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  • 1.
    Andersson, Jonas
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Johansson, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Ladenvall, Per
    Wiklund, Per-Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jern, Christina
    Boman, Kurt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    C-reactive protein is a determinant of first-ever stroke: prospective nested case-referent study2009In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 27, no 6, p. 544-551Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: C-reactive protein (CRP) is a determinant of stroke, but there are no prospective studies on CRP and first ischemic stroke divided into etiologic subtypes. Our primary aim was to study CRP as a determinant of ischemic stroke, classified according to Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria, and intracerebral hemorrhage (ICH) in a prospective study. A secondary aim was to study the relationship between the 1444C>T polymorphism, plasma levels of CRP and stroke.

    METHODS: The study was a prospective population-based case-referent study nested within the Northern Sweden Cohorts. We defined 308 cases of ischemic stroke and 61 ICH. Two controls for each case were defined from the same cohort.

    RESULTS: The OR for the highest (>3 mg/l) versus lowest group (<1 mg/l) of CRP was 2.58 (95% CI 1.74-3.84) for ischemic stroke and 1.63 (95% CI 0.67-3.93) for ICH. In a multivariate model including traditional risk factors, CRP remained associated with ischemic stroke (OR 2.06; 95% CI 1.29-3.29). Small-vessel disease was associated with CRP in the multivariate model (OR 3.88; 95% CI 1.10-13.7). The CRP 1444 (CC/CT vs. TT) polymorphism was associated with plasma levels of CRP but neither with ischemic stroke nor with ICH.

    CONCLUSIONS: This prospective population-based study shows that CRP is significantly associated with the risk of having a first ischemic stroke, especially for small-vessel disease. No significant associations were found between the CRP 1444C>T polymorphism and any stroke subtype.

  • 2. Appelros, Peter
    et al.
    Jonsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asberg, Signild
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asberg, Kerstin Hulter
    Norrving, Bo
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terent, Andreas
    Trends in Stroke Treatment and Outcome between 1995 and 2010: Observations from Riks-Stroke, the Swedish Stroke Register2014In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 37, no 1, p. 22-29Article in journal (Refereed)
    Abstract [en]

    Background: Continuous changes in stroke treatment and care, as well as changes in stroke characteristics, may alter stroke outcome over time. The aim of this paper is to describe time trends for treatment and outcome data, and to discuss if any such changes could be attributed to quality changes in stroke care.

    Methods: Data from Riks-Stroke, the Swedish stroke register, were analyzed for the time period of 1995 through 2010. The total number of patients included was 320,181. The following parameters were included: use of computed tomography (CT), stroke unit care, thrombolysis, medication before and after the stroke, length of stay in hospital, and discharge destination. Three months after stroke, data regarding walking, toileting and dressing ability, as well social situation, were gathered. Survival status after 7, 27 and 90 days was registered. Results: In 1995, 53.9% of stroke patients were treated in stroke units. In 2010 this proportion had increased to 87.5%. Fewer patients were discharged to geriatric or rehabilitation departments in later years (23.6% in 2001 compared with 13.4% in 2010), but more were discharged directly home (44.2 vs. 52.4%) or home with home rehabilitation (0 vs. 10.7%). The need for home help service increased from 18.2% in 1995 to 22.1% in 2010. Regarding prevention, more patients were on warfarin, antihypertensives and statins both before and after the stroke. The functional outcome measures after 3 months did improve from 2001 to 2010. In 2001, 83.8% of patients were walking independently, while 85.6% were independent in 2010. For toileting, independence increased from 81.2 to 84.1%, and for dressing from 78.0 to 80.4%. Case fatality (CF) rates after 3 months increased from 18.7% (2001) to 20.0% (2010). This trend is driven by patients with severe strokes.

    Conclusions: Stroke outcomes may change over a relatively short time period. In some ways, the quality of care has improved. More stroke patients have CT, more patients are treated in stroke units and more have secondary prevention. Patients with milder strokes may have benefited more from these measures than patients with severe strokes. Increased CF rates for patients with severe stroke may be caused by shorter hospital stays, shorter in-hospital rehabilitation periods and lack of suitable care after discharge from hospital. (C) 2013 S. Karger AG, Basel

  • 3. Appelros, Peter
    et al.
    Jonsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asberg, Kerstin Hulter
    Norrving, Bo
    Stegmayr, Birgitta
    Epidemiologic Center, National Board of Health and Welfare, Stockholm.
    Terént, Andreas
    Trends in baseline patient characteristics during the years 1995-2008: observations from Riks-Stroke, the Swedish Stroke Register2010In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 30, no 2, p. 114-119Article in journal (Refereed)
    Abstract [en]

    Many baseline parameters in Riks-Stroke have changed over the years. This has consequences for the interpretation of outcome data. Some changes may be due to inclusion bias, others due to alterations in general health, evolution of vascular risk factors or demographics.

  • 4. Appelros, Peter
    et al.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terént, Andreas
    Riks-Stroke och hur fallgropar vid tolkning av resultaten undviks2008In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 105, no 8, p. 529-533Article in journal (Other academic)
  • 5. Appelros, Peter
    et al.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terént, Andreas
    Sex differences in stroke epidemiology: a systematic review2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 4, p. 1082-1090Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Epidemiological studies, mainly based on Western European surveys, have shown that stroke is more common in men than in women. In recent years, sex-specific data on stroke incidence, prevalence, subtypes, severity and case-fatality have become available from other parts of the world. The purpose of this article is to give a worldwide review on sex differences in stroke epidemiology. METHODS: We searched PubMed, tables-of-contents, review articles, and reference lists for community-based studies including information on sex differences. In some areas, such as secular trends, ischemic subtypes and stroke severity, noncommunity-based studies were also reviewed. Male/female ratios were calculated. RESULTS: We found 98 articles that contained relevant sex-specific information, including 59 incidence studies from 19 countries and 5 continents. The mean age at first-ever stroke was 68.6 years among men, and 72.9 years among women. Male stroke incidence rate was 33% higher and stroke prevalence was 41% higher than the female, with large variations between age bands and between populations. The incidence rates of brain infarction and intracerebral hemorrhage were higher among men, whereas the rate of subarachnoidal hemorrhage was higher among women, although this difference was not statistically significant. Stroke tended to be more severe in women, with a 1-month case fatality of 24.7% compared with 19.7% for men. CONCLUSIONS: Worldwide, stroke is more common among men, but women are more severely ill. The mismatch between the sexes is larger than previously described.

  • 6.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eliasson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    [What the MONICA project has taught us about cardiovascular diseases--society, public health and health care]2006In: Lakartidningen, ISSN 0023-7205, Vol. 103, no 40, p. 3006-11Article in journal (Other academic)
  • 7.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hulter Åsberg, Kerstin
    Appelros, Peter
    Bjarne, Daniela
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Johansson, Åsa
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jonsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Stegmayr, Birgitta
    Terént, Andreas
    Wallin, Sari
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Wester, Per-Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The Riks-Stroke story: building a sustainable national register for quality assessment of stroke care2011In: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, Vol. 6, no 2, p. 99-108Article in journal (Refereed)
    Abstract [en]

    Background Riks-Stroke, the Swedish Stroke Register, is the world's longest-running national stroke quality register (established in 1994) and includes all 76 hospitals in Sweden admitting acute stroke patients. The development and maintenance of this sustainable national register is described.

    Methods Riks-Stroke includes information on the quality of care during the acute phase, rehabilitation and secondary prevention of stroke, as well as data on community support. Riks-Stroke is unique among stroke quality registers in that patients are followed during the first year after stroke. The data collected describe processes, and medical and patient-reported outcome measurements. The register embraces most of the dimensions of health-care quality (evidence-based, safe, provided in time, distributed fairly and patient oriented).

    Result Annually, approximately 25 000 patients are included. In 2009, approximately 320 000 patients had been accumulated (mean age 76-years). The register is estimated to cover 82% of all stroke patients treated in Swedish hospitals. Among critical issues when building a national stroke quality register, the delicate balance between simplicity and comprehensiveness is emphasised. Future developments include direct transfer of data from digital medical records to Riks-Stroke and comprehensive strategies to use the information collected to rapidly implement new evidence-based techniques and to eliminate outdated methods in stroke care.

    Conclusions It is possible to establish a sustainable quality register for stroke at the national level covering all hospitals admitting acute stroke patients. Riks-Stroke is fulfilling its main goals to support continuous quality improvement of Swedish stroke services and serve as an instrument for following up national stroke guidelines.

  • 8.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jonsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    National Board of Health and Welfare, Stockholm, Sweden; Department of Neurology .
    Appelros, Peter
    University Hospital. Örebro, Sweden; Department of Neurology .
    Norrving, Bo
    University Hospital, Lund, Sweden; Department of Medicine.
    Terént, Andreas
    Akademiska University Hospital, Uppsala, Sweden; Department of Medicine.
    Åsberg, Kerstin Hulter
    Enköping Hospital, Enköping, Sweden.
    Patient dissatisfaction with acute stroke care2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 12, p. 3851-3856Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Riks-Stroke, the Swedish Stroke Register, was used to explore patient characteristics and stroke services as determinants of patient dissatisfaction with acute in-hospital care. METHODS: All 79 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. During 2001 to 2007, 104 876 patients (87% of survivors) responded to a follow-up questionnaire 3 months after acute stroke; this included questions on satisfaction with various aspects of stroke care. RESULTS: The majority (>90%) were satisfied with acute in-hospital stroke care. Dissatisfaction was closely associated with outcome at 3 months. Patient who were dependent regarding activities of daily living, felt depressed, or had poor self-perceived general health were more likely to be dissatisfied. Dissatisfaction with global acute stroke care was linked to dissatisfaction with other aspects of care, including rehabilitation and support by community services. Patients treated in stroke units were less often dissatisfied than patients in general wards, as were patients who had been treated in a small hospital (vs medium or large hospitals) and patient who had participated in discharge planning. In multivariate analyses, the strongest predictor of dissatisfaction with acute care was poor outcome (dependency regarding activities of daily living, depressed mood, poor self-perceived health). CONCLUSIONS: Dissatisfaction with in-hospital acute stroke care is part of a more extensive complex comprising poor functional outcome, depressive mood, poor self-perceived general health, and dissatisfaction not only with acute care but also with health care and social services at large. Several aspects of stroke care organization are associated with a lower risk of dissatisfaction.

  • 9.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Lundström, Staffan
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    End of life after stroke: a nationwide study of 42,502 deaths occurring within a year after stroke2018In: European Stroke Journal, ISSN 2396-9873, E-ISSN 2396-9881, Vol. 3, no 1, p. 74-81Article in journal (Refereed)
    Abstract [en]

    Introduction: In the scientific literature, there is very limited empirical information on end-of-life issues after stroke in the scientific literature. The present nationwide study describes the circumstances surrounding deaths that occur within a year after a stroke. Patients and methods: Datasets from three nationwide Swedish registers (on stroke, palliative care and cause of death) were linked. Basic information was available for 42,502 unselected cases of death that occurred within a year after a stroke and more detailed information was available for 16,408 deaths. Odds ratios for characteristics of end-of-life care were calculated by logistic regression. Results: In the late phase after stroke (three months to one year), 46% of patients died in a nursing home, whereas 37% of patients died in a hospital after readmission and 10% of patients died at home. Eleven per cent of deaths were reported as being unexpected. A next of kin was present at 49% of deaths. The frequency of unattended deaths (neither next of kin nor staff were present at the time of death) ranged from 5% at home with specialised home care to 25% in hospitals. Discussion: This is, by far, the largest study published on end-of-life issues after stroke. Major differences between countries in healthcare, community services, family structure and culture may limit direct transfer of the present results to other settings. Conclusion: There is considerable discordance between presumed good death' late after stroke (dying at home surrounded by family members) and the actual circumstances at the end of life.

  • 10.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Sukhova, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Diagnostic procedures, treatments, and outcomes in stroke patients admitted to different types of hospitals2015In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 46, no 3, p. 806-812Article in journal (Refereed)
    Abstract [en]

    Background and Purpose: In many countries, including Sweden, initiatives have been taken to reduce between-hospital differences in the quality of stroke services. We have explored to what extent hospital type (university, specialized nonuniversity, or community hospital) influences hospital performance. Methods: Riksstroke collects clinical data during hospital stay (national coverage 94%). Follow-up data at 3 months were collected using administrative registers and a questionnaire completed by surviving patients (response rate 88%). Structural data were collected from a questionnaire completed by hospital staff (response rate 100%). Multivariate analyses with adjustment for clustering were used to test differences between types of hospitals. Results: The proportion of patients admitted directly to a stroke unit was highest in community hospitals and lowest in university hospitals. Magnetic resonance, carotid imaging, and thrombectomy were more frequently performed in university hospitals, and the door-to-needle time for thrombolysis was shorter. Secondary prevention with antihypertensive drugs was used less often, and outpatient follow-up was less frequent in university hospitals. Fewer patients in community hospitals were dissatisfied with their rehabilitation. After adjusting for possible confounders, poor outcome (dead or activities of daily living dependency 3 months after stroke) was not significantly different between the 3 types of hospital. Conclusions: In a setting with national stroke guidelines, stroke units in all hospitals, and measurement of hospital performance and benchmarking, outcome (after case-mix adjustment) is similar in university, specialized nonuniversity, and community hospitals. There seems to be fewer barriers to organizing well-functioning stroke services in community hospitals compared with university hospitals.

  • 11. Cooper, Richard S
    et al.
    Wolf-Maier, Katharina
    Luke, Amy
    Adeyemo, Adebowale
    Banegas, J.R
    Forrester, Terrence
    Giampaoli, Simona
    Joffres, Michel
    Kastarinen, Mika
    Primatesta, Paola
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine.
    Thamm, Michael
    An international comparative study of blood pressure in populations of European vs. African descent.2005In: BMC Med, ISSN 1741-7015, Vol. 3, p. 2-Article in journal (Refereed)
  • 12. Custodio, Hipolito M
    et al.
    Broberg, Karin
    Wennberg, Maria
    Jansson, Jan-Håkan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Vessby, Bengt
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Skerfving, Staffan
    Polymorphisms in glutathione-related genes affect methylmercury retention.2004In: Arch Environ Health, ISSN 0003-9896, Vol. 59, no 11, p. 588-95Article in journal (Refereed)
  • 13. Cvetkovic, Jasmina Trifunovic
    et al.
    Wållberg-Jonsson, Solveig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Rantapää-Dahlqvist, Solbritt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Reumatology.
    Lefvert, Ann Kari
    Susceptibility for and clinical manifestations of rheumatoid arthritis are associated with polymorphisms of the TNF-alpha, IL-1 beta, and IL-lRa genes2002In: Journal of Rheumatology, ISSN 0315-162X, E-ISSN 1499-2752, Vol. 29, no 2, p. 212-219Article in journal (Refereed)
    Abstract [en]

    Objective. To analyze the association of genetic polymorphisms of pro-inflammatory cytokines with rheumatoid arthritis (RA) in comparison with healthy controls from Northern Sweden and the potential contribution of these genetic variants for disease severity and development of cardiovascular complications.

    Methods. Polymerase chain reaction amplification was used for analysis of TaqI restriction fragment length polymorphism (RFLP) of interleukin-1 beta (IL-1beta), variable tandem repeat polymorphism of IL-1 receptor antagonist (IL-1Ra) gene and NcoI RFLP at position -308 of tumor necrosis factor-alpha (TNF-alpha) gene, One hundred and fifty-four patients with RA, 42 men and 112 women, were consecutively recruited into the study through the Department of Rheumatology.

    Results. The allele A1 of TNF-alpha was more common in the patient group (p < 0.01 OR = 1.62). Patients having the genotype A1A2 seemed to develop more severe disease compared with patients with A1A1 genotype: they were younger at disease onset (p < 0.05), had a higher accumulated disease activity (p < 0.05) and worse functional class (p < 0.05), Patients with genotype A2A2 of IL-1beta had higher accumulated disease activity score than patients with A1A1 and A1A2 (p < 0.05). The allelic combination A1 IL-1beta/A2 IL-1Ra was less prevalent in RA patients who developed cardiovascular complications (p < 0.005 OR = 0.20).

    Conclusions. The A1 allele of TNF-alpha associates with RA. Genotypes A1A2 of TNF-alpha and A2A2 of IL-1beta are associated with more severe disease. The allelic combination A1 IL-1beta/A2 IL-1Ra is less often present in RA patients who developed cardiovascular complications.

  • 14.
    Darehed, David
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine. 1 Department of Medicine, Ga¨llivare Hospital, Sweden.
    Norrving, Bo
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Zingmark, Karin
    Blom, Mathias C.
    Patients with acute stroke are less likely to be admitted directly to a stroke unit when hospital beds are scarce: a Swedish multicenter register study2017In: European Stroke Journal, ISSN 2396-9873, E-ISSN 2396-9881, Vol. 2, no 2, p. 178-186Article in journal (Refereed)
    Abstract [en]

    Introduction: It is well established that managing patients with acute stroke in dedicated stroke units is associated with improved functioning and survival. The objectives of this study are to investigate whether patients with acute stroke are less likely to be directly admitted to a stroke unit from the Emergency Department when hospital beds are scarce and to measure variation across hospitals in terms of this outcome.

    Patients and methods: This register study comprised data on patients with acute stroke admitted to 14 out of 72 Swedish hospitals in 2011-2014. Data from the Swedish stroke register were linked to administrative daily data on hospital bed occupancy (measured at 6 a.m.). Logistic regression analysis was used to analyse the association between bed occupancy and direct stroke unit admission.

    Results: A total of 13,955 hospital admissions were included; 79.6% were directly admitted to a stroke unit from the Emergency Department. Each percentage increase in hospital bed occupancy was associated with a 1.5% decrease in odds of direct admission to a stroke unit (odds ratio = 0.985, 95% confidence interval = 0.978-0.992). The best-performing hospital exhibited an odds ratio of 3.8 (95% confidence interval = 2.6-5.5) for direct admission to a stroke unit versus the reference hospital.

    Discussion and conclusion: We found an association between hospital crowding and reduced quality of care in acute stroke, portrayed by a lower likelihood of patients being directly admitted to a stroke unit from the Emergency Department. The magnitude of the effect varied considerably across hospitals.

  • 15.
    Ekblom, Kim
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology, Cariology.
    Van Guelpen, Bethany
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Johansson, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wiklund, Per-Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Marklund, Stefan L
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Iron stores and HFE genotypes are not related to increased risk of ischemic stroke.: a prospective nested case-referent study2007In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 24, no 5, p. 405-411Article in journal (Refereed)
    Abstract [en]

    Background: High iron levels can increase the formation of noxious oxygen radicals, which are thought to contribute to cerebrovascular disease. The aim of this prospective study was to determine if iron status and HFE genotypes constitute risk factors for stroke.

    Methods: First-ever stroke cases (231 ischemic and 42 hemorrhagic) and matched double referents from the population-based Northern Sweden cohorts were studied in a nested case-referent setting.

    Results: For total iron binding capacity, an increased risk of ischemic stroke was seen in the highest quartile (OR 1.80; 95% CI 1.14-2.83; p for trend 0.012). The highest quartile of transferrin iron saturation showed a decreased risk of ischemic stroke in men (OR 0.44; 95% CI 0.22-0.87; p for trend 0.028), but not in women. There was an increased risk of hemorrhagic stroke in the second (OR 4.07; 95% CI 1.09-15.20) and third quartile (OR 4.22; 95% CI 1.08-16.42) of ferritin. Neither quartiles of plasma iron concentrations nor the HFE C282Y and H63D genotypes were associated with ischemic or hemorrhagic stroke.

    Conclusions: Iron stores were not positively related to increased risk of ischemic stroke. Furthermore, HFE genotypes did not influence the risk of ischemic or hemorrhagic stroke. Copyright (c) 2007 S. Karger AG, Basel.

  • 16.
    Eliasson, Mats
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Jansson, Jan-Håkan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Time trends in population cholesterol levels 1986-2004: influence of lipid-lowering drugs, obesity, smoking and educational level. The northern Sweden MONICA study.2006In: J Intern Med, ISSN 0954-6820, Vol. 260, no 6, p. 551-9Article in journal (Refereed)
  • 17.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Medicine. Medicin.
    Appelros, Peter
    Norrving, Bo
    Terént, Andreas
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Medicine. Medicin.
    Assessment of functional outcome in a national quality register for acute stroke: can simple self-reported items be transformed into the modified Rankin Scale?2007In: Stroke, ISSN 1524-4628, Vol. 38, no 4, p. 1384-1386Article in journal (Refereed)
  • 18.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Medicin.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Medicin.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Medicin.
    Norrving, Bo
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Medicin.
    Terent, Andreas
    Hulter Åsberg, Kerstin
    Wester, Per-Olov
    Self-reported depression and use of antidepressants after stroke: a national survey.2004In: Stroke, ISSN 1524-4628, Vol. 35, no 4, p. 936-941Article in journal (Refereed)
  • 19.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Acute stroke alert activation, emergency service use, and reperfusion therapy in Sweden2017In: Brain and Behavior, ISSN 2162-3279, E-ISSN 2162-3279, Vol. 7, no 4, article id e00654Article in journal (Refereed)
    Abstract [en]

    Objectives: Ambulance services and stroke alerts reduce the time from stroke onset to acute stroke diagnosis. We describe the use of stroke alerts and ambulance services in different hospitals and patient groups and their relationship with reperfusion therapy. Methods: This nationwide study included 49,907 patients admitted with acute stroke who were registered in The Swedish Stroke Register (Riksstroke) in 2011-2012. Results: The proportions of patients admitted as stroke alerts out of all acute stroke admissions varied from 12.2% to 45.7% in university hospitals (n=9), 0.5% to 38.7% in specialized nonuniversity hospitals (n=22), and 4.2% to 40.3% in community hospitals (n=41). Younger age, atrial fibrillation (AF), living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were factors associated with a higher probability of stroke alerts. Living alone, primary school education, non-European origin, previous stroke, diabetes, smoking, and dependency in activities of daily living (ADL) were associated with a lower probability of stroke alert. The proportion of patients arriving at the hospital by ambulance varied from 60.3% to 94.5%. Older age, living alone, primary school education, being born in a European country, previous stroke, AF, dependency in ADL, living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were associated with ambulance services. Hospital stroke alert frequencies correlated strongly with reperfusion rates (r=.75). Conclusion: Acute stroke alerts have a significant potential to improve stroke reperfusion rates. Prehospital stroke management varies conspicuously between hospitals and patient groups, and the elderly and patients living alone have a markedly reduced likelihood of stroke alerts.

  • 20.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
    Norrving, Bo
    the Department of Neurology, Lund University Hospital, Lund, Sweden.
    Terént, Andreas
    the Department of Medical Sciences, Uppsala University Hospital, Uppsala.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Sex differences in stroke care and outcome in the Swedish national quality register for stroke care2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 3, p. 909-914Article in journal (Refereed)
    Abstract [en]

    Background and purpose: Previous reports concerning sex-related differences in stroke management and outcome are inconsistent and are sometimes difficult to interpret. We used data from a national stroke register to further explore possible differences between men and women in baseline characteristics, stroke treatment, and outcome.

    Methods: This study included 24633 stroke events registered in Riks-Stroke, the Swedish national quality register for stroke care, during 2006. Information on background variables and treatment was collected during the hospital stay. After 3 months, the patients' living situation and outcome were assessed.

    Results: Women were older than men when they had their stroke (mean age, 78.4 versus 73.6 years; P<0.001). On admission to the hospital, women were more often unconscious. Among conscious patients, there was no sex-related difference in the use of stroke unit care. Men and women had equal probability to receive thrombolysis and oral anticoagulants. Women were more likely to develop deep venous thromboses and fractures, whereas men were more likely to develop pneumonia during their hospital stay. Women had a lower 3-month survival, a difference that was associated with higher age and impaired level of consciousness on admission. Women were less often living at home at the 3-month follow-up. However, the difference in residency was not present in patients <85 years who were living at home without community support before the stroke.

    Conclusions: Reported sex differences in stroke care and outcome were mainly explained by the women's higher age and lower level of consciousness on admission.

  • 21.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Holmgren, L.
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jansson, Jan-Håkan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Medicine, Skellefteå Hospital, Skellefteå.
    Lundblad, Dan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Medicine, Sunderby Hospital, Luleå.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. National Board of Health and Welfare, Stockholm.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eliasson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Medicine, Sunderby Hospital, Luleå.
    Large improvements in major cardiovascular risk factors in the population of northern Sweden: the MONICA study 1986–20092011In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 269, no 2, p. 219-231Article in journal (Refereed)
    Abstract [en]

    Objectives. The incidence of cardiovascular disease has declined rapidly in Sweden since the 1980s. We explored changes in major cardiovascular risk factors in northern Sweden between 1986 and 2009.

    Design. Since 1986, six population surveys have been carried out in northern Sweden using procedures of the World Health Organization MONICA project. The population age range was 25–64 years in 1986 and 1990, and 25–74 years from 1994. Trends were analysed using generalized linear models.

    Results. A total of 10 586 subjects were included in the surveys. Blood pressure decreased by 4.9/3.9 mmHg in women and 1.8/1.5 mmHg in men aged 25–64 years between 1986 and 2009. In men and women aged 65–74 years, the decrease was 12.6/6.1 mmHg between 1994 and 2009. From 1994, the use of blood pressure‐lowering drugs increased, particularly among the older subgroup. The prevalence of smoking halved between 1986 and 2009; 11% of women and 9% of men were smokers in 2009. Cholesterol levels decreased by 0.9 mmol L−1 in the younger age group (25–64 years), and the use of lipid‐lowering agents increased from 1994. Among subjects aged 25–64 years, one in five was obese in 2009, which was twice as many as in 1986, and body mass index (BMI) increased by 1.5 kg m−2, corresponding to an increase in weight of 4 kg. There was no further increase in BMI from 2004. The prevalence of diabetes did not change between 1986 and 2009. The proportion that received a university education increased markedly in all age groups, especially in women, during the study period.

    Conclusions. Significant improvements were observed in major cardiovascular risk factors in northern Sweden between 1986 and 2009.

  • 22.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jonsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Appelros, Peter
    Asberg, Kerstin Hulter
    Norrving, Bo
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terént, Andreas
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Dissemination of thrombolysis for acute ischemic stroke across a nation: experiences from the Swedish stroke register, 2003 to 20082010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 6, p. 1115-22Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: We used Riks-Stroke, the Swedish Stroke Register, to explore how thrombolysis has been disseminated in Swedish hospitals since it was approved in 2003. METHODS: All 78 hospitals in Sweden admitting patients with acute stroke participate in Riks-Stroke. Between 2003 and 2008, 72 033 adult patients were hospitalized for acute ischemic stroke. We analyzed thrombolysis use by region, patient characteristics, and stroke service settings. RESULTS: Nationwide, the use of thrombolysis increased from 0.9% in 2003 to 6.6% in 2008. There were marked regional differences in the dissemination of thrombolysis, but these gaps narrowed over time. Nonuniversity hospitals reached treatment levels similar to university settings, although with a 2- to 3-year delay. Symptomatic intracranial hemorrhage remained at the 3% to 9% level without an apparent time trend during dissemination. Independent predictors of higher thrombolysis use included younger age, male sex, not living alone, and no history of stroke or diabetes. In 2008, patients admitted to a stroke unit were 5 times more likely to receive thrombolysis than those admitted to general wards. CONCLUSIONS: Nationwide implementation of thrombolysis has been slow but has accelerated mainly due to increased access outside university hospitals. The increased use has been achieved safely, but access has been unequal.

  • 23.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stecksén, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Appelros, Peter
    Hulter Åsberg, Kerstin
    Stegmayr, Birgitta
    The National Board of Health and Welfare, Stockholm, Sweden.
    Terént, Andreas
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Discarding heparins as treatment for progressive stroke in Sweden 2001 to 20082010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 11, p. 2552-2558Article in journal (Refereed)
    Abstract [en]

    There is no immediate, stepwise effect of new scientific information and national guidelines on clinical practice. Rather, the phasing out of heparin has followed a linear course over several years, with less variation between hospitals. We speculate that open comparisons between hospitals in a national stroke register may have helped to reduce the variations in clinical practice.

  • 24. Feigin, Valery L.
    et al.
    Parmar, Priya G.
    Barker-Collo, Suzanne
    Bennett, Derrick A.
    Anderson, Craig S.
    Thrift, Amanda G.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Rothwell, Peter M.
    Giroud, Maurice
    Bejot, Yannick
    Carvil, Phillip
    Krishnamurthi, Rita
    Kasabov, Nikola
    Geomagnetic Storms Can Trigger Stroke Evidence From 6 Large Population-Based Studies in Europe and Australasia2014In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 45, no 6, p. 1639-1645Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-Although the research linking cardiovascular disorders to geomagnetic activity is accumulating, robust evidence for the impact of geomagnetic activity on stroke occurrence is limited and controversial. Methods-We used a time-stratified case-crossover study design to analyze individual participant and daily geomagnetic activity (as measured by Ap Index) data from several large population-based stroke incidence studies (with information on 11 453 patients with stroke collected during 16 031 764 person-years of observation) in New Zealand, Australia, United Kingdom, France, and Sweden conducted between 1981 and 2004. Hazard ratios and corresponding 95% confidence intervals (CIs) were calculated. Results-Overall, geomagnetic storms (Ap Index 60+) were associated with 19% increase in the risk of stroke occurrence (95% CI, 11%-27%). The triggering effect of geomagnetic storms was most evident across the combined group of all strokes in those aged <65 years, increasing stroke risk by >50%: moderate geomagnetic storms (60-99 Ap Index) were associated with a 27% (95% CI, 8%-48%) increased risk of stroke occurrence, strong geomagnetic storms (100-149 Ap Index) with a 52% (95% CI, 19%-92%) increased risk, and severe/extreme geomagnetic storms (Ap Index 150+) with a 52% (95% CI, 19%-94%) increased risk (test for trend, P<2x10(-16)). Conclusions-Geomagnetic storms are associated with increased risk of stroke and should be considered along with other established risk factors. Our findings provide a framework to advance stroke prevention through future investigation of the contribution of geomagnetic factors to the risk of stroke occurrence and pathogenesis.

  • 25. Fiskesund, Roland
    et al.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Vikström, Max
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    de Faire, Ulf
    Frostegård, Johan
    Low levels of antibodies against phosphorylcholine predict development of stroke in a population-based study from northern Sweden2010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 4, p. 607-612Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Natural immunoglobulin M antibodies specific for phosphorylcholine (anti-PC) have been implicated in atherosclerosis. We have shown previously that high levels of anti-PC predict a slower progression of atherosclerosis in humans and that low levels of anti-PC are associated with higher risk for cardiovascular disease. Here we determine the association between anti-PC and the incidence of stroke. METHODS: Using a nested case control study design, we examined 227 incident cases (125 men and 102 women) of first-time stroke and 455 age- and sex-matched controls identified during a 13-year time period (1985 to 1999) within the population-based cohorts of the Västerbotten Intervention Project (VIP) and the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (WHO MONICA) project in Northern Sweden. Odds ratios of stroke with 95% CIs with adjustments for age, gender, smoking, serum cholesterol, diabetes, body mass index, and blood pressure were determined. Anti-PC levels were measured using ELISA. RESULTS: A significant association between low levels of anti-PC at baseline and incident stroke was seen for the whole group of anti-PC levels below the 30th percentile (multivariately adjusted odds ratio, 1.62; CI, 1.11 to 2.35). Analyses of gender-specific associations indicated fairly strong associations for females, especially at the lowest 30th percentile (multivariately adjusted odds ratio, 2.65; CI, 1.41 to 4.95). No associations were noted for men. CONCLUSION: Low anti-PC is a novel independent risk marker for development of stroke. Measurements of anti-PC could be used to identify immunodeficient subjects at an increased risk for stroke. The possibility that such subjects might be targets for novel modes of treatment such as immunotherapies deserves further investigation.

  • 26. Gao, W
    et al.
    Eliasson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Does the constellation of risk factors with and without abdominal adiposity associate with different cardiovascular mortality risk?2008In: International journal of obesity (2005), ISSN 1476-5497, Vol. 32, no 5, p. 757-62Article in journal (Refereed)
    Abstract [en]

    AIMS: To evaluate whether the metabolic syndrome (MetS) defined by the International Diabetes Federation (IDF) criteria, which has abdominal adiposity as a mandatory element, predicts cardiovascular disease (CVD) mortality better than the cluster of other IDF-defined abnormalities not including abdominal adiposity. METHODS: Data from nine European population-based studies, including 7782 men and 7739 women (aged 30-89 years), with a median follow-up of 8.55 years, were jointly analyzed. Hazard ratios for CVD mortality were calculated with Cox regression models. RESULTS: In total, 41% of the men and 38% of the women had the IDF MetS. Individuals with the IDF MetS were by definition more obese and had a higher prevalence of diabetes than non-obese subjects with > or = 2 IDF abnormalities; whereas non-obese men with > or = 3 factors had more atherogenic lipid profiles. Multivariate adjusted hazard ratio for CVD death in men and women with the IDF MetS was 2.44 (1.69-2.98) and 2.32 (1.27-4.23); in non-obese men with 2 and > or = 3 factors the hazard ratio was 1.60 (1.12-2.30) and 2.44 (1.62-3.66), respectively, and in non-obese women with 2 factors the hazard ratio was 2.41 (1.09-5.33). CONCLUSIONS: The cluster of the CVD risk factors predicted CVD mortality regardless of the presence or absence of the abdominal adiposity. Inclusion of abdominal adiposity as a prerequisite will miss those non-obese individuals who have increased CVD mortality.

  • 27. Giampaoli, Simona
    et al.
    Capewell, Simon
    Shelley, Emer
    Allender, Steven
    Briggs, Andrew
    Jorgensen, Torben
    Labarthe, Darwin
    Marques-Vidal, Pedro
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Medicine.
    Verschuren, W M Monique
    Zdrojewski, Tomasz
    Foreword.2007In: Eur J Cardiovasc Prev Rehabil, ISSN 1741-8267, Vol. 14 Suppl 3, p. S1-Article in journal (Refereed)
  • 28.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Poststroke Fatigue: A 2-Year Follow-Up Study of Stroke Patients in Sweden2002In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 33, p. 1327-1333Article in journal (Refereed)
    Abstract [en]

    Background and Purpose Fatigue is common among stroke patients. This study determined the prevalence of fatigue among long-term survivors after stroke and what impact fatigue had on various aspects of daily life and on survival.

    Methods— This study was based on Riks-Stroke, a hospital-based national register for quality assessment of acute stroke events in Sweden. During the first 6 months of 1997, 8194 patients were registered in Riks-Stroke, and 5189 were still alive 2 years after the stroke. They were followed up by a mail questionnaire, to which 4023 (79%) responded. Patients who reported that they always felt depressed were excluded.

    Results— To the question, “Do you feel tired?” 366 (10.0%) of the patients answered that they always felt tired, and an additional 1070 (29.2%) were often tired. Patients who always felt tired were on average older than the rest of the study population (74.5 versus 71.5 years, P<0.001); therefore, all subsequent analyses were age adjusted. Fatigue was an independent predictor for having to move into an institutional setting after stroke. Fatigue was also an independent predictor for being dependent in primary activities of daily living functions. Three years after stroke, patients with fatigue also had a higher case fatality rate.

    Conclusions— Fatigue is frequent and often severe, even late after stroke. It is associated with profound deterioration of several aspects of everyday life and with higher case fatality, but it usually receives little attention by healthcare professionals. Intervention studies are needed.

  • 29.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Johansson, Lennart
    National Board of Health and Welfare, Stockholm, Sweden.
    Hulter-Åsberg, Kerstin
    Department of Medicine, Enköping Hospital, Enköping, Sweden.
    Wester, P.-O.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Differences in Long-Term Outcome Between Patients Treated in Stroke Units and in General Wards: A 2-Year Follow-Up of Stroke Patients in Sweden2001In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 32, p. 2124-2130Article in journal (Refereed)
    Abstract [en]

    Background and Purpose— The long-term beneficial effects of stroke unit care have been proved in several randomized trials. However, there is a question of large-scale applicability in routine clinical practice of interventions used by dedicated investigators in small randomized trials. The objective of this study was to compare, 21/2 years after stroke, patients who had been treated in stroke units and those treated in general wards in routine clinical practice.

    Methods— This is a prospective cohort study based on 8194 patients who were included, during the first 6 months in 1997, in Riks-Stroke, the Swedish National Register for quality assessment of acute stroke. Two years after the event, 5189 patients were still alive and 5104 were followed up with a postal questionnaire to which 4038 responded.

    Results— Among the group of patients who were independent in activities of daily living (ADL) functions before the stroke, patients who were treated in stroke units were less often dependent in ADL functions, after adjustment for case mix (OR, 0.79; CI, 0.66 to 0.94). If they also lived at home before the stroke, then they had a lower case-fatality rate 2 years after the stroke (OR, 0.81; CI, 0.72 to 0.92).

    Conclusions— Long-term beneficial effects of treatment in stroke units were shown for patients who were independent in ADL functions before the stroke. No benefits were shown for patients who were dependent on help for primary ADL before the stroke. Further studies on this group of patients with more detailed outcome measures are needed.

  • 30.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terent, Andreas
    Department of Clinical Neuroscience, Lund University, Lund, Sweden.
    Hulter-Åsberg, Kerstin
    Department of Medical Science, Uppsala University, Uppsala, Sweden.
    Wester, P.-O.
    Department of Medicine, Enköping Hospital, Enköping, Sweden.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Large variations in the use of oral anticoagulants in stroke patients with atrial fibrillation: A Swedish national perspective2004In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 255, no 1, p. 22-32Article in journal (Refereed)
    Abstract [en]

    Objectives. To explore nation-wide use of anticoagulation in stroke patients with atrial fibrillation, in routine clinical practice in Sweden.

    Design.  Cross-sectional cohort study.

    Setting. Patients included in Riks-Stroke, the Swedish national quality register for stroke care, during 2001.

    Subjects. Hospitals with incomplete coverage were excluded, leaving 4538 stroke patients with atrial fibrillation amongst 18 276 stroke patients from 75 hospitals in six health care regions.

    Main outcome measure.  Treatment with oral anticoagulants.

    Results. At stroke onset, the proportion of patients with atrial fibrillation and first-ever stroke, receiving oral anticoagulants as primary prevention was 11.0% (range 8.4–13.5% between regions and 2.5–24.4% between hospitals). Younger age, male sex and diabetes at stroke onset independently predicted primary prevention with oral anticoagulants. The proportion of stroke patients with atrial fibrillation receiving oral anticoagulants as secondary prevention at discharge was 33.5% (range 29.9–40.6% between regions and 16.4–61.9% between hospitals). Independent predictors for secondary prevention were younger age, male sex and independent activities of daily life (ADL) function before the stroke, being discharged to home, being fully conscious on admission and health care region.

    Conclusion.  There were variations between hospitals and regions that differences in age, sex, functional impairments and comorbidities could not fully explain. This indicates that evidence-based primary and secondary prevention of embolic stroke is insufficiently practised. Local factors seem to determine whether patients with atrial fibrillation gain access to optimal prevention of stroke or not.

  • 31.
    Hallmans, Göran
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Agren, A
    Johansson, G
    Johansson, Anders
    Umeå University, Faculty of Medicine, Department of Odontology, Periodontology.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jansson, JH
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lindahl, B
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Nilsson, M
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology, Cariology.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Cardiovascular disease and diabetes in the Northern Sweden Health and Disease Study Cohort: evaluation of risk factors and their interactions.2003In: Scandinavian Journal of Public Health. Supplement Links, ISSN 1403-4956, Vol. 61, p. 18-24Article in journal (Refereed)
    Abstract [en]

    The purpose of this paper is, first, to describe the organization, sampling procedures, availability of samples/database, ethical considerations, and quality control program of the Northern Sweden Health and Disease Study Cohort. Secondly, some examples are given of studies on cardiovascular disease and diabetes with a focus on the biomarker programme. The cohort has been positioned as a national and international resource for scientific research.

  • 32. Hermansson, Jonas
    et al.
    Gillander Gådin, Katja
    Karlsson, Berndt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Lindahl, Bernt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Knutsson, Anders
    Ischemic stroke and shift work.2007In: Scand J Work Environ Health, ISSN 0355-3140, Vol. 33, no 6, p. 435-9Article in journal (Refereed)
  • 33.
    Hultdin, Johan
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Van Guelpen, Bethany
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Winkvist, Anna
    Department of Clinical Nutrition, Göteborg University, Gothenburg, Sweden.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Nilsson, Torbjörn K.
    Department of Laboratory Medicine, Örebro University Hospital, Örebro, Sweden.
    Prospective study of first stroke in relation to plasma homocysteine and MTHFR 677C > T and 1298A > C genotypes and haplotypes: evidence for an association with hemorrhagic stroke2011In: Clinical Chemistry and Laboratory Medicine, ISSN 1434-6621, E-ISSN 1437-4331, Vol. 49, no 9, p. 1555-1562Article in journal (Refereed)
    Abstract [en]

    Background: Abnormalities in homocysteine metabolism have been suggested as risk factors for stroke. The aim of this prospective study was to examine whether total plasma homocysteine concentration (tHcy) and its main genetic determinant, methylene tetrahydrofolate reductase (MTHFR) polymorphisms, were associated with first ischemic or hemorrhagic stroke.

    Methods: This was a nested case-referent study of 321 ischemic and 60 hemorrhagic stroke cases, defined by WHO MONICA criteria and each matched with two event-free referents for sex, age, cohort, recruitment date and geographical area. All subjects were from the population-based Northern Sweden Health and Disease Study cohorts. Odds ratios were determined by conditional logistic regression.

    Results: The mean follow-up time was 4.2 years. Both tHcy and MTHFR were independent predictors of hemorrhagic stroke in multivariate models including body mass index, hypertension and, for MTHFR, tHcy [OR for the highest vs. lowest tHcy quartile 8.13 (95% CI 1.83-36.1), p(trend)=0.002; OR for MTHFR 677TT vs. 677CC genotype 3.62 (95% CI 0.77-17.0), p(trend)=0.040]. Haplotype analyses confirmed that the MTHFR 677T-1298A haplotype was positively associated with hemorrhagic stroke [OR 1.81 (95% CI 1.09-3.00), p=0.022], whereas the MTHFR 677C-1298C haplotype was not significantly related to either hemorrhagic or ischemic stroke. Neither tHcy nor the MTHFR polymorphisms were significant predictors of ischemic stroke.

    Conclusion: Both elevated plasma homocysteine levels and the MTHFR 677T allele are indicators of increased risk of hemorrhagic stroke in the northern Swedish population.

  • 34. Hyvärinen, Marjukka
    et al.
    Qiao, Qing
    Tuomilehto, Jaakko
    Laatikainen, Tiina
    Heine, Robert J
    Stehouwer, Coen D A
    Alberti, K George M M
    Pyörälä, Kalevi
    Zethelius, Björn
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Medicine.
    Hyperglycemia and stroke mortality: comparison between fasting and 2-h glucose criteria.2009In: Diabetes Care, ISSN 0149-5992, E-ISSN 1935-5548, Vol. 32, no 2, p. 348-354Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: We investigated stroke mortality in individuals in different categories of glycemia and compared hazard ratios (HRs) corresponding to a 1-SD increase in 2-h plasma glucose and fasting plasma glucose (FPG) criteria. RESEARCH DESIGN AND METHODS: We examined data from 2-h 75-g oral glucose tolerance tests taken from 13 European cohorts comprising 11,844 (55%) men and 9,862 (45%) women who were followed up for a median of 10.5 years. A multivariate adjusted Cox proportional hazards model was used to estimate HRs for stroke mortality. RESULTS: In men and women without a prior history of diabetes, multivariate adjusted HRs for stroke mortality corresponding to a 1-SD increase in FPG were 1.02 (95% CI 0.83-1.25) and 1.52 (1.22-1.88) and those in 2-h plasma glucose 1.21 (1.06-1.38) and 1.31 (1.06-1.61), respectively. Addition of 2-h plasma glucose to the model with FPG significantly improved prediction of stroke mortality in men (chi2 = 10.12; P = 0.001) but not in women (chi2 = 0.01; P = 0.94), whereas addition of FPG to 2-h plasma glucose improved stroke mortality in women (chi2 = 4.08; P = 0.04) but not in men (chi2 = 3.29; P = 0.07). CONCLUSIONS: Diabetes defined by either FPG or 2-h plasma glucose increases the risk of stroke mortality. In individuals without a history of diabetes, elevated 2-h postchallenge glucose is a better predictor than elevated fasting glucose in men, whereas the latter is better than the former in women.

  • 35.
    Janunger, Tomas
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Nilsson-Ardnor, Sofie
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Wiklund, Per-Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lindgren, P
    Escher, S A
    Lackovic, K
    Nilsson, A K
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Holmberg, Dan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    A novel stroke locus identified in a northern Sweden pedigree: linkage to chromosome 9q31-33.2009In: Neurology, ISSN 0028-3878, E-ISSN 1526-632X, Vol. 73, no 21, p. 1767-1773Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The population of northern Sweden is characterized by reduced genetic diversity and a high incidence of stroke. We sought to reduce genetic variation further, using genealogic analysis in a set of nuclear families affected by stroke, and we subsequently performed a genome-wide scan to identify novel stroke susceptibility loci. METHODS: Through genealogy, 7 nuclear families with a common ancestor, connected over 8 generations, were identified. A genome-wide scan using 449 microsatellite markers was performed with subsequent haplotype analyses. RESULTS: A maximum allele-sharing lod score of 4.81 on chromosome 9q31-q33 was detected. Haplotype analysis identified a common 2.2-megabase interval in the chromosomal region in 4 of the nuclear families, where an overrepresentation of intracerebral hemorrhage was observed. CONCLUSIONS: We have identified a novel susceptibility locus for stroke. Haplotype analysis suggests that a shared genetic factor is of particular importance for intracerebral hemorrhage.

  • 36.
    Johansson, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Odontology.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Åhrén, Ann-Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Systemic antibodies to the leukotoxin of the oral pathogen Actinobacillus actinomycetemcomitans correlate negatively with stroke in women2005In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 20, no 4, p. 226-232Article in journal (Refereed)
    Abstract [en]

    Background: Chronic infections and associated inflammatory markers are suggested risk factors for cardiovascular diseases (CVD) and stroke. The proinflammatory cytokine interleukin (IL)-1β is suggested to play a role in the regulation of local inflammatory responses in both CVD and periodontitis. The leukotoxin from the periodontal pathogen Actinobacillus actinomycetemcomitans has recently been shown to cause abundant secretion of IL-1β  from macrophages. The aim of the present study was to compare the prevalence of systemic antibodies to A. actinomycetemcomitansleukotoxin in stroke cases (n = 273) and matched controls (n = 546) in an incident case-control study nested within the Northern Sweden MONICA and Västerbotten Intervention cohorts.

    Methods: Antibodies to A. actinomycetemcomitans leukotoxin were analyzed in a bioassay with HL-60 cells (leukocytes), purified A. actinomycetemcomitans leukotoxin, and plasma. Plasma samples which inhibited lactate dehydrogenase release from leukotoxin-lysed cells by ≥50% were classified as antibody positive.

    Results: Antibodies to A. actinomycetemcomitans leukotoxin were detected in 18.8% of the women and 15.2% of the men. Women with those antibodies had a significantly decreased risk for stroke (OR = 0.28, 95% CI: 0.13–0.59), but not men (OR = 0.88, 95% CI: 0.52–1.51).

    Conclusion: The immunoreactivity to A. actinomycetemcomitans leukotoxin correlates negatively with a future stroke in woman, but not in men. Further studies are needed to explain the underlying mechanisms, as well as the biological relevance of this finding.

  • 37.
    Johansson, Ingegerd
    et al.
    Umeå University, Faculty of Medicine, Department of Odontology, Cariology.
    Nilsson, Lena Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Stegmayr, Birgitta
    The National Board of Welfare, Stockholm, Sweden .
    Boman, Kurt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Medicine, Skellefteå County Hospital, Skellefteå, Sweden.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Winkvist, Anna
    Associations among 25-year trends in diet, cholesterol and BMI from 140,000 observations in men and women in Northern Sweden2012In: Nutrition Journal, ISSN 1475-2891, E-ISSN 1475-2891, Vol. 11, article id 40Article in journal (Refereed)
    Abstract [en]

    Background: In the 1970s, men in northern Sweden had among the highest prevalences of cardiovascular diseases (CVD) worldwide. An intervention program combining population- and individual-oriented activities was initiated in 1985. Concurrently, collection of information on medical risk factors, lifestyle and anthropometry started. Today, these data make up one of the largest databases in the world on diet intake in a population- based sample, both in terms of sample size and follow-up period. The study examines trends in food and nutrient intake, serum cholesterol and body mass index (BMI) from 1986 to 2010 in northern Sweden.

    Methods: Cross-sectional information on self-reported food and nutrient intake and measured body weight, height, and serum cholesterol were compiled for over 140,000 observations. Trends and trend breaks over the 25-year period were evaluated for energy-providing nutrients, foods contributing to fat intake, serum cholesterol and BMI.

    Results: Reported intake of fat exhibited two significant trend breaks in both sexes: a decrease between 1986 and 1992 and an increase from 2002 (women) or 2004 (men). A reverse trend was noted for carbohydrates, whereas protein intake remained unchanged during the 25-year period. Significant trend breaks in intake of foods contributing to total fat intake were seen. Reported intake of wine increased sharply for both sexes (more so for women) and export beer increased for men. BMI increased continuously for both sexes, whereas serum cholesterol levels decreased during 1986 - 2004, remained unchanged until 2007 and then began to rise. The increase in serum cholesterol coincided with the increase in fat intake, especially with intake of saturated fat and fats for spreading on bread and cooking.

    Conclusions: Men and women in northern Sweden decreased their reported fat intake in the first 7 years (19861992) of an intervention program. After 2004 fat intake increased sharply for both genders, which coincided with introduction of a positive media support for low carbohydrate-high-fat (LCHF) diet. The decrease and following increase in cholesterol levels occurred simultaneously with the time trends in food selection, whereas a constant increase in BMI remained unaltered. These changes in risk factors may have important effects on primary and secondary prevention of cardiovascular disease (CVD).

  • 38.
    Johansson, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jansson, Jan-Håkan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Nilsson, Torbjörn K
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Boman, Kurt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hemostatic factors as risk markers for intracerebral hemorrhage: a prospective incident case-referent study.2004In: Stroke, ISSN 1524-4628, Vol. 35, no 4, p. 826-30Article in journal (Refereed)
  • 39.
    Koster, Max
    et al.
    Natl Board Hlth & Welf, SE-10630 Stockholm, Sweden.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Johansson, Åsa
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Natl Board Hlth & Welf, SE-10630 Stockholm, Sweden.
    Refinement of Swedish Administrative Registers to Monitor Stroke Events on the National Level2013In: Neuroepidemiology, ISSN 0251-5350, E-ISSN 1423-0208, Vol. 40, no 4, p. 240-246Article in journal (Refereed)
    Abstract [en]

    Background: Routinely collected databases are kept for administrative purposes. We have refined the analyses of the Swedish National Patient Register and the Cause of Death Register and explored their validity to monitor stroke at the population level. Methods: First-ever strokes (incident cases) and all stroke events were measured by combining the two administrative registers and adding refinements. The administrative registers were validated against the Northern Sweden MONICA, a well-validated population-based epidemiological stroke register. Positive predictive values (PPVs) and sensitivity were calculated. Results: After refinements (restriction to first-ever strokes and additional minor delineations), the PPV of the two administrative registers combined was 94% and sensitivity 92% when compared with all MONICA stroke categories together. For stroke attacks (first and recurrent events together), the PPV in the administrative registers was 85% and sensitivity 91%. The PPV was higher in women than in men, whereas the sensitivity was similar. The PPV was lower but sensitivity higher in people below compared with those above 75 years of age. Both PPV and sensitivity were lower among fatal cases than among cases that survived 28 days. Conclusions: After refinement, Swedish national administrative registers may, with some caveats, be used as a low-resource-consuming alternative to crudely monitor stroke incidence rates at the national level. If further accuracy is strived for, high-quality conventional epidemiological registers are required. Copyright (C) 2013 S. Karger AG, Basel

  • 40.
    Lilja, Mikael
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Eliasson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Olsson, Tommy
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Trends in obesity and its distribution: data from the Northern Sweden MONICA survey, 1986–20042008In: Obesity, ISSN 1930-7381, E-ISSN 1930-739X, Vol. 16, no 5, p. 1120-1128Article in journal (Refereed)
    Abstract [en]

    Objective: Obesity, especially abdominal, is a risk factor for many diseases. This study explored trends in theprevalence of general and abdominal obesity, 1986–2004, in northern Sweden.

    Methods and Procedures: Cross-sectional population surveys were performed in 1986, 1990, 1994, 1999, and 2004;250 men and 250 women aged 25−34, 35−44, 45−54, and 55−64 years (from 1994, also 65−74 years) were randomlyselected; the overall participation rate was 77%. Anthropometric data were used.

    Results: Weight and BMI increased in all men, most significantly in men aged 25−64 years (P < 0.0005). Weightincreased in women aged 25−64 years (P < 0.005) and BMI in women aged 25−44 years (P < 0.005). Prevalence ofobesity (BMI≥ 30) increased significantly in men aged 25−44 and 55−74 years (P < 0.005; for men 65−74 years old,P< 0.05) and in women aged 25−44 years (P < 0.005). Waist circumference decreased significantly between 1986and 1990 in all women (P < 0.005) and in men aged 55−64 years (P < 0.05). After 1990 waist circumference increased, most markedly so in women; by 2004 circumference measurements for women, and for men aged 55−64 years, were equal to those of 1986, while for men aged 25−54 years they were higher. Prevalence of abdominal obesity has increased since 1990, most markedly so in women aged 45−64 years (P < 0.0005).

    Discussion: The rapid increase in both general and central obesity raises concern for the future; increasing abdominalobesity in women is particularly alarming.

  • 41. Lindmark, Ulrika
    et al.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lindahl, Bernt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology, Cariology.
    Food selection associated with sense of coherence in adults.2005In: Nutrition Journal, ISSN 1475-2891, E-ISSN 1475-2891, Vol. 28, no 4, p. 9-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Favorable dietary habits promote health, whereas unfavorable habits link to various chronic diseases. An individual's "sense of coherence" (SOC) is reported to correlate with prevalence of some diseases to which dietary habits are linked. However, understanding what determines an individual's dietary preferences and how to change his/her behavior remains limited. The aim of the present study was to evaluate associations between dietary intake and SOC in adults. METHODS: Diet intake was recorded by an 84-item semi-quantitative food frequency questionnaire and SOC was measured by the 13-item Antonovsky questionnaire in 2,446 men and 2,545 women (25-74 years old) from the population based northern Sweden MONICA screening in 1999. RESULTS: Intakes of energy, total and saturated fat, ascorbic acid, sucrose, and servings of fruits, vegetables, cereals, and sweets correlated with SOC among women, whereas intakes of total and saturated fat, ascorbic acid, fiber, and alcohol, and servings of fruits, vegetables, bread, bread and cereals, fish, and potatoes correlated with SOC among men. With a few exceptions, intakes of these nutrients/foods were significantly explained by SOC quartile scores in linear GLM models. Both women and men classified into the highest SOC quartile had significantly higher age-BMI-education standardized mean intakes of vegetables than those in the lowest quartiles. Women in the highest SOC quartile also had higher intake of fruits but lower intakes of energy, total and saturated fat, sucrose, and sweets. Projection to latent structures (PLS) multivariate modeling of intakes of the 84 food items and food aggregates simultaneously on SOC scores supported low SOC to coincide with a presumably less health promoting dietary preference, e.g. intake of pizza, soft drinks, candies, sausages for main course, hamburgers, mashed potato, chips and other snacks, potato salad, French fries, whereas men and women with high SOC scores were characterized by e.g. high intake of rye crisp whole meal bread, boiled potato, vegetables, berries, and fruits. CONCLUSION: Both men and women in the highest, as compared with the lowest, SOC score quartile reported more "healthy" food choices. Dietary habits for individuals in the lowest SOC quartile therefore may render a higher risk for various endemic diseases.

  • 42.
    Lundberg, Vivan
    et al.
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Medicine.
    Tolonen, Hanna
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Medicine.
    Kuulasmaa, Kari
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Medicine.
    Use of oral contraceptives and hormone replacement therapy in the WHO MONICA project.2004In: Maturitas, ISSN 0378-5122, Vol. 48, no 1, p. 39-49Article in journal (Refereed)
  • 43.
    Nilsson, Berit
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Holmgren, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Westman, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sense of coherence - stability over time and relation to health, disease, and psychosocial changes in a general population: a longitudinal study2003In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 31, no 4, p. 297-304Article in journal (Refereed)
    Abstract [en]

    Aims: To explore the stability of sense of coherence (SOC) over time in a normal population and to examine its relation to gender and psychosocial factors. Methods: The Northern Sweden MONICA Project population surveys were performed in 1994 and 1999. A cohort of 1,254 subjects participating in both surveys answered questions about experiences of disease, perceived health, marital status, psychosocial factors, and Antonovsky's SOC scale with 13 items. Results: The mean SOC score showed a decrease in the five-year follow-up and those with identified disease and the oldest age group (45 - 74 years) had the largest decrease of the SOC score. People with the lowest SOC scores in 1994 had the largest decrease during the period. Men and women shared a similar pattern regarding the decrease in SOC over time. The impact of individual social changes during the study period showed that both men and women who had experienced loss of perceived good health and high social support had the largest decrease. Furthermore, women seemed to be more affected by changes than men. Conclusions: We found that SOC was only stable for those with initially high levels of SOC. For other people, individual conditions and societal changes influenced their SOC. Further longitudinal studies in normal populations are needed to investigate the stability of SOC scores.

  • 44.
    Nilsson, Berit
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Holmgren, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Westman, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sense of coherence in two cross-sectional studies in northern Sweden 1994 and 1999: Patterns among men and womenManuscript (preprint) (Other academic)
  • 45.
    Nilsson-Ardnor, Sofie
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Wiklund, Per-Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Lindgren, Petter
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Nilsson, Anna Karin
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Janunger, Tomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Andersson Escher, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Hallbeck, Björn
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Holmberg, Dan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Linkage of ischemic stroke to the PDE4D region on 5q in a Swedish population.2005In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 36, no 8, p. 1666-1671Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Recent Icelandic studies have demonstrated linkage for common forms of stroke to chromosome 5q12 and association between phosphodiesterase4D (PDE4D) and ischemic stroke. Using a candidate region approach, we wanted to test the validity of these findings in a different population from northern Sweden. METHODS: A total of 56 families with 117 affected individuals were included in the linkage study. Genotyping was performed with polymorphic microsatellite markers with an average distance of 4.5 cM on chromosome 5. In the association study, 275 cases of first-ever stroke were included together with 550 matched community controls. Polymorphisms were tested individually for association of PDE4D to stroke. RESULTS: Maximum allele-sharing lod score in favor of linkage was observed at marker locus D5S424 (lod score=2.06; P=0.0010). Conditional logistic regression calculations revealed no significant association of ischemic stroke to the defined at-risk allele in PDE4D (odds ratio, 1.1; 95% confidence interval, 0.84 to 1.45). A protective effect may though be implied for 2 of the polymorphisms analyzed in PDE4D. CONCLUSIONS: Using a candidate region approach in a set of stroke families from northern Sweden, we have replicated linkage of stroke susceptibility to the PDE4D gene region on chromosome 5q. Association studies in an independent nested case-control sample from the same geographically located population suggested that different alleles confer susceptibility/protection to stroke in the Icelandic and the northern Swedish populations.

  • 46.
    Nordfjäll, Katarina
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology. Patologi.
    Eliasson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Melander, Olle
    Nilsson, Peter
    Roos, Göran
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology. Patologi.
    Telomere Length Is Associated With Obesity Parameters but With a Gender Difference.2008In: Obesity (Silver Spring), ISSN 1930-7381, Vol. 16, no 12, p. 2682-2689Article in journal (Refereed)
  • 47.
    Nordfjäll, Kathrine
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology. Patologi.
    Eliasson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lundin, S
    Roos, Göran
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology. Patologi.
    Nilsson, P M
    Increased abdominal obesity, adverse psychosocial factors and shorter telomere length in subjects reporting early ageing; the MONICA Northern Sweden Study.2008In: Scand J Public Health, ISSN 1403-4948, Vol. 36, no 7, p. 744-752Article in journal (Other academic)
  • 48.
    Nordström, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sports Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Nordström, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Low bone mineral density is an independent risk factor for stroke and death2010In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 29, no 2, p. 130-136Article in journal (Refereed)
    Abstract [en]

    We found that decreased BMD as well as osteoporosis of the femoral neck are independently associated with stroke and death. Given the impact of osteoporosis and stroke on morbidity and mortality, this relationship is of high interest for further studies.

  • 49.
    Norrman, Signild
    et al.
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Medicine.
    Hedbäck, Bo
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine.
    Burell, Gunilla
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine.
    Brulin, Christine
    Depressive mood after a cardiac event: gender inequality and participation in rehabilitation programme.2004In: Eur J Cardiovasc Nurs, ISSN 1474-5151, Vol. 3, no 4, p. 295-302Article in journal (Refereed)
  • 50.
    Persson, Mats
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nilsson, Leif
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lindholm, Lars Hjalmar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Risk stratification by guidelines compared to tisk assessment by risk equations applied to a MONICA sample2003In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 21, no 6, p. 1089-1095Article in journal (Refereed)
    Abstract [en]

    Background: The World Health Organization/International Society of Hypertension (WHO/ISH) Hypertension Guidelines from 1999 propose a risk stratification scheme for estimating absolute risk for cardiovascular disease (CVD). Risk equations estimated by statistical methods are another way of predicting cardiovascular risk. Objective: We studied the differences between these two approaches when applied to the same set of individuals with high blood pressure. Design and methods: The two northernmost counties in Sweden (NSW) constitute one of the centres in the WHO MONICA (monitoring trends and determinants in cardiovascular disease) Project. Three population surveys have been carried out in 1986, 1990 and 1994, and were used to estimate a risk equation for predicting the 10-year risk of fatal/non-fatal stroke and myocardial infarction. Another MONICA sample from 1999, a total of 5997 subjects, was classified according to the recent WHO/ISH risk stratification scheme. A risk assessment was also performed, by using the risk equations from the NSW MONICA sample and Framingham risk equations. Results: The agreement between the two methods was good when the values obtained from the risk equation were averaged for each risk group obtained from the risk classification by guidelines. However, if the predicted risk for each individual was considered, the agreement was poor for the medium and high-risk groups. Although the average risk for all individuals is the same, many subjects have a higher risk or a lower risk than predicted by guidelines. Conclusions: Risk classification by the 1999 WHO/ISH Hypertension Guidelines is not accurate and detailed enough for medium- and high-risk patients, which could be of clinical importance in the medium risk group.

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