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  • 1. Alemu, Yihun Mulugeta
    et al.
    Awoke, Worku
    Wilder-Smith, Annalies
    Institute of Public Health, Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
    Determinants for tuberculosis in HIV-infected adults in Northwest Ethiopia: a multicentre case-control study2016Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, nr 4, artikel-id e009058Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: The objective of this study was to identify determinants for tuberculosis (TB) among HIV-infected adults in Northwest Ethiopia.

    DESIGN: Case-control study.

    SETTING: Three hospitals and 10 health centres in Northwest Ethiopia.

    PARTICIPANTS: A total of 446 individuals consented to participate in the study (150 cases and 296 controls). Cases were HIV-infected adults diagnosed with active TB, and controls were HIV-infected adults without active TB.

    MAIN OUTCOME MEASURE: The link between TB and determinants was assessed using logistic regression. Determinants were categorised as sociodemographic, host-related, clinical and environmental.

    RESULTS: Smoking (adjusted OR (AOR) 5.47; 95% CI 2.26 to 13.22), presence of a TB patient in the family (AOR 2.66; 95% CI 1.25 to 5.66), alcohol consumption (AOR 2.49; 95% CI 1.29 to 4.80) and chewing khat (AOR 2.22; 95% CI 1.11 to 4.41) were independent determinants for increased occurrence of TB. Highly active antiretroviral therapy (HAART) (AOR 0.25; 95% CI 0.13 to 0.51), isoniazid preventive therapy (IPT) (AOR 0.22; 95% CI 0.11 to 0.41) and cotrimoxazole preventive therapy (AOR 0.32; 95% CI 0.19 to 0.55) had a protective effect against TB.

    CONCLUSIONS: HIV-infected adults with substance abuse (tobacco smoking, khat chewing and alcohol) should be prioritised for TB screening. This study reaffirmed that HAART and IPT are some of the best strategies for reducing TB occurrence in HIV-infected adults. These findings provide impetus to intensify tracing of TB household contacts.

  • 2. Aman, Malin
    et al.
    Forssblad, Magnus
    Henriksson-Larsén, Karin
    Insurance claims data: a possible solution for a national sports injury surveillance system? An evaluation of data information against ASIDD and consensus statements on sports injury surveillance2014Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 4, nr 6, artikel-id e005056Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Before preventive actions can be suggested for sports injuries at the national level, a solid surveillance system is required in order to study their epidemiology, risk factors and mechanisms. There are guidelines for sports injury data collection and classifications in the literature for that purpose. In Sweden, 90% of all athletes (57/70 sports federations) are insured with the same insurance company and data from their database could be a foundation for studies on acute sports injuries at the national level.

    OBJECTIVE: To evaluate the usefulness of sports injury insurance claims data in sports injury surveillance at the national level.

    METHOD: A database with 27 947 injuries was exported to an Excel file. Access to the corresponding text files was also obtained. Data were reviewed on available information, missing information and dropouts. Comparison with ASIDD (Australian Sports Injury Data Dictionary) and existing consensus statements in the literature (football (soccer), rugby union, tennis, cricket and thoroughbred horse racing) was performed in a structured manner.

    RESULT: Comparison with ASIDD showed that 93% of the suggested data items were present in the database to at least some extent. Compliance with the consensus statements was generally high (13/18). Almost all claims (83%) contained text information concerning the injury.

    CONCLUSIONS: Relatively high-quality sports injury data can be obtained from a specific insurance company at the national level in Sweden. The database has the potential to be a solid base for research on acute sports injuries in different sports at the national level.

  • 3. Andersson, Ola
    et al.
    Hellstrom-Westas, Lena
    Domellöf, Magnus
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik.
    Elective caesarean: does delay in cord clamping for 30 s ensure sufficient iron stores at 4 months of age? A historical cohort control study2016Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, nr 11, artikel-id e012995Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To compare iron stores in infants born after elective caesarean section (CS) and a 30 s delay of umbilical cord clamping with those born vaginally after early (<= 10 s) or delayed (>= 180 s) cord clamping. Design: Prospective observational study with historical control. Setting: Swedish county hospital. Population: 64 infants born after elective CS were compared with a historical control of 166 early clamped and 168 delayed clamped after vaginal birth. Methods: Blood and iron status were measured in blood samples collected at birth, 48-96 hours after birth, 4 and 12 months of age. Primary and secondary outcome measures: Ferritin at 4 months of age was the primary outcome, second outcome measures were other indicators of iron status, and haemoglobin, at 4 and 12 months of age, as well as respiratory distress at 1 and 6 hours after birth. Results: At 4 months infants born by elective CS had better iron status than those born vaginally subjected to early cord clamping, shown by higher adjusted mean difference of ferritin concentration (39 mu g/L (95% CI 10 to 60)) and mean cell volume (1.8 fL (95% CI 0.6 to 3.0)); and lower levels of transferrin receptors (-0.39 mg/L (95% CI -0.69 to -0.08)). No differences were seen between infants born after elective CS and delayed clamped vaginally born infants at 4 months. No differences were found between groups at 12 months of age. Conclusions: Waiting to clamp the umbilical cord for 30 s after elective CS results in higher iron stores at 4 months of age compared with early cord clamping after vaginal birth, and seems to ensure iron status comparable with those achieved after 180 s delayed cord clamping after vaginal birth.

  • 4.
    Arnetz, Bengt B.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Department of Family Medicine, College of Human Medicine, Michigan State University, Michigan, USA; Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
    Lewalski, Philip
    Arnetz, Judy
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Department of Family Medicine, College of Human Medicine, Michigan State University, Michigan, USA; Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
    Breejen, Karen
    Przyklenk, Karin
    Examining self-reported and biological stress and near misses among Emergency Medicine residents: a single-centre cross-sectional assessment in the USA2017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 8, artikel-id e016479Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To examine the relationship between perceived and biological stress and near misses among Emergency Medicine residents.

    Design: Self-rated stress and stress biomarkers were assessed in residents in Emergency Medicine before and after a day shift. The supervising physicians and residents reported numbers of near misses.

    Setting: The study took place in the Emergency Department of a large trauma 1 centre, located in Detroit, USA. Participants Residents in Emergency Medicine volunteered to participate. The sample consisted of 32 residents, with complete data on 28 subjects. Residents' supervising physicians assessed the clinical performance of each resident.

    Primary and secondary outcome measures: Participants' preshift and postshift stress, biological stress (salivary cortisol, plasma interleukin-6, tumour necrosis factor-alpha (TNF-alpha) and high-sensitivity C-reactive protein), residents' and supervisors' reports of near misses, number of critically ill and patients with trauma seen during the shift.

    Results: Residents' self-reported stress increased from an average preshift level of 2.79 of 10 (SD 1.81) to a postshift level of 5.82 (2.13) (p<0.001). Residents cared for an average of 2.32 (1.52) critically ill patients and 0.68 (1.06) patients with trauma. Residents reported a total of 7 near misses, compared with 11 reported by the supervising physicians. After controlling for baseline work-related exhaustion, residents that cared for more patients with trauma and had higher levels of TNF-a reported a higher frequency of near misses (R-2=0.72; p=0.001). Residents' preshift ratings of how stressful they expected the shift to be were related to the supervising physicians' ratings of residents' near misses during the shift.

    Conclusion: Residents' own ratings of near misses were associated with residents' TNF-alpha, a biomarker of systemic inflammation and the number of patients with trauma seen during the shift. In contrast, supervisor reports on residents' near misses were related only to the residents' preshift expectations of how stressful the shift would be.

  • 5.
    Arumugam, Ashokan
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Avdelningen för fysioterapi.
    Strong, Andrew
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Avdelningen för fysioterapi.
    Tengman, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Avdelningen för fysioterapi.
    Röijezon, Ulrik
    Häger, Charlotte
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Avdelningen för fysioterapi.
    Psychometric properties of knee proprioception tests targeting healthy individuals and those with anterior cruciate ligament injury managed with or without reconstruction: a systematic review protocol2019Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, nr 4, artikel-id e027241Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Introduction: An anterior cruciate ligament (ACL) injury affects knee proprioception and sensorimotor control and might contribute to an increased risk of a second ACL injury and secondary knee osteoarthritis. Therefore, there is a growing need for valid, reliable and responsive knee proprioception tests. No previous study has comprehensively reviewed all the relevant psychometric properties (PMPs) of these tests together. The aim of this review protocol is to narrate the steps involved in synthesising the evidence for the PMPs of specific knee proprioception tests among individuals with an ACL injury and knee-healthy controls.

    Methods and analysis: The Preferred Reporting Items for Systematic reviews and Meta-Analyses will be followed to report the review. A combination of four conceptual groups of terms-(1) construct (knee proprioception), (2) target population (healthy individuals and those with an ACL injury managed conservatively or with a surgical reconstruction), (3) measurement instrument (specific knee proprioception tests) and (4) PMPs (reliability, validity and responsiveness)-will be used for electronic databases search. PubMed, AMED, CINAHL, SPORTDiscus, Web of Science, Scopus, the Cochrane Central Register of Controlled Trials and ProQuest will be searched from their inception to November 2018. Two reviewers will independently screen titles, abstracts and full text articles, extract data and perform risk of bias assessment using the updated COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist for the eligible studies. A narrative synthesis of the findings and a meta-analysis will be attempted as appropriate. Each PMP of knee proprioception tests will be classified as 'sufficient', 'indeterminate' or 'insufficient'. The overall level of evidence will be ascertained using an established set of criteria.

    Ethics and dissemination: Ethical approval or patient consent is not required for a systematic review. The review findings will be submitted as a series of manuscripts for peer-review and publication in scientific journals.

  • 6. Askelöf, Ulrica
    et al.
    Andersson, Ola
    Domellöf, Magnus
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik.
    Fasth, Anders
    Hallberg, Boubou
    Hellström-Westas, Lena
    Pettersson, Karin
    Westgren, Magnus
    Wiklund, Ingela E.
    Götherström, Cecilia
    Wait a minute?: An observational cohort study comparing iron stores in healthy Swedish infants at 4 months of age after 10-, 60-and 180-second umbilical cord clamping2017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 12, artikel-id e017215Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background and objective: Umbilical cord blood (UCB) is a valuable stem cell source used for transplantation. Immediate umbilical cord (UC) clamping is widely practised, but delayed UC clamping is increasingly advocated to reduce possible infant anaemia. The aim of this study was to investigate an intermediate UC clamping time point and to evaluate iron status at the age of 4 months in infants who had the UC clamped after 60 s and compare the results with immediate and late UC clamping.

    Design: Prospective observational study with two historical controls.

    Setting: A university hospital in Stockholm, Sweden, and a county hospital in Halland, Sweden.

    Methods: Iron status was assessed at 4 months in 200 prospectively recruited term infants whose UC was clamped 60 s after birth. The newborn baby was held below the uterine level for the first 30 s before placing the infant on the mother's abdomen for additional 30 s. The results were compared with data from a previously conducted randomised controlled trial including infants subjected to UC clamping at <= 10 s (n= 200) or >= 180 s (n= 200) after delivery.

    Results: After adjustment for age differences at the time of follow- up, serum ferritin concentrations were 77, 103 and 114 mu g/L in the 10, 60 and 180 s groups, respectively. The adjusted ferritin concentration was significantly higher in the 60 s group compared with the 10 s group (P=0.002), while the difference between the 60 and 180 s groups was not significant (P=0.29).

    Conclusion: In this study of healthy term infants, 60 s UC clamping with 30 s lowering of the baby below the uterine level resulted in higher serum ferritin concentrations at 4 months compared with 10 s UC clamping. The results suggest that delaying the UC clamping for 60 s reduces the risk for iron deficiency.

  • 7. Barman, Malin
    et al.
    Murray, Fiona
    Bernardi, Angelina I.
    Broberg, Karin
    Bölte, Sven
    Hesselmar, Bill
    Jacobsson, Bo
    Jonsson, Karin
    Kippler, Maria
    Rabe, Hardis
    Ross, Alastair B.
    Sjöberg, Fei
    Strömberg, Nicklas
    Umeå universitet, Medicinska fakulteten, Institutionen för odontologi.
    Vahter, Marie
    Wold, Agnes E.
    Sandberg, Ann-Sofie
    Sandin, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik. Sunderby Research Unit, Region Norrbotten, Luleå, Sweden.
    Nutritional impact on Immunological maturation during Childhood in relation to the Environment (NICE): a prospective birth cohort in northern Sweden2018Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, nr 10, artikel-id e022013Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction Prenatal and neonatal environmental factors, such as nutrition, microbes and toxicants, may affect health throughout life. Many diseases, such as allergy and impaired child development, may be programmed already in utero or during early infancy. Birth cohorts are important tools to study associations between early life exposure and disease risk. Here, we describe the study protocol of the prospective birth cohort, 'Nutritional impact on Immunological maturation during Childhood in relation to the Environment' (NICE). The primary aim of the NICE cohort is to clarify the effect of key environmental exposures-diet, microbes and environmental toxicants-during pregnancy and early childhood, on the maturation of the infant's immune system, including initiation of sensitisation and allergy as well as some secondary outcomes: infant growth, obesity, neurological development and oral health. Methods and analysis The NICE cohort will recruit about 650 families during mid-pregnancy. The principal inclusion criterion will be planned birth at the Sunderby Hospital in the north of Sweden, during 2015-2018. Questionnaires data and biological samples will be collected at 10 time-points, from pregnancy until the children reach 4 years of age. Samples will be collected primarily from mothers and children, and from fathers. Biological samples include blood, urine, placenta, breast milk, meconium, faeces, saliva and hair. Information regarding allergic heredity, diet, socioeconomic status, lifestyle including smoking, siblings, pet ownership, etc will be collected using questionnaires. Sensitisation to common allergens will be assessed by skin prick testing and allergic disease will be diagnosed by a paediatrician at 1 and 4 years of age. At 4 years of age, the children will also be examined regarding growth, neurobehavioural and neurophysiological status and oral health. Ethics and dissemination The NICE cohort has been approved by the Regional Ethical Review Board in Umea, Sweden (2013/18-31M). Results will be disseminated through peer-reviewed journals and communicated on scientific conferences.

  • 8.
    Blomstedt, Yulia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för demografi och åldrandeforskning (CEDAR).
    Norberg, Margareta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för demografi och åldrandeforskning (CEDAR).
    Stenlund, Hans
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lönnberg, Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Boman, Kurt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Wall, Stig
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Weinehall, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för demografi och åldrandeforskning (CEDAR).
    Impact of a combined community and primary care prevention strategy on all-cause and cardiovascular mortality: a cohort analysis based on 1 million person-years of follow-up in Västerbotten County, Sweden, during 1990-20062015Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, nr 12, artikel-id e009651Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: To evaluate the impact of the Västerbotten Intervention Programme (VIP) by comparing all eligible individuals (target group impact) according to the intention-to-treat principle and VIP participants with the general Swedish population.

    DESIGN: Dynamic cohort study.

    SETTING/PARTICIPANTS: All individuals aged 40, 50 or 60 years, residing in Västerbotten County, Sweden, between 1990 and 2006 (N=101 918) were followed from their first opportunity to participate in the VIP until age 75, study end point or prior death.

    INTERVENTION: The VIP is a systematic, long-term, county-wide cardiovascular disease (CVD) intervention that is performed within the primary healthcare setting and combines individual and population approaches. The core component is a health dialogue based on a physical examination and a comprehensive questionnaire at the ages of 40, 50 and 60 years.

    PRIMARY OUTCOMES: All-cause and CVD mortality.

    RESULTS: For the target group, there were 5646 deaths observed over 1 054 607 person-years. Compared to Sweden at large, the standardised all-cause mortality ratio was 90.6% (95% CI 88.2% to 93.0%): for women 87.9% (95% CI 84.1% to 91.7%) and for men 92.2% (95% CI 89.2% to 95.3%). For CVD, the ratio was 95.0% (95% CI 90.7% to 99.4%): for women 90.4% (95% CI 82.6% to 98.7%) and for men 96.8% (95% CI 91.7 to 102.0). For participants, subject to further impact as well as selection, when compared to Sweden at large, the standardised all-cause mortality ratio was 66.3% (95% CI 63.7% to 69.0%), whereas the CVD ratio was 68.9% (95% CI 64.2% to 73.9%). For the target group as well as for the participants, standardised mortality ratios for all-cause mortality were reduced within all educational strata.

    CONCLUSIONS: The study suggests that the VIP model of CVD prevention is able to impact on all-cause and cardiovascular mortality when evaluated according to the intention-to-treat principle.

  • 9. Bohman, Tony
    et al.
    Bottai, Matteo
    Björklund, Martin
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering. Department of Occupational Health Sciences and Psychology, University of Gävle, Gävle, Sweden.
    Predictive models for short-term and long-term improvement in women under physiotherapy for chronic disabling neck pain: a longitudinal cohort study2019Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, nr 4, artikel-id e024557Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To develop predictive models for short-term and long-term clinically important improvement in women with non-specific chronic disabling neck pain during the clinical course of physiotherapy.

    Design: Longitudinal cohort study based on data from a randomised controlled trial evaluating short-term and long-term effects on sensorimotor function over 11 weeks of physiotherapy.

    Participants and settings: Eighty-nine women aged 31–65 years with non-specific chronic disabling neck pain from Gävle, Sweden.

    Measures: The outcome, clinically important improvement, was measured with the Patient Global Impression of Change Scale (PGICS) and the Neck Disability Index (NDI), assessed by self-administered questionnaires at 3, 9 and 15 months from the start of the interventions (baseline). Twelve baseline prognostic factors were considered in the analyses. The predictive models were built using random-effects logistic regression. The predictive ability of the models was measured by the area under the receiver operating characteristic curve (AUC). Internal validity was assessed with cross-validation using the bootstrap resampling technique.

    Results: Factors included in the final PGICS model were neck disability and age, and in the NDI model, neck disability, depression and catastrophising. In both models, the odds for short-term and long-term improvement increased with higher baseline neck disability, while the odds decreased with increasing age (PGICS model), and with increasing level of depression (NDI model). In the NDI model, higher baseline levels of catastrophising indicated increased odds for short-term improvement and decreased odds for long-term improvement. Both models showed acceptable predictive validity with an AUC of 0.64 (95% CI 0.55 to 0.73) and 0.67 (95% CI 0.59 to 0.75), respectively.

    Conclusion: Age, neck disability and psychological factors seem to be important predictors of improvement, and may inform clinical decisions about physiotherapy in women with chronic neck pain. Before using the developed predictive models in clinical practice, however, they should be validated in other populations and tested in clinical settings.

  • 10. Bunker, Aditi
    et al.
    Sewe, Maquins Odhiambo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sié, Ali
    Rocklöv, Joacim
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sauerborn, Rainer
    Excess burden of non-communicable disease years of life lost from heat in rural Burkina Faso: a time series analysis of the years 2000-20102017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 11, artikel-id e018068Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: Investigate the association of heat exposure on years of life lost (YLL) from non-communicable diseases (NCD) in Nouna, Burkina Faso, between 2000 and 2010.

    Design: Daily time series regression analysis using distributed lag non-linear models, assuming a quasi-Poisson distribution of YLL.

    Setting: Nouna Health and Demographic Surveillance System, Kossi Province, Rural Burkina Faso.

    Participants: 18 367 NCD-YLL corresponding to 790 NCD deaths recorded in the Nouna Health and Demographic Surveillance Site register over 11 years.

    Main outcome measure: Excess mean daily NCD-YLL were generated from the relative risk of maximum daily temperature on NCD-YLL, including effects delayed up to 14 days.

    Results: Daily average NCD-YLL were 4.6, 2.4 and 2.1 person-years for all ages, men and women, respectively. Moderate 4-day cumulative rise in maximum temperature from 36.4 degrees C (50th percentile) to 41.4 degrees C (90th percentile) resulted in 4.44 (95% CI 0.24 to 12.28) excess daily NCDYLL for all ages, rising to 7.39 (95% CI 0.32 to 24.62) at extreme temperature (42.8 degrees C; 99th percentile). The strongest health effects manifested on the day of heat exposure (lag 0), where 0.81 (95% CI 0.13 to 1.59) excess mean NCD-YLL occurred daily at 41.7 degrees C compared with 36.4 degrees C, diminishing in statistical significance after 4 days. At lag 0, daily excess mean NCD-YLL were higher for men, 0.58 (95% CI 0.11 to 1.15) compared with women, 0.15 (95% CI -0.25 to 9.63) at 41.7 degrees C vs 36.4 degrees C.

    Conclusion: Premature death from NCD was elevated significantly with moderate and extreme heat exposure. These findings have important implications for developing adaptation and mitigation strategies to reduce ambient heat exposure and preventive measures for limiting NCD in Africa.

  • 11.
    Carlsen, Hanne Krage
    et al.
    Centre of Public Health Sciences, University of Iceland, Reykjavik, Iceland.
    Gislason, Thorarinn
    Benediktsdottir, Bryndis
    Kolbeinsson, Thorir Bjorn
    Hauksdottir, Arna
    Thorsteinsson, Throstur
    Briem, Haraldur
    A survey of early health effects of the Eyjafjallajokull 2010 eruption in Iceland: a population-based study2012Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 2, nr 2, s. e000343-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective To estimate physical and mental health effects of the Eyjafjallajökull volcanic eruption on nearby residents.

    Design Cross-sectional study.

    Setting The Icelandic volcano Eyjafjallajökull erupted on 14 April 2010. The eruption lasted for about 6 weeks and was explosive, ejecting some 8 million tons of fine particles into the atmosphere. Due to prevailing winds, the ash spread mostly to the south and south-east, first over the rural region to the south, later over the Atlantic Ocean and Europe, closing European air space for several days.

    Participants Residents (n=207) of the most ash-exposed rural area south and east of the volcano.

    Methods The study period was from 31 May to 11 June 2010. Participants were examined by a physician. To ascertain respiratory health, standardised spirometry was performed before and after the use of a bronchodilator. All adult participants answered questionnaires about mental and physical health, their children's health and the use of protective equipment.

    Results Every other adult participant reported irritation in eyes and upper airway when exposed to volcanic ash. Adults (n=26) and children (n=5) with pre-existing asthma frequently reported worsening of their symptoms. No serious health problems requiring hospitalisation could be attributed to the eruption. The majority of the participants reported no abnormal physical or mental symptoms to the examining physician. Compared to an age- and gender-matched reference group, the ash-exposed participants reported lower smoking rates and were less likely to have ventilation impairment. Less than 10% of the participants reported symptoms of stress, anxiety or depression.

    Conclusions Short-term ash exposure was associated with upper airway irritation symptoms and exacerbation of pre-existing asthma but did not contribute to serious health problems. The exposure did not impair respiratory function compared to controls. Outdoor use of protective glasses and face masks was considered protective against irritation in eyes and upper airway.                                  

  • 12.
    Carlsen, Hanne Krage
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Hauksdottir, Arna
    Valdimarsdottir, Unnur Anna
    Gíslason, Thorarinn
    Einarsdottir, Gunnlaug
    Runolfsson, Halldor
    Briem, Haraldur
    Finnbjornsdottir, Ragnhildur Gudrun
    Gudmundsson, Sigurdur
    Kolbeinsson, Thorir Björn
    Thorsteinsson, Throstur
    Pétursdóttir, Gudrun
    Health effects following the Eyjafjallajökull volcanic eruption: a cohort study2012Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 2, nr 6Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: The study aimed to determine whether exposure to a volcanic eruption was associated with increased prevalence of physical and/or mental symptoms.

    DESIGN: Cohort, with non-exposed control group.

    SETTING: Natural disasters like volcanic eruptions constitute a major public-health threat. The Icelandic volcano Eyjafjallajökull exposed residents in southern Iceland to continuous ash fall for more than 5 weeks in spring 2010. This study was conducted during November 2010-March 2011, 6-9 months after the Eyjafjallajökull eruption.

    PARTICIPANTS: Adult (18-80 years of age) eruption-exposed South Icelanders (N=1148) and a control population of residents of Skagafjörður, North Iceland (N=510). The participation rate was 72%.

    MAIN OUTCOME MEASURES: Physical symptoms in the previous year (chronic), in the previous month (recent), General Health Questionnaire (GHQ-12) measured psychological morbidity.

    RESULTS: The likelihood of having symptoms during the last month was higher in the exposed population, such as; tightness in the chest (OR 2.5; 95% CI 1.1 to 5.8), cough (OR 2.6; 95% CI 1.7 to 3.9), phlegm (OR 2.1; 95% CI 1.3 to 3.2), eye irritation (OR 2.9; 95% CI 2.0 to 4.1) and psychological morbidity symptoms (OR 1.3; 95% CI 1.0 to 1.7). Respiratory symptoms during the last 12 months were also more common in the exposed population; cough (OR 2.2; 95% CI 1.6 to 2.9), dyspnoea (OR 1.6; 95% CI 1.1 to 2.3), although the prevalence of underlying asthma and heart disease was similar. Twice as many in the exposed population had two or more symptoms from nose, eyes or upper-respiratory tract (24% vs 13%, p<0.001); these individuals were also more likely to experience psychological morbidity (OR 4.7; 95% CI 3.4 to 6.5) compared with individuals with no symptoms. Most symptoms exhibited a dose-response pattern within the exposed population, corresponding to low, medium and high exposure to the eruption.

    CONCLUSIONS: 6-9 months after the Eyjafjallajökull eruption, residents living in the exposed area, particularly those closest to the volcano, had markedly increased prevalence of various physical symptoms. A portion of the exposed population reported multiple symptoms and may be at risk for long-term physical and psychological morbidity. Studies of long-term consequences are therefore warranted.

  • 13.
    Carlsen, Hanne Krage
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Modig, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Levinsson, Anna
    Kim, Jeong-Lim
    Toren, Kjell
    Nyberg, Fredrik
    Olin, Anna-Carin
    Exposure to traffic and lung function in adults: a general population cohort study2015Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, nr 6, artikel-id e007624Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To investigate the association between living near dense traffic and lung function in a cohort of adults from a single urban region. Design: Cross-sectional results from a cohort study. Setting: The adult-onset asthma and exhaled nitric oxide (ADONIX) cohort, sampled during 2001-2008 in Gothenburg, Sweden. Exposure was expressed as the distance from participants' residential address to the nearest road with dense traffic (>10 000 vehicles per day) or very dense traffic (>30 000 vehicles per day). The exposure categories were: low (>500 m; reference), medium (75-500 m) or high (<75 m). Participants: The source population was a population-based cohort of adults (n=6153). The study population included 5441 participants of European descent with good quality spirometry and information about all outcomes and covariates. Outcome measures: Forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) were measured at a clinical examination. The association with exposure was examined using linear regression adjusting for age, gender, body mass index, smoking status and education in all participants and stratified by sex, smoking status and respiratory health status. Results: We identified a significant dose-response trend between exposure category and FEV1 (p=0.03) and borderline significant trend for FVC (p=0.06) after adjusting for covariates. High exposure was associated with lower FEV1 (-1.0%, 95% CI -2.5% to 0.5%) and lower FVC (-0.9%, 95% CI -2.2% to 0.4%). The effect appeared to be stronger in women. In highly exposed individuals with current asthma or chronic obstructive pulmonary disease, FVC was lower (-4.5%, 95% CI -8.8% to -0.1%). Conclusions: High traffic exposure at the residential address was associated with lower than predicted FEV1 and FVC lung function compared with living further away in a large general population cohort. There were particular effects on women and individuals with obstructive disease.

  • 14.
    Chmielewska, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik.
    Chmielewski, Grzegorz
    Domellöf, Magnus
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik.
    Lewandowski, Zbigniew
    Szajewska, Hania
    Effect of iron supplementation on psychomotor development of non-anaemic, exclusively or predominantly breastfed infants: a randomised, controlled trial2015Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, nr 11, artikel-id e009441Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Uncertainty exists regarding the effects of iron supplementation during infancy on neurodevelopmental outcomes in the absence of anaemia. The aim of the study is to establish whether psychomotor and mental development is influenced by early iron supplementation in healthy, non-anaemic, exclusively or predominantly breastfed infants.

    METHODS AND ANALYSIS: Healthy term infants will be recruited. If exclusively or predominantly breast fed (>50% of daily feedings) and not anaemic at 4 months, they will be randomised to receive either iron pyrophosphate (approximately 1 mg/kg) or placebo daily until 9 months of age. The primary outcome measure is neurodevelopment assessed with the Bayley Scales of Infant and Toddler Development (Bayley-III) at 12 months, and repeated at 24 and 36 months of age. Haematological parameters of iron metabolism also will be measured.

    ETHICS AND DISSEMINATION: The Bioethics Committee of the Medical University of Warsaw approved the study protocol before recruitment started. Study results will be submitted to peer-reviewed journals in the fields of paediatrics and nutrition, and presented at relevant conferences.

    TRIAL REGISTRATION NUMBER: NCT02242188.

  • 15. Dantoft, Thomas M.
    et al.
    Skovbjerg, Sine
    Andersson, Linus
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för psykologi. Department of Occupational and Public Health Sciences, University of Gävle, Sweden.
    Claeson, Anna-Sara
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för psykologi.
    Engkilde, Kaare
    Lind, Nina
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för psykologi. Department of Economics, Swedish University of Agricultural Sciences, Uppsala, Sweden.
    Nordin, Steven
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för psykologi.
    Hellgren, Lars I.
    Gene expression profiling in persons with multiple chemical sensitivity before and after a controlled n-butanol exposure session2017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 2, artikel-id e013879Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To investigate the pathophysiological pathways leading to symptoms elicitation in multiple chemical sensitivity (MCS) by comparing gene expression in MCS participants and healthy controls before and after a chemical exposure optimised to cause symptoms among MCS participants. The first hypothesis was that unexposed and symptom=-free MCS participants have similar gene expression patterns to controls and a second hypothesis that MCS participants can be separated from controls based on differential gene expression upon a controlled n=-butanol exposure.

    Design: Participants were exposed to 3.7 ppm n-butanol while seated in a windowed exposure chamber for 60 min. A total of 26 genes involved in biochemical pathways found in the literature have been proposed to play a role in the pathogenesis of MCS and other functional somatic syndromes were selected. Expression levels were compared between MCS and controls before, within 15 min after being exposed to and 4 hours after the exposure.

    Settings: Participants suffering from MCS and healthy controls were recruited through advertisement at public places and in a local newspaper.

    Participants: 36 participants who considered themselves sensitive were prescreened for eligibility. 18 sensitive persons fulfilling the criteria for MCS were enrolled together with 18 healthy controls.

    Outcome measures: 17 genes showed sufficient transcriptional level for analysis. Group comparisons were conducted for each gene at the 3 times points and for the computed area under the curve (AUC) expression levels.

    Results: MCS participants and controls displayed similar gene expression levels both at baseline and after the exposure and the computed AUC values were likewise comparable between the 2 groups. The intragroup variation in expression levels among MCS participants was noticeably greater than the controls.

    Conclusions: MCS participants and controls have similar gene expression levels at baseline and it was not possible to separate MCS participants from controls based on gene expression measured after the exposure.

  • 16. Edem, Idara J.
    et al.
    Dare, Anna J.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    D'Ambruoso, Lucia
    Kahn, Kathleen
    Leather, Andy J. M.
    Tollman, Stephen
    Whitaker, John
    Davies, Justine
    External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study2019Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, nr 6, artikel-id e027576Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: Injury burden is highest in low-income and middle-income countries. To reduce avoidable deaths, it is necessary to identify health system deficiencies preventing timely, quality care. We developed criteria to use verbal autopsy (VA) data to identify avoidable deaths and associated health system deficiencies.

    Setting: Agincourt, a rural Bushbuckridge municipality, Mpumalanga Province, South Africa.

    Participants: Agincourt Health and Socio-Demographic Surveillance System and healthcare providers (HCPs) from local hospitals.

    Methods: A literature review to explore definitions of avoidable deaths after trauma and barriers to access to care using the ‘three delays framework’ (seeking, reaching and receiving care) was performed. Based on these definitions, this study developed criteria, applicable for use with VA data, for identifying avoidable death and which of the three delays contributed to avoidable deaths. These criteria were then applied retrospectively to the VA-defined category external injury deaths (EIDs—a subset of which are trauma deaths) from 2012 to 2015. The findings were validated by external expert review. Key informant interviews (KIIs) with HCPs were performed to further explore delays to care.

    Results: Using VA data, avoidable death was defined with a focus on survivability, using level of consciousness at the scene and ability to seek care as indicators. Of 260 EIDs (189 trauma deaths), there were 104 (40%) avoidable EIDs and 78 (30%) avoidable trauma deaths (41% of trauma deaths). Delay in receiving care was the largest contributor to avoidable EIDs (61%) and trauma deaths (59%), followed by delay in seeking care (24% and 23%) and in reaching care (15% and 18%). KIIs revealed context-specific factors contributing to the third delay, including difficult referral systems.

    Conclusions: A substantial proportion of EIDs and trauma deaths were avoidable, mainly occurring due to facility-based delays in care. Interventions, including strengthening referral networks, may substantially reduce trauma deaths.

  • 17. Ekstrom, Magnus
    et al.
    Gustafson, Torbjörn
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Boman, Kurt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Nilsson, Kenneth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Lungmedicin.
    Tornling, Goran
    Murgia, Nicola
    Toren, Kjell
    Effects of smoking, gender and occupational exposure on the risk of severe pulmonary fibrosis: a population-based case-control study2014Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 4, nr 1, s. e004018-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To estimate the effects of smoking, gender and occupational exposure on the risk of developing severe pulmonary fibrosis (PF), including dose-response and interaction effects. Methods: National case-control study of 171 patients (cases) who had started a long-term oxygen therapy for PF in Sweden between February 1997 and April 2000, and 719 random control participants from the general population. Of these cases, 137 had probable idiopathic PF (IPF). The ORs for smoking, gender and occupational exposure were estimated using Mantel-Haenszel analysis and conditional logistic regression, controlling for age and year of diagnosis. Results: The adverse effect of smoking was amplified by male gender and occupational exposure, OR 4.6 (95% CI 2.1 to 10.3) for PF, and OR 3.0 (1.3 to 6.5) for IPF, compared with in non-exposed women. Higher cumulative smoking exposure was linearly associated with increased risks. Compared with smoking less than 10 pack-years, smoking >= 20 pack-years was associated with increased risk of PF and IPF, OR 2.6 (1.4 to 4.9) and OR 2.5 (1.3 to 5.0), respectively. Conclusions: Smoking has a dose-related association with increased risk of severe PF. Men with a history of smoking and occupational exposure is a particular risk group for developing severe PF.

  • 18. Ekström, Nils
    et al.
    Cederholm, Jan
    Zethelius, Björn
    Eliasson, Björn
    Fhärm, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Rolandsson, Olov
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Miftaraj, Mervete
    Svensson, Ann-Marie
    Gudbjörnsdottir, Soffia
    Aspirin treatment and risk of first incident cardiovascular diseases in patients with type 2 diabetes: an observational study from the Swedish National Diabetes Register2013Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, nr 4, s. e002688-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives To investigate the benefits and risks associated with aspirin treatment in patients with type 2 diabetes and no previous cardiovascular disease (CVD) in clinical practice. Design Population-based cohort study between 2005 and 2009, mean follow-up 3.9years. Setting Hospital outpatient clinics and primary care in Sweden. Participants Men and women with type 2 diabetes, free from CVD, including atrial fibrillation and congestive heart failure, at baseline, registered in the Swedish National Diabetes Register, with continuous low-dose aspirin treatment (n=4608) or no aspirin treatment (n=14038). Main outcome measures Risks of CVD, coronary heart disease (CHD), stroke, mortality and bleedings, associated with aspirin compared with no aspirin, were analysed in all patients and in subgroups by gender and estimated cardiovascular risk. Propensity scores were used to adjust for several baseline risk factors and characteristics at Cox regression, and the effect of unknown covariates was evaluated in a sensitivity analysis. Results There was no association between aspirin use and beneficial effects on risks of CVD or death. Rather, there was an increased risk of non-fatal/fatal CHD associated with aspirin; HR 1.19 (95% CI 1.01 to 1.41), p=0.04. The increased risk of cardiovascular outcomes associated with aspirin was seen when analysing women separately; HR 1.41 (95% CI 1.07 to 1.87), p=0.02, and HR 1.28 (95% CI 1.01 to 1.61), p=0.04, for CHD and CVD, respectively, but not for men separately. There was a trend towards increased risk of a composite of bleedings associated with aspirin, n=157; HR 1.41 (95% CI 0.99 to 1.99). Conclusions The results support the trend towards more restrictive use of aspirin in patients with type 2 diabetes and no previous CVD. More research is needed to explore the differences in aspirin's effects in women and men.

  • 19.
    Enochsson, Lars
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap. Sunderby Research Unit, Luleå.
    Blohm, My
    Sandblom, Gabriel
    Jonas, Eduard
    Hallerbäck, Bengt
    Lundell, Lars
    Österberg, Johanna
    Inversed relationship between completeness of follow-up and coverage of postoperative complications in gallstone surgery and ERCP: a potential source of bias in patient registers2018Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, nr 1, artikel-id e019551Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To analyse the completeness in GallRiks of the follow-up frequency in relation to the intraoperative and postoperative outcome.

    Design: Population-based register study.

    Setting: Data from the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP), GallRiks.

    Population: All cholecystectomies and ERCPs recorded in GallRiks between 1 January 2006 and 31 December 2014.

    Main outcome measures: Outcomes for intraprocedural as well as postprocedural adverse events between units with either a 30-day follow-up of AO% compared with those with a less frequent follow-up (<90%).

    Results: Between 2006 and 2014, 162 212 cholecystectomies and ERCP procedures were registered in GallRiks. After the exclusion of non-index procedures and those with incomplete data 152 827 procedures remained for final analyses. In patients having a cholecystectomy, there were no differences regarding the adverse event rates, irrespective of the follow-up frequency. However, in the more complicated endoscopic ERCP procedures, the postoperative adverse event rates were significantly higher in those with a more frequent and complete 30-day follow-up (OR 1.92; 95% Cl 1.76 to 2.11).

    Conclusions: Differences in the follow-up frequency in registries affect the reported outcomes as exemplified by the complicated endoscopic ERCP procedures. A high and complete follow-up rate shall serve as an additional quality indicator for surgical registries.

  • 20. Feldman, Inna
    et al.
    Eurenius, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Häggstrom, Jenny
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet.
    Sampaio, Filipa
    Lindkvist, Marie
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet.
    Pulkki-Brannstrom, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Effectiveness and cost-effectiveness of the Salut Programme: a universal health promotion intervention for parents and children-protocol of a register-based retrospective observational study2016Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, nr 8, artikel-id e011202Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: There is inadequate evidence for the effectiveness and cost-effectiveness of health promotion interventions. The Salut Programme aims to reach all parents and children in the Vasterbotten County of Sweden with a combination of health promotion interventions initiated during pregnancy and continued over the childhood period. This study protocol describes an effectiveness study and an economic evaluation study, where the ongoing Salut Programme is compared to care-as-usual over the periods of pregnancy, delivery and the child's first 2 years of life. Methods: A register-based retrospective observational study design will be used with existing data sources with respect to exposures and outcomes. Outcomes of interest are clustered at 3 points: around the child's birth, 1 month after the child's birth and 2 years after the child's birth. We will simulate an experiment by retrospectively identifying and comparing children and their parents in the geographical areas where the Salut Programme was implemented since 2006 and onwards, and the areas where the Programme was not implemented before 2009. Outcomes will be analysed and compared for the premeasure period, and the postmeasure period for both groups. Our analysis combines difference-in-difference estimation with matching. A complementary analysis will be carried out on the longitudinal subsample of mothers who gave birth at least once during each of the time periods. The economic evaluation aims to capture the wider societal costs and benefits of the Salut Programme for the first 2 years of the children's lives. Incremental costs will be compared with incremental health gains and the results will be presented as a cost-consequence analysis. Ethics and dissemination: The Regional Ethical Review Board in Umea has given clearance for the Salut Programme research (2010-63-31M). No individual's identity will be revealed when presenting results. This study will provide information that can guide decision-makers to allocate resources optimally.

  • 21. Finnbjornsdottir, Ragnhildur Gudrun
    et al.
    Oudin, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Elvarsson, Bjarki Thor
    Gislason, Thorarinn
    Rafnsson, Vilhjalmur
    Hydrogen sulfide and traffic-related air pollutants in association with increased mortality: a case-crossover study in Reykjavik, Iceland2015Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, nr 4, artikel-id e007272Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: To study the association between daily mortality and short-term increases in air pollutants, both traffic-related and the geothermal source-specific hydrogen sulfide (H2S).

    DESIGN: Population-based, time stratified case-crossover. A lag time to 4 days was considered. Seasonal, gender and age stratification were calculated. Also, the best-fit lag when introducing H2S >7 µg/m(3) was selected by the Akaike Information Criterion (AIC).

    SETTING: The population of the greater Reykjavik area (n=181 558) during 2003-2009.

    PARTICIPANTS: Cases were defined as individuals living in the Reykjavik capital area, 18 years or older (N=138 657), who died due to all natural causes (ICD-10 codes A00-R99) other than injury, poisoning and certain other consequences of external causes, or cardiovascular disease (ICD-10 codes I00-I99) during the study period.

    MAIN OUTCOME MEASURE: Percentage increases in risk of death (IR%) following an interquartile range increase in pollutants.

    RESULTS: The total number of deaths due to all natural causes was 7679 and due to cardiovascular diseases was 3033. The interquartile range increased concentrations of H2S (2.6 µg/m(3)) were associated with daily all natural cause mortality in the Reykjavik capital area. The IR% was statistically significant during the summer season (lag 1: IR%=5.05, 95% CI 0.61 to 9.68; lag 2: IR%=5.09, 95% CI 0.44 to 9.97), among males (lag 0: IR%=2.26, 95% CI 0.23 to 4.44), and among the elderly (lag 0: IR%=1.94, 95% CI 0.12 to 1.04; lag 1: IR%=1.99, 95% CI 0.21 to 1.04), when adjusted for traffic-related pollutants and meteorological variables. The traffic-related pollutants were generally not associated with statistical significant IR%s.

    CONCLUSIONS: The results suggest that ambient H2S air pollution may increase mortality in Reykjavik, Iceland. To the best of our knowledge, ambient H2S exposure has not previously been associated with increased mortality in population-based studies and therefore the results should be interpreted with caution. Further studies are warranted to confirm or refute whether H2S exposure induces premature deaths.

  • 22.
    Frykholm, Erik
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Fysioterapi.
    Lima, Vanessa Pereira
    Janaudis-Ferreira, Tania
    Nyberg, Andre
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Fysioterapi.
    Physiological responses to arm versus leg activity in patients with chronic obstructive pulmonary disease: a systematic review protocol2018Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, BMJ open, Vol. 8, nr 2, s. 1-5Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Compared with healthy older adults, people with chronic obstructive pulmonary disease (COPD) have reduced capacity and increased symptoms during leg and arm activities. While the mechanisms underlying limitations and symptoms during leg activities have been investigated in detail, limitations and symptoms during arm activities are not well understood, and the potential differences between physiological responses of leg and arm activities have not been systematically synthesised. Determining physiological responses and symptoms of arm activities compared with physiological responses and symptoms of leg activities will help us understand the mechanisms behind the difficulties that people with COPD experience when performing physical activities, and determine how exercise training should be prescribed. Thus, the aim of this systematic review is to compare the physiological responses and symptoms during activities involving the arms relative to activities involving the legs in people diagnosed with COPD.

  • 23. Godbolt, Alison K.
    et al.
    Stenberg, Maud
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Rehabiliteringsmedicin.
    Jakobsson, Jan
    Sorjonen, Kimmo
    Krakau, Karolina
    Stålnacke, Britt-Marie
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Rehabiliteringsmedicin.
    DeBoussard, Catharina Nygren
    Subacute complications during recovery from severe traumatic brain injury: frequency and associations with outcome2015Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, nr 4, artikel-id e007208Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Medical complications after severe traumatic brain injury (S-TBI) may delay or prevent transfer to rehabilitation units and impact on long-term outcome.

    Objective: Mapping of medical complications in the subacute period after S-TBI and the impact of these complications on 1-year outcome to inform healthcare planning and discussion of prognosis with relatives.

    Setting: Prospective multicentre observational study. Recruitment from 6 neurosurgical centres in Sweden and Iceland.

    Participants and assessments: Patients aged 18-65 years with S-TBI and acute Glasgow Coma Scale 3-8, who were admitted to neurointensive care. Assessment of medical complications 3 weeks and 3 months after injury. Follow-up to 1 year. 114 patients recruited with follow-up at 1 year as follows: 100 assessed, 7 dead and 7 dropped out.

    Outcome measure: Glasgow Outcome Scale Extended.

    Results: 68 patients had >= 1 complication 3 weeks after injury. 3 weeks after injury, factors associated with unfavourable outcome at 1 year were: tracheostomy, assisted ventilation, on-going infection, epilepsy and nutrition via nasogastric tube or percutaneous endoscopic gastroscopy (PEG) tube (univariate logistic regression analyses). Multivariate analysis demonstrated that tracheostomy and epilepsy retained significance even after incorporating acute injury severity into the model. 3 months after injury, factors associated with unfavourable outcome were tracheostomy and heterotopic ossification (Fisher's test), infection, hydrocephalus, autonomic instability, PEG feeding and weight loss (univariate logistic regression). PEG feeding and weight loss at 3 months were retained in a multivariate model.

    Conclusions: Subacute complications occurred in two-thirds of patients. Presence of a tracheostomy or epilepsy at 3 weeks, and of PEG feeding and weight loss at 3 months, had robust associations with unfavourable outcome that were incompletely explained by acute injury severity.

  • 24. Gudnadóttir, Arna Ýr
    et al.
    Ólafsdóttir, Inga Sif
    Middelveld, Roelinde
    Ekerljung, Linda
    Forsberg, Bertil
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Franklin, Karl
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Lindberg, Eva
    Janson, Christer
    An investigation on the use of snus and its association with respiratory and sleep-related symptoms: a cross-sectional population study2017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 5, artikel-id e015486Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Studies of the health effects of moist oral tobacco, snus, have produced inconsistent results. The main objective of this study is to examine the health effects of snus use on asthma, respiratory symptoms and sleep-related problems, a field that has not been investigated before.

    METHODS AND MATERIAL: This cross-sectional study was based on a postal questionnaire completed by 26 697 (59.3%) participants aged 16 to 75 years and living in Sweden. The questionnaire included questions on tobacco use, asthma, respiratory symptoms and sleeping problems. The association of snus use with asthma, respiratory symptoms and sleep-related symptoms was mainly tested in never-smokers (n=16 082).

    RESULTS: The current use of snus in never-smokers was associated with an increased risk of asthma (OR 1.51 (95% CI 1.28 to 1.77)), asthmatic symptoms, chronic bronchitis and chronic rhinosinusitis. This association was not present among ex-snus users. Snoring was independently related to both the former and current use of snus ((OR 1.37 (95% CI 1.12 to 1.68)) and (OR 1.59 (95% CI 1.34 to 1.89), respectively)). A higher risk of difficulty inducing sleep was seen among snus users.

    CONCLUSION: Snus use was associated with a higher prevalence of asthma, respiratory symptoms and snoring. Healthcare professionals should be aware of these possible adverse effects of snus use.

  • 25.
    Hajdarevic, Senada
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Rasmussen, Birgit H
    Overgaard Hasle, Trine L
    Ziebland, Sue
    Qualitative cross-country comparison of whether, when and how people diagnosed with lung cancer talk about cigarette smoking in narrative interviews2018Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, nr 11, artikel-id e023934Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: To compare and examine whether, when and how patients with lung cancer in three countries, with different survival rates, talk about cigarette smoking and its relationship with help-seeking.

    DESIGN: A qualitative cross-country comparison with analysis of narrative interviews.

    SETTING: Participants in Sweden, Denmark and England were interviewed during 2015-2016. Interviews, using a narrative approach, were conducted in participants' home by trained and experienced qualitative researchers.

    PARTICIPANTS: Seventy-two men and women diagnosed with lung cancer were interviewed within 6 months of their diagnosis.

    RESULTS: The English participants, regardless of their own smoking status, typically raised the topic of smoking early in their interviews. Smoking was mentioned in relation to symptom appraisal and interactions with others, including health professionals. Participants in all three countries interpreted their symptoms in relation to their smoking status, but in Sweden (unlike England) there was no suggestion that this deterred them from seeking care. English participants, but not Swedish or Danish, recounted reluctance to consult healthcare professionals with their symptoms while they were still smoking, some gave up shortly before consulting. Some English patients described defensive strategies to challenge stigma or pre-empt other people's assumptions about their culpability for the disease. A quarter of the Danish and 40% of the Swedish participants did not raise the topic of smoking at any point in their interview.

    CONCLUSION: The causal relationship between smoking and lung cancer is well known in all three countries, yet this comparative analysis suggests that the links between a sense of responsibility, stigma and reluctance to consult are not inevitable. These findings help illuminate why English patients with lung cancer tend to be diagnosed at a later stage than their Swedish counterparts.

  • 26.
    Hedman, Linnéa
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Andersson, Martin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Stridsman, Caroline
    Rönmark, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Evaluation of a tobacco prevention programme among teenagers in Sweden2015Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, nr 5, artikel-id e007673Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To study the prevalence of tobacco use among teenagers, to evaluate a tobacco prevention programme and to study factors related to participation in the prevention programme. Design and setting: Population-based prospective cohort study. Method: Within the Obstructive Lung disease in Northern Sweden (OLIN) studies, a cohort study about asthma in schoolchildren started in 2006. All children aged 7-8 years in three municipalities were invited to a questionnaire survey and 2585 (96%) participated. The cohort was followed up at age 11-12 years (n=2612, 95% of invited) and 14-15 years (n=2345, 88% of invited). In 2010, some of the children in the OLIN cohort (n=447) were invited to a local tobacco prevention programme and 224 (50%) chose to participate. Results: At the age of 14-15 years, the prevalence of daily smoking was 3.5%. Factors related to smoking were female sex, having a smoking mother, participation in sports and lower parental socioeconomic status (SES). The prevalence of using snus was 3.3% and risk factors were male sex, having a smoking mother, having a snus-using father and non-participation in the prevention programme. In the prevention programme, the prevalence of tobacco use was significantly lower among the participants compared with the controls in the cohort. Factors related to non-participation were male sex, having a smoking mother, lower parental SES and participation in sports. Conclusions: The prevalence of tobacco use was lower among the participants in the tobacco prevention programme compared with the non-participants as well as with the controls in the cohort. However, the observed benefit of the intervention may be overestimated as participation was biased by selection.

  • 27.
    Holmlund, Sophia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Lan, Pham Thi
    Department of Dermatology and Venereology, Hanoi Medical University, Hanoi, Vietnam.
    Edvardsson, Kristina
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi. Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia.
    Phuc, Ho Dang
    Department of Probability and Mathematical Statistics, Institute of Mathematics, Vietnam Academy of Science and Technology, Hanoi, Vietnam.
    Ntaganira, Joseph
    School of Public Health, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda.
    Small, Rhonda
    Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia; Department of Women's and Children's and Reproductive Health, Karolinska Institutet, Stockholm, Sweden.
    Kidanto, Hussein
    Department of Obstetrics and Gynecology, Aga Khan University - Tanzania, Dar es Salaam, Tanzania.
    Ngarina, Matilda
    Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania.
    Mogren, Ingrid
    Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia.
    Health professionals’ experiences and views on obstetric ultrasound in Vietnam: a regional, cross-sectional study2019Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, artikel-id e031761Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: Obstetric ultrasound is an important part of antenatal care in Vietnam, although there are great differences in access to antenatal care and ultrasound services across the country. The aim of this study was to explore Vietnamese health professionals’ experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.

    Design: A cross-sectional questionnaire study was performed as part of the CROss Country UltraSound study.

    Setting: Health facilities (n=29) in urban, semiurban and rural areas of Hanoi region in Vietnam.

    Participants: Participants were 289 obstetricians/ gynaecologists and 535 midwives.

    Results: A majority (88%) of participants agreed that ‘every woman should undergo ultrasound examination’ during pregnancy to determine gestational age. Participants reported an average of six ultrasound examinations as medically indicated during an uncomplicated pregnancy. Access to ultrasound at participants’ workplaces was reported as always available regardless of health facility level. Most participants performing ultrasound reported high-level skills for fetal heart rate examination (70%), whereas few (23%) reported being skilled in examination of the anatomy of the fetal heart. Insufficient ultrasound training leading to suboptimal pregnancy management was reported by 37% of all participants. ‘Better quality of ultrasound machines’, ‘more physicians trained in ultrasound’ and ‘more training for health professionals currently performing ultrasound’ were reported as ways to improve the utilisation of ultrasound.

    Conclusions: Obstetric ultrasound is used as an integral part of antenatal care at all selected health facility levels in the region of Hanoi, and access was reported as high. However, reports of insufficient ultrasound training resulting in suboptimal pregnancy management indicate a need for additional training of ultraso

  • 28.
    Hultin, Magnus
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Anestesiologi och intensivvård.
    Jonsson, Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Anestesiologi och intensivvård. Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Härgestam, Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Lindkvist, Marie
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Brulin, Christine
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Reliability of instruments that measure situation awareness, team performance and task performance in a simulation setting with medical students2019Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, nr 9, artikel-id e029412Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: The assessment of situation awareness (SA), team performance and task performance in a simulation training session requires reliable and feasible measurement techniques. The objectives of this study were to test the Airways-Breathing-Circulation-Disability-Exposure (ABCDE) checklist and the Team Emergency Assessment Measure (TEAM) for inter-rater reliability, as well as the application of Situation Awareness Global Assessment Technique (SAGAT) for feasibility and internal consistency.

    DESIGN: Methodological approach.

    SETTING: Data collection during team training using full-scale simulation at a university clinical training centre. The video-recorded scenarios were rated independently by four raters.

    PARTICIPANTS: 55 medical students aged 22-40 years in their fourth year of medical studies, during the clerkship in anaesthesiology and critical care medicine, formed 23 different teams. All students answered the SAGAT questionnaires, and of these students, 24 answered the follow-up postsimulation questionnaire (PSQ). TEAM and ABCDE were scored by four professionals.

    MEASURES: The ABCDE and TEAM were tested for inter-rater reliability. The feasibility of SAGAT was tested using PSQ. SAGAT was tested for internal consistency both at an individual level (SAGAT) and a team level (Team Situation Awareness Global Assessment Technique (TSAGAT)).

    RESULTS: The intraclass correlation was 0.54/0.83 (single/average measurements) for TEAM and 0.55/0.83 for ABCDE. According to the PSQ, the items in SAGAT were rated as relevant to the scenario by 96% of the participants. Cronbach's alpha for SAGAT/TSAGAT for the two scenarios was 0.80/0.83 vs 0.62/0.76, and normed χ² was 1.72 vs 1.62.

    CONCLUSION: Task performance, team performance and SA could be purposefully measured, and the reliability of the measurements was good.

  • 29.
    Häggström, Christel
    et al.
    Umeå universitet, Medicinska fakulteten, Enheten för biobanksforskning. Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Liedberg, Fredrik
    Hagberg, Oskar
    Aljabery, Firas
    Ströck, Viveka
    Hosseini, Abolfazl
    Gårdmark, Truls
    Sherif, Amir
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Urologi och andrologi.
    Malmström, Per-Uno
    Garmo, Hans
    Jahnson, Staffan
    Holmberg, Lars
    Cohort profile: The Swedish National Register of Urinary Bladder Cancer (SNRUBC) and the Bladder Cancer Data Base Sweden (BladderBaSe)2017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 9, artikel-id e016606Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    PURPOSE: To monitor the quality of bladder cancer care, the Swedish National Register of Urinary Bladder Cancer (SNRUBC) was initiated in 1997. During 2015, in order to study trends in incidence, effects of treatment and survival of men and women with bladder cancer, we linked the SNRUBC to other national healthcare and demographic registers and constructed the Bladder Cancer Data Base Sweden (BladderBaSe).

    PARTICIPANTS: The SNRUBC is a nationwide register with detailed information on 97% of bladder cancer cases in Sweden as compared with the Swedish Cancer Register. Participants in the SNRUBC have registered data on tumour characteristics at diagnosis, and for 98% of these treatment data have been captured. From 2009, the SNRUBC holds data on 88% of eligible participants for follow-up 5 years after diagnosis of non-muscle invasive bladder cancer, and from 2011, data on surgery details and complications for 85% of participants treated with radical cystectomy. The BladderBaSe includes all data in the SNRUBC from 1997 to 2014, and additional covariates and follow-up data from linked national register sources on comorbidity, socioeconomic factors, detailed information on readmissions and treatment side effects, and causes of death.

    FINDINGS TO DATE: Studies based on data in the SNRUBC have shown inequalities in survival and treatment indication by gender, regions and hospital volume. The BladderBaSe includes 38 658 participants registered in SNRUBC with bladder cancer diagnosed from 1 January 1997 to 31 December 2014. The BladderBaSe initiators are currently in collaboration with researchers from the SNRUBC investigating different aspects of bladder cancer survival.

    FUTURE PLANS: The SNRUBC and the BladderBaSe project are open for collaborations with national and international research teams. Collaborators can submit proposals for studies and study files can be uploaded to servers for remote access and analysis. For more information, please contact the corresponding author.

  • 30.
    Häggström, Jenny
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet, Statistik.
    Sampaio, Filipa
    Eurenius, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindkvist, Marie
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet, Statistik. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Feldman, Inna
    Is the Salut Programme an effective and cost-effective universal health promotion intervention for parents and their children?: a register-based retrospective observational study2017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 9, artikel-id e016732Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: This study investigates the effectiveness and cost-effectiveness of the Salut Programme, a universal health promotion intervention, compared with care-as-usual, over the periods of pregnancy, delivery and the child's first 2 years of life.

    METHOD: We adopted a register-based retrospective observational design using existing data sources with respect to both exposures and outcomes. Health outcomes and costs were compared between geographical areas that received care-as-usual (non-Salut area) and areas where the programme was implemented (Salut area). We included mothers and their children from both the Salut and non-Salut areas if: (1) the child was born 2002-2004 (premeasure period) or (2) the child was born 2006-2008 (postmeasure period). The effectiveness study adopted two strategies: (1) a matched difference-in-difference analysis using data from all participants and (2) a longitudinal analysis restricted to mothers who had given birth twice, that is, both in the premeasure and postmeasure periods. The economic evaluation was performed from a healthcare and a limited societal perspective. Outcomes were clustered during pregnancy, delivery and birth and the child's first 2 years.

    RESULTS: Difference-in-difference analyses did not yield any significant effect on the outcomes. Longitudinal analyses resulted in significant positive improvement in Apgar scores, reflecting the newborn's physical condition, with more children having a normal Apgar score (1 min +3%, 5 min +1%). The cost of the programme was international dollar (INT$)308/child. From both costing perspectives, the programme yielded higher effects and lower costs than care-as-usual, being thus cost-saving (probability of around 50%).

    CONCLUSIONS: Our findings suggest that the Salut Programme is an effective universal intervention to improve maternal and child health, and it may be good value for money; however, there is large uncertainty around the cost estimates.

  • 31.
    Härgestam, Maria
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Anestesiologi och intensivvård.
    Lindkvist, Marie
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet, Statistik. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Brulin, Christine
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Jacobsson, Maritha
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Hultin, Magnus
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Anestesiologi och intensivvård.
    Communication in interdisciplinary teams: Exploring closed-loop communication during in situ trauma team training2013Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, nr 10, artikel-id e003525Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: Investigate the use of call-out (CO) and closed-loop communication (CLC) during a simulated emergency situation, and its relation to profession, age, gender, ethnicity, years in profession, educational experience, work experience and leadership style.

    Design: Exploratory study.

    Setting: In situ simulator-based interdisciplinary team training using trauma cases at an emergency department.

    Participants: The result was based on 16 trauma teams with a total of 96 participants. Each team consisted of two physicians, two registered nurses and two enrolled nurses, identical to a standard trauma team.

    Results: The results in this study showed that the use of CO and CLC in trauma teams was limited, with an average of 20 CO and 2.8 CLC/team. Previous participation in trauma team training did not increase the frequency of use of CLC while ≥2 structured trauma courses correlated with increased use of CLC (risk ratio (RR) 3.17, CI 1.22 to 8.24). All professions in the trauma team were observed to initiate and terminate CLC (except for the enrolled nurse from the operation theatre). The frequency of team members’ use of CLC increased significantly with an egalitarian leadership style (RR 1.14, CI 1.04 to 1.26).

    Conclusions: This study showed that despite focus on the importance of communication in terms of CO and CLC, the difficulty in achieving safe and reliable verbal communication within the interdisciplinary team remained. This finding indicates the need for validated training models combined with further implementation studies.

  • 32.
    Härgestam, Maria
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Anestesiologi och intensivvård.
    Lindkvist, Marie
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet, Statistik.
    Jacobsson, Maritha
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Brulin, Christine
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hultin, Magnus
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Anestesiologi och intensivvård.
    Trauma teams and time to early management during in situ trauma team training2016Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, nr 1, artikel-id e009911Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: To investigate the association between the time taken to make a decision to go to surgery and gender, ethnicity, years in profession, experience of trauma team training, experience of structured trauma courses and trauma in the trauma team, as well as use of closed-loop communication and leadership styles during trauma team training.

    DESIGN: In situ trauma team training. The patient simulator was preprogrammed to represent a severely injured patient (injury severity score: 25) suffering from hypovolemia due to external trauma.

    SETTING: An emergency room in an urban Scandinavian level one trauma centre.

    PARTICIPANTS: A total of 96 participants were divided into 16 trauma teams. Each team consisted of six team members: one surgeon/emergency physician (designated team leader), one anaesthesiologist, one registered nurse anaesthetist, one registered nurse from the emergency department, one enrolled nurse from the emergency department and one enrolled nurse from the operating theatre.

    PRIMARY OUTCOME: HRs with CIs (95% CI) for the time taken to make a decision to go to surgery was computed from a Cox proportional hazards model.

    RESULTS: Three variables remained significant in the final model. Closed-loop communication initiated by the team leader increased the chance of a decision to go to surgery (HR: 3.88; CI 1.02 to 14.69). Only 8 of the 16 teams made the decision to go to surgery within the timeframe of the trauma team training. Conversely, call-outs and closed-loop communication initiated by the team members significantly decreased the chance of a decision to go to surgery, (HR: 0.82; CI 0.71 to 0.96, and HR: 0.23; CI 0.08 to 0.71, respectively).

    CONCLUSIONS: Closed-loop communication initiated by the leader appears to be beneficial for teamwork. In contrast, a high number of call-outs and closed-loop communication initiated by team members might lead to a communication overload.

  • 33. Ji, Jiadong
    et al.
    Yuan, Zhongshang
    Zhang, Xiaoshuai
    Li, Fangyu
    Xu, Jing
    Liu, Ying
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Li, Hongkai
    Wang, Jia
    Xue, Fuzhong
    Detection for pathway effect contributing to disease in systems epidemiology with a case-control design2015Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, nr 1, s. e006721-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: Identification of pathway effects responsible for specific diseases has been one of the essential tasks in systems epidemiology. Despite some advance in procedures for distinguishing specific pathway (or network) topology between different disease status, statistical inference at a population level remains unsolved and further development is still needed. To identify the specific pathways contributing to diseases, we attempt to develop powerful statistics which can capture the complex relationship among risk factors. Setting and participants: Acute myeloid leukaemia (AML) data obtained from 133 adults (98 patients and 35 controls; 47% female). Results: Simulation studies indicated that the proposed Pathway Effect Measures (PEM) were stable; bootstrap-based methods outperformed the others, with bias-corrected bootstrap CI method having the highest power. Application to real data of AML successfully identified the specific pathway (Treg -> TGF beta -> Th17) effect contributing to AML with p values less than 0.05 under various methods and the bias-corrected bootstrap CI (-0.214 to -0.020). It demonstrated that Th17-Treg correlation balance was impaired in patients with AML, suggesting that Th17-Treg imbalance potentially plays a role in the pathogenesis of AML. Conclusions: The proposed bootstrap-based PEM are valid and powerful for detecting the specific pathway effect contributing to disease, thus potentially providing new insight into the underlying mechanisms and ways to study the disease effects of specific pathways more comprehensively.

  • 34. Karjala, Jaana
    et al.
    Eriksson, Staffan
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Fysioterapi. Centre for Clinical Research Sörmland, Uppsala University, Sweden; Department of Neuroscience, Physiotherapy, Uppsala University, Sweden.
    Inter-rater reliability between nurses for a new paediatric triage system based primarily on vital parameters: the Paediatric Triage Instrument (PETI)2017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 2, artikel-id e012748Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: The major paediatric triage systems are primarily based on flow charts involving signs and symptoms for orientation and subjective estimates of the patient's condition. In contrast, the 4-level Paediatric Triage Instrument (PETI) is primarily based on vital parameters and was developed exclusively for paediatric triage in patients with medical symptoms. The aim of this study was to assess the inter-rater reliability of this triage system in children when used by nurses.

    Methods: A design was employed in which triage was performed simultaneously and independently by a research nurse and an emergency department (ED) nurse using the PETI. All patients aged <= 12 years who presented at the ED with a medical symptom were considered eligible for participation.

    Results: The 89 participants exhibited a median age of 2 years and were triaged by 28 different nurses. The inter-rater reliability between nurses calculated with the quadratic-weighted kappa was 0.78 (95% CI 0.67 to 0.89); the linear-weighted kappa was 0.67 (95% CI 0.56 to 0.80) and the unweighted kappa was 0.59 (95% CI 0.44 to 0.73). For the patients aged <1, 1-3 and >3 years, the quadratic-weighted kappa values were 0.67 (95% CI 0.39 to 0.94), 0.86 (95% CI 0.75 to 0.97) and 0.73 (95% CI 0.49 to 0.97), respectively. The median triage duration was 6 min.

    Conclusions: The PETI exhibited substantial reliability when used in children aged <= 12 years and almost perfect reliability among children aged 1-3 years. Moreover, rapid application of the PETI was demonstrated. This study has some limitations, including sample size and generalisability, but the PETI exhibited promise regarding reliability, and the next step could be either a larger reliability study or a validation study.

  • 35. Kastbom, Alf
    et al.
    Coster, Lars
    Ärlestig, Lisbeth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Reumatologi.
    Chatzidionysiou, Aikaterini
    van Vollenhoven, Ronald F.
    Padyukov, Leonid
    Rantapää-Dahlqvist, Solbritt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Reumatologi.
    Saevarsdottir, Saedis
    Influence of FCGR3A genotype on the therapeutic response to rituximab in rheumatoid arthritis: an observational cohort study2012Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 2, nr 5, s. e001524-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To determine whether a polymorphism in the Fc gamma receptor type IIIA (FCGR3A-F158V), influencing immunoglobulin G binding affinity, relates to the therapeutic efficacy of rituximab in rheumatoid arthritis (RA) patients. Design: Observational cohort study. Setting: Three university hospital rheumatology units in Sweden. Participants: Patients with established RA (n=177; 145 females and 32 males) who started rituximab (Mabthera) as part of routine care. Primary outcome measures: Response to rituximab therapy in relation to FCGR3A genotype, including stratification for sex. Results: The frequency of responders differed significantly across FCGR3A genotypes (p=0.017 in a 3x2 contingency table). Heterozygous patients showed the highest response rate at 83%, as compared with patients carrying 158FF (68%) or 158VV (56%) (p=0.028 and 0.016, respectively). Among 158VV patients, response rates differed between male and female patients (p=0.036), but not among 158FF or 158VF patients (p=0.72 and 0.46, respectively). Conclusions: Therapeutic efficacy of rituximab in RA patients is influenced by FCGR3A genotype, with the highest response rates found among heterozygous patients. This may suggest that different rituximab mechanisms of action in RA are optimally balanced in FCGR3A-158VF patients. Similar to the previously described associations with RA susceptibility and disease course, the impact of 158VV on rituximab response may be influenced by sex.

  • 36. Klevebro, S.
    et al.
    Lundgren, P.
    Hammar, U.
    Smith, L. E.
    Bottai, M.
    Domellöf, Magnus
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik.
    Lofqvist, C.
    Hallberg, B.
    Hellstrom, A.
    Cohort study of growth patterns by gestational age in preterm infants developing morbidity2016Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, nr 11, artikel-id e012872Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives To examine differences in growth patterns in preterm infants developing major morbidities including retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), necrotising enterocolitis (NEC) and intraventricular haemorrhage (IVH).

    Study design Cohort study of 2521 infants born at a gestational age (GA) of 23–30 weeks from 11 level III neonatal intensive care units in USA and Canada, and 3 Swedish population-based cohorts.

    Outcomes Birth weight and postnatal weight gain were examined relative to birth GA and ROP, BPD, NEC and IVH development.

    Results Among infants with a birth GA of 25–30 weeks, birth weight SD score and postnatal weight were lower in those developing ROP and BPD. Infants developing ROP showed lower growth rates during postnatal weeks 7–9 in the 23–24 weeks GA group, during weeks 4–6 in the 25–26 weeks GA group and during weeks 1–5 in the 27–30 weeks GA group. Infants with BPD born at 27–30 weeks GA showed lower growth rates during postnatal weeks 3–5. Infants with NEC had lower growth rates after postnatal week 6 in all GA groups, with no significant differences in birth weight SD score. IVH was not associated with prenatal or postnatal growth.

    Conclusions In this cohort study of extremely preterm infants, we found that the postnatal growth pattern was associated with morbidities such as ROP, BPD and NEC as well as with gestational age at birth.

  • 37.
    Kriit, Hedi Katre
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för hållbar hälsa.
    Stewart Williams, Jennifer
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Forsberg, Bertil
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för hållbar hälsa.
    Sommar, Johan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för hållbar hälsa.
    Health economic assessment of a scenario to promote bicycling as active transport in Stockholm, Sweden2019Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, nr 9, artikel-id e030466Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: To conduct a health economic evaluation of a proposed investment in urban bicycle infrastructure in Stockholm County, Sweden.

    DESIGN: A cost-effectiveness analysis is undertaken from a healthcare perspective. Investment costs over a 50-year life cycle are offset by averted healthcare costs and compared with estimated long-term impacts on morbidity, quantified in disability-adjusted life years (DALYs). The results are re-calculated under different assumptions to model the effects of uncertainty.

    SETTING: The Municipality of Stockholm (population 2.27 million) committed funds for bicycle path infrastructure with the aim of achieving a 15% increase in the number of bicycle commuters by 2030. This work is based on a previously constructed scenario, in which individual registry data on home and work address and a transport model allocation to different modes of transport identified 111 487 individuals with the physical capacity to bicycle to work within 30 min but that currently drive a car to work.

    RESULTS: Morbidity impacts and healthcare costs attributed to increased physical activity, change in air pollution exposure and accident risk are quantified under the scenario. The largest reduction in healthcare costs is attributed to increased physical activity and the second largest to reduced air pollution exposure among the population of Greater Stockholm. The expected net benefit from the investment is 8.7% of the 2017 Stockholm County healthcare budget, and 3.7% after discounting. The economic evaluation estimates that the intervention is cost-effective and each DALY averted gives a surplus of €9933. The results remained robust under varied assumptions pertaining to reduced numbers of additional bicycle commuters.

    CONCLUSION: Investing in urban infrastructure to increase bicycling as active transport is cost-effective from a healthcare sector perspective.

  • 38. Kufe, Nyuyki Clement
    et al.
    Masemola, Maphoko
    Chikowore, Tinashe
    Kengne, Andre Pascal
    Olsson, Tommy
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Goedecke, Julia H.
    Micklesfield, Lisa K.
    Protocol for systematic review and meta-analysis of sex hormones and diabetes risk in ageing men and women of African ancestry2019Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, nr 1, artikel-id e024446Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Aim: To present the protocol of a systematic review and meta-analysis of the available evidence examining the association between sex hormones and type 2 diabetes risk in ageing men and women of African descent.

    Methods: We shall conduct a comprehensive search of published studies that examined the association between sex hormones and type 2 diabetes risk in men and women aged ≥40 years from 01/01/1980 to 31/03/2018 with no language restriction. Databases to be searched include: PubMed, Scopus, Cochrane Library, Cumulative Index to Nursing and Allied Health, ISI Web of Science, Clinical Trial registries, Google Scholar and institutional websites such as the WHO, American Diabetes Association, International Diabetes Federation, World Diabetes Foundation, European Association for the Study of Diabetes, African Journal Online and ProQuest databases. This protocol is developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. Independent screening for eligible studies using defined criteria and data extraction, will be completed in duplicate. Discrepancies will be resolved by consensus or consultation with a third researcher. Risk of bias of included studies will be assessed by the appropriate Cochrane risk of bias tool. The overall association estimates will be pooled using appropriate meta-analytic techniques. Heterogeneity will be assessed using Cochrane Q statistic and the inconsistency index (I2). The random effects model will be used to calculate a pooled estimate.

    Ethics and dissemination: No ethics clearance is required as no primary data will be collected. The systematic review and meta-analysis are part of a PhD project at WITS University (Johannesburg, South Africa) and results will be presented at conferences and published in a peer-review journal. The results will guide future population specific interventions.

  • 39.
    Larsson, Nirina
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Lungmedicin.
    Rankin, Gregory D.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Lungmedicin.
    Bicer, Elif M.
    Roos-Engstrand, Ester
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Lungmedicin.
    Pourazar, Jamshid
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Lungmedicin.
    Blomberg, Anders
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Lungmedicin.
    Mudway, Ian S.
    Behndig, Annelie F.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Lungmedicin.
    Identification of vitamin C transporters in the human airways: a cross-sectional in vivo study2015Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, nr 4, artikel-id e006979Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: Vitamin C is an important low-molecular weight antioxidant at the air-lung interface. Despite its critical role as a sacrificial antioxidant, little is known about its transport into the respiratory tract lining fluid (RTLF), or the underlying airway epithelial cells. While several vitamin C transporters have been identified, such as sodium-ascorbate cotransporters (SVCT1/2) and glucose transporters (GLUTs), the latter transporting dehydroascorbate, knowledge of their protein distribution within the human lung is limited, in the case of GLUTs or unknown for SVCTs.

    Setting and participants: Protein expression of vitamin C transporters (SVCT1/2 and GLUT1-4) was examined by immunohistochemistry in endobronchial biopsies, and by FACS in airway leucocytes from lavage fluid, obtained from 32 volunteers; 16 healthy and 16 mild asthmatic subjects. In addition, antioxidant concentrations were determined in RTLF. The study was performed at one Swedish centre.

    Primary and secondary outcome measures: The primary outcome measure was to establish the location of vitamin C transporters in the human airways. As secondary outcome measures, RTLF vitamin C concentration was measured and related to transporter expression, as well as bronchial epithelial inflammatory and goblet cells numbers.

    Results: Positive staining was identified for SVCT1 and 2 in the vascular endothelium. SVCT2 and GLUT2 were present in the apical bronchial epithelium, where SVCT2 staining was predominately localised to goblet cells and inversely related to RTLF vitamin C concentrations.

    Conclusions: This experimental study is the first to demonstrate protein expression of GLUT2 and SVCT2 in the human bronchial epithelium. A negative correlation between SVCT2-positive goblet cells and bronchial RTLF vitamin C concentrations suggests a possible role for goblet cells in regulating the extracellular vitamin C pool.

  • 40. Lekander, Ingrid
    et al.
    Willers, Carl
    Ekstrand, Elisabeth
    von Euler, Mia
    Fagervall-Yttling, Birgitta
    Henricson, Lena
    Kostulas, Konstantinos
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Sunnerhagen, Katharina S.
    Teichert, Jorg
    Pessah-Rasmussen, Helene
    Hospital comparison of stroke care in Sweden: a register-based study2017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 9, artikel-id e015244Artikel i tidskrift (Refereegranskat)
    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.

  • 41.
    Lilja, Aina
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    DeMarinis, Valerie
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Department of Theology, Psychology of Religion and Cultural Psychology, Uppsala University, Uppsala, Sweden; Mental Health Division, Innlandet Hospital Trust, Hamar, Norway.
    Lehti, Arja
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Professionell utveckling.
    Forssén, Annika
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Experiences and explanations of mental ill health in a group of devout Christians from the ethnic majority population in secular Sweden: a qualitative study2016Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, nr 10, artikel-id e011647Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: To explore existential meaning-making in an ethnic-majority subgroup with mental ill health and to increase knowledge about the importance of gaining access to such information in mental healthcare.

    DESIGN: Qualitative study using in-depth interviews and systematic text condensation analysis.

    PARTICIPANTS: 17 devote Christians with an ethnic-Swedish background, 12 women and 5 men, 30-73 years old, from different congregations across Sweden, having sought medical care for mental ill health of any kind.

    SETTING: The secular Swedish society.

    RESULTS: A living, although asymmetric, relationship with God often was seen as the most important relationship, giving hope and support when ill, but creating feelings of abandonment and fear if perceived as threatened. Symptoms were interpreted through an existential framework influenced by their view of God. A perceived judging God increased feelings of guilt, sinfulness and shame. A perceived merciful God soothed symptoms and promoted recovery. Existential consequences, such as being unable to pray or participate in congregational rituals, caused feelings of 'spiritual homelessness'. Participants gave biopsychosocial explanations of their mental ill health, consonant with and sometimes painfully conflicting with existential explanations, such as being attacked by demons. Three different patterns of interaction among biopsychosocial and existential dimensions in their explanatory systems of illness causation were identified: (a) comprehensive thinking and consensus; (b) division and parallel functions and (c) division and competitive functions.

    CONCLUSIONS: Prevailing medical models for understanding mental ill health do not include the individual's existential experiences, which are important for identifying risk and protective factors as well as possible resources for recovery. The various expressions of existential meaning-making identified in this devout religious subgroup illustrate that existential information cannot be generalised, even within a small, seemingly homogenous group. The three identified patterns of interactions formed a typology that may be of use in clinical settings.

  • 42. MacArtney, John
    et al.
    Malmström, Marlene
    Overgaard Nielsen, Trine
    Evans, Julie
    Bernhardson, Britt-Marie
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Chapple, Alison
    Eriksson, Lars E.
    Locock, Louise
    Rasmussen, Birgit
    Vedsted, Peter
    Tishelman, Carol
    Sand Andersen, Rikke
    Ziebland, Sue
    Patients’ initial steps to cancer diagnosis in Denmark, England and Sweden: what can a qualitative, cross-country comparison of narrative interviews tell us about potentially modifiable factors?2017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 11, artikel-id e018210Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives To illuminate patterns observed in International Cancer Benchmarking Programme studies by extending understanding of the various influences on presentation and referral with cancer symptoms.

    Design Cross-country comparison of Denmark, England and Sweden with qualitative analysis of in-depth interview accounts of the prediagnostic process in lung or bowel cancer.

    Participants 155 women and men, aged between 35 and 86 years old, diagnosed with lung or bowel cancer in 6 months before interview.

    Setting Participants recruited through primary and secondary care, social media and word of mouth. Interviews collected by social scientists or nurse researchers during 2015, mainly in participants’ homes.

    Results Participants reported difficulties in interpreting diffuse bodily sensations and symptoms and deciding when to consult. There were examples of swift referrals by primary care professionals in all three countries. In all countries, participants described difficulty deciding if and when to consult, highlighting concerns about access to general practitioner appointments and overstretched primary care services, although this appears less prominent in the Swedish data. It was not unusual for there to be more than one consultation before referral and we noted two distinct patterns of repeated consultation: (1) situations where the participant left the primary care consultation with a plan of action about what should happen next; (2) participants were unclear about under which conditions to return to the doctors. This second pattern sometimes extended over many weeks during which patients described uncertainty, and sometimes frustration, about if and when they should return and whether there were any other feasible investigations. The latter pattern appeared more evident in the interviews in England and Denmark than Sweden.

    Conclusion We suggest that if clear action plans, as part of safety netting, were routinely used in primary care consultations then uncertainty, false reassurance and the inefficiency and distress of multiple consultations could be reduced.

  • 43. Magnusson, Peter
    et al.
    Mörner, Stellan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Kardiologi.
    EvaLuation Using Cardiac Insertable Devices And TelephonE in Hypertrophic Cardiomyopathy (ELUCIDATE HCM) – rationale and design: a prospective observational study on incidence of arrhythmias in Sweden2017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 12, artikel-id e019541Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: Hypertrophic cardiomyopathy (HCM) is a heterogeneous disease associated with sudden cardiac death (SCD) mainly due to ventricular tachycardia (VT) or fibrillation even though life-threatening bradycardia occurs. Risk stratification takes several variables into consideration including non-sustained VT (NSVT). An implantable cardioverter defibrillator effectively prevents SCD. Atrial fibrillation (AF) is common among patients with HCM and warrants anticoagulation even without conventional risk factors according to European guidelines. Routinely, the evaluation of arrhythmias using a 48-hour ambulatory external monitor takes place every 6-24 months if patients do not report palpitations. The remaining time the potential burden arrhythmia is unknown. Therefore, the aim of the present study is to assess NSVT and AF incidence during 18 months by an insertable cardiac monitor (ICM).

    Methods: Adult patients, aged 18-65 years, with a validated diagnosis of HCM are eligible for the study. The study sample is planned to include 30 patients. A Confirm Rx is implanted at the level of the fourth rib on the left side subcutaneously after local anaesthesia. The application for monitoring is installed in the patients' smartphone and symptoms registered by the patient activation and VT detection programmed as 160 bpm during >= 8 intervals. An AF episode is recorded based on >= 2 min duration. Bradycardia is recorded at <= 40 bpm or pause >= 3.0 s. The patients are followed during 18 months before explant.

    Ethics and dissemination: The study was approved by The Regional Ethical Committee in Umea (protocol number 2017/13-31). The study protocol, including variables and prespecified research questions, the study was registered at Clinical Trial Registration NCT03259113. Each patient is informed about the study in both oral and written form by a physician and included after written consent.

  • 44. Manousou, Sofia
    et al.
    Johansson, Birgitta
    Chmielewska, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik. Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland.
    Eriksson, Janna
    Gutefeldt, Kerstin
    Tornhage, Carl-Johan
    Eggertsen, Robert
    Malmgren, Helge
    Hulthen, Lena
    Domellöf, Magnus
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik.
    Nyström Filipsson, Helena
    Role of iodine-containing multivitamins during pregnancy for children’s brain function: protocol of an ongoing randomised controlled trial: the SWIDDICH study2018Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, nr 4, artikel-id e019945Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: Iodine is essential for normal brain development. Moderate and severe fetal iodine deficiency results in substantial to serious developmental delay in children. Mild iodine deficiency in pregnancy is associated with neurodevelopmental deficits in the offspring, but evidence from randomised trials is lacking. The aim of the Swedish Iodine in Pregnancy and Development in Children study is to determine the effect of daily supplementation with 150 µg iodine during pregnancy on the offspring’s neuropsychological development up to 14 years of age.

    Methods and analysis: Thyroid healthy pregnant women (n=1275: age range 18–40 years) at ≤12 weeks gestation will be randomly assigned to receive multivitamin supplements containing 150 µg iodine or non-iodine-containing multivitamin daily throughout pregnancy. As a primary outcome, IQ will be measured in the offspring at 7 years (Wechsler Intelligence Scale for Children-V). As secondary outcomes, IQ will be measured at 3.5 and 14 years, psychomotor development at 18 months and 7 years, and behaviour at 3.5, 7 and 14 years. Iodine status (urinary iodine concentration) will be measured during pregnancy and in the offspring at 3.5, 7 and 14 years. Thyroid function (thyroid hormones, thyroglobulin), and deiodinase type 2 polymorphisms will be measured during pregnancy and in the offspring at 7 and 14 years. Structural MRI or other relevant structural or functional brain imaging procedures will be performed in a subgroup of children at 7 and 14 years. Background and socioeconomic information will be collected at all follow-up times.

    Ethics and dissemination: This study is approved by the Ethics Committee in Göteborg, Sweden (Diary numbers: 431-12 approved 18 June 2012 (pregnancy part) and 1089-16 approved 8 February 2017 (children follow-up)). According to Swedish regulations, dietary supplements are governed by the National Food Agency and not by the Medical Product Agency. Therefore, there is no requirement for a monitoring committee and the National Food Agency does not perform any audits of trial conduct. The trial will be conducted in accordance with the Declaration of Helsinki. The participating sites will be contacted regarding important protocol changes, both orally and in writing, and the trial registry database will be updated accordingly. Study results will be presented at relevant conferences, and submitted to peer-reviewed journals with open access in the fields of endocrinology, paediatrics and nutrition. After the appropriate embargo period, the results will be communicated to participants, healthcare professionals at the maternal healthcare centres, the public and other relevant groups, such as the national guideline group for thyroid and pregnancy and the National Food Agency.

  • 45.
    Martinsson, Lisa
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Fürst, Carl Johan
    Lundström, Staffan
    Nathanaelsson, Lena
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Axelsson, Bertil
    Registration in a quality register: a method to improve end-of-lifecare—a cross-sectional study2012Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 2, nr 4, artikel-id e001328Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: Structured methods to assess and support improvement in the quality of end-of-life care are lacking and need to be developed. This need is particularly high outside the specialised palliative care. This study examines whether participation in a national quality register increased the quality of end-of-life care.

    DESIGN: This study is a cross-sectional longitudinal register study.

    SETTING: The Swedish Register of Palliative Care (SRPC) collects data about end-of-life care for deaths in all types of healthcare units all over Sweden. Data from all 503 healthcare units that had reported patients continuously to the register during a 3-year period were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES: Data on provided care during the last weeks of life were compared year-by-year with logistic regression.

    PARTICIPANTS: The study included a total 30 283 patients. The gender distribution was 54% women and 46% men. A total of 60% of patients in the study had a cancer diagnosis.

    RESULTS: Provided end-of-life care improved in a number of ways. The prevalence of six examined symptoms decreased. The prescription of 'as needed' medications for pain, nausea, anxiety and death rattle increased. A higher proportion of patients died in their place of preference. The patient's next of kin was more often offered a follow-up appointment after the patient's death. No changes were seen with respect to providing information to the patient or next of kin.

    CONCLUSIONS: Participation in a national quality register covariates with quality improvements in end-of-life care over time.

  • 46.
    Mathias, Kaaren
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. New Delhi, India .
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kermode, Michelle
    Victoria, Australia.
    Singh, Lawrence
    Uttarakhand, India.
    Shidhaye, Rahul
    New Delhi, India.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Cross-sectional study of depression and help-seeking in Uttarakhand, North India2015Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, nr 11, artikel-id e008992Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: This study sought to use a population-based cross-sectional survey to describe depression prevalence, healthcare seeking and associations with socioeconomic determinants in a district in North India.

    SETTING: This study was conducted in Sahaspur and Raipur, administrative blocks of Dehradun district, Uttarakhand, in July 2014.

    PARTICIPANTS: A population-based sample of 960 people over the age of 18 years was selected in 30 randomised clusters after being stratified by rural:urban census ratios.

    PRIMARY OUTCOME MEASURES: The survey used a validated screening tool, Patient Health Questionnaire, to identify people with depression, and collected information regarding socioeconomic variables and help-seeking behaviours. Depression prevalence and health seeking behaviours were calculated, and multivariable logistic regression was used to assess associations between risk factors and depression.

    RESULTS: Prevalence of depression was 6% (58/960), with a further 3.9% (37/960) describing a depressive episode of over 2 weeks in the past 12 months. Statistically significant adjusted OR for depression of more than 2 were found for people who were illiterate, classified as Scheduled Caste/Tribe or Other Backward Castes, living in temporary material housing and who had recently taken a loan. While over three quarters of people with depression (79%) had attended a private or government general medical practitioner in the past 3 months, none had received talking therapy (100% treatment gap) and two people (3.3%) had been prescribed antidepressants.

    CONCLUSIONS: There are clear associations between social, educational and economic disadvantage and depression in this population. Strategies that address the social determinants of depression, such as education, social exclusion, financial protection and affordable housing for all are indicated. To address the large treatment gap in Uttarakhand, we must ensure access to primary and secondary mental health providers who can recognise and appropriately manage depression.

  • 47. Mazzocato, Pamela
    et al.
    Stenfors-Hayes, Terese
    von Thiele Schwarz, Ulrica
    Hasson, Henna
    Nyström, Monica Elisabeth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kaizen practice in healthcare: a qualitative analysis of hospital employees' suggestions for improvement2016Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, nr 7, artikel-id e012256Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: Kaizen, or continuous improvement, lies at the core of lean. Kaizen is implemented through practices that enable employees to propose ideas for improvement and solve problems. The aim of this study is to describe the types of issues and improvement suggestions that hospital employees feel empowered to address through kaizen practices in order to understand when and how kaizen is used in healthcare.

    METHODS: We analysed 186 structured kaizen documents containing improvement suggestions that were produced by 165 employees at a Swedish hospital. Directed content analysis was used to categorise the suggestions into following categories: type of situation (proactive or reactive) triggering an action; type of process addressed (technical/administrative, support and clinical); complexity level (simple or complex); and type of outcomes aimed for (operational or sociotechnical). Compliance to the kaizen template was calculated.

    RESULTS: 72% of the improvement suggestions were reactions to a perceived problem. Support, technical and administrative, and primary clinical processes were involved in 47%, 38% and 16% of the suggestions, respectively. The majority of the kaizen documents addressed simple situations and focused on operational outcomes. The degree of compliance to the kaizen template was high for several items concerning the identification of problems and the proposed solutions, and low for items related to the test and implementation of solutions.

    CONCLUSIONS: There is a need to combine kaizen practices with improvement and innovation practices that help staff and managers to address complex issues, such as the improvement of clinical care processes. The limited focus on sociotechnical aspects and the partial compliance to kaizen templates may indicate a limited understanding of the entire kaizen process and of how it relates to the overall organisational goals. This in turn can hamper the sustainability of kaizen practices and results.

  • 48.
    Molin, Jenny
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Lindgren, Britt-Marie
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hällgren Graneheim, Ulla
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Ringnér, Anders
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik.
    Does 'Time Together' increase quality of interaction and decrease stress?: A study protocol of a multisite nursing intervention in psychiatric inpatient care, using a mixed method approach2017Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 8, artikel-id e015677Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: Despite the long-known significance of the nurse–patient relationship, research in psychiatric inpatient care still reports unfulfilled expectations of, and difficulties in, interactions and relationships between patients and staff. Interventions that create structures to allow quality interactions between patients and staff are needed to solve these problems. The aim of this project is to test effects of the nursing intervention Time Together and to evaluate the intervention process.

    Methods and analysis: This is a multisite study with a single-system experimental design using frequent measures. The primary outcomes are quality interactions for patients and perceived stress for staff. Secondary outcomes are levels of symptoms of anxiety and depression for patients and stress of conscience for staff. A process evaluation is performed to describe contextual factors and experiences. Data are collected using questionnaires, participant observations and semistructured interviews. For analysis of quantitative data, both visual and statistical methods will be used. Qualitative data will be analysed using qualitative content analysis.

    Ethics and dissemination: Ethical approval was granted by the Ethical Review Board in the region (Dnr 2016/339-31). The findings will contribute to the development of nursing interventions in general, but more specifically to the development of the intervention. This is relevant both nationally and internationally as similar interventions are needed but sparse. The findings will be disseminated through conference presentations and peer-reviewed publications.

  • 49. Mosson, Rebecca
    et al.
    von Thiele Schwarz, Ulrica
    Hasson, Henna
    Lundmark, Robert
    Department of Learning, Informatics, Management and Ethics, Procome Research Group, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.
    Richter, Anne
    How do iLead? Validation of a scale measuring active and passive implementation leadership in Swedish healthcare2018Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, nr 6, artikel-id e021992Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: This study aims to describe the creation of a scale-the iLead scale-through adaptations of existing domain-specific scales that measure active and passive implementation leadership, and to describe the psychometric properties of this scale.

    METHODS: Data collected from a leadership intervention were used in this validation study. Respondents were 336 healthcare professionals (90% female and 10% male; mean age 47 years) whose first-line and second-line managers participated in the intervention. The data were collected in the Stockholm regional healthcare organisation that offer primary, psychiatric, rehabilitation and acute hospital care, among other areas. The items for measuring implementation leadership were based on existent research and the full-range leadership model. Confirmatory factor analysis was performed to evaluate the dimensionality of the scale, followed by tests for reliability and convergent, discriminant and criterion-related validity using correlations and multilevel regression analyses.

    RESULTS: The final scale consists of 16 items clustered into four subscales representing active implementation leadership, and one scale signifying passive implementation leadership. Findings showed that the hypothesised model had an acceptable model fit (χ2(99)=382.864**, Comparative Fit Index=0.935, Tucker-Lewis Index=0.911, root mean square error of approximation=0.059). The internal consistency and convergent, discriminant and criterion-related validity were all satisfactory.

    CONCLUSIONS: The iLead scale is a valid measure of implementation leadership and is a tool for understanding how active and passive leader behaviours influence an implementation process. This brief scale may be particularly valuable to apply in training focusing on facilitating implementation, and in evaluating leader training. Moreover, the scale can be useful in evaluating various leader behaviours associated with implementation success or failure.

  • 50.
    Nordberg, Gunnar F
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Lundström, Nils-Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Forsberg, Bertil
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Hagenbjörk-Gustafsson, Annika
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Lagerkvist, Birgitta J-Son
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Nilsson, Johan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Svensson, Mona
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Blomberg, Anders
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Lungmedicin.
    Nilsson, Leif
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin. Umeå universitet, Teknisk-naturvetenskapliga fakulteten, Institutionen för matematik och matematisk statistik.
    Bernard, Alfred
    Dumont, Xavier
    Bertilsson, Helen
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Eriksson, Kåre
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Lung function in volunteers before and after exposure to trichloramine in indoor pool environments and asthma in a cohort of pool workers2012Ingår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 2, nr 5, s. e000973-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: Exposure to trichloramine (NCl(3)) in indoor swimming-pool environments is known to cause mucous membrane irritation, but if it gives rise to changes in lung function or asthma in adults is not known. (1) We determined lung function in volunteers before and after exposure to indoor pool environments. (2) We studied the occurrence of respiratory symptoms and asthma in a cohort of pool workers.

    DESIGN/METHODS/PARTICIPANTS: (1) We studied two groups of volunteers, 37 previously non-exposed healthy persons and 14 pool workers, who performed exercise for 2 h in an indoor pool environment. NCl(3) in air was measured during pool exposures and in 10 other pool environments. Filtered air exposures were used as controls. Lung function and biomarkers of pulmonary epithelial integrity were measured before and after exposure. (2) We mailed a questionnaire to 1741 persons who indicated in the Swedish census 1990 that they worked at indoor swimming-pools.

    RESULTS: (1) In previously non-exposed volunteers, statistically significant decreases in FEV(1) (forced expiratory volume) and FEV(%) (p=0.01 and 0.05, respectively) were found after exposure to pool air (0.23 mg/m(3) of NCl(3)). In pool workers, a statistically significant decrease in FEV(%) (p=0.003) was seen (but no significant change of FEV(1))(.) In the 10 other pool environments the median NCl(3) concentration was 0.18 mg/m(3). (2) Our nested case/control study in pool workers found an OR for asthma of 2.31 (95% CI 0.79 to 6.74) among those with the highest exposure. Exposure-related acute mucous membrane and respiratory symptoms were also found.

    CONCLUSIONS: This is the first study in adults showing statistically significant decreases in lung function after exposure to NCl(3). An increased OR for asthma among highly exposed pool workers did not reach statistical significance, but the combined evidence supports the notion that current workroom exposures may contribute to asthma development. Further research on sensitive groups is warranted.

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