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Schunemann, H. J., Lerda, D., Dimitrova, N., Alonso-Coello, P., Grawingholt, A., Quinn, C., . . . Parmelli, E. (2019). Methods for Development of the European Commission Initiative on Breast Cancer Guidelines Recommendations in the Era of Guideline Transparency. Annals of Internal Medicine, 171(4), 273-280
Open this publication in new window or tab >>Methods for Development of the European Commission Initiative on Breast Cancer Guidelines Recommendations in the Era of Guideline Transparency
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2019 (English)In: Annals of Internal Medicine, ISSN 0003-4819, E-ISSN 1539-3704, Vol. 171, no 4, p. 273-280Article in journal (Refereed) Published
Abstract [en]

Neither breast cancer prevention and early-detection programs, nor their outcomes, are uniform across Europe. This article describes the rationale, methods, and process for development of the European Commission ( EC) Initiative on Breast Cancer Screening and Diagnosis Guidelines. To be consistent with standards set by the Institute of Medicine and others, the EC followed 6 general principles. First, the EC selected, via an open call, a panel with broad representation of areas of expertise. Second, it ensured that all recommendations were supported by systematic reviews. Third, the EC separately considered important subgroups of women, included patient advocates in the guidelines development group, and focused on good communication to inform women's decisions. Fourth, EC rules on conflicts of interest were followed and the GRADE ( Grading of Recommendations Assessment, Development and Evaluation) Evidence to Decision frameworks were used to structure the process and minimize the influence of competing interests. Fifth, it focused its recommendations on outcomes that matter to women, and certainty of the evidence is rated for each. Sixth, the EC elicited stakeholder feedback to ensure that the recommendations remain up to date and relevant to practice. This article describes the approach and highlights ways of disseminating and adapting the recommendations both within and outside Europe, using innovative information technology tools.

Place, publisher, year, edition, pages
American College of Physicians, 2019
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-162845 (URN)10.7326/M18-3445 (DOI)000481642800019 ()31330534 (PubMedID)
Available from: 2019-09-13 Created: 2019-09-13 Last updated: 2019-09-13Bibliographically approved
Mgaya, A. H., Kidanto, H. L., Nyström, L. & Essen, B. (2019). Use of a criteria-based audit to optimize uptake of cesarean delivery in a low-resource setting. International Journal of Gynecology & Obstetrics, 144(2), 199-209
Open this publication in new window or tab >>Use of a criteria-based audit to optimize uptake of cesarean delivery in a low-resource setting
2019 (English)In: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479, Vol. 144, no 2, p. 199-209Article in journal (Refereed) Published
Abstract [en]

Objective: To evaluate the impact of a criteria‐based audit (CBA) of obstructed labor and fetal distress on cesarean delivery and perinatal outcomes.

Methods: A cross‐sectional study was performed at a tertiary referral hospital in Tanzania. Data were collected before and after CBA (January 2013–November 2013 and July 2015–June 2016). Outcomes of fetal distress (baseline CBA, n=248; re‐audit, n=251) and obstructed labor (baseline CBA, n=260; re‐audit n=250) were assessed using a checklist. Additionally, 27 960 parturients were assessed using the Robson classification.

Results: Perinatal morbidity and mortality decreased from 42 of 260 (16.2%) to 22 of 250 (8.8%) among patients with obstructed labor after CBA (P=0.012). Cesarean delivery rate decreased for referred term multiparas with induced labor or prelabor cesarean delivery (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.09–0.82). Cesarean delivery rate for preterm pregnancies increased among both referred (OR 1.28, 95% CI 1.02–1.63) and non‐referred (OR 2.78, 95% CI 1.98–3.90) groups. Neonatal distress rate decreased for referred term multiparas (OR 0.72, 95% CI 0.56–0.92), referred preterm pregnancies (OR 0.32, 95% CI 0.25–0.39), and non‐referred preterm pregnancies (OR 0.26, 95% CI 0.18–0.36).

Conclusion: Use of CBA reduced poor perinatal outcomes of obstructed labor and increased uptake of cesarean delivery.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2019
Keywords
Cesarean delivery, Criteria-based audit, Fetal distress, Low-resource setting, Obstructed labor, Robson classification
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-155628 (URN)10.1002/ijgo.12726 (DOI)000454953100012 ()30499099 (PubMedID)
Available from: 2019-01-28 Created: 2019-01-28 Last updated: 2019-01-28Bibliographically approved
Pujilestari, C. U., Nyström, L., Norberg, M. & Ng, N. (2019). Waist circumference and all-cause mortality among older adults in rural Indonesia. International Journal of Environmental Research and Public Health, 16, Article ID 116.
Open this publication in new window or tab >>Waist circumference and all-cause mortality among older adults in rural Indonesia
2019 (English)In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 16, article id 116Article in journal (Refereed) Published
Abstract [en]

Waist circumference, a measure of abdominal obesity, is associated with all-cause mortality in general adult population. However, the link between abdominal obesity with all-cause mortality in the studies of older adults is unclear. This study aims to determine the association between waist circumference and all-cause mortality in older adults in Indonesia. The association between waist circumference and all-cause mortality was examined in 10,997 men and women aged 50 years and older, in the World Health Organization (WHO) and International Network of field sites for continuous Demographic Evaluation of Populations and their Health in developing countries (INDEPTH) collaboration Study on global AGEing and adult health (SAGE) in Purworejo District Central Java, Indonesia during 2007–2010. Multivariate Cox regression analysis with restricted cubic splines was used to assess the non-linear association between waist circumference and all-cause mortality. During the 3-year follow-up, a total of 511 men and 470 women died. The hazard ratio plot shows a pattern of U-shape relationship between waist circumference and all-cause mortality among rich women, though the result was significant only for women in the lower end of waist circumference distribution (p < 0.05). Poor men with a low waist circumference (5th percentile) have a two times higher mortality risk (HR = 2.1; 95% CI = 1.3, 3.3) relative to those with a waist circumference of 90 cm. Poor women with a low waist circumference (25th percentile) have a 1.4 times higher mortality risk (HR = 1.4; 95% CI = 1.1, 1.8) relative to those with a waist circumference of 80 cm. This study shows a significant association between low waist circumference measure and mortality, particularly among poor men and women. Though the association between large waist circumference and mortality was not significant, we observed a trend of higher mortality risk particularly among rich women with large waist circumference measure. Public health intervention should include efforts to improve nutritional status among older people and promoting healthy lifestyle behaviours including healthy food and active lifestyle.

Place, publisher, year, edition, pages
MDPI, 2019
Keywords
abdominal obesity, deaths, Indonesia, older people, waist circumference
National Category
Gerontology, specialising in Medical and Health Sciences Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-152117 (URN)10.3390/ijerph16010116 (DOI)000459111400116 ()30609857 (PubMedID)
Note

Originally included in thesis in manuscript form

Available from: 2018-09-27 Created: 2018-09-27 Last updated: 2019-03-20Bibliographically approved
Wu, W.-Y. Y., Nyström, L. & Jonsson, H. (2018). Estimation of overdiagnosis in breast cancer screening using a non-homogeneous multi-state model: a simulation study. Journal of Medical Screening, 25(4), 183-190
Open this publication in new window or tab >>Estimation of overdiagnosis in breast cancer screening using a non-homogeneous multi-state model: a simulation study
2018 (English)In: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 25, no 4, p. 183-190Article in journal (Refereed) Published
Abstract [en]

Objectives: Overdiagnosis is regarded as a harm of screening. We aimed to develop a non-homogeneous multi-state model to consider the age-specific transition rates for estimation of overdiagnosis, to validate the model by a simulation study where the true frequency of overdiagnosis can be calculated, and to compare our estimate with the cumulative incidence method. Methods: We constructed a four-state model to describe the natural history of breast cancer. The latent disease progression and the observed states for each individual were simulated in a trial with biennial screening of women aged 51-69 and a control group of the same size without screening. We performed 100 repetitions of the simulation with one million women to evaluate the performance of estimates. A sensitivity analysis with reduced number of controls was performed to imitate the data from the service screening programme. Results Based on the 100 repetitions, the mean value of the true frequency of overdiagnosis was 12.5% and the average estimates by the cumulative incidence method and the multi-state model were 12.9% (interquartile range: 2.46%) and 13.4% (interquartile range: 2.16%), respectively. The multi-state model had a greater bias of overdiagnosis than the cumulative incidence method, but the variation in the estimates was smaller. When the number of unscreened group was reduced, the variation of multi-state model estimates increased. Conclusions: The multi-state model produces a proper estimate of overdiagnosis and the results are comparable with the cumulative incidence method. The multi-state model can be used in the estimation of overdiagnosis, and might be useful for the ongoing service screening programmes.

Place, publisher, year, edition, pages
Sage Publications, 2018
Keywords
Overdiagnosis, breast cancer screening, mammography, multi-state model, cumulative incidence method
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-154901 (URN)10.1177/0969141317733294 (DOI)000452324300004 ()29153013 (PubMedID)
Available from: 2019-01-04 Created: 2019-01-04 Last updated: 2019-01-04Bibliographically approved
Wu, W.-Y. Y., Törnberg, S., Elfström, K. M., Liu, X., Nyström, L. & Jonsson, H. (2018). Overdiagnosis in the population-based organized breast cancer screening program estimated by a non-homogeneous multi-state model: a cohort study using individual data with long-term follow-up. Breast Cancer Research, 20, Article ID 153.
Open this publication in new window or tab >>Overdiagnosis in the population-based organized breast cancer screening program estimated by a non-homogeneous multi-state model: a cohort study using individual data with long-term follow-up
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2018 (English)In: Breast Cancer Research, ISSN 1465-5411, E-ISSN 1465-542X, Vol. 20, article id 153Article in journal (Refereed) Published
Abstract [en]

Background: Overdiagnosis, defined as the detection of a cancer that would not become clinically apparent in a woman’s lifetime without screening, has become a growing concern. Similar underlying risk of breast cancer in the screened and control groups is a prerequisite for unbiased estimates of overdiagnosis, but a contemporary control group is usually not available in organized screening programs.

Methods: We estimated the frequency of overdiagnosis of breast cancer due to screening in women 50–69 years old by using individual screening data from the population-based organized screening program in Stockholm County 1989–2014. A hidden Markov model with four latent states and three observed states was constructed to estimate the natural progression of breast cancer and the test sensitivity. Piecewise transition rates were used to consider the time-varying transition rates. The expected number of detected non-progressive breast cancer cases was calculated.

Results: During the study period, 2,333,153 invitations were sent out; on average, the participation rate in the screening program was 72.7% and the average recall rate was 2.48%. In total, 14,648 invasive breast cancer cases were diagnosed; among the 8305 screen-detected cases, the expected number of non-progressive breast cancer cases was 35.9, which is equivalent to 0.43% (95% confidence interval (CI) 0.10%–2.2%) overdiagnosis. The corresponding estimates for the prevalent and subsequent rounds were 15.6 (0.87%, 95% CI 0.20%–4.3%) and 20.3 (0.31%, 95% CI 0.07%–1.6%), respectively. The likelihood ratio test showed that the non-homogeneous model fitted the data better than an age-homogeneous model (P<0.001).

Conclusions: Our findings suggest that overdiagnosis in the organized biennial mammographic screening for women 50–69 in Stockholm County is a minor phenomenon. The frequency of overdiagnosis in the prevalent screening round was higher than that in subsequent rounds. The non-homogeneous model performed better than the simpler, traditional homogeneous model.

Place, publisher, year, edition, pages
BioMed Central, 2018
Keywords
Overdiagnosis, Breast cancer, Organized screening program, Mammography, Multi-state model
National Category
Cancer and Oncology
Identifiers
urn:nbn:se:umu:diva-155103 (URN)10.1186/s13058-018-1082-z (DOI)000453551900001 ()30558679 (PubMedID)
Funder
Swedish Research CouncilVästerbotten County Council
Available from: 2019-01-10 Created: 2019-01-10 Last updated: 2019-01-10Bibliographically approved
Olsson, J., Hojer, S., Nyström, L. & Emmelin, M. (2017). Orphanhood and mistreatment drive children to leave home: A study from early AIDS-affected Kagera region, Tanzania. International Social Work, 60(5), 1218-1232
Open this publication in new window or tab >>Orphanhood and mistreatment drive children to leave home: A study from early AIDS-affected Kagera region, Tanzania
2017 (English)In: International Social Work, ISSN 0020-8728, E-ISSN 1461-7234, Vol. 60, no 5, p. 1218-1232Article in journal (Refereed) Published
Abstract [en]

The aim of this mixed-method study was to explore the trajectories of leaving home, and views and experiences among children and youth in the Kagera region in Tanzania, who have lived on the streets or been domestic workers. The main results showed that orphanhood and mistreatment were the main reasons for leaving home: few children lived with their parents before they left, and leaving home was a complex process over several years where three trajectories were identified. The children who had left home showed strong agency and competency but lived in vulnerable conditions, especially young children living on the streets.

Keywords
Child domestic workers, HIV, AIDS, orphans, street children, Tanzania
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-140949 (URN)10.1177/0020872816641751 (DOI)000408871000012 ()
Available from: 2017-11-17 Created: 2017-11-17 Last updated: 2018-06-09Bibliographically approved
Tyrberg, M., Nyström, L., Arnqvist, H. J., Bolinder, J., Gudbjörnsdottir, S., Landin-Olsson, M., . . . Svensson, M. K. (2017). Overweight, hyperglycemia and tobacco use are modifiable risk factors for onset of retinopathy 9 and 17 years after the diagnosis of diabetes: a retrospective observational nation-wide cohort study. Diabetes Research and Clinical Practice, 133, 21-29
Open this publication in new window or tab >>Overweight, hyperglycemia and tobacco use are modifiable risk factors for onset of retinopathy 9 and 17 years after the diagnosis of diabetes: a retrospective observational nation-wide cohort study
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2017 (English)In: Diabetes Research and Clinical Practice, ISSN 0168-8227, E-ISSN 1872-8227, Vol. 133, p. 21-29Article in journal (Refereed) Published
Abstract [en]

Background: The aims of this study were to estimate the risk for diabetic retinopathy (DR) and to identify risk factors. We investigated a nationwide population-based cohort with diabetes diagnosed at age 15-34 years.

Patients and methods: Of 794 patients registered 1987-1988 in the Diabetes Incidence Study in Sweden (DISS) 444 (56%) patients with retinal photos available for classification of retinopathy participated in a follow-up study 15-19 (median 17) years after diagnosis. Mean age was 42.3 +/- 5.7 years, BMI 26.1 +/- 4.1 kg/m(2), 62% were male and 91% had type 1 diabetes. A sub-study was performed in 367 patients with retinal photos from both the 9 and 17 year follow up and the risk for development of retinopathy between 9 and 17 years of follow up was calculated.

Results: After median 17 years 324/444 (73%, 67% of T1D and 71% of T2D), had developed any DR but only 5.4% proliferative DR. Male sex increased the risk of developing retinopathy (OR 1.9, 95% CI 1.2-2.9). In the sub-study obesity (OR 1.2, 95% CI 1.04-1.4), hyperglycemia (OR 2.5, 95% CI 1.6-3.8) and tobacco use (OR 2.9, 95% CI 1.1-7.3) predicted onset of retinopathy between 9 and 17 years after diagnosis of diabetes.

Conclusion: The number of patients with severe retinopathy after 17 years of diabetes disease was small. The risk of developing retinopathy with onset between 9 and 17 years after diagnosis of diabetes was strongly associated to modifiable risk factors such as glycemic control, obesity and tobacco use.

Place, publisher, year, edition, pages
Elsevier, 2017
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-142672 (URN)10.1016/j.diabres.2017.08.009 (DOI)000415623700005 ()28888147 (PubMedID)
Available from: 2017-12-13 Created: 2017-12-13 Last updated: 2018-06-09Bibliographically approved
Pujilestari, C. U., Nyström, L., Norberg, M., Weinehall, L., Hakimi, M. & Ng, N. (2017). Socioeconomic inequality in abdominal obesity among older people in Purworejo District, Central Java, Indonesia: a decomposition analysis approach. International Journal for Equity in Health, 16(1), Article ID 214.
Open this publication in new window or tab >>Socioeconomic inequality in abdominal obesity among older people in Purworejo District, Central Java, Indonesia: a decomposition analysis approach
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2017 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, no 1, article id 214Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Obesity has become a global health challenge as its prevalence has increased globally in recent decades. Studies in high-income countries have shown that obesity is more prevalent among the poor. In contrast, obesity is more prevalent among the rich in low- and middle-income countries, hence requiring different focal points to design public health policies in the latter contexts. We examined socioeconomic inequalities in abdominal obesity in Purworejo District, Central Java, Indonesia and identified factors contributing to the inequalities.

METHODS: We utilised data from the WHO-INDEPTH Study on global AGEing and adult health (WHO-INDEPTH SAGE) conducted in the Purworejo Health and Demographic Surveillance System (HDSS) in Purworejo District, Indonesia in 2010. The study included 14,235 individuals aged 50 years and older. Inequalities in abdominal obesity across wealth groups were assessed separately for men and women using concentration indexes. Decomposition analysis was conducted to assess the determinants of socioeconomic inequalities in abdominal obesity.

RESULTS: Abdominal obesity was five-fold more prevalent among women than in men (30% vs. 6.1%; p < 0.001). The concentration index (CI) analysis showed that socioeconomic inequalities in abdominal obesity were less prominent among women (CI = 0.26, SE = 0.02, p < 0.001) compared to men (CI = 0.49, SE = 0.04, p < 0.001). Decomposition analysis showed that physical labour was the major determinant of socioeconomic inequalities in abdominal obesity among men, explaining 47% of the inequalities, followed by poor socioeconomic status (31%), ≤ 6 years of education (15%) and current smoking (11%). The three major determinants of socioeconomic inequalities in abdominal obesity among women were poor socio-economic status (48%), physical labour (17%) and no formal education (16%).

CONCLUSION: Abdominal obesity was more prevalent among older women in a rural Indonesian setting. Socioeconomic inequality in abdominal obesity exists and concentrates more among the rich population in both sexes. The inequality gap is less prominent among women, indicating a trend towards obesity being more common in poor women. Policies to address social determinants of health need to be developed to address the socioeconomic inequality gaps in obesity, with particular focus on addressing the existing burden of obesity among the better-off population group, while preventing the imminent burden of obesity among the worst-off group, particularly among women.

Keywords
Abdominal obesity, Decomposition analysis, Low- and middle-income countries, Older people, Socio-economic inequality
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-143310 (URN)10.1186/s12939-017-0708-6 (DOI)000417841700001 ()29233136 (PubMedID)
Available from: 2017-12-20 Created: 2017-12-20 Last updated: 2018-10-02Bibliographically approved
Mgaya, A. H., Litorp, H., Kidanto, H. L., Nyström, L. & Essén, B. (2016). Criteria-based audit to improve quality of care of foetal distress: standardising obstetric care at a national referral hospital in a low resource setting, Tanzania. BMC Pregnancy and Childbirth, 16, Article ID 343.
Open this publication in new window or tab >>Criteria-based audit to improve quality of care of foetal distress: standardising obstetric care at a national referral hospital in a low resource setting, Tanzania
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2016 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 343Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: In Tanzania, substandard intrapartum management of foetal distress contributes to a third of perinatal deaths, and the majority are term deliveries. We conducted a criteria-based audit with feedback to determine whether standards of diagnosis and management of foetal distress would be improved in a low-resource setting.

METHODS: During 2013-2015, a criteria-based audit was performed at the national referral hospital in Dar es Salaam. Case files of deliveries with a diagnosis of foetal distress were identified and audited. Two registered nurses under supervision of a nurse midwife, a specialist obstetrician and a consultant obstetrician, reviewed the case files. Criteria for standard diagnosis and management of foetal distress were developed based on international and national guidelines, and literature reviews, and then, stepwise applied, in an audit cycle. During the baseline audit, substandard care was identified, and recommendations for improvement of care were proposed and implemented. The effect of the implementations was assessed by the differences in percentage of standard diagnosis and management between the baseline and re-audit, using Chi-square test or Fisher's exact test, when appropriate.

RESULTS: In the baseline audit and re-audit, 248 and 251 deliveries with a diagnosis of foetal distress were identified and audited, respectively. The standard of diagnosis increased significantly from 52 to 68 % (p < 0.001). Standards of management improved tenfold from 0.8 to 8.8 % (p < 0.001). Improved foetal heartbeat monitoring using a Fetal Doppler was the major improvement in diagnoses, while change of position of the mother and reduced time interval from decision to perform caesarean section to delivery were the major improvements in management (all p < 0.001). Percentage of cases with substandard diagnosis and management was significantly reduced in both referred public and non-referred private patients (all p ≤ 0.01) but not in non-referred public and referred private patients.

CONCLUSION: The criteria-based audit was able to detect substandard diagnosis and management of foetal distress and improved care using feedback and available resources.

Keywords
Caesarean section, Criteria-based audit, Foetal distress, Fetal Doppler, Low-resource setting
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-127500 (URN)10.1186/s12884-016-1137-z (DOI)000387607600003 ()27825311 (PubMedID)
Available from: 2016-11-14 Created: 2016-11-14 Last updated: 2018-06-09Bibliographically approved
Brunström, M., Dahlström, J., Lindholm, L. H., Lönnberg, G., Hallström, S., Norberg, M., . . . Carlberg, B. (2016). From efficacy in trials to effectiveness in clinical practice: The Swedish Stroke Prevention Study. Blood Pressure, 25(4), 206-211
Open this publication in new window or tab >>From efficacy in trials to effectiveness in clinical practice: The Swedish Stroke Prevention Study
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2016 (English)In: Blood Pressure, ISSN 0803-7051, E-ISSN 1651-1999, Vol. 25, no 4, p. 206-211Article in journal (Refereed) Published
Abstract [en]

Blood pressure treatment has shown great efficacy in reducing cardiovascular events in randomized controlled trials. If this is effective in reducing cardiovascular disease in the general population, is less studied. Between 2001 and 2009 we performed an intervention to improve blood pressure control in the county of Vasterbotten, using Sodermanland County as a control. The intervention was directed towards primary care physicians and included lectures on blood pressure treatment, a computerized decision support system with treatment recommendations, and yearly feed back on hypertension control. Each county had approximately 255000 inhabitants. Differences in age and incidence of cardiovascular disease were small. During follow-up, more than 400000 patients had their blood pressure recorded. The mean number of measurements was eight per patient, yielding a total of 3.4 million blood pressure recordings. The effect of the intervention will be estimated combining the blood pressure data collected from the electronic medical records, with data on stroke, myocardial infarction and mortality from Swedish health registers. Additional variables, from health registers and Statistics Sweden, will be collected to address for confounders. The blood pressure data collected within this study will be an important asset for future epidemiological studies within the field of hypertension.

Keywords
Blood pressure, clinical trials, hypertension, intervention
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-124833 (URN)10.3109/08037051.2015.1127556 (DOI)000380053800002 ()26854107 (PubMedID)
Available from: 2016-10-03 Created: 2016-08-26 Last updated: 2018-06-09Bibliographically approved
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Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-5095-3454

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