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  • 151.
    Nilsson, Berit
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Stegmayr, Birgitta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Holmgren, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Westman, Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Sense of coherence in two cross-sectional studies in northern Sweden 1994 and 1999: Patterns among men and womenManuskript (preprint) (Annet vitenskapelig)
  • 152.
    Nilsson, Berit
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Westman, Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    The impact of patients' influence on recovery in a group of patients with dyspepsia1999Inngår i: Family Practice, ISSN 0263-2136, E-ISSN 1460-2229, Vol. 16, nr 5, s. 515-521Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background. The approach to health and disease can either be salutogenic (origins of health) or pathogenic (disease causing), which thus makes recovery a concept featuring several different angles. Antonovsky, with his concept of salutogenesis, tried to reach a more complete understanding of its favourable effects on health.

    Objective. We aimed to investigate, understand and learn from the experiences of a small group of patients about factors leading to recovery.

    Methods.A qualitative approach was used to explore patient experiences. One semi-structured interview was conducted by one of the authors (BN) with each of the 18 patients suffering from dyspepsia who had been investigated by means of gastroscopy at a university hospital clinic 12–15 years previously. The interviews were recorded either in written notes composed directly after the interviews or tape-recorded and subsequently transcribed. A modified form of grounded theory according to Strauss-Corbin was used to analyse the data.

    Results. A pattern featuring five types of patients' influence on their lives was discerned, ranging from “a sense of no possibility of having an influence on existence/life” to “having influence”. Strategies used by patients to maintain health could be categorized into four types: “extremists”, “oscillators”, “leapers” and “full-scalers”.

    Conclusions.Listening to patients who had experiences with dyspepsia brought patient influence on their own lives and on the care process into focus. We consider that there might be a link between patients having an influence on their lives and their being healthy today. In clinical practice, patient recovery and health promotion could gain from a perspective where patient influence is treated with esteem and emphasized in the consultation. In the future, research design could benefit from taking patient influence on the care process into consideration. However, no causal linkage between patient influence and patient outcome was established in this study. In order to do that, studies with quantitative design should be undertaken in the future.

  • 153.
    Nilsson, Gunnar
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Ischaemic heart disease - risk assessment, diagnosis, and secondary preventive treatment in primary care: with special reference to the relevance of exercise ECG2016Doktoravhandling, med artikler (Annet vitenskapelig)
    Abstract [en]

    Background: Ischaemic heart disease is a diagnostic and therapeutic challenge to most general practitioners. We sought to identify diagnostic characteristics and prognoses of patients in primary care that received exercise electrocardiography (ECG). We compared the ECG test results with respect to probability of subsequent cardiologist referrals. We also aimed to identify determinants for pre-hospital delays and lack of statin treatment before a first-time myocardial infarction (MI).

    Methods: Setting: Region of Jämtland Härjedalen, Sweden (adult population, approximately 99 000); study period 2010-2014. Patients and study designs: studies I and II: 865 patients referred to exercise ECG. Primary outcome: Incidence of cardiovascular events (I) and cardiologist referrals within six months after exercise ECG (II). Observed outcomes were compared to predictions from multivariable logistic models. Study III: 265 patients with first-time MI. Characteristics were analysed for determinants of pre-hospital delay ≥ 2 hours. Study IV: Survey of 931 patients with first-time MI. Analyses of characteristics associated with rates of statin treatment in patients with previously diagnosed cardiovascular diseases (CVD).

    Results: Study I: Exercise test results were associated with exertional chest pain, a pathologic ST-T segment on resting ECG, angina diagnosis according to the patient's opinion, and medication for dyslipidaemia. Cardiovascular events occurred in 52.7%, 18.3%, and 2.0% of patients with positive (ST-segment depression >1mm and chest pain indicative of angina), inconclusive (ST depression or chest pain), or negative tests, respectively. Study II: Positive or inconclusive exercise tests were associated with cardiologist referrals. Among patients with positive exercise tests, referral rates decreased with age, after adjusting for co-morbidity. Self-employed women were referred to cardiologic evaluations more often than other employed women. Study III: The first medical contact was a primary care facility for 52.3% of patients. The pre-hospital delay time was ≥ 2 h for 67.0% of patients in primary care and 44.7% of patients that called emergency medical services or were self-referred to hospital. Study IV: Among patients with prior CVD, 34.5% received current statin treatment before for the first MI. Statin treatment rates decreased with age, after adjusting for CVD and diabetes; women ≥70 years old were treated half as often as men of the same age.

    Conclusions: Clinical characteristics can be used to identify patients at low risk of cardiac events. The prognosis in patients with a negative exercise ECG was benign for six months after the exercise ECG. Exercise tests are important for selecting patients that require cardiologic evaluations. Age, gender, and employment status interacted with rates of referrals for cardiac evaluation. The pre-hospital delay time was considerably prolonged, particularly when primary care was the first medical contact. Only one third of patients with a prior CVD received statin treatment. Pre-MI statin treatment decreased with age, particularly among women ≥70 years old. In making medical decisions, it is necessary to be aware of biases regarding age, gender, and socioeconomic status. Methodologies for case finding and follow-up need to be improved and implemented in clinical practice.

    Keywords: Exercise ECG, Ischaemic heart disease, Myocardial infarction, Pre-hospital delay, Primary care, Prognosis, Referral, Statins, Secondary prevention

  • 154.
    Nilsson, Gunnar
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Unit Clin Res Ctr Östersund, Umeå, Sweden.
    Mooe, Thomas
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Stenlund, Hans
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Samuelsson, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Diagnostic characteristics and prognoses of primary-care patients referred for clinical exercise testing: a prospective observational study2014Inngår i: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 15, artikkel-id 71Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Evaluation of angina symptoms in primary care often includes clinical exercise testing. We sought to identify clinical characteristics that predicted the outcome of exercise testing and to describe the occurrence of cardiovascular events during follow-up. Methods: This study followed patients referred to exercise testing for suspected coronary disease by general practitioners in the County of Jamtland, Sweden (enrolment, 25 months from February 2010). Patient characteristics were registered by pre-test questionnaire. Exercise tests were performed with a bicycle ergometer, a 12-lead electrocardiogram, and validated scales for scoring angina symptoms. Exercise tests were classified as positive (ST-segment depression > 1 mm and chest pain indicative of angina), non-conclusive (ST depression or chest pain), or negative. Odds ratios (ORs) for exercise-test outcome were calculated with a bivariate logistic model adjusted for age, sex, systolic blood pressure, and previous cardiovascular events. Cardiovascular events (unstable angina, myocardial infarctions, decisions on revascularization, cardiovascular death, and recurrent angina in primary care) were recorded within six months. A probability cut-off of 10% was used to detect cardiovascular events in relation to the predicted test outcome. Results: We enrolled 865 patients (mean age 63.5 years, 50.6% men); 6.4% of patients had a positive test, 75.5% were negative, 16.4% were non-conclusive, and 1.7% were not assessable. Positive or non-conclusive test results were predicted by exertional chest pain (OR 2.46, 95% confidence interval (Cl) 1.69-3.59), a pathologic ST-T segment on resting electrocardiogram (OR 2.29, 95% Cl 1.44-3.63), angina according to the patient (OR 1.70, 95% Cl 1.13-2.55), and medication for dyslipidaemia (OR 1.51, 95% CI 1.02-2.23). During follow-up, cardiovascular events occurred in 8% of all patients and 4% were referred to revascularization. Cardiovascular events occurred in 52.7%, 18.3%, and 2% of patients with positive, non-conclusive, or negative tests, respectively. The model predicted 67/69 patients with a cardiovascular event. Conclusions: Clinical characteristics can be used to predict exercise test outcome. Primary care patients with a negative exercise test have a very low risk of cardiovascular events, within six months. A predictive model based on clinical characteristics can be used to refine the identification of low-risk patients.

  • 155.
    Nilsson, Gunnar
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Mooe, Thomas
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Söderström, Lars
    Region Jämtland Härjedalen.
    Samuelsson, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Pre-hospital delay in patients with first time myocardial infarction: an observational study in a northern Swedish population2016Inngår i: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 16, nr 1, artikkel-id 93Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: In myocardial infarction (MI), pre-hospital delay is associated with increased mortality and decreased possibility of revascularisation. We assessed pre-hospital delay in patients with first time MI in a northern Swedish population and identified determinants of a pre-hospital delay ≥2 h.

    Methods: A total of 89 women (mean age 72.6 years) and 176 men (mean age 65.8 years) from a secondary prevention study were enrolled in an observational study after first time MI between November 2009 and March 2012. Total pre-hospital delay was defined as the time from the onset of symptoms suggestive of MI to admission to the hospital. Decision time was defined as the time from the onset of symptoms until the call to Emergency Medical Services (EMS). The time of symptom onset was assessed during the episode of care, and the time of call to EMS and admission to the hospital was based on recorded data. The first medical contact was determined from a mailed questionnaire. Determinants associated with pre-hospital delay ≥ 2 h were identified by multivariable logistic regression.

    Results: The median total pre-hospital delay was 5.1 h (IQR 18.1), decision time 3.1 h (IQR 10.4), and transport time 1.2 h (IQR 1.0). The first medical contact was to primary care in 52.3 % of cases (22.3 % as a visit to a general practitioner and 30 % by telephone counselling), 37.3 % called the EMS, and 10.4 % self-referred to the hospital. Determinants of a pre-hospital delay ≥ 2 h were a visit to a general practitioner (OR 10.77, 95 % CI 2.39–48.59), call to primary care telephone counselling (OR 3.82, 95 % CI 1.68–8.68), chest pain as the predominant presenting symptom (OR 0.24, 95 % CI 0.08–0.77), and distance from the hospital (OR 1.03, 95 % CI 1.02–1.04). Among patients with primary care as the first medical contact, 67.0 % had a decision time ≥ 2 h, compared to 44.7 % of patients who called EMS or self-referred (p = 0.002).

    Conclusions: Pre-hospital delay in patients with first time MI is prolonged considerably, particularly when primary care is the first medical contact. Actions to shorten decision time and increase the use of EMS are still necessary.

  • 156.
    Nilsson, Gunnar
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Unit of Research, Education and Development, Östersund Hospital, Östersund, Sweden.
    Mooe, Thomas
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Söderström, Lars
    Samuelsson, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Use of exercise tests in primary care: importance for referral decisions and possible bias in the decision process; a prospective observational study2014Inngår i: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 15, artikkel-id 182Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: The utility of clinical exercise tests depends on their support of treatment decisions. We sought to assess the utility of exercise tests for the selection of primary-care patients for referral to cardiologic care, and to determine whether referral decisions were biased by gender or socioeconomic status. We also evaluated referral rates and cardiovascular events in patients with positive exercise tests. 

    Methods: We designed a prospective observational study of 438 men and 427 women from 28 Swedish primary-care clinics who were examined with exercise testing for suspected coronary disease. All participants were followed-up with respect to cardiologist referrals and cardiovascular events (hospitalisation for unstable angina, myocardial infarction, and cardiovascular death) within six months and revascularisation within 250 days. Variables associated with referral were identified by multivariable logistic regression. Socioeconomic status was determined by educational level and employment. 

    Results: Positive/inconclusive exercise tests and exertional chest pain predicted referral in men and women. Of 865 participants, patients with positive, inconclusive, or negative exercise tests were referred to cardiologists in 67.3%, 26.1%, and 3.5% of cases, respectively. Overall, there was no significant difference in referral rates related to gender or socioeconomic level. Self-employed women were referred more frequently compared to other women (odds ratio (OR) 3.62, 95% confidence interval (CI) 1.19-10.99). Among non-manual employees, women were referred to cardiologic examination less frequently than men (OR 0.40, 95% CI 0.16-1.00; p = 0.049; ORs adjusted for age, exertional chest pain, and exercise test result). In patients with positive exercise tests, the referral rate decreased continuously with age (OR 0.48, 95% CI 0.23-0.97; adjusted for cardiovascular co-morbidity). Cardiovascular events occurred in 22.2% (4/18) of non-referred patients with positive exercise tests; 56% (10/18) of these patients were not considered for cardiologic care, with continuity problems in primary care as one possible contributing cause. 

    Conclusions: Exercise tests are important for selecting patients for referral to cardiologic care. Interactions related to gender and socioeconomic status affected referral rates. In patients with positive exercise tests, referral rates decreased with age. An increased awareness of possible bias regarding age, gender, and socioeconomic status, which may influence medical decisions, is therefore necessary.

  • 157.
    Nilsson, Gunnar
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Samuelsson, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Söderström, Lars
    Region Jämtland Härjedalen.
    Mooe, Thomas
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Treatment with statins prior to first time myocardial infarction, with special reference to patients with previously diagnosed cardiovascular disease: a population-based surveyManuskript (preprint) (Annet vitenskapelig)
  • 158.
    Nilsson, Maria
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Beaglehole, Robert
    Sauerborn, Rainer
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Climate policy: lessons from tobacco control2009Inngår i: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 374, nr 9706, s. 1955-1956Artikkel i tidsskrift (Fagfellevurdert)
  • 159.
    Norberg, Bo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    B-vitaminer i primärvården: behov, brist, biverkningar2006Inngår i: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 103, nr 13, s. 1047-1047Artikkel i tidsskrift (Annet (populærvitenskap, debatt, mm))
  • 160.
    Norberg, Bo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Homocystein: kris – utveckling2006Inngår i: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 103, nr 5, s. 305-305Artikkel i tidsskrift (Annet (populærvitenskap, debatt, mm))
  • 161.
    Norberg, Bo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Vitamin B12 och folat: ett förtydligande2005Inngår i: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 102, nr 45, s. 3404-3404Artikkel i tidsskrift (Annet (populærvitenskap, debatt, mm))
  • 162.
    Norberg, Bo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Vitamin B12 och folat: sista smörjelsen?2005Inngår i: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 102, nr 34, s. 2333-2333Artikkel i tidsskrift (Annet (populærvitenskap, debatt, mm))
  • 163.
    Norberg, Margareta
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Stenlund, Hans
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Lindahl, B
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Andersson, Christer
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Eriksson, Jan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Weinehall, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Work stress and low emotional support is associated with increased risk of future type 2 diabetes in women2007Inngår i: Diabetes Research and Clinical Practice, ISSN 0168-8227, E-ISSN 1872-8227, Vol. 76, nr 3, s. 368-377Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    A case-referent study nested within a population-based health survey investigated the associations between psychosocial stress, such as work stress and low emotional support, and future development of type 2 diabetes among occupationally working middle-aged men and women. All participants in a health survey conducted during 1989-2000 (n=33,336) in Umeå in northern Sweden, were included. We identified 191 cases, who were not diabetic initially but were diagnosed with type 2 diabetes after 5.4+/-2.6 years. Two age- and sex-matched referents were selected for each case. Multivariate logistic regression analyses and interaction effects between variables were evaluated.

    In women, passive or tense working situations were associated with future type 2 diabetes with odds ratios 3.6 (95% confidence interval 1.1-11.7) and 3.6 (1.0-13.3), respectively, and also low emotional support 3.0 (1.3-7.0). These associations were not seen in men. In women, they remained after adjustment for BMI, civil status and educational level, and there were also tendencies for interactions between work stress and low emotional support.

    In conclusion, work stress and low emotional support may increase the risk of type 2 diabetes in women, but not in men. These findings contribute to our understanding of psychosocial stress as potential risk factors for type 2 diabetes in a Swedish population.

  • 164. Nordin, Pär
    et al.
    van der Linden, Willem
    Volume of procedures and risk of recurrence after repair of groin hernia: national register study2008Inngår i: BMJ. British Medical Journal (International Ed.), ISSN 0959-8146, E-ISSN 0959-535X, Vol. 336, nr 7650, s. 934-937Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVE: To determine whether the association between volume and outcome found in major surgery also holds true for a minor operation. DESIGN: Review of outcomes after hernia surgery in Sweden.

    SETTING: Surgical units registered with the Swedish hernia register, which in 2004 covered about 95% of all hernia operations in Sweden.

    PARTICIPANTS: 86,409 patients over 15 years, who underwent 96,601 unilateral or bilateral groin hernia repairs (94,077 inguinal and 2524 femoral) in 1996-2004 at the participating surgical units.

    MAIN OUTCOME MEASURE: Re-operation for recurrence.

    RESULTS: There was a significantly higher rate of re-operation in surgeons who carried out 1-5 repairs a year than in surgeons who carried out more repairs. There was no association between outcome and further increases in volume. Although about half of surgeons in Sweden who repair hernias are low volume operators, they performed only 8.4% of all repairs.

    CONCLUSIONS: Sweden's numerous low volume hernia surgeons perform such a small proportion of all operations that the impact of their inferior results on the nationwide re-operation rate is minimal. Volume indicates an approximate minimum value for the number of hernia repairs a surgeon should do each year but the outcome in surgeons who carry out more than that number disqualifies volume as an indicator of proficiency.

  • 165.
    Nordström, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Rehabiliteringsmedicin. Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Idrottsmedicin.
    Edin, Benoni B.
    Umeå universitet, Medicinska fakulteten, Institutionen för integrativ medicinsk biologi (IMB), Fysiologi.
    Lindström, Sara
    Nordström, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Geriatrik.
    Cognitive function and other risk factors for mild traumatic brain injury in young men: nationwide cohort study2013Inngår i: BMJ. British Medical Journal, E-ISSN 1756-1833, Vol. 346, s. f723-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective To investigate cognitive function and other risk factors for mild traumatic brain injury in young men.

    Design Nationwide prospective cohort study.

    Setting Sweden.

    Participants 305 885 men conscripted for military service from 1989 to 1994.

    Main outcome measure mild traumatic brain injuries in relation to cognitive function and other potential risk factors assessed at conscription and follow-up.

    Results Men with one mild traumatic brain injury within two years before (n=1988) or after cognitive testing (n=2214) had about 5.5% lower overall cognitive function scores than did men with no mild traumatic brain injury during follow up (P<0.001 for both). Moreover, men with at least two mild traumatic brain injuries after cognitive testing (n=795) had 15% lower overall cognitive function scores compared with those with no such injury (P<0.001). Independent strong risk factors (P<1x10(-10)) for at least one mild traumatic brain injury after cognitive testing (n=12 494 events) included low overall cognitive function, a previous mild traumatic brain injury, hospital admission for intoxications, and low education and socioeconomic status. In a sub-cohort of twin pairs in which one twin had a mild traumatic brain injury before cognitive testing (n=63), both twins had lower logical performance and technical performance compared with men in the total cohort with no mild traumatic brain injury (P<0.05 for all).

    Conclusion Low cognitive function, intoxications, and factors related to low socioeconomic status were strong independent risk factors for mild traumatic brain injuries in men. The low cognitive function in twin pairs discordant for mild traumatic brain injury suggests a genetic component to the low cognitive function associated with such injuries. The study included only men, so inferences to women should be made with caution.

  • 166.
    Nordström, Anna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Idrottsmedicin.
    Eriksson, Marie
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Stegmayr, Birgitta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Gustafson, Yngve
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Geriatrik.
    Nordström, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Geriatrik.
    Low bone mineral density is an independent risk factor for stroke and death2010Inngår i: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 29, nr 2, s. 130-136Artikkel i tidsskrift (Fagfellevurdert)
    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.

  • 167.
    Nordström, Peter
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Geriatrik.
    Gustafson, Yngve
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Geriatrik.
    Michaëlsson, Karl
    Nordström, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Length of hospital stay after hip fracture and short term risk of death after discharge: a total cohort study in Sweden2015Inngår i: BMJ. British Medical Journal, ISSN 1756-1833, Vol. 350, artikkel-id h696Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective To investigate relation between inpatient length of stay after hip fracture and risk of death after hospital discharge. Setting Population >= 50 years old living in Sweden as of 31 December 2005 with a first hip fracture the years 2006-12. Participants 116 111 patients with an incident hip fracture from a closed nationwide cohort. Main outcome measure Death within 30 days of hospital discharge in relation to hospital length of stay after adjustment for multiple covariates. Results Mean inpatient length of stay after a hip fracture decreased from 14.2 days in 2006 to 11.6 days in 2012 (P<0.001). The association between length of stay and risk of death after discharge was non-linear (P<0.001), with a threshold for this non-linear effect of about 10 days. Thus, for patients with length of stay of <= 10 days (n=59 154), each 1-day reduction in length of stay increased the odds of death within 30 days of discharge by 8% in 2006 (odds ratio 1.08 (95% confidence interval 1.04 to 1.12)), which increased to16% in 2012 (odds ratio 1.16 (1.12 to 1.20)). In contrast, for patients with a length of stay of >= 11 days (n=56 957), a 1-day reduction in length of stay was not associated with an increased risk of death after discharge during any of the years of follow up. Limitations No accurate evaluation of the underlying cause of death could be performed. Conclusion Shorter length of stay in hospital after hip fracture is associated with increased risk of death after hospital discharge, but only among patients with length of stay of 10 days or less. This association remained robust over consecutive years.

  • 168.
    Nordström, Peter
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Geriatrik.
    Nordström, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Idrottsmedicin.
    Eriksson, Marie
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet, Statistik.
    Wahlund, Lars-Olof
    Gustafson, Yngve
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Geriatrik.
    Risk factors in late adolescence for young-onset dementia in men: a nationwide cohort study2013Inngår i: JAMA internal medicine, ISSN 2168-6114, Vol. 173, nr 17, s. 1612-1618Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    IMPORTANCE: Young-onset dementia (YOD), that is, dementia diagnosed before 65 years of age, has been related to genetic mutations in affected families. The identification of other risk factors could improve the understanding of this heterogeneous group of syndromes.

    OBJECTIVE: To evaluate risk factors in late adolescence for the development of YOD later in life.

    DESIGN: We identified the study cohort from the Swedish Military Service Conscription Register from January 1, 1969, through December 31, 1979. Potential risk factors, such as cognitive function and different physical characteristics, were assessed at conscription. We collected other risk factors, including dementia in parents, through national register linkage.

    PARTICIPANTS: All Swedish men conscripted for mandatory military service (n = 488 484) with a mean age of 18 years.

    SETTING: Predominantly Swedish men born from January 1, 1950, through December 31, 1960.

    EXPOSURE: Potential risk factors for dementia based on those found in previous studies, data available, and quality of register data.

    MAIN OUTCOMES AND MEASURE: All forms of YOD.

    RESULTS: During a median follow-up of 37 years, 487 men were diagnosed as having YOD at a median age of 54 years. In multivariate Cox regression analysis, significant risk factors (all P &lt; .05) for YOD included alcohol intoxication (hazard ratio, 4.82 [95% CI, 3.83-6.05]); population-attributable risk, 0.28), stroke (2.96 [2.02-4.35]; 0.04), use of antipsychotics (2.75 [2.09-3.60]; 0.12), depression (1.89 [1.53-2.34]; 0.28), father's dementia (1.65 [1.22-2.24]; 0.04), drug intoxication other than alcohol (1.54 [1.06-2.24]; 0.03), low cognitive function at conscription (1.26 per 1-SD decrease [1.14-1.40]; 0.29), low height at conscription (1.16 per 1-SD decrease [1.04-1.29]; 0.16), and high systolic blood pressure at conscription (0.90 per 1-SD decrease [0.82-0.99]; 0.06). The population-attributable risk associated with all 9 risk factors was 68%. Men with at least 2 of these risk factors and in the lowest third of overall cognitive function were found to have a 20-fold increased risk of YOD during follow-up (hazard ratio, 20.38 [95% CI, 13.64-30.44]).

    CONCLUSIONS AND RELEVANCE: In this nationwide cohort, 9 independent risk factors were identified that accounted for most cases of YOD in men. These risk factors were multiplicative, most were potentially modifiable, and most could be traced to adolescence, suggesting excellent opportunities for early prevention.

  • 169.
    Nordström, Peter
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Geriatrik.
    Pedersen, Nancy L
    Gustafson, Yngve
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Geriatrik.
    Michaëlsson, Karl
    Nordström, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Risks of Myocardial Infarction, Death, and Diabetes in Identical Twin Pairs With Different Body Mass Indexes2016Inngår i: JAMA Internal Medicine, ISSN 2168-6106, E-ISSN 2168-6114, Vol. 176, nr 10, s. 1522-1529Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    IMPORTANCE Observational studies have shown that obesity is a major risk factor for cardiovascular disease and death. The extent of genetic confounding in these associations is unclear. OBJECTIVE To compare the risk of myocardial infarction (MI), type 2 diabetes, and death in monozygotic (MZ) twin pairs discordant for body mass index (BMI). DESIGN, SETTING, AND PARTICIPANTS A cohort of 4046 MZ twin pairs with discordant BMIs (difference >0.01) was identified using the nationwide Swedish twin registry. The study was conducted from March 17, 1998, to January 16, 2003, with follow-up regarding incident outcomes until December 31, 2013. MAIN OUTCOMES AND MEASURES The combined primary end point of death or MI and the secondary end point of incident diabetes were evaluated in heavier compared with leaner twins in a co-twin control analysis using multivariable conditional logistic regression. RESULTS Mean (SD) baseline age for both cohorts was 57.6 (9.5) years (range, 41.9-91.8 years). During a mean follow-up period of 12.4 (2.5) years, 203 MIs (5.0%) and 550 deaths (13.6%) occurred among heavier twins (mean [SD] BMI, 25.9 [3.6] [calculated as weight in kilograms divided by height in meters squared]) compared with 209 MIs (5.2%) and 633 deaths (15.6%) among leaner twins (mean [SD] BMI, 23.9 [3.1]; combined multivariable adjusted odds ratio [OR], 0.75; 95% CI, 0.63-0.91). Even in twin pairs with BMI discordance of 7.0 or more (mean [SE], 9.3 [0.7]), where the heavier twin had a BMI of 30.0 or more (n = 65 pairs), the risk of MI or death was not greater in heavier twins (OR, 0.42; 95% CI, 0.15-1.18). In contrast, in the total cohort of twins, the risk of incident diabetes was greater in heavier twins (OR, 2.14; 95% CI, 1.61-2.84). Finally, increases in BMI since 30 years before baseline were not associated with the later risk of MI or death (OR, 0.97; 95% CI, 0.89-1.05) but were associated with the risk of incident diabetes (OR, 1.13; 95% CI, 1.01-1.26). CONCLUSIONS AND RELEVANCE In MZ twin pairs, higher BMI was not associated with an increased risk of MI or death but was associated with the onset of diabetes. These results may suggest that lifestyle interventions to reduce obesity are more effective in decreasing the risk of diabetes than the risk of cardiovascular disease or death.

  • 170.
    Novo, Mehmed
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Young and unemployed - does the trade cycle matter for health?: a study of young men and women during times of prosperity and times of recession2000Doktoravhandling, med artikler (Annet vitenskapelig)
  • 171.
    Nygren, Karina
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Bergström, Erik
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik.
    Janlert, Urban
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Nygren, Lennart
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Adolescent self-reported health in relation to school factors: a multilevel analysis2014Inngår i: Journal of School Nursing, ISSN 1059-8405, E-ISSN 1546-8364, Vol. 30, nr 2, s. 114-122Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    The aim of the study was to examine school-related determinants of self-reported health among adolescents. Questionnaire survey data comprising 4,972 students, Grades 7 through 9, from 20 schools in northern Sweden were used. Also, complimentary data about each school were collected from the Swedish National Agency for Education. Using multilevel logistic regression analyses, results showed that most variation in self-reported health was explained by individual-level differences. Truancy, bullying, and poor relations with teachers significantly increased the odds ratio of reporting poor general health, for boys and for girls. Most variables at the school level, for example, school size and student-teacher ratio, did not render significant associations with students' self-reported health. In conclusion, this study indicates that health promotion at school, including school health services, may benefit from focusing primarily on individual-level determinants of health, that is, students' relations to peers and teachers, without ignoring that bullying and weak student-teacher relationships also may induce school-level interventions.

  • 172.
    Nyström, Emma
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Self-Management of Urinary Incontinence Using eHealth: clinically relevant improvement, treatment effect and factors associated with success2018Doktoravhandling, med artikler (Annet vitenskapelig)
    Abstract [en]

    Background: Urinary incontinence is common among women, with prevalence most often reported to be between 25% and 45%. The most common type is stress urinary incontinence (SUI), defined as leakage upon exertion. First-line treatment includes pelvic floor muscle training (PFMT) and lifestyle advice. eHealth, the use of information and communication technology for health, can lower barriers to seeking help, save time and provide easily accessible care. In other conditions, the use of mobile technology has been argued to improve adherence to, and serve as a support for, self-management leading to improved symptom control.

    Aim: To evaluate self-management of urinary incontinence via eHealth with respect to clinically relevant improvement, treatment effect and factors associated with success. This thesis focuses on self-management of SUI via the mobile app Tät®.

    Methods: This thesis is based on four papers (I-IV) with data from three different studies (1-3). Studies 1 and 2 were randomised controlled trials, to which adult, community-dwelling women with at least weekly SUI were recruited via the website of the research project. In study 3, we studied the use of the Tät® app once it had been made freely available after study 2. All users with urinary incontinence that were 18 years of age or older were included. All interventions were developed within the research project, focused on PFMT and included lifestyle advice

    In study 1, participants were randomised to either internet-based or brochurebased SUI management. Data from both groups were analysed for correlation with the Patient Global Impression of Improvement (PGI-I) questionnaire and the changes in validated symptom (ICIQ-UI SF) questionnaire and in the quality of life (ICIQ-LUTSqol) questionnaire. We then determined a minimal important difference (MID) for non-face-to-face treatment of SUI. (Paper I)

    In study 2, participants were randomised to three months of self-management with the Tät® app or to control group (waiting list). The primary outcomes were ICIQ-UI SF and ICIQ-LUTSqol. These were analysed according to intention to treat using a linear mixed model. (Paper II) Data from the participants that were randomised to app management were analysed using logistic regression to identify factors associated with success. Success was defined as participants stating that they were much/very much better according to PGI-I. (Paper III)

    In study 3, users were asked to participate by completing questionnaires upon download of the app and three months thereafter. Background factors, PFMT iv frequency and app usage were analysed using logistic regression to identify factors associated with three outcomes: completion of three months of selfmanagement, improvement (according to PGI-I) and success (defined as described above). (Paper IV)

    Results: We found that the symptom and quality of life scores capture a clinically relevant improvement. The MIDs were determined to be a reduction of 2.52 points for ICIQ-UI SF and 3.71 points for ICIQ-LUTSqol. (Paper I)

    The Tät® app had a positive effect on symptoms with a mean ICIQ-UI SF reduction of 3.9 points (95% CI 3.0 -4.7), and improved quality of life with a mean ICIQ-LUTSqol reduction of 4.8 points (95% CI 3.4-6.2). These scores differed significantly from the control group and were well above the MIDs, and therefore clinically relevant improvements. Women in the intervention groups also had a greater decrease in incontinence episode frequency, and significantly reduced their pad use compared to the control group. In terms of patient satisfaction, 97% found the app to be “good” or “very good”. (Paper II)

    After three months of self-management with Tät®, 34 out of 61 participants (56%) stated that they were much or very much better. Three factors were associated with successful management: high expectations on treatment, weight control and self-assessed improvement in pelvic floor muscle strength. (Paper III)

    Once the app was freely available, 1 861 of 13 257 users (14%) completed the three-month follow-up. Four factors predicted completion: age, higher educational level, stress-type incontinence episodes and language. Together these factors accounted for 2.7% of the variability (Nagelkerke R2). Among the users that completed self-management, 68% improved and 29% were successful according to the PGI-I. Stress-type leakage and language were also associated with improvement. At least weekly PFMT and app usage predicted both improvement and successful self-management. (Paper IV)

    Conclusion: Self-management for urinary incontinence via a mobile app has clinically relevant effects on symptoms and quality of life. This is particularly the case for women with high expectations on app self-management and for those who used the app and exercised their pelvic floor at least weekly. Furthermore, beyond the study setting once the app was freely available, the majority of users’ symptoms improved if users completed three months of training.

  • 173. Nzenze, Susan A
    et al.
    Shiri, Tinevimbo
    Nunes, Marta C
    Klugman, Keith P
    Kahn, Kathleen
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Twine, Rhian
    de Gouveia, Linda
    von Gottberg, Anne
    Madhi, Shabir A
    Temporal changes in pneumococcal colonization in a rural African community with high HIV prevalence following routine infant pneumococcal immunization2013Inngår i: The Pediatric Infectious Disease Journal, ISSN 0891-3668, E-ISSN 1532-0987, Vol. 32, nr 11, s. 1270-1278Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Pneumococcal conjugate vaccine (PCV) immunization of children decreases their risk of nasopharyngeal acquisition of vaccine serotypes. We studied the impact of routine infant PCV immunization alone on the epidemiology of nasopharyngeal pneumococcal colonization among a rural African community with high prevalence of HIV positivity.

    Methods: Two cross-sectional surveys were undertaken in a rural South African community from May to October 2009 (period 1) and 2011 (period 2). Seven-valent PCV was introduced into the public immunization program for infants in April 2009, without catch-up campaign for older children. Randomly selected households with at least 1 child <2 years of age were recruited. Nasopharyngeal swabs from all consenting household members were obtained for Streptococcus pneumoniae culture and serotyping by Quellung method.

    Results: The median ages (SD) of children enrolled were 4.32 (SD, 3.4) and 3.80 (SD, 3.4) years in periods 1 and 2, respectively. Overall, the prevalence of vaccine serotype colonization declined from 18.3% (368/2010) in period 1 to 11.4% (418/3659) by period 2 (P < 0.0001). This included reductions (adjusted risk ratio) of 50% [95% confidence interval (95% CI): 0.42-0.59], 34% (95% CI: 0.48-0.92) and 64% (95% CI: 0.18-0.74) in age groups < 2 years, 6-12 years and adults. The prevalence of vaccine serotype colonization among primary caregivers decreased from 10.2% to 5.4% (P <= 0.001) by period 2. The prevalence of nonvaccine serotype colonization increased by 35% (95% CI: 1.17-1.56) among <2-year-old children by period 2, while it declined by 45-54% among adolescents and adults.

    Conclusions: An indirect effect of PCV7 was realized in a high HIV prevalence setting within 2 years of PCV introduction. The unexpected decline in nonvaccine serotypes colonization among adolescents/adults may indicate lag in replacement colonization by nonvaccine serotypes in this group.

  • 174.
    Näsman, Amanda
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Asthma, asthma medication and training intensity in Swedish competitive athletes: An internet-based survey2015Independent thesis Basic level (professional degree), 20 poäng / 30 hpOppgave
  • 175. Okin, Peter M
    et al.
    Wachtell, Kristian
    Devereux, Richard B
    Harris, Katherine E
    Jern, Sverker
    Kjeldsen, Sverre E
    Julius, Stevo
    Lindholm, Lars H
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Nieminen, Markku S
    Edelman, Jonathan M
    Hille, Darcy A
    Dahlöf, Björn
    Regression of electrocardiographic left ventricular hypertrophy and decreased incidence of new-onset atrial fibrillation in patients with hypertension2006Inngår i: Journal of the American Medical Association (JAMA), ISSN 0098-7484, E-ISSN 1538-3598, Vol. 296, nr 10, s. 1242-1248Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Context Atrial fibrillation (AF) is associated with increased risk of mortality and cardiovascular events, particularly stroke, making prevention of new-onset AF a clinical priority. Although the presence and severity of electrocardiographic left ventricular hypertrophy (LVH) appear to predict development of AF, whether regression of electrocardiographic LVH is associated with a decreased incidence of AF is unclear. Objective To test the hypothesis that in-treatment regression or continued absence of electrocardiographic LVH during antihypertensive therapy is associated with a decreased incidence of AF, independent of blood pressure and treatment modality. Design, Setting, and Participants Double-blind, randomized, parallel-group study conducted in 1995-2001 among 8831 men and women with hypertension, aged 55-80 years (median, 67 years), with electrocardiographic LVH by Cornell voltage-duration product or Sokolow-Lyon voltage, with no history of AF, without AF on the baseline electrocardiogram, and enrolled in the Losartan Intervention for Endpoint Reduction in Hypertension Study. Interventions Losartan-or atenolol-based treatment regimens, with follow-up assessments at 6 months and then yearly until death or study end. Main Outcome Measure New-onset AF in relation to electrocardiographic LVH determined at baseline and subsequently. Electrocardiographic LVH was measured using sex-adjusted Cornell product criteria ({R-aVL + S-V3 [+6 mm in women]} X QRS duration). Results After a mean (SD) follow-up of 4.7 (1.1) years, new-onset AF occurred in 290 patients with in-treatment regression or continued absence of Cornell product LVH for a rate of 14.9 per 1000 patient-years and in 411 patients with in-treatment persistence or development of LVH by Cornell product criteria for a rate of 19.0 per 1000 patient-years. In time-dependent Cox analyses adjusted for treatment effects, baseline differences in risk factors for AF, baseline and in-treatment blood pressure, and baseline severity of electrocardiographic LVH, lower in-treatment Cornell product LVH treated as a time-varying covariate was associated with a 12.4% lower rate of new-onset AF (adjusted hazard ratio [HR], 0.88; 95% CI, 0.80-0.97; P = .007) for every 1050 mm X msec (per 1-SD) lower Cornell product, with persistence of the benefit of losartan vs atenolol therapy on developing AF (HR, 0.83; 95% CI, 0.71-0.97; P = .01). Conclusions Lower Cornell product electrocardiographic LVH during antihypertensive therapy is associated with a lower likelihood of new-onset AF, independent of blood pressure lowering and treatment modality in essential hypertension. These findings suggest that antihypertensive therapy targeted at regression or prevention of electrocardiographic LVH may reduce the incidence of new-onset AF.

  • 176. Olofsson, Niclas
    et al.
    Lindqvist, Kent
    Danielsson, Ingela
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi. Västernorrland Cty Council, Dept Res & Dev, S-87185 Härnösand, Sundsvall, Sweden.
    Higher Risk of Violence Exposure in Men and Women With Physical or Sensory Disabilities: Results From a Public Health Survey2015Inngår i: Journal of Interpersonal Violence, ISSN 0886-2605, E-ISSN 1552-6518, Vol. 30, nr 10, s. 1671-1686Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    The World Health Organization has declared that violence is a global public health problem. The prevalence of violence exposure among adults with intellectual and unspecific disabilities has been demonstrated in several studies, whereas only a few articles on people with sensory disabilities have been published. The aim of this study was to investigate the prevalence and risk for exposure to physical violence, psychological offence, or threats of violence in people with physical and/or sensory disabilities, compared with people with no such disabilities, controlling for socioeconomic data. Data from a public health survey were analyzed. A nationally representative sample of women and men aged 16 to 84 years had answered a questionnaire. In the present study, the whole sample, comprised of 25,461 women and 21,545 men, was used. Women with auditory disabilities were generally more often violence exposed than non-disabled women, whereas men with physical disabilities were more often violence exposed than non-impaired men. Some age groups among both women and men with visual disabilities had higher prevalence rates than women and men without disabilities. The adjusted odds ratios (ORs) were significantly higher among the auditory impairment group for exposure to physical (OR = 1.4, confidence interval [CI] = [1.1, 1.9]) and psychological (OR = 1.4, CI = [1.1, 1.8]) violence among women. Men with physical disabilities had raised odds ratios for physical violence (OR = 1.7, CI = [1.2, 2.4]) and psychological violence (OR = 1.4, CI = [1.0, 2.0]) compared with the non-disabled group. Both men and women with a physical or sensory disability showed higher odds of being exposed to violence than men and women without a disability. The results indicated that socioeconomic situation, smoking, and hazardous drinking strengthened the association between impairment and violence.

  • 177. Olofsson, P
    et al.
    Söderström, L
    Jern, C
    Sirsjö, A
    Ria, M
    Sundler, E
    de Faire, U
    Wiklund, Per-Gunnar
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Ohrvik, J
    Hedin, U
    Paulsson-Berne, G
    Hamsten, A
    Eriksson, P
    Hansson, G
    Genetic variants of TNFSF4 and risk for carotid artery disease and stroke2008Inngår i: Journal of Molecular Medicine, ISSN 0946-2716, E-ISSN 1432-1440, Vol. 87, nr 4, s. 337-346Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    In two independent human cohorts, the minor allele of SNP rs3850641 in TNFSF4 was significantly more frequent in individuals with myocardial infarction than in controls. In mice, Tnfsf4 expression is associated with increased atherosclerosis. The expression of TNFSF4 in human atherosclerosis and the association between genotype and cerebrovascular disease have not yet been investigated. TNFSF4 messenger RNA (mRNA) levels were significantly higher in human atherosclerotic lesions compared with controls (730 +/- 30 vs 330 +/- 65 arbitrary units, p < 0.01). TNFSF4 was mainly expressed by macrophages in atherosclerotic lesions. In cell culture, endothelial cells upregulated TNFSF4 in response to tumor necrosis factor alpha (TNF-alpha; 460 +/- 110 vs 133 +/- 8 arbitrary units, p < 0.001 after 6 h of stimulation). We analyzed the TNFSF4 gene in 239 patients who had undergone carotid endarterectomy and 138 matching controls from The Biobank of Karolinska Carotid Endarterectomies and Stockholm Heart Epidemiology Program cohorts and 929 patients and 1,382 matching controls from the Sahlgrenska Academy Study on Ischemic Stroke and Case Control Study of Stroke cohorts, limiting inclusion to patients with ischemic stroke. Participants were genotyped for the rs3850641 SNP in TNFSF4. Genotype associations were neither found with TNFSF4 mRNA levels nor with atherosclerosis associated systemic factors or risk for stroke. This study shows that TNFSF4 is expressed on antigen-presenting cells in human carotid atherosclerotic lesions but provides no evidence for an association of TNFSF4 gene variation with the risk for ischemic stroke.

  • 178.
    Olsén, Christina
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Attitudes and perceptions of virtual health room (VHR) among patients in primary health care in northern Sweden2018Independent thesis Basic level (professional degree), 20 poäng / 30 hpOppgave
  • 179. Ott, Michael
    et al.
    Stegmayr, Bernd
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Salander Renberg, Ellinor
    Werneke, Ursula
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Psykiatri.
    Lithium intoxication: Incidence, clinical course and renal function - a population-based retrospective cohort study2016Inngår i: Journal of Psychopharmacology, ISSN 0269-8811, E-ISSN 1461-7285, Vol. 30, nr 10, s. 1008-1019Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    When prescribing lithium, the risk of toxicity remains a concern. In this study, we examined a cohort of patients exposed to lithium between 1997 and 2013. The aims of this study were to determine the frequency of lithium intoxication and to evaluate the clinical course and changes in renal function. Of 1340 patients, 96 had experienced at least one episode of lithium levels ⩾1.5 mmol/L, yielding an incidence of 0.01 per patient-year. Seventy-seven patients available for review had experienced 91 episodes, of whom 34% required intensive care and 13% were treated with haemodialysis. There were no fatalities. Acute kidney injury occurred, but renal function at baseline was not different to renal function after the episode. Renal impairment was often associated with co-morbidities and other factors. Both intermittent and continuous-venovenous haemodialysis were used, but the clearance of continuous-venovenous haemodialysis can be too low in cases where large amounts of lithium have been ingested. Saline and forced diuresis have been used and are safe. Lithium intoxication seems rare and can be safely managed in most cases. Physicians should not withhold lithium for fear of intoxication in patients who benefit from it. Yet, physicians should have a low threshold to screen for toxicity.

  • 180.
    Parkinson, Lynne
    et al.
    Research Centre for Gender, Health and Ageing, The University of Newcastle, Newcastle, Australia.
    Doljagore, Xenia
    Gibson, Richard
    Doran, Evan
    Notley, Lisa
    Stewart Williams, Jenny
    Research Centre for Gender, Health and Ageing, The University of Newcastle, Newcastle, Australia.
    Kowal, Paul
    Byles, Julie E
    An observational study of the discrediting of COX-2 NSAIDs in Australia: Vioxx or class effect?2011Inngår i: BMC public health, ISSN 1471-2458, Vol. 11, s. 892-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: When a medicine such as rofecoxib (Vioxx) is withdrawn, or a whole class of medicines discredited such as the selective COX-2 inhibitors (COX-2s), follow-up of impacts at consumer level can be difficult and costly. The Australian Longitudinal Study on Women's Health provides a rare opportunity to examine individual consumer medicine use following a major discrediting event, the withdrawal of rofecoxib and issuing of safety warnings on the COX-2 class of medicines. The overall objective of this paper was to examine the impact of this discrediting event on dispensing of the COX-2 class of medicines, by describing medicine switching behaviours of older Australian women using rofecoxib in September 2004; the uptake of other COX-2s; and the characteristics of women who continued using a COX-2.

    METHODS: Participants were concessional beneficiary status women from the Older cohort (born 1921-26) of the Australian Longitudinal Study on Women's Health who consented to linkage to Pharmaceutical Benefits Scheme data, with at least one rofecoxib prescription dispensed in the 12 months before rofecoxib withdrawal. A prescription was defined as one dispensing occasion. Women were grouped by rofecoxib pattern of use: continuous (nine or more prescriptions dispensed in the 12 months prior to rofecoxib withdrawal) or non-continuous (eight or less prescriptions dispensed in the 12 months prior to rofecoxib withdrawal) users. Incidence rate per 100,000 person days and incidence risk ratio described uptake of alternate medicines, following rofecoxib withdrawal. Kaplan-Meier curves described differences in uptake patterns by medicine and pattern of rofecoxib use. Patterns of use of COX-2s in the next 100 days after first COX-2 uptake were described.

    RESULTS: Medicine switches and pattern of medicines uptake differed significantly depending upon whether a woman was a continuous or non-continuous rofecoxib user prior to rofecoxib discrediting. Continuous rofecoxib users overwhelmingly switched to another COX-2 and remained continuing COX-2 users for at least 100 days post-switch.

    CONCLUSIONS: The typical switching behaviour of this group of women suggests that the issues leading to the discrediting of rofecoxib were not seen as a COX-2 class effect by prescribers to this high use group of consumers.

  • 181. Partonen, Timo
    et al.
    Treutlein, Jens
    Alpman, Asude
    Frank, Josef
    Johansson, Carolina
    Depner, Martin
    Aron, Liviu
    Rietschel, Marcella
    Wellek, Stefan
    Soronen, Pia
    Paunio, Tiina
    Koch, Andreas
    Chen, Ping
    Lathrop, Mark
    Adolfsson, Rolf
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Psykiatri.
    Persson, Maj-Liz
    Kasper, Siegfried
    Schalling, Martin
    Peltonen, Leena
    Schumann, Gunter
    Three circadian clock genes Per2, Arnt1, and Npas2 contribute to winter depression2007Inngår i: Annals of Medicine, ISSN 0785-3890, E-ISSN 1365-2060, Vol. 39, nr 3, s. 229-238Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background. Multiple lines of evidence suggest that the circadian clock contributes to the pathogenesis of winter depression or seasonal affective disorder (SAD). We hypothesized that sequence variations in three genes, including Per2, Arntl, and Npas2, which form a functional unit at the core of the circadian clock, predispose to winter depression.

    Methods. In silico analysis of the biological effects of allelic differences suggested the target single-nucleotide polymorphisms (SNPs) to be analyzed in a sample of 189 patients and 189 matched controls. The most relevant SNP in each gene was identified for the interaction analysis and included in the multivariate assessment of the combined effects of all three SNPs on the disease risk.

    Results. SAD was associated with variations in each of the three genes in gene-wise logistic regression analysis. In combination analysis of variations of Per2, Arntl, and Npas2, we found additive effects and identified a genetic risk profile for the disorder. Carriers of the risk genotype combination had the odds ratio of 4.43 of developing SAD as compared with the remaining genotypes, and of 10.67 as compared with the most protective genotype combination.

    Conclusion. Variations in the three circadian clock genes Per2, Arntl, and Npas2 are associated with the disease, supporting the hypothesis that the circadian clock mechanisms contribute to winter depression.

  • 182.
    Paulsson, Gustav
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    EKG Verifierad Vänsterkammarhypertrofi - Hos patienter som genomgår aortaklaffbyte2015Independent thesis Basic level (professional degree), 20 poäng / 30 hpOppgave
  • 183.
    Persson, Mats
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Bring hypertension guidelines into play: guideline-based decision support system for drug treatment of hypertension and epidemiological aspects of hypertension guidelines2003Doktoravhandling, med artikler (Annet vitenskapelig)
  • 184.
    Persson, Mats
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Carlberg, Bo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Mjörndal, Tom
    Umeå universitet, Medicinska fakulteten, Institutionen för farmakologi och klinisk neurovetenskap, Klinisk farmakologi.
    Asplund, Kjell
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Bohlin, Jens
    Umeå universitet, Teknisk-naturvetenskapliga fakulteten, Institutionen för datavetenskap.
    Lindholm, Lars Hjalmar
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    1999 WHO/ISH Guidelines applied to a 1999 MONICA sample from northern Sweden2002Inngår i: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 20, s. 29-35Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background : Treating hypertension with drugs is so far the most cost-effective way to reduce this important risk factor for cardiovascular disease (CVD). It is, however, important to determine absolute risk, and thereby estimate indication for drug treatment, in order to maintain a cost-effective drug treatment. WHO/ISH Hypertension Guidelines from 1999 propose a risk stratification for estimating absolute risk for CVD based on blood pressure and additional risk factors, target organ damage (TOD) and CVD. Objectives : We studied the consequences of applying the recent WHO/ISH risk stratification scheme to a MONICA sample of 6000 subjects from a geographically defined population in northern Sweden, regarding indications for treatment, target blood pressure and risk distribution. Methods : We have risk-classified each of these patients using a computer program, according to the WHO/ISH scheme. Data on TOD were not available. Results : In all, 917 (15%) had drug-treated hypertension. Three-quarters (n = 737) were inadequately treated, with blood pressure levels at or above 140 or 90 mmHg. 1773 (30% of 5997) untreated subjects had a blood pressure of 140/90 or above; 16% in the low-, 62% in the medium-, 8% in the high-, and 14% in the very-high-risk group. The corresponding risk-group pattern for the inadequately treated hypertensives (n = 737) was 5.5, 48.3, 11.1 and 35.2%, respectively. If we shifted the target blood pressure from below 140/90 to below 130/85 for drug-treated subjects under 60 (n = 278) the number of inadequately treated subjects increased by 34 (12.2% of 278); 14 in the low-risk group, 15 in the medium-risk group, and only five in the high- or very-high-risk groups. Conclusions : Only one-fifth of the drug-treated hypertensives were well controlled. Moreover, the incidence of newly detected blood pressure elevation was high. The majority of younger subjects with high blood pressure had low risk, but in those aged 45-54 this had already risen to a medium risk. Changing the target blood pressure to below 130/85, for subjects aged below 60, as recommended by WHO/ISH, affects predominantly low- and medium-risk groups.

  • 185.
    Persson, Mats
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Carlberg, Bo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Weinehall, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Nilsson, Leif
    Umeå universitet, Teknisk-naturvetenskapliga fakulteten, Institutionen för matematik och matematisk statistik.
    Stegmayr, Birgitta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Lindholm, Lars Hjalmar
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Risk stratification by guidelines compared to tisk assessment by risk equations applied to a MONICA sample2003Inngår i: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 21, nr 6, s. 1089-1095Artikkel i tidsskrift (Fagfellevurdert)
    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.

  • 186.
    Persson, Mats
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Mjörndal, Tom
    Umeå universitet, Medicinska fakulteten, Institutionen för farmakologi och klinisk neurovetenskap, Klinisk farmakologi.
    Carlberg, Bo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Bohlin, Jens
    Umeå universitet, Teknisk-naturvetenskapliga fakulteten, Institutionen för datavetenskap.
    Lindholm, Lars Hjalmar
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Evaluation of a computer-based decision support system for treatment of hypertension with drugs: retrospective, nonintervention testing of cost and guideline adherence2000Inngår i: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 247, nr 1, s. 87-93Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective. To evaluate a computerized decision support system (DSS) for drug treatment of hypertension, regarding quality, safety, and cost compared to actual antihypertensive drug treatment.

    Design. The medical profiles of 338 hypertensive patients treated with drugs against hypertension were processed by the DSS. The drug treatment proposed by the system was then compared to actual treatment given by their physician.

    Setting. Four health centres in the county of Västerbotten, in Sweden.

    Subjects. A list of hypertensive patients was extracted from the computerized medical records of each health centre and every fifth patient’s medical profile was assessed by the system.

    Interventions. None.

    Main outcome measures. Drug used, drug used in relation to certain major diseases such as diabetes mellitus, asthma, ischaemic heart disease (IHD), and previous myocardial infarction. Adherence to hypertension guidelines, safety, and cost.

    Results. The DSS suggested significantly more thiazides and significantly fewer calcium antagonists than the physicians had prescribed, with a total cost reduction of 33–40%, depending on doses chosen. The DSS drug profile was more adherent to guidelines in patients with major complicating diseases, suggesting an improvement in treatment quality for these patients by the DSS.

    Conclusion. The DSS which fully implements current guidelines may improve the quality of antihypertensive treatment, concurrently leading to a considerable reduction in drug costs.

  • 187.
    Petersson, Agnes
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Thrombocytosis as risk marker of cancer: A cross-sectional study of lung, colorectal, and bladder or urinary tract cancer2017Independent thesis Basic level (professional degree), 20 poäng / 30 hpOppgave
  • 188.
    Pourhamidi, Kaveh
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Peripheral nerve function: metabolic features, clinical assessment, and heat shock protein 272013Doktoravhandling, med artikler (Annet vitenskapelig)
    Abstract [en]

    Peripheral neuropathy is a common complication among patients with diabetes mellitus, but whether peripheral neuropathy is present in individuals with impaired glucose tolerance (IGT) is debatable. In order to identify and diagnose peripheral neuropathy correctly, it is important to evaluate diagnostic tools that can be implemented in routine health care to assess both large and small nerve fibre function. There is currently limited knowledge about neuroprotective factors that could be useful for measuring peripheral nerve function in individuals at risk of developing neuropathy such as those with diabetes mellitus. Thus, studies are needed to investigate potential neuroprotective factors in relation to peripheral nerve function in humans.

    Objectives: The overall goal of this thesis was to study the metabolic features and clinical assessment of peripheral nerve function and the potential relationship between the neuroprotective factor heat shock protein 27 (HSP27) and peripheral nerve function.

    Methods: Thirty-nine participants with normal glucose tolerance (NGT) and 29 participants with IGT were recruited from the population-based Västerbotten Intervention Programme in 2003–2004. Patients with type 2 diabetes mellitus (T2DM, n = 51) were recruited from primary health care centres. NGT and IGT individuals underwent two separate oral glucose tolerance tests to verify their glucose status. The peripheral nerve function in the lower limb was assessed by nerve conduction studies, neuropathy disability scoring, quantitative sensory tests, and skin biopsies with subsequent quantification of intraepidermal nerve fibre density (IENFD). The concentrations of HSP27 in serum were determined in the NGT, IGT, and T2DM individuals. Patients with type 1 diabetes mellitus (T1DM) were recruited from the Diabetes Clinic, Skåne University Hospital in Malmö, Sweden (n = 27) in 1992 and were followed-up in 2005. Baseline and follow-up concentrations of HSP27 were determined in T1DM patients as well as in healthy non-diabetic controls (n = 397). The T1DM patients underwent nerve conduction studies and thermal and vibration perception threshold tests at baseline and at follow-up. Delta changes in HSP27 concentrations and small and large nerve fibre function were calculated.

    Results: There was no difference between IGT and NGT in sural nerve conduction, intraepidermal nerve fibre density, or thermal thresholds. The biothesiometer had a sensitivity of 82% and a specificity of 72% in identifying peripheral neuropathy with a cut-off value of ≥24.5 V at the medial malleolus. Adding the quantification of IENFD to the combination of the tuning fork and biothesiometer increased the diagnostic sensitivity from 81% to 95%, the negative predictive value from 87% to 94%, and the positive likelihood ratio from 1.8 to 1.9 when identifying small nerve fibre dysfunction. T2DM patients had lower HSP27 concentrations (mean HSP27 = 412 pg/mL, 95% CI 284–598 pg/mL) than NGT (mean HSP27 = 722 pg/mL, 95% CI 564–922 pg/mL) and IGT (mean HSP27 = 1010 pg/mL, 95% CI 638–1300 pg/mL) individuals (p <0.05 for both comparisons). T1DM patients had lower HSP27 concentrations at baseline (mean HSP27 = 547 pg/mL, 95% CI 421–711 pg/mL) and at follow-up (mean HSP27 = 538 pg/mL, 95% CI 417–693 pg/mL) compared to healthy controls (mean HSP27 = 785 pg/mL, 95% CI 732–842 pg/mL), p <0.05 for both comparisons). High concentrations of HSP27 were associated with better large nerve fibre function (Odds ratio = 2.51, 95% CI 1.25–5.05, p <0.05). Deteriorating large nerve fibre function correlated with decreasing HSP27 concentrations over time in T1DM patients (r = 0.50, p = 0.01).

    Conclusions: Measures of large and small nerve fibre function in IGT individuals do not differ significantly from NGT individuals. The existence of peripheral neuropathy as a consequence of IGT is not likely, and extensive control of neuropathy in IGT individuals is not advocated by this thesis. The biothesiometer is a useful clinical tool to identify peripheral neuropathy in routine health care. Quantification of IENFD using skin biopsies in combination with methods measuring vibrotactile sense, such as the biothesiometer and the tuning fork, increase the diagnostic usefulness of identifying small nerve fibre dysfunction. High HSP27 concentrations are associated with better peripheral large nerve fibre function. Patients with diabetes mellitus have lower HSP27 concentrations than healthy non-diabetic controls, and deterioration of large nerve fibre function correlates with a decrease in HSP27 concentrations over time in T1DM. This could be indicative of insufficient neuroprotection in patients with diabetes mellitus.

  • 189.
    Pourhamidi, Kaveh
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Dahlin, Lars B
    Boman, Kurt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Rolandsson, Olov
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Heat shock protein 27 is associated with better nerve function and fewer signs of neuropathy2011Inngår i: Diabetologia, ISSN 0012-186X, E-ISSN 1432-0428, Vol. 54, nr 12, s. 3143-3149Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Aims/hypothesis High levels of serum heat shock protein 27 (sHSP27) have been associated with distal symmetric polyneuropathy in patients with type 1 diabetes. Our objective was to investigate the association between sHSP27, neuropathic signs and nerve function in individuals with normal glucose tolerance (NGT), impaired glucose tolerance (IGT) and type 2 diabetes.

    Methods Participants were recruited consecutively from the population-based Vasterbotten Intervention Program (NGT, n=39, IGT, n=29, and type 2 diabetes, n=51) and were matched for age and sex. sHSP27 levels were measured and nerve conduction studies were performed (peroneal and sural nerves). z Scores for each nerve conduction measure were calculated and compiled into a composite z score for the leg. Neuropathy disability score (NDS) was used to assess neuropathic signs.

    Results Patients with diabetes had significantly lower sHSP27 levels (geometric mean sHSP27 206 pg/ml, 95% CI 142, 299) than those with IGT (geometric mean sHSP27 455 pg/ml, 95% CI 319, 650, p<0.05) and controls (geometric mean sHSP27 361 pg/ml, 95% CI 282, 461, p<0.05). Participants with few signs of neuropathy (first tertile, NDS <= 2) had significantly higher sHSP27 levels (geometric mean sHSP27 401 pg/ml, 95% CI 310, 520) than participants with many signs (third tertile, NDS >= 7) (geometric mean sHSP27 192 pg/ml, 95% CI 128, 288, p=0.007). The highest sHSP27 tertile was associated with better nerve function, adjusted for age, sex, statin medication and HbA(1c) (OR 2.51, 95% CI 1.25, 5.05, p<0.05).

    Conclusions/interpretation High sHSP27 levels were associated with better nerve function and fewer neuropathic signs in NGT, IGT and type 2 diabetes.

  • 190.
    Pourhamidi, Kaveh
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Dahlin, Lars B
    Englund, Elisabet
    Rolandsson, Olov
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Evaluation of clinical tools and their diagnostic use in distal symmetric polyneuropathy2014Inngår i: Primary care diabetes, ISSN 1878-0210, Vol. 8, nr 1, s. 77-84Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    AIMS: To compare the diagnostic usefulness of tuning fork, monofilament, biothesiometer and skin biopsies in peripheral neuropathy in individuals with varying glucose metabolism.

    METHODS: Normoglycaemic, impaired glucose tolerance (IGT) and type 2 diabetes (T2DM) individuals were recruited. Nerve conduction studies (NCS) and thermal threshold tests were performed. Vibrotactile sense was tested with a biothesiometer and a 128-Hz tuning fork. Touch/pressure perception was examined with a 10-g monofilament. Skin biopsies were performed and intraepidermal nerve fibres were quantified. Distal symmetric polyneuropathy (DSPN) was defined as neuropathy disability score ≥2 and abnormal NCS. Thermal threshold tests were used to define small nerve fibre neuropathy (sDSPN) in cases where NCS (large nerve fibres) were normal.

    RESULTS: The prevalence of DSPN and sDSPN in the whole group (n=119) was 18% and 23%, respectively. For the biothesiometer, a cut-off of ≥24.5V had a sensitivity of 82% and specificity of 70% (AUC=0.81, 95% CI 0.71-0.91) when evaluating DSPN. An intraepidermal nerve fibre density cut-off of ≤3.39fibres/mm showed a sensitivity of 74% and specificity of 70% in the detection of sDSPN, whereas the sensitivity of the tuning fork and the biothesiometer were relatively low, 46% and 67%, respectively. When combining skin biopsies with the tuning fork, 10 more sDSPN cases were identified. Adding skin biopsy to the combination of the tuning fork and biothesiometer increased the sensitivity of finding sDSPN cases, but not DSPN, from 81% to 93%.

    CONCLUSION: Using a biothesiometer in clinical routine might be a sensitive method to detect large nerve fibre dysfunction in the lower extremity, whereas skin biopsies in combination with methods measuring vibrotactile sense could increase the diagnostic sensitivity of detecting peripheral neuropathy at an early stage.

  • 191.
    Pourhamidi, Kaveh
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Dahlin, Lars B
    Englund, Elisabet
    Rolandsson, Olov
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Intraepidermal nerve fibre density is associated with weight2011Konferansepaper (Annet vitenskapelig)
    Abstract [en]

    Background and aims: Intraepidermal nerve fibre density (IENFD) quantification is regarded to be a sensitive and specific measure of small nerve fibre dysfunction and IENFD loss is an early feature in glucose dysregulation. Our aims were to study IENFD in individuals with normal glucose tolerance (NGT), impaired glucose tolerance (IGT) and type 2 diabetes (T2D) and to study if IENFD was associated to metabolic traits, e.g. obesity and dyslipidemia, and to neurophysiologic assessments of nerve function.

    Materials and methods: Participants were consecutively recruited from the population-based Västerbotten Intervention Program; NGT (n=22), IGT (n=14), T2D (n=24), at the age of 60±1 years. The individuals’ height and weight were measured. Blood glucose and lipids were measured. Nerve conduction studies (NCS) were performed (sural and peroneal nerves) and the results were standardized to z-scores and compiled into a composite Z-score representing the nerve function in the leg. Neuropathy disability score (NDS) was used to evaluate neuropathic signs. In addition, thermal threshold tests (TTT) were performed to assess small nerve fibre function. Skin biopsies were performed using a 3-mm punch taken 10 cm proximal to the lateral malleolus. The intraepidermal nerve fibres were evaluated by routine immunohistochemistry and stained with anti-PGP9.5 (ubiquitin carboxyl-terminal hydrolase) antibodies. Light microscopy was used to identify nerve fibres in thin sections (5 µm) according to a standardized protocol. The IENFD was given as the mean of counts in 3 sections per millimeter of epidermal length. The assessors were blinded to the identity of the samples.

    Results: Patients with diabetes had lower IENFD (median 2.9 nerves mm-1, IQR 1.2-4.8) than controls (median 4.4 nerves mm-1, IQR 3.5-6.3; Mann-Whitney U test p=0.007). IGT individuals did not differ in IENFD (median 3.2 nerves mm-1, IQR 1.4-5.5) compared to controls (p=0.12) or diabetic patients (p=0.53). IENFD was positively correlated to NCS (r=0.39, p=0.002), but not to TTT and NDS. Individuals in the 3rd tertile of composite Z-score (i.e. better nerve conduction) had higher IENFD (median 4.1 nerves mm-1, IQR 2.7-5.8) than individuals in the 1st tertile (median 2.4 nerves mm-1, IQR 0.7-3.9; p=0.009). Triglycerides and cholesterols were not associated with IENFD. However, a stepwise multiple linear regression analysis revealed that weight was independently associated to IENFD, after adjustment for age, sex, height, and diabetic status (β=-0.419, p<0.001).

    Conclusion: We conclude that skin biopsies for IENFD quantification in thin sections is a simple useful method for assessing small nerve fibre neuropathy in individuals with diabetes. The association between weight and IENFD indicates that metabolic traits other than glucose dysmetabolism might play a role in the development small nerve fibre neuropathy.

  • 192.
    Pourhamidi, Kaveh
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Dahlin, Lars B
    Department of Clinical Sciences Malmö, Hand Surgery, Skåne University Hospital, Lund University, Malmö, Sweden.
    Englund, Elisabet
    Division of Neuropathology, Department of Pathology, Lund University, Lund, Sweden.
    Rolandsson, Olov
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    No difference in small or large nerve fiber function between individuals with normal glucose tolerance and impaired glucose tolerance2013Inngår i: Diabetes Care, ISSN 0149-5992, E-ISSN 1935-5548, Vol. 36, nr 4, s. 962-964Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVE To assess small and large nerve fiber function in people with normal glucose tolerance (NGT), impaired glucose tolerance (IGT), and type 2 diabetes (T2D).

    RESEARCH DESIGN AND METHODS Participants were recruited consecutively from a population-based cohort: NGT (n = 39), IGT (n = 29), and T2D (n = 51). Electrophysiological measures included nerve conduction studies and thermal thresholds. Intraepidermal nerve fiber density (IENFD) in skin biopsies was calculated.

    RESULTS There was no difference between IGT and NGT in sural nerve conduction, IENFD, and thermal thresholds. IENFD was significantly lower in T2D (median = 2.8 fibers/mm [Interquartile range 1.1–4.7 fibers/mm]) than NGT individuals (4.5 fibers/mm [3.4–6.1 fibers/mm]; P < 0.05). T2D participants had poorer nerve conduction and higher heat thresholds than NGT and IGT.

    CONCLUSIONS Large and small nerve function in people with IGT did not differ from those with NGT. Our finding does not support the existence of neuropathy in a prediabetic stage.

  • 193.
    Pourhamidi, Kaveh
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Skärstrand, Hanna
    Department of Clinical Sciences, Malmö, Lund University, Skåne University Hospital, Sweden.
    Dahlin, Lars B
    Department of Clinical Sciences, Malmö, Hand Surgery, Skåne University Hospital, Lund University, Malmö, Sweden.
    Rolandsson, Olov
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Heat shock protein 27 concentrations are lower in patientswith type 1 diabetes mellitus than in healthy controls andcorrelates with large nerve fibre dysfunctionManuskript (preprint) (Annet vitenskapelig)
    Abstract [en]

    Objective Heat shock protein 27 (HSP27) may contribute to the survival of neurons. Our aims were to study whether HSP27 concentrations differ between individuals with and without type 1 diabetes, and evaluate the relationship between the progression of peripheral nerve dysfunction and HSP27 concentrations.

    Research Design and Methods Type 1 diabetes patients (n=27, 41% women; mean age 41±8 years) were recruited in 1992 with a follow-up in 2005; serum HSP27 concentrations were determined in baseline and follow-up samples and compared to non-diabetic controls (n=397, 34% women; mean age 43±14 years). The type 1 diabetes patients underwent nerve conduction studies and thermal and vibration perception threshold tests at baseline and at follow-up. Reference data was used to standardise results for age, height and sex by calculating the Z-scores. Delta changes in HSP27 (follow-up HSP27 – baseline HSP27) and small and large nerve fibre function were used for correlation analyses.

    Results Type 1 diabetes patients had lower HSP27 concentrations at baseline (mean HSP27547 pg/ml, 95% CI 421, 711) and at follow-up (mean HSP27 538 pg/ml, 95% CI 417,693) compared to healthy controls (mean HSP27 785 pg/ml, 95% CI 732, 842; p<0.05 for both comparisons). Deteriorating large nerve fibre function correlated with delta HSP27 concentrations in type 1 diabetes (r=0.50, p=0.01).

    Conclusions Patients with type 1 diabetes had lower HSP27 concentrations than non-diabetic controls and progression of large nerve fibre dysfunction correlated with decreasing HSP27 concentrations during the follow-up period. This could be indicative ofinsufficient neuroprotection in type 1 diabetes.

  • 194. Rangamani, Sukanya
    et al.
    Obalesha, Kannamedi Bheemappa
    Gaitonde, Rakhal
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health issues of sanitation workers in a town in Karnataka: Findings from a lay health-monitoring study2015Inngår i: National Medical Journal of India, ISSN 0970-258X, Vol. 28, nr 2, s. 70-73Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background. Official estimates are not available for mortality or morbidity among sanitation workers (including manual scavengers) in India. Little is known about their health issues and health-seeking behaviour in the context of their occupational hazards (work practices and exposures). We attempted to understand the nature of health problems of sanitation workers using a lay epidemiological process. Methods. A community-based organization working in Chitradurga town in Karnataka for the development of sanitation workers recorded the health problems of workers and their treatment-seeking practices every month using a health-monitoring tool. We used a lay epidemiological approach to identify occupational health problems and deficiencies in healthcare access through the narrative of workers' perceptions of their illness. Descriptive analysis was done to map the occupational health status, healthcare-seeking practices and the social support mechanisms in place. Results. Injuries and chest pain were the most commonly reported illnesses. Most workers continued to work without appropriate treatment as they ignored their illness, and did not want to miss their wages or lose their job. Self-medication was common. Intake of alcohol was prevalent to cope with the inhuman task of cleaning filthy sewage, and as a modality to forget their health problems. The pattern of illnesses reported during monthly monitoring was also reported as long-standing illnesses. Health and safety mechanisms at workplace did not exist and were not mandated by regulatory bodies. Conclusion. Health and safety of sanitation workers has been inadequately addressed in public health research. Sanitation work lacks specific protective regulatory guidelines to address health hazards unlike other hazardous occupations. The government needs to institute an adequate health-monitoring and healthcare system for sanitation workers.

  • 195.
    Reine, Ieva
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Novo, Mehmed
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Rehabiliteringsmedicin.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Is participation in labour market programmes related to mental health?: results from a 14-year follow-up of the Northern Swedish cohort2011Inngår i: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 39, nr 1, s. 26-34Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Aims: There is a lack of empirical studies assessing the possible impact of active labour market programmes (ALMP) on health. The aim of this study was to analyze whether participation in ALMP, in contrast to being unemployed and not participating in ALMP (UNALMP), was related to mental health at different ages.

    Methods: The study was carried out in a medium-sized industrial town in the north of Sweden. The cohort, consisting of all 1,083 pupils who attended or should have attended the last year of compulsory school in 1981, was followed up at the ages of 16, 18, 21 and 30. Data on 381 individuals at age 21, and 281 at age 30 were used in the study. The main health measurement was psychological symptoms among participants of ALMP in contrast to UNALMP at ages 21 and 30, and was analyzed by propensity score matching method (PSM) and multivariate logistic regression.

    Results: Generally, ALMP had higher scores of psychological symptoms than UNALMP. Nevertheless, participation in ALMP was not related to mental health. Due to methodological shortages our results have to be interpreted with caution. Adjustment for either all background selection variables or the propensity score in multivariate logistic regression showed similar associations, suggesting that propensity score could be used to adjust for background selection variables.

    Conclusions: There is a need for more well-designed studies, using a theoretical framework, within the field, that are based on larger samples.

  • 196.
    Reveiz, Ludovic
    et al.
    National University of Colombia.
    Guerrero-Lozano, Rafael
    National University of Colombia.
    Camacho, Angela
    National University of Colombia.
    Yara, Lina
    National University of Colombia.
    Mosquera Méndez, Paola Andrea
    Stress ulcer, gastritis, and gastrointestinal bleeding prophylaxis in critically ill pediatric patients: a systematic review2010Inngår i: Pediatric Critical Care Medicine, ISSN 1529-7535, E-ISSN 1947-3893, Vol. 11, nr 1, s. 124-132Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVE: To identify and evaluate the quality of evidence supporting prophylactic use of treatments for stress ulcers and upper gastrointestinal bleeding. Stress ulcers, erosions of the stomach and duodenum, and upper gastrointestinal bleeding are well-known complications of critical illness in children admitted to the pediatric intensive care unit.

    DATA SOURCES: Studies were identified from the Cochrane Central Register of Controlled Trials, PUBMED; LILACS; Scirus. We also scanned bibliographies of relevant studies.

    STUDY SELECTION: This systematic review of randomized controlled trials assessed the effects of drugs for stress-related ulcers, gastritis, and upper gastrointestinal bleeding in critically ill children admitted to the pediatric intensive care unit.

    DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted the relevant data. Most randomized controlled trials were judged as having unclear risk of bias. When pooling two randomized controlled trials, treatment was significantly more effective in preventing upper gastrointestinal bleeding (macroscopic or important bleeding) compared with no treatment (two studies = 300 participants; relative risk, 0.41; 95% confidence interval, 0.19-0.91; I = 12%). Meta-analysis of two studies found no significant difference in death rates among groups (two randomized controlled trials = 132 participants; relative risk, 1.39; 95% confidence interval, 0.70-2.79; I = 4%). The rate of pneumonia was not significantly different when comparing treatment and no treatment in one study. When comparing ranitidine with no treatment, significant differences were found in the proportion of mechanically ventilated children with normal gastric mucosal endoscopic findings by histologic specimens (one randomized controlled trial = 48 participants; relative risk, 3.53; 95% confidence interval, 1.34-9.29). No significant differences were found when comparing different drugs (omeprazole, ranitidine, sucralfate, famotidine, amalgate), doses, or regimens for main outcomes (deaths, endoscopic findings of erosion or ulcers, upper gastrointestinal bleeding, or pneumonia).

    CONCLUSIONS: Although pooled data of two studies suggested that critically ill pediatric patients may benefit from receiving prophylactic treatment to prevent upper gastrointestinal bleeding, we found that high-quality evidence to guide clinical practice is still limited.

  • 197.
    Rexvid, Devin
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Blom, Björn
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Evertsson, Lars
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Forssén, Annika
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Allmänläkares och socialarbetares respons på riskreduceringsteknologier: en litteraturstudie2012Inngår i: “Partnership in social work – active collaboration withdifferent actors”,9th Forsa Nordic conference, 4th-6th oct-2012 in Trondheim, 2012Konferansepaper (Annet vitenskapelig)
    Abstract [sv]

    Bakgrund: Allmänläkare och socialarbetare utgör exempel på välfärdsprofessioner vars villkor anses ha förändrats i det så kallade risk- och granskningssamhället. Minskad autonomi, inskränkt diskretion och försvagad jurisdiktion lyfts i professionsforskningen fram som några av uttrycksformerna för de förändrade villkoren.  

    Syfte: Att beskriva och analysera allmänläkares och socialarbetares respons på evidensbaserade och organisatoriska riskreduceringsteknologier (ERRT och ORRT).

    Metod: Artikeln är baserad på en innehållsanalys av resultatet från en litteraturöversikt av referee-granskade empiriska artiklar, publicerade i vetenskapliga tidskrifter, om dessa professioners kunskapsanvändning i form av respons på RRT.

    Resultat: Det framkommer att båda professionerna, trots en i grunden positiv inställning till ERRT, intar en ambivalent inställning till dessa. Ambivalensen är såväl patient- och klientrelaterad som expertisrelaterad. Professionernas respons på ORRT skiljer sig dock i den bemärkelsen att allmänläkare ställer sig skeptiska till ORRT medan socialarbetare förhåller sig mer pragmatiskt till ORRT.

  • 198.
    Rexvid, Devin
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Blom, Björn
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Evertsson, Lars
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Forssén, Annika
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Socialarbetares och allmänläkares (icke-) användning av kunskap i risksamhället2011Konferansepaper (Annet vitenskapelig)
    Abstract [sv]

    Bakgrund: Dagens samhälle beskrivs ofta som ett risksamhälle. Karaktäristiskt för risksamhället är ökad komplexitet, eskalerande osäkerhet och minskat eller brutet förtroende för professioners kompetens och förmåga att handskas med den ökande komplexiteten och osäkerheten. Närmare bestämt handlar det urholkade förtroendet för professioner om ett ifrågasättande av deras definitionsmakt, autonomi och diskretion. Idag är det i hög grad kraven på riskreduceringstekniker, exempelvis evidensbaserad praktik och standardiserade riskbedömningsinstrument, som står för kontroverserna om professionsutövningens natur, villkor och utmaningar.

    Syfte: Att undersöka hur risk påverkar (icke-)användning av kunskap i professionell praktik i socialt arbete och allmänmedicin, samt att belysa hur de två professionerna förhåller sig till riskteknologins imperativ.

    Metod: Studien är ett utsnitt ur en större systematisk litteraturöversikt över socialarbetares och allmänläkares (icke-)användning av kunskap i praktiken. Föreliggande paper bygger på knappt hälften av de 100 referee-granskade artiklar som översikten inbegriper. 

    Resultat: I studien framkommer bl.a. att det finns mer forskning om allmänläkares oföljsamhet gentemot riskreduceringstekniker, om osäkerhet och komplexitet samt hantering av dessa faktorer, om mer användning av informella än standardiserade osäkerhets- och komplexitetsreduceringsteknologier, jämfört med dito forskning i socialt arbete. Ett annat resultat är att forskning i socialt arbete sätter socialarbetares risktagande i relation till deras bristande kunskap medan forskning om allmänläkare relaterar det till deras icke-användning av riskreduceringstekniker.

    Konklusion: En preliminär slutsats är att skillnaderna mellan socialt arbete och allmänmedicin är så pass stora – även om människovård är en gemensam nämnare – att det inte automatiskt går att överföra principer och modeller mellan dem.

  • 199.
    Risberg, Gunilla
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Hamberg, Katarina
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Johansson, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Gender perspective in medicine: a vital part of medical scientific rationality. A useful model for comprehending structures and hierarchies within medical science.2006Inngår i: BMC Medicine, ISSN 1741-7015, E-ISSN 1741-7015, nr 4, s. 20-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: During the past few decades, research has reported gender bias in various areas of clinical and academic medicine. To prevent such bias, a gender perspective in medicine has been requested, but difficulties and resistance have been reported from implementation attempts. Our study aimed at analysing this resistance in relation to what is considered good medical research.

    METHOD: We used a theoretical model, based on scientific competition, to understand the structures of scientific medicine and how they might influence the resistance to a gender perspective in medicine. The model was originally introduced to discuss how pluralism improves rationality in the social sciences.

    RESULTS: The model provided a way to conceptualise different fields of research in medicine: basic research, applied research, medical philosophy, and 'empowering' research. It clarified how various research approaches within medicine relate to each other, and how they differ and compete. It also indicated why there might be conflicts between them: basic and applied research performed within the biomedical framework have higher status than gender research and other research approaches that are performed within divergent research paradigms.

    CONCLUSION: This hierarchy within medical research contributes to the resistance to a gender perspective, causing gender bias and making medical scientific rationality suboptimal. We recommend that the theoretical model can be applied in a wider medical context when different and hierarchically arranged research traditions are in conflict. In this way, the model might contribute to shape a medical community where scientific pluralism is acknowledged to enlarge, not to disturb, the scientific rationality of medicine.

  • 200.
    Risberg, Gunilla
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Johansson, Eva E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Hamberg, Katarina
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    "Important...but of low status": male education leaders´ views on gender in medicine2011Inngår i: Medical Education, ISSN 0308-0110, E-ISSN 1365-2923, Vol. 45, nr 6, s. 613-624Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objectives The implementation of and communication about matters associated with gender in medical education have been predominantly perceived as women's issues. This study aimed to explore attitudes towards and experiences of gender-related issues among key male members of faculties of medicine.

    Methods We conducted semi-structured interviews with 20 male education leaders from the six medical schools in Sweden. The interviews were analysed qualitatively using a modified grounded theory approach.

    Results The core category -'important... but of low status'- reflects ambivalent attitudes towards gender-related issues in medicine among male education leaders. All informants were able to articulate why gender matters. As doctors, they saw gender as a determinant of health and, as bystanders, they had witnessed inequalities and the wasting of women's competence. However, they had doubts about gender-related issues and found them to be overemphasised. Gender education was seen as a threat to medical school curricula as a consequence of the time and space it requires. Gender-related issues were considered to be unscientifically presented, to mostly concern women's issues and to tend to involve 'male bashing' (i.e. gender issues were often labelled as ideological and political). Interviewees asked for facts and knowledge, but questioned specific lessons and gender theory. Experiences of structural constraints, such as prejudice, hierarchies and homosociality, were presented, making gender education difficult and downgrading it.

    Conclusions The results indicate that male faculty leaders embrace the importance of gender-related issues, but do not necessarily recognise or defend their impact on an area of significant knowledge and competence in medicine. To change this and to engage more men in gender education, faculty measures are needed to counteract prejudice and to upgrade the time allocation, merits and status of gender implementation work. Based on our findings, we present and discuss possible ways to interest more men and to improve gender education in medicine.

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