oslo, Norway, June 29 – July 2, 2019. European Journal of Neurology, 26(S1), 926-926
Open this publication in new window or tab >>Quality of care in acute dizziness presentations
2019 (English)In: European Journal of Neurology, ISSN 1351-5101, E-ISSN 1468-1331, Vol. 26, no S1, p. 926-926Article in journal, Meeting abstract (Other academic) Published
Abstract [en]

Background and aims: Dizziness is a common symptom at emergency departments. Studies have shown poor quality of care in acute dizziness presentations, including the overuse of computed tomography (CT) and failure to detect benign causes. This study aims to evaluate whether a management algorithm has improved the quality of care for dizzy patients at Umeå University Hospital, Sweden.

Methods: This was an interventional study using medical records to collect data for acute dizziness presentations before (period 1, 2012–2014) and after (period 2, 2016-2017) the implementation of a management algorithm (see figure). Outcomes were changes in a set of pre-defined quality markers and health economic effects.

Results: Total n=2126 and n=1487 acute dizziness presentations were identified in period 1 and 2, respectively. Baseline characteristics were similar. The proportion of patients undergoing Dix-Hallpike testing increased, 20.8% vs. 37.7%, (p<0.01), as did BPPV diagnoses, 7.6% vs. 15.3%, (p<0.01). Hospitalization became less common, 61.5% vs. 47.6% (p<0.01). The proportion undergoing any neuroradiological investigation decreased, 44.8% vs. 36.3% (p<0.01) with a shift from CT to MRI, with unchanged sensitivity for diagnosing cerebrovascular causes. The average cost for the care of one dizzy patient decreased from $2561 during period 1 to $1808 during period 2.

Conclusion: This study shows how the implementation of a management algorithm for dizzy patients can improve the quality of care and lower the expenses, without an increased number of missed stroke cases.

Place, publisher, year, edition, pages
John Wiley & Sons, 2019
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-161916 (URN)10.1111/ene.14019 (DOI)000474481004132 ()
Conference
5th Congress of the European Academy of Neurology, Oslo, Norway, June 29 – July 2, 2019
Available from: 2019-08-09 Created: 2019-08-09 Last updated: 2019-11-28Bibliographically approved
Hallberg, S., Boremalm, M., Evertsson, B., Lillvall, E., Johansson, F., Lycke, J., . . . Svenningsson, A. (2019). Risk of hypogammaglobulinemia in long-term treatment with rituximab in multiple sclerosis. Paper presented at 35th Congress of the European-Committee-for-Treatment-and-Research-in-Multiple-Sclerosis (ECTRIMS) / 24th Annual Conference of Rehabilitation in MS, SEP 11-13, 2019, Stockholm, SWEDEN. Multiple Sclerosis, 25, 20-20
Open this publication in new window or tab >>Risk of hypogammaglobulinemia in long-term treatment with rituximab in multiple sclerosis
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2019 (English)In: Multiple Sclerosis, ISSN 1352-4585, E-ISSN 1477-0970, Vol. 25, p. 20-20Article in journal, Meeting abstract (Other academic) Published
Place, publisher, year, edition, pages
Sage Publications, 2019
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-164054 (URN)000485303100040 ()
Conference
35th Congress of the European-Committee-for-Treatment-and-Research-in-Multiple-Sclerosis (ECTRIMS) / 24th Annual Conference of Rehabilitation in MS, SEP 11-13, 2019, Stockholm, SWEDEN
Note

Supplement: 2 

Special Issue: SI 

Meeting Abstract: 64

Available from: 2019-10-17 Created: 2019-10-17 Last updated: 2019-11-28Bibliographically approved
Alping, P., Piehl, F., Langer-Gould, A., Frisell, T., Burman, J., Fink, K., . . . Vrethem, M. (2019). Validation of the Swedish Multiple Sclerosis Register Further Improving a Resource for Pharmacoepidemiologic Evaluations. Epidemiology, 30(2), 230-233
Open this publication in new window or tab >>Validation of the Swedish Multiple Sclerosis Register Further Improving a Resource for Pharmacoepidemiologic Evaluations
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2019 (English)In: Epidemiology, ISSN 1044-3983, E-ISSN 1531-5487, Vol. 30, no 2, p. 230-233Article in journal (Refereed) Published
Abstract [en]

The Swedish Multiple Sclerosis Register is a national register monitoring treatment and clinical course for all Swedish multiple sclerosis (MS) patients, with high coverage and close integration with the clinic. Despite its great value for epidemiologic research, it has not previously been validated. In this brief report, we summarize a large validation of >3,000 patients in the register using clinical chart review in the context of the COMBAT-MS study. While further improving the data quality for a central cohort of patients available for future epidemiologic research, this study also allowed us to estimate the accuracy and completeness of the register data.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2019
Keywords
Multiple sclerosis, Pharmacoepidemiology, Register, Validation
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-156860 (URN)10.1097/EDE.0000000000000948 (DOI)000458417200017 ()30721167 (PubMedID)
Available from: 2019-03-13 Created: 2019-03-13 Last updated: 2019-11-27Bibliographically approved
Granqvist, M., Boremalm, M., Poorghobad, A., Svenningsson, A., Salzer, J., Frisell, T. & Piehl, F. (2018). Comparative Effectiveness of Rituximab and Other Initial Treatment Choices for Multiple Sclerosis. JAMA Neurology, 75(3), 320-327
Open this publication in new window or tab >>Comparative Effectiveness of Rituximab and Other Initial Treatment Choices for Multiple Sclerosis
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2018 (English)In: JAMA Neurology, ISSN 2168-6149, E-ISSN 2168-6157, Vol. 75, no 3, p. 320-327Article in journal (Refereed) Published
Abstract [en]

IMPORTANCE Comparative real-world effectiveness studies of initial disease-modifying treatment (DMT) choices for relapsing-remitting multiple sclerosis (RRMS) that include rituximab are lacking.

OBJECTIVE To assess the effectiveness and drug discontinuation rates of rituximab among patients with newly diagnosed RRMS compared with injectable DMTs, dimethyl fumarate, fingolimod, or natalizumab.

DESIGN, SETTING, AND PATIENTS This retrospective cohort study used prospectively collected data to examine specialized care of 2 Swedish county-based community samples of patients with RRMS. Patients with RRMS who received diagnoses from January 1, 2012, to October 31, 2015, who resided in Stockholm or Vasterbotten Counties were identified from a Swedish multiple sclerosis registry.

MAIN OUTCOMES AND MEASURES All reasons for drug discontinuation of initial treatment choice (main outcome) and specific reasons for switching (secondary outcomes) were analyzed with multivariable Cox regression, including propensity scores.

RESULTS Among 494 patients (median [interquartile range] age, 34.4 [27.4-43.4] years; 158 men [32.0%]), 215 received an injectable DMT (43.5%); 86 (17.4%), dimethyl fumarate; 17 (3.4%), fingolimod; 50 (10.1%), natalizumab; 120 (24.3%), rituximab; and 6 (1.2%), other DMT. Regional preferences were pronounced, with 42 of 52 (81%) and 78 of 442 (18%) receiving rituximab in Vasterbotten and Stockholm, respectively. The annual discontinuation rate for rituximab, injectable DMTs, dimethyl fumarate, fingolimod, and natalizumab were 0.03, 0.53, 0.32, 0.38, and 0.29, respectively. Continued disease activity was the main reason for discontinuation of injectable DMTs, dimethyl fumarate, and fingolimod; positive John Cunningham virus serology results were the main reason for discontinuation of natalizumab. Rate of clinical relapses and/or neuroradiologic disease activity were significantly lower for rituximab compared with injectable DMTs and dimethyl fumarate, with a tendency for lower relapse rates also compared with natalizumab and fingolimod. The annual discontinuation rate of initial treatment choice was significantly lower in Vasterbotten compared with Stockholm (0.09 and 0.37, respectively).

CONCLUSIONS AND RELEVANCE Rituximab was superior to all other DMT in terms of drug discontinuation and displayed better clinical efficacy compared with injectable DMTs and dimethyl fumarate with borderline significance compared with natalizumab and fingolimod. The county where rituximab constituted the main initial treatment choice displayed better outcomes in most measured variables. Collectively, our findings suggest that rituximab performs better than other commonly used DMTs in patients with newly diagnosed RRMS.

Place, publisher, year, edition, pages
American Medical Association, 2018
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-146450 (URN)10.1001/jamaneurol.2017.4011 (DOI)000427265700010 ()29309484 (PubMedID)
Available from: 2018-05-03 Created: 2018-05-03 Last updated: 2019-11-19Bibliographically approved
Ljunggren, M., Persson, J. & Salzer, J. (2018). Dizziness and the Acute Vestibular Syndrome at the Emergency Department: A Population-Based Descriptive Study. European Neurology, 79(1–2), 5-12
Open this publication in new window or tab >>Dizziness and the Acute Vestibular Syndrome at the Emergency Department: A Population-Based Descriptive Study
2018 (English)In: European Neurology, ISSN 0014-3022, E-ISSN 1421-9913, Vol. 79, no 1–2, p. 5-12Article in journal (Refereed) Published
Abstract [en]

Background: Dizziness is a common occurrence witnessed at emergency departments (EDs). This study aims to describe the epidemiology and management of dizzy patients with and without an acute vestibular syndrome (AVS) in the ED at Umea University Hospital. Methods: A total of n = 2,126 ED dizziness visits during 3 years were identified. Data were obtained through retrospective review of medical records. Cases were stratified based on presentation, including AVS and neurological deficits. The outcomes analyzed included cerebrovascular causes of dizziness. A Poisson distribution was assumed when calculating incidence CIs. Results: Dizziness accounted for 2.1% of all ED visits, incidence 477/100,000 inhabitants (95% CI 457-498). Among dizzy patients, 19.2% had an AVS, incidence 92/100,000 inhabitants (95% CI 74-113). Top medical diagnostic groups were otovestibular (15.1%), cardiovascular (8.7%) and neurological diseases (7.7%), including stroke and transitory ischemic attack (4.8%). Cerebrovascular causes of dizziness were more common among those with an AVS (10.0%) vs. those without (3.6%), p < 0.01. Conclusion: The risk for cerebrovascular causes of dizziness, although low in an unselected cohort, increases with the presence of neurological signs and an AVS. These population-based data may be useful when planning and implementing dizziness and AVS management algorithms at EDs.

Place, publisher, year, edition, pages
S. Karger, 2018
Keywords
Dizziness, Vertigo, Epidemiology, Emergency medicine, Acute vestibular syndrome, Cerebrovascular disease (stroke, TIA)
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-146465 (URN)10.1159/000481982 (DOI)000427724100001 ()29131011 (PubMedID)
Available from: 2018-04-10 Created: 2018-04-10 Last updated: 2018-06-09Bibliographically approved
Johansson, E. & Salzer, J. (2018). Interaction should guide management decisions [Letter to the editor]. American Journal of Neuroradiology, 39(5), E57-E57
Open this publication in new window or tab >>Interaction should guide management decisions
2018 (English)In: American Journal of Neuroradiology, ISSN 0195-6108, E-ISSN 1936-959X, Vol. 39, no 5, p. E57-E57Article in journal, Letter (Other academic) Published
Place, publisher, year, edition, pages
American Society of Neuroradiology, 2018
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-149381 (URN)10.3174/ajnr.A5579 (DOI)000432175900003 ()29545244 (PubMedID)2-s2.0-85047092923 (Scopus ID)
Available from: 2018-06-20 Created: 2018-06-20 Last updated: 2019-11-25Bibliographically approved
Khalil, M. & Salzer, J. (2016). CSF neurofilament light: A universal risk biomarker in multiple sclerosis?. Neurology, 87(11), 1068-1069
Open this publication in new window or tab >>CSF neurofilament light: A universal risk biomarker in multiple sclerosis?
2016 (English)In: Neurology, ISSN 0028-3878, E-ISSN 1526-632X, Vol. 87, no 11, p. 1068-1069Article in journal, Editorial material (Refereed) Published
National Category
Clinical Medicine
Identifiers
urn:nbn:se:umu:diva-131140 (URN)10.1212/WNL.0000000000003107 (DOI)000384178000005 ()27521432 (PubMedID)
Available from: 2017-02-06 Created: 2017-02-06 Last updated: 2018-06-09Bibliographically approved
Salzer, J., Rajda, C., Sundström, P., Vågberg, M., Vecsei, L. & Svenningsson, A. (2016). How to minimize the risk for headache?: a lumbar puncture practice questionnaire study. IDEGGYOGYASZATI SZEMLE-CLINICAL NEUROSCIENCE, 69(11-12), 397-402
Open this publication in new window or tab >>How to minimize the risk for headache?: a lumbar puncture practice questionnaire study
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2016 (English)In: IDEGGYOGYASZATI SZEMLE-CLINICAL NEUROSCIENCE, ISSN 0019-1442, Vol. 69, no 11-12, p. 397-402Article in journal (Refereed) Published
Abstract [en]

Background - To lower the risk for post lumbar puncture (LP) headache the American Academy of Neurology (AAN) recommended using small bore atraumatic needles together with stylet reinsertion in a report from 2005. It is unclear whether these recommendations are followed or not. Objectives To investigate the diagnostic LP preferences with respect to the AAN guidelines among neurologists by use of a short online questionnaire, and to review previously published literature on the subject. Results - A total of 284 respondents who performed diagnostic LPs completed the questionnaire. Almost half (41%) answered that they always use atraumatic needles. The most common reason (73%) for not using atraumatic needles was that these were not available. Less than half of the respondents who performed LPs had knowledge about the MN guidelines for diagnostic LPs, and 48-76% agreed with the different recommendations therein. Five previously (1998-2015) published studies investigating LP practice among neurologists were identified. The reported frequency of atraumatic needle use (always/routinely) varied between 2 and 16%. Discussion - Atraumatic needle use was more common in this study compared with previous publications. There is still skepticism regarding some of the MN recommendations, and needle availability appears to be the most important factor preventing atraumatic needle use. To increase the use of atraumatic needles we may perform additional studies investigating their potential benefits, and arrange training sessions for neurologists to increase their awareness and level of comfort with the atraumatic LP technique.

Keywords
lumbar puncture, LP, questionnaire, AAN guidelines, post lumbar puncture headache
National Category
Neurosciences
Identifiers
urn:nbn:se:umu:diva-131002 (URN)10.18071/isz.69.0397 (DOI)000391162900005 ()
Available from: 2017-02-08 Created: 2017-02-02 Last updated: 2018-06-09Bibliographically approved
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Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-9205-0771

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