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  • 1.
    Asklund, Ina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nyström, E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Sjöström, M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Umefjord, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Treatment of stress urinary incontinence via a smartphone application: a randomised controlled trial2015In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 34, no Supplement 3 Meeting Abstract 16, p. S40-S42Article in journal (Other academic)
  • 2.
    Asklund, Ina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Nyström, Emma
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sjöström, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Umefjord, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Mobile app for treatment of stress urinary incontinence: a randomized controlled trial2017In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 36, no 5, p. 1369-1376Article in journal (Refereed)
    Abstract [en]

    AIMS: To evaluate the effect of a mobile app treatment for stress urinary incontinence (SUI) in women.

    METHODS: Randomized controlled trial, conducted 2013-2014 in Sweden. Community-dwelling adult women with ≥1 SUI episode/week recruited through our website and randomized to app treatment (n = 62) or control group (postponed treatment, n = 61). One participant from each group was lost to follow-up. Intervention was the mobile app Tät(®) with a treatment program focused on pelvic floor muscle training (PFMT), and information about SUI and lifestyle factors. Primary outcomes, 3 months after randomization: symptom severity (International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form [ICIQ-UI SF]); and condition-specific quality of life (ICIQ Lower Urinary Tract Symptoms Quality of Life [ICIQ-LUTSqol]).

    RESULTS: One hundred and twenty-three women were included (mean age 44.7), with moderate/severe SUI (97.5%, 120/123), mean ICIQ-UI SF score 11.1 (SD 2.8) and mean ICIQ-LUTSqol score 34.4 (SD 6.1) at baseline. At follow-up, the app group reported improvements in symptom severity (mean ICIQ-UI SF score reduction: 3.9, 95% confidence interval 3.0-4.7) and condition-specific quality of life (mean ICIQ-LUTSqol score reduction: 4.8, 3.4-6.2) and the groups were significantly different (mean ICIQ-UI SF score difference: -3.2, -4.3to -2.1; mean ICIQ-LUTSqol score difference: -4.6, -7.8 to -1.4). In the app group, 98.4% (60/61) performed PFMT at follow-up, and 41.0% (25/61) performed it daily.

    CONCLUSIONS: The mobile app treatment was effective for women with SUI and yielded clinically relevant improvements. This app may increase access to first-line treatment and adherence to PFMT.

  • 3.
    Asklund, Ina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    THE USE OF AN APP WITH A PFMT PROGRAMME AMONG PREGNANT AND POSTNATAL WOMEN FOR PREVENTIVE USE AND TREATMENT OF URINARY INCONTINENCE2019In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 38, p. S452-S453Article in journal (Other academic)
  • 4.
    Asklund, Ina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hamberg, Katarina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Umefjord, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sjöström, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    User Experience of an App-Based Treatment for Stress Urinary Incontinence: Qualitative Interview Study2019In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 21, no 3, article id e11296Article in journal (Refereed)
    Abstract [en]

    Background: Stress urinary incontinence (SUI) affects 10%-39% of women. Its first-line treatment consists of lifestyle interventions and pelvic floor muscle training (PFMT), which can be performed supervised or unsupervised. Health apps are increasing in number and can be used to improve adherence to treatments. We developed the Tät app, which provides a 3-month treatment program with a focus on PFMT for women with SUI. The app treatment was evaluated in a randomized controlled trial, which demonstrated efficacy for improving incontinence symptoms and quality of life. In this qualitative interview study, we investigated participant experiences of the app-based treatment.

    Objective: This study aimed to explore women’s experiences of using an app-based treatment program for SUI.

    Methods: This qualitative study is based on telephone interviews with 15 selected women, with a mean age of 47 years, who had used the app in the previous randomized controlled trial. A semistructured interview guide with open-ended questions was used, and the interviews were transcribed verbatim. Data were analyzed according to the grounded theory.

    Results: The results were grouped into three categories: “Something new!” “Keeping motivation up!” and “Good enough?” A core category, “Enabling my independence,” was identified. The participants appreciated having a new and modern way to access a treatment program for SUI. The use of new technology seemed to make incontinence treatment feel more prioritized and less embarrassing for the subjects. The closeness to their mobile phone and app features like reminders and visual graphs helped support and motivate the women to carry through the PFMT. The participants felt confident that they could perform the treatment program on their own, even though they expressed some uncertainty about whether they were doing the pelvic floor muscle contractions correctly. They felt that the app-based treatment increased their self-confidence and enabled them to take responsibility for their treatment.

    Conclusions: Use of the app-based treatment program for SUI empowered the women in this study and helped them self-manage their incontinence treatment. They appreciated the app as a new tool for supporting their motivation to carry through a slightly challenging PFMT program.

    Trial Registration: ClinicalTrials.gov NCT01848938; https://clinicaltrials.gov/ct2/show/NCT01848938 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT01848938)

  • 5. Björk, Anna-Bell
    et al.
    Sjöström, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Johansson, Eva E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Umefjord, Goran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Women's Experiences of Internet-Based or Postal Treatment for Stress Urinary Incontinence2014In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 24, no 4, p. 484-493Article in journal (Refereed)
    Abstract [en]

    Stress urinary incontinence is common and sometimes embarrassing. New, simple, and easily accessible treatments are needed. We telephone interviewed 21 women who participated in a randomized controlled study comparing two treatment programs based on instructions for pelvic floor muscle training. One program was Internet-based and included email support by a urotherapist; the other was sent by post. There was no face-to-face contact in either program. Our main aim was to explore the women's experiences of the Internet-based treatment. Grounded theory analysis revealed three categories: hidden but present, at a distance but close, and by myself but not alone. These were incorporated in a core category: acknowledged but not exposed. The leakage was often a well-hidden secret, but the study treatments lowered the barrier for seeking care. In the Internet group, a supportive patient-provider relationship developed despite the lack of face-to-face contact. Internet-based treatment programs can increase access to care and empower women.

  • 6.
    Bokne, Kajsa
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sjöström, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Unit of Research, Education and Development – Östersund.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Self-management of stress urinary incontinence: effectiveness of two treatment programmes focused on pelvic floor muscle training, one booklet and one Internet-based2019In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724Article in journal (Refereed)
    Abstract [en]

    Objectives: In a previous study, self-management of stress urinary incontinence (SUI), via an Internet-based programme or a booklet improved symptoms and quality of life. We wanted to evaluate the effectiveness of these programmes when implemented for free use, as well as to characterize the users.

    Design: Pragmatic prospective cohort study.

    Setting and subjects: Information about the Internet programme and the booklet was provided at www.tät.nu and by nurse midwives. Both programmes included a three-month pelvic floor muscle training (PFMT) programme. Questionnaires were used at the start and after three months.

    Main outcome measures: Characteristics of the participants regarding age and education. Reductions in symptom severity was measured using the validated ICIQ-UI SF.

    Results: 109 women using the booklet, and 166 women using the Internet-based programme responded to the pre-treatment questionnaire. Of these, 53 (48.6%) in the booklet group and 27 (16.3%) in the Internet group responded to the follow-up. The mean age of booklet users was higher, 59.4 years vs. 54.5 years (p = .005). The proportion of women with post-secondary education was high, 59% in the booklet group and 67% in the Internet group. The mean reduction in the symptom score was 2.6 points (SD 3.4) in the booklet group, and 3.4 (SD 2.9) in the Internet group. These reductions were significant within both groups, with no difference between the groups, and in the same order of magnitude as in the previous randomised controlled study.

    Conclusion: Two self-management programmes for SUI, one provided as a booklet and one as an Internet-based programme, also rendered clinically relevant improvements when made freely available.

    Key points:

    • Female stress urinary incontinence can be treated using self-management programmes focused on pelvic floor muscle training. This study evaluates the effect of two different programmes, one provided as a booklet and one Internet-based, when made freely available to the public.
    • Both programmes rendered clinically relevant improvements, in the same order of magnitude as in the previous randomised controlled study.
    • Self-management of stress urinary incontinence should be recommended to women that request treatment.
  • 7.
    Danielsson, Ulla EB
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Bengs, Carita
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Johansson, Eva E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    "My greatest dream is to be normal": the impact of gender on depression narratives of young Swedish women and men2011In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 21, no 5, p. 612-624Article in journal (Refereed)
    Abstract [en]

    Depression is common among young people. Gender differences in diagnosing depression appear during adolescence. The study aim was to explore the impact of gender on depression in young Swedish men and women. Grounded theory was used to analyze interviews with 23 young people aged 17 to 25 years who had been diagnosed with depression. Their narratives were marked by a striving to be normal and disclosed strong gender stereotypes, constructed in interaction with parents, friends, and the media. Gender norms were upheld by feelings of shame, and restricted the acting space of our informants. However, we also found transgressions of these gender norms. Primary health care workers could encourage young men to open up emotionally and communicate their personal distress, and young women to be daring and assertive of their own strengths, so that both genders might gain access to the positive coping strategies practiced respectively by each.

  • 8. Franzen, Karin
    et al.
    Andersson, Gunnel
    Odeberg, Jenny
    Midlöv, Patrik
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Stenzelius, Karin
    Hammarström, Margareta
    Surgery for urinary incontinence in women 65 years and older: a systematic review2015In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 26, no 8, p. 1095-1102Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is common among the elderly, but the literature is sparse on the surgical treatment of UI among the elderly. This systematic review aims to assess the effectiveness of surgical interventions as treatment for urinary incontinence in the elderly population ≥65 years of age.

    METHODS: Randomized controlled trials (RCT) and prospective nonrandomized studies (NRS) were included. The databases PubMed (NLM), EMBASE (Elsevier), Cochrane Library (Wiley), and Cinahl (EBSCO) were searched for the period 1966 up to October 2013. The population had to be ≥65 years of age and had to have undergone urethral sling procedures, periurethral injection of bulking agents, artificial urinary sphincter surgery, bladder injection treatment with onabotulinumtoxin A or sacral neuromodulation treatment. Eligible outcomes were episodes of incontinence/urine leakage, adverse events, and quality of life. The studies included had to be at a moderate or low risk of bias. Mean difference (MD) or standard mean difference (SMD)as well as risk difference (RD) and the 95 % CI were calculated.

    RESULTS: Five studies-all on the suburethral sling procedure in women- that fulfilled the inclusion criteria were identified. The proportion of patients reporting persistent SUI after surgery ranged from 5.2 to 17.6 %. One study evaluating quality of life (QoL) showed a significant improvement after surgery. The complication rates varied between 1 and 26 %, mainly bladder perforation, bladder emptying disturbances, and de novo urge.

    CONCLUSION: The suburethral sling procedure improves continence as well as QoL among elderly women with SUI; however, evidence is limited.

  • 9. Hedenmalm, Karin
    et al.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Family Medicine.
    Fatal venous thromboembolism associated with different combined oral contraceptives: a study of incidences and potential biases in spontaneous reporting.2005In: Drug Saf, ISSN 0114-5916, Vol. 28, no 10, p. 907-16Article in journal (Refereed)
  • 10. Hedenmalm, Karin
    et al.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Family Medicine.
    Spigset, Olav
    Pulmonary embolism associated with combined oral contraceptives: reporting incidences and potential risk factors for a fatal outcome.2004In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, Vol. 83, no 6, p. 576-85Article in journal (Refereed)
  • 11. Hoffman, Victoria
    et al.
    Söderström, Lars
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Self-management of stress urinary incontinence via a mobile app: two-year follow-up of a randomized controlled trial2017In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 96, no 10, p. 1180-1187Article in journal (Refereed)
    Abstract [en]

    Introduction. We investigated the long-term effects of using a mobile app to treat stress urinary incontinence with a focus on pelvic floor muscle training. Material and methods. A previous randomized controlled trial of 123 women aged 27-72 years found that three months of self-managing stress urinary incontinence with support from the Tat((R)) app was effective. We followed up the women in the app group (n=62) two years after the initial trial with the same primary outcomes for symptom severity (International Consultation on Incontinence Questionnaire Short Form) and condition-specific quality of life (ICIQ-Lower Urinary Tract Symptom Quality of Life) and compared the scores with those at baseline. Results. Of the 62 women, 61 and 46 (75.4%), respectively, participated in three-month and two-year follow-ups. Baseline data did not differ between responders and non-responders at follow-up. The mean decreases in International Consultation on Incontinence Questionnaire Short Form and ICIQ-Lower Urinary Tract Symptom Quality of Life scores after two years were 3.1 (95% confidence interval 2.0-4.2) and 4.0 (95% confidence interval 2.1-5.9), respectively. Of the 46 women, four (8.7%) rated themselves as very much better, nine (19.6%) as much better, and 16 (34.8%) as a little better. The use of incontinence protection products decreased significantly (p=0.04), and the proportion of women who felt they could contract their pelvic muscles correctly increased from 14/46 (30.4%) at baseline to 31/46 (67.4%) at follow-up (p<0.001). Conclusions. Self-management of stress urinary incontinence with support from the Tat((R)) app had significant and clinically relevant long-term effects and may serve as first-line treatment.

  • 12. Holmberg, Sara
    et al.
    André, Malin
    Ostgren, Carl Johan
    Björkelund, Cecilia
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Thulesius, Hans
    Midlöv, Patrik
    Nager, Anna
    Engfeldt, Peter
    [Does the Choice Care prevent general medicine research?].2011In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 108, no 41, p. 2004-Article in journal (Refereed)
  • 13.
    Högberg, Cecilia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Department of Public Health and Clinical Medicine, Unit of Research, Education and Development - Östersund, Umeå University, Umeå, Sweden .
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lilja, Mikael
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Department of Public Health and Clinical Medicine, Unit of Research, Education and Development - Östersund, Umeå University, Umeå, Sweden .
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Could it be colorectal cancer?: general practitioners' use of the faecal occult blood test and decision making - a qualitative study2015In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 16, no 1, p. 153-161Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Abdominal complaints are common reasons for contacting primary care physicians, and it can be challenging for general practitioners (GPs) to identify patients with suspected colorectal cancer (CRC) for referral to secondary care. The immunochemical faecal occult blood test (iFOBT) is used as a diagnostic aid in primary care, but it is unclear how test results are interpreted. Studies show that negative tests are associated with a risk of delayed diagnosis of CRC and that some patients with positive tests are not investigated further. The aim of this study was to explore what makes GPs suspect CRC and to investigate their practices regarding investigation and referral, with special attention on the use of iFOBTs.

    METHOD: Semi-structured individual interviews were conducted with eleven purposely selected GPs and registrars in Region Jämtland Härjedalen, Sweden, and subjected to qualitative content analysis.

    RESULTS: In the analysis of the interviews four categories were identified that described what made the physicians suspect CRC and their practices. Careful listening-with awareness of the pitfalls: Attentive listening was described as essential, but there was a risk of being misled by, for example, the patient's own explanations. Tests can help-the iFOBT can also complicate the diagnosis: All physicians used iFOBTs to various extents. In the absence of guidelines, all found their own ways to interpret and act on the test results. To refer or not to refer-safety margins are necessary: Uncertainty was described as a part of everyday work and was handled in different ways. Common vague symptoms could be CRC and thus justified referral with safety margins. Growing more confident-but also more humble: With increasing experience, the GPs described becoming more confident in their decisions but they were also more cautious.

    CONCLUSIONS: Listening carefully to the patient's history was essential. The iFOBT was frequently used as support, but there were considerable variations in the interpretation and handling of the results. The diagnostic process can be described as navigating uncertain waters with safety margins, while striving to keep the patient's best interests in mind. The iFOBT may be useful as a diagnostic aid in primary care, but more research and evidence-based guidelines are needed.

  • 14. Kristiansson, P
    et al.
    Samuelsson, Eva
    Uppsala universitet.
    von Schoultz, B
    Svärdsudd, K
    Reproductive hormones and stress urinary incontinence in pregnancy2001In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 80, no 12, p. 1125-1130Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The cause of transient stress urinary incontinence during pregnancy remains uncertain. Anatomical change, such as a pressure effect of the enlarged uterus, changes in renal function, and alterations in bladder and urethral function have been proposed. There is little information about the role of reproductive hormones in stress urinary incontinence with onset during pregnancy.

    METHODS: In a prospective, longitudinal, observational cohort study 200 consecutive women attending in early pregnancy were observed by repeated measurements of stress urinary incontinence, its possible determinants as well as serum concentrations of progesterone, estradiol and relaxin.

    RESULTS: The prevalence rate of stress urinary incontinence increased to a stable level of about 25% from mid-pregnancy and increased with parity. A higher serum relaxin value early in pregnancy was correlated to a lower prevalence rate of stress urinary incontinence with onset during pregnancy, also when the influence of potentially important factors was taken into account in a multivariate analysis. No significant difference was shown regarding serum concentrations of estrogen or progesterone, maternal age, weight gain, time since last delivery or smoking, although this can be due to a small sample size.

    CONCLUSION: The reproductive hormone relaxin might have a role in maintaining urinary continence during pregnancy. A mechanism is uncertain.

  • 15.
    Lindh, A.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sjöström, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Non-face-to-face treatment of stress urinary incontinence: predictors of success after 1 year2015In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 34, no S3, p. S443-S444Article in journal (Other academic)
  • 16.
    Lindh, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sjöström, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Non-face-to-face treatment of stress urinary incontinence: predictors of success after 1 year2016In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 27, no 12, p. 1857-1865Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION AND HYPOTHESIS: The objective was to determine predictors of long-term success in women with stress urinary incontinence (SUI) treated with a 3-month pelvic floor muscle training (PFMT) program delivered via the Internet or a brochure.

    METHODS: We included 169 women with SUI ≥1 time/week who completed the 1-year follow-up (n = 169, mean age 50.3, SD 10.1 years). Three outcome variables defined success after 1 year: Patient Global Impression of Improvement (PGI-I), International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF), and sufficient treatment. Using logistic regression, we analyzed data from the baseline, and from the 4-month and 1-year follow-ups, for potential predictors of success.

    RESULTS: Of the participants, 77 % (129 out of 169) were successful in ≥1 of the outcomes, 23 % (37 out of 160) were successful in all 3. Participants with successful short-term results were more likely to succeed in the corresponding outcome at 1 year than those without successful short-term results (adjusted odds ratios [ORs]: PGI 5.15, 95 % confidence interval [CI] 2.40-11.03), ICIQ-UI SF 6.85 (95 % CI 2.83-16.58), and sufficient treatment 3.78 (95 % CI 1.58-9.08). Increasing age predicted success in PGI-I and sufficient treatment (adjusted OR 1.06, 95 % CI 1.02-1.10, and 1.08, 95 % CI, 1.03-1.13 respectively). Compared with not training regularly, regular PFMT at 1 year predicted success for PGI and sufficient treatment (adjusted OR 2.32, 95 % CI 1.04-5.20, and 2.99, 95 % CI 1.23-7.27 respectively).

    CONCLUSION: The long-term success of a non-face-to-face treatment program for SUI with a focus on PFMT can be predicted by successful short-term results, increasing age, and the performance of regular PFMT after 1 year.

  • 17. Linnér, Love
    et al.
    Schiöler, Helena
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Milsom, Ian
    Nilsson, Fredrik
    Low persistence of anticholinergic drug use in Sweden2011In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 67, no 5, p. 535-536Article in journal (Refereed)
  • 18. Nilsson, Fredrik O. L.
    et al.
    Linner, Love
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Milsom, Ian
    Cost-effectiveness analysis of newer anticholinergic drugs for urinary incontinence vs oxybutynin and no treatment using data on persistence from the Swedish prescribed drug registry2012In: BJU International, ISSN 1464-4096, E-ISSN 1464-410X, Vol. 110, no 2, p. 240-246Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE To analyse the cost-effectiveness of newer anticholinergic drugs in relation to oxybutynin immediate release (IR) and no treatment for patients with urgency urinary incontinence. PATIENTS AND METHODS A decision analytic model was constructed. Results were collected from randomized trials and combined with registry data on persistence of medicine use and estimated number of severe adverse events. The setting corresponds to Swedish clinical practice. The costs and effects of the treatment options were analysed over a period of 1 year. Costs included drug costs, treatment costs and costs for pad use. Patients' utilities were based on treatment effect and the lack or presence of adverse events. RESULTS No treatment was the least costly treatment but also resulted in the fewest number of quality adjusted life years (QALYs). Treatment with newer anticholinergic drug medications is the most costly option but also the most efficient treatment. Sensitivity analyses showed that the results were robust. Treatment with newer anticholinergics resulted in a cost per QALY gained of (sic)21 045 compared with no treatment and no effect and (sic)65 435 compared with no treatment and placebo effect. Compared with oxybutynin IR, the cost per QALY gained was (sic)37 119. These calculations are based on relatively low pad costs, resulting in higher costs per QALY for the original drugs. CONCLUSIONS The newer anticholinergic medications are likely to be cost effective in relation to oxybutynin IR. The cost-effectiveness of the newer anticholinergics compared with no treatment depends on assumptions of the effect of no treatment, the severity of the treated condition and the treated individual's risk of adverse events. Treatment is less likely to be cost effective for elderly persons or for persons otherwise at higher risk for adverse events.

  • 19.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Unit Clin Res Ctr Östersund, Umeå, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Diagnostic characteristics and prognoses of primary-care patients referred for clinical exercise testing: a prospective observational study2014In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 15, article id 71Article in journal (Refereed)
    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.

  • 20.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Söderström, Lars
    Region Jämtland Härjedalen.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Pre-hospital delay in patients with first time myocardial infarction: an observational study in a northern Swedish population2016In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 16, no 1, article id 93Article in journal (Refereed)
    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.

  • 21.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Unit of Research, Education and Development, Östersund Hospital, Östersund, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Söderström, Lars
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Use of exercise tests in primary care: importance for referral decisions and possible bias in the decision process; a prospective observational study2014In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 15, article id 182Article in journal (Refereed)
    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.

  • 22.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Söderstrom, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Low use of statins for secondary prevention in primary care: a survey in a northern Swedish population2016In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 17, article id 110Article in journal (Refereed)
    Abstract [en]

    Background: Cholesterol-lowering therapy with statins is recommended in established cardiovascular disease (CVD) and should be considered for patients at high cardiovascular risk. We surveyed statin treatment before first-time myocardial infarction in clinical practice compared to current guidelines, in patients with and without known CVD in primary care clinics with general practitioners (GPs) on short-term contracts vs. permanent staff GPs. Methods: A total of 931 patients (345 women) in northern Sweden were enrolled in the study between November 2009 and December 2014 and stratified by prior CVD, comprising angina pectoris, revascularisation, ischaemic stroke or transitory ischaemic attack, or peripheral artery disease. Primary care clinics were classified by the proportion of GP salaries that were paid to GPs working on short-term contracts: low (0-9 %), medium (10-39 %), or high (>= 40 %). We used logistic regression to identify determinants of statin treatment. Results: Among patients with prior CVD, only 34.5 % received statin treatment before myocardial infarction. The probability of statin treatment decreased with age (>= 70 years OR 0.30; 95 % CI 0.13-0.66) and female gender (OR 0.39; 95 % CI 0.20-0.78) but increased in patients with diabetes (OR 3.52; 95 % CI 1.75-7.08). Among patients with prior CVD, the type of primary care clinic was not predictive of statin treatment. In the entire study cohort, 17.3 % of patients were treated with statins; women < 70 years old were more likely to receive statin treatment than women >= 70 years old (OR 3.24; 95 % CI 1.64-6.38), and men >= 70 years old were twice as likely to be treated with statins than women of the same age (OR 2.22; 95 % CI 1.31-3.76) after adjusting for diabetes and CVD. Overall, patients from clinics with predominantly permanent staff GPs received statin therapy less frequently than those with GPs on short-term contracts. Conclusions: In patients with prior CVD we found considerable under-treatment with statins, especially among women and the elderly. Methodologies for case findings, recall, and follow-up need to be improved and implemented to reach the goals for CVD prevention in clinical practice.

  • 23.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Söderström, Lars
    Region Jämtland Härjedalen.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Treatment with statins prior to first time myocardial infarction, with special reference to patients with previously diagnosed cardiovascular disease: a population-based surveyManuscript (preprint) (Other academic)
  • 24.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Soderstrom, L.
    Alverlind, K.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Hand-held cardiac ultrasound examinations performed in primary care patients by nonexperts to identify reduced ejection fraction2019In: BMC Medical Education, ISSN 1472-6920, E-ISSN 1472-6920, Vol. 19, article id 282Article in journal (Refereed)
    Abstract [en]

    BackgroundEarly identification of patients with reduced left ventricular ejection fraction (LVEF) could facilitate the care of patients with suspected heart failure (HF). We examined if (1) focused cardiac ultrasound (FCU) performed with a hand-held device (Vscan 1.2) could identify patients with LVEF <50%, and (2) the distribution of HF types among patients with suspected HF seen at primary care clinics.MethodsFCU performed by general practitioners (GPs)/GP registrars after a training programme comprising 20 supervised FCU examinations were compared with the corresponding results from conventional cardiac ultrasound by specialists. The agreement between groups of estimated LVEF <50%, after visual assessment of global left ventricular function, was compared. Types of HF were determined according to the outcomes from the reference examinations and serum levels of natriuretic peptides (NT-proBNP).ResultsOne hundred patients were examined by FCU that was performed by 1-4 independent examiners as well as by the reference method, contributing to 140 examinations (false positive rate, 19.0%; false negative rate, 52.6%; sensitivity, 47.4% [95% confidence interval [CI]: 27.3-68.3]; specificity, 81.0% [95% CI: 73.1-87.0]; Cohen's kappa measure for agreement=0.22 [95% CI: 0.03-0.40]). Among patients with false negative examinations, 1/7 had HF with LVEF <40%, while the others had HF with LVEF 40-49% or did not meet the full criteria for HF. In patients with NT-proBNP >125ng/L and fulfilling the criteria for HF (68/94), HF with preserved LVEF (>= 50%) predominated, followed by mid-range (40-49%) or reduced LVEF (<40%) HF types (53.2, 11.7 and 7.4%, respectively).ConclusionsThere was poor agreement between expert examiners using standard ultrasound equipment and non-experts using a handheld ultrasound device to identify patients with reduced LVEF. Asides from possible shortcomings of the training programme, the poor performance of non-experts could be explained by their limited experience in identifying left ventricular dysfunction because of the low percentage of patients with HF and reduced ejection fraction seen in the primary care setting.Trial registrationThe study was registered at ClinicalTrials.gov (NCT02939157). Registered 19 October 2016.

  • 25.
    Nyström, Emma
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Unit of Research, Education and Development, Östersund.
    Asklund, Ina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Unit of Research, Education and Development, Östersund.
    Sjöström, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Unit of Research, Education and Development, Östersund.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Re: Treatment of stress urinary incontinence with a mobile app: factors associated with success2018In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 29, no 6, p. 925-925Article in journal (Other academic)
  • 26.
    Nyström, Emma
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Unit of Research, Education and Development - Östersund, Umeå University, Umeå, Sweden.
    Asklund, Ina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Unit of Research, Education and Development - Östersund, Umeå University, Umeå, Sweden.
    Sjöström, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Unit of Research, Education and Development - Östersund, Umeå University, Umeå, Sweden.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Treatment of stress urinary incontinence with a mobile app: factors associated with success2018In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 29, no 9, p. 1325-1333Article in journal (Refereed)
    Abstract [en]

    Introduction and hypothesis: Stress urinary incontinence is common among women. First-line treatment includes pelvic floor muscle training (PFMT) and lifestyle advice, which can be provided via a mobile app. The efficacy of app-based treatment has been demonstrated in a randomized controlled trial (RCT). In this study, we aimed to analyze factors associated with successful treatment.

    Methods: Secondary analysis of data from the RCT. At baseline and 3-month follow-up, participants (n = 61) answered questions about symptoms, quality of life, background, and PFMT. Success was defined as rating the condition as much or very much better according to the validated Patient Global Impression of Improvement questionnaire. Factors possibly associated with success were analyzed with univariate logistic regression; if p < 0.20, the factor was entered into a multivariate model that was adjusted for age. Variables were then removed stepwise.

    Results: At follow-up, 34 out of 61 (56%) of participants stated that their condition was much or very much better. Three factors were significantly associated with success: higher expectations for treatment (odds ratio [OR] 11.38, 95% confidence interval [CI] 2.02-64.19), weight control (OR 0.44 per kg gained, 95% CI 0.25-0.79), and self-rated improvement of pelvic floor muscle strength (OR 35.54, 95% CI 4.96-254.61). Together, these factors accounted for 61.4% (Nagelkerke R-2) of the variability in success.

    Conclusion: These results indicate that app-based treatment effects are better in women who are interested in and have high expectations of such treatment. Also, the findings underline the importance of strengthening the pelvic floor muscles and offering lifestyle advice.

  • 27.
    Nyström, Emma
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sjöström, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    ICIQ symptom and quality of life instruments measure clinically relevant improvements in women with stress urinary incontinence2015In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 34, no 8, p. 747-751Article in journal (Refereed)
    Abstract [en]

    AIMS: To determine whether changes in questionnaire scores on symptoms and condition-specific quality of life reflect clinically relevant improvements in women with stress urinary incontinence (SUI).

    METHODS: We retrospectively analyzed questionnaires collected during a randomized controlled trial in women with SUI, that received pelvic floor muscle training (PFMT) in two different formats. We included 218 women that answered validated self-assessment questionnaires at baseline and at a 4-month follow-up. We registered changes on two questionnaires, the International Consultation on Incontinence Modular Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and the Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol). We compared these score changes to responses from the Patient Global Impression of Improvement (PGI-I) questionnaire. Differences were analyzed with the Spearman rho and one-way-ANOVA. The minimum important difference (MID) was the mean change in score for women that experienced a small improvement.

    RESULTS: The PGI-I correlated significantly to both the ICIQ-UI SF (r = 0.547, P < 0.0001) and ICIQ-LUTSqol (r = 0.520, P < 0.0001). Thus, larger reductions in symptoms or quality of life scores were associated with greater impressions of improvement. The changes in ICIQ-UI SF and ICIQ-LUTSqol scores were significant across all PGI-I groups from "no change" to "very much improved" (P < 0.05). The MIDs were 2.52 (SD 2.56) for ICIQ-UI SF and 3.71 (SD 4.95) for ICIQ-LUTSqol.

    CONCLUSIONS: The change in ICIQ-UI SF and ICIQ-LUTSqol scores after PFMT reflected clinically relevant improvements in women with SUI. The MIDs established for this population may facilitate future research, treatment evaluations, and comparisons between studies. 

  • 28.
    Nyström, Emma
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Söderström, Lars
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Self-Management of Incontinence Using a Mobile App: Factors Associated with Completion and ImprovementManuscript (preprint) (Other academic)
  • 29. Rodhe, Nils
    et al.
    Englund, Lars
    Mölstad, Sigvard
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Research and Development Unit, Jämtland County Council, Sweden.
    Bacteriuria is associated with urge urinary incontinence in older women2008In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 26, no 1, p. 35-39Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate the association between bacteriuria and frequency and type of urinary incontinence in elderly people living in the community. Bacteriuria and urinary incontinence are common conditions and often coexisting in this population; the authors have previously reported the prevalence of bacteriuria to be 22.4% in women and 9.4% in men.

    DESIGN: Cross-sectional study.

    SETTING: The catchment area of a primary healthcare centre in a Swedish middle-sized town.

    SUBJECTS: Residents, except for those in nursing homes, aged 80 and over. Participation rate: 80.3% (431/537).

    MAIN OUTCOME MEASURES: Urinary cultures and questionnaire data on urinary incontinence.

    RESULTS: In women the OR for having bacteriuria increased with increasing frequency of urinary incontinence; the OR was 2.83 (95% CI 1.35-5.94) for women who were incontinent daily as compared with continent women. Reporting urge urinary incontinence increased the risk of having bacteriuria: 3.36 (95% CI 1.49-7.58) in comparison with continent women while there was no significant association between stress urinary incontinence and bacteriuria. The prevalence of bacteriuria among men was too low to make any meaningful calculations about the association between bacteriuria and frequency and type of incontinence.

    CONCLUSION: Bacteriuria is associated with more frequent leakage and predominantly with urge urinary incontinence. The causes of this association and their clinical implications remain unclear. There might be some individuals who would benefit from antibiotic treatment, but further studies are warranted.

  • 30.
    Samuelsson, E C
    et al.
    Uppsala universitet.
    Victor, F T
    Tibblin, G
    Svärdsudd, K F
    Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors.1999In: American Journal of Obstetrics and Gynecology, ISSN 0002-9378, E-ISSN 1097-6868, Vol. 180, no 2 Pt 1, p. 299-305Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Our objective was to study the prevalence of genital prolapse and possible related factors in a general population of women 20 to 59 years of age.

    STUDY DESIGN: Of 641 eligible women in a primary health care district, 487 (76%) answered a questionnaire and accepted an invitation to a gynecologic health examination.

    RESULTS: The prevalence of any degree of prolapse was 30.8%. Only 2% of all women had a prolapse that reached the introitus. In a set of multivariate analyses, age (P <.0001), parity (P <.0001), and pelvic floor muscle strength (P <.01)-and among parous women, the maximum birth weight (P <.01)-were significantly and independently associated with presence of prolapse, whereas the woman's weight and sustained hysterectomy were not.

    CONCLUSIONS: Signs of genital prolapse are frequently found in the female general population but are seldom symptomatic. Of factors associated with genital prolapse found in this study, pelvic floor muscle strength appears to be the only one that could be affected.

  • 31.
    Samuelsson, Eva C
    et al.
    Uppsala universitet.
    Victor, F T Arne
    Svärdsudd, Kurt F
    Five-year incidence and remission rates of female urinary incontinence in a Swedish population less than 65 years old2000In: American Journal of Obstetrics and Gynecology, ISSN 0002-9378, E-ISSN 1097-6868, Vol. 183, no 3, p. 568-574Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: We sought to determine the incidence and remission rates of urinary incontinence in a population-based sample of women.

    STUDY DESIGN: A total of 382 (87.6%) of 436 eligible women aged 20 to 59 years answered a questionnaire and underwent a gynecologic examination at baseline and were followed up approximately 5 years later.

    RESULTS: Urinary incontinence was present in 23.6% of women at baseline and in 27.5% at follow-up. The mean annual incidence rate of incontinence was 2.9%, and the mean annual incidence rate of incontinence weekly or more often was 0.5%. Women that were receiving estrogen at baseline were more likely than other women to have incontinence during follow-up. The mean annual remission rate among the 90 women who were incontinent at baseline was 5.9%. The annual net increase of incontinence in the study population was 0. 82%.

    CONCLUSION: Female urinary incontinence seems to be a dynamic condition with a relatively high rate of spontaneous remission, a fact of which physicians should be aware when assessing and planning prevention and treatment strategies.

  • 32.
    Samuelsson, Eva
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hedenmalm, Karin
    Persson, Ingemar
    Mortality from venous thromboembolism in young Swedish women and its relation to pregnancy and use of oral contraceptives: an approach to specifying rates2005In: European Journal of Epidemiology, ISSN 0393-2990, E-ISSN 1573-7284, Vol. 20, no 6, p. 509-516Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Pregnancy and use of combined oral contraceptives (COCs) are major risk factors for venous thromboembolism (VTE) in young women and we wanted to obtain accurate VTE mortality data overall, by age, associated with the use of COCs and pregnancy. METHODS: From the Swedish Cause of Death Register (CDR) we identified women aged 15-44 with VTE as underlying or contributory cause of death during the period 1990-1999. We scrutinized medical records and included verified VTE cases without active cancer or terminal disease. Pregnancy statistics and COC utilization data were obtained from national databases. RESULTS: Of the 120 cases included, 9 (8%) were associated with pregnancy and 28 (23%) with current COC use. The overall refined VTE mortality rate in current COC users was 7.5[4.7; 10.3] per million user-years and the corresponding pregnancy-related rate was 8.9[4.1;17.0] per million pregnancy years, rates increasing with age. For ages 15-24, the rate was significantly higher in current COC users than in non-pregnant women not using COCs: 6.0[3.1; 10.5] per million user-years vs. 0.3[0.0; 1.2] per million woman years. Underlying cause mortality data included 82% of VTE deaths associated with COCs, and 56% of maternal deaths had a pregnancy-related code. CONCLUSION: Mortality figures from VTE associated with the use of COCs and pregnancy were similar. COC use had an important impact on the total VTE mortality in the youngest age group. Standard mortality statistics do not allow accurate monitoring of VTE mortality in young women due to missing data, misdiagnoses and coding rules.

  • 33.
    Samuelsson, Eva
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hellgren, Margareta
    Högberg, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Pregnancy-related deaths due to pulmonary embolism in Sweden.2007In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, Vol. 86, no 4, p. 435-43Article in journal (Refereed)
  • 34.
    Samuelsson, Eva
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Groth, Katarina
    medicinkliniken och Brunflo Hälsocentral, Jämtlands läns landsting.
    Hedenmalm, Karin
    Läkemedelsverket, Uppsala.
    Ung kvinna med p-ring drabbad av armtrombos: möjligt samband med mutation i protrombingenen2007In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 104, no 1-2, p. 32-34Article in journal (Other academic)
    Abstract [en]

    We report a case of axillary vein thrombosis in a young woman. The only identified risk factors included heterozygosity for the prothrombin 20210A variant, heavy lifting, and use of NuvaRing, a novel form of combined hormonal contraception. Thrombosis of the upper extremity veins is a rare condition that is often associated with specific local risk factors such as the presence of a central venous catheter, strenuous muscular effort or upper limb trauma. Recent research has also shown an association to traditional risk factors for venous thromboembolism (VTE) including coagulation abnormalities, surgery, immobilization, use of hormonal contraception and a family history of VTE. It is important to be aware of the rare occurrence of VTE associated with combined hormonal contraception. There is no evidence that vaginal administration is associated with a lower risk of VTE. Four cases of VTE with NuvaRing have hitherto been reported to the Swedish Medical Products Agency accounting for a reported incidence of 5,3 (95% CI 1,4-13,5) cases per 10 000 women years of use.

  • 35.
    Samuelsson, Eva
    et al.
    Uppsala universitet.
    Hägg, S
    Bäckström, M
    Granberg, K
    Mjörndal, T
    [Thrombosis caused by oracl contraceptives. Underreporting to the adverse effects registry].1996In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 93, no 37, p. 3117-8, 3121Article in journal (Refereed)
  • 36.
    Samuelsson, Eva
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hägg, Staffan
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology.
    Incidence of venous thromboembolism in young Swedish women and possibly preventable cases among combined oral contraceptive users2004In: Acta Obstetricia et Gynecologica Scandinavica, Supplement, ISSN 0300-8835, Vol. 83, no 7, p. 674-681Article in journal (Refereed)
    Abstract [en]

    Background. We wanted to study the incidence of venous thromboembolism (VTE), acquired risk factors of VTE and preventable cases among users of combined oral contraceptives (COCs).

    Methods. All women aged 15–44 years, (n = 24 373) living in the county of Jämtland, Sweden, between 1991 and 2000, constituted the study base in a retrospective case-reference study. Women with VTE were identified through hospital registers and interviewed by telephone. The utilization of COCs according to age was obtained from a prospective prescription database, and data from national health databases were used.

    Results. Of 88 women with first-time VTE, 43 (49%) were COC users and 13 (15%) were pregnant. All women had at least one known risk factor, and 51 (58%) women had combinations of risk factors. The total incidence rate of VTE per 100 000 women-years for all women were 36 (29–44), for nonusers 19 (12–25) for women using third generation COCs 115 (67–184), for women using other COCs 60 (37–83), and for women during pregnancy and postpartum 103 (55–177). Of the total 244 000 women-years represented, COC users constituted 24%, pregnant women 5%, and women with other acquired risk factors 5%. The corresponding incidence rates after excluding VTE cases with other acquired risk factors were 10 (6–14), 1.2 (0.14–4.4), 64 (29–121), 27 (13–48), and 59 (24–121), per 100 000 women-years. In 11 (26%) of the COC-related VTE cases, there were relative contraindications for use of COCs or lack of thromboprophylaxis in relation to surgery.

    Conclusion. We found a very low incidence of idiopathic VTE among young non-OC users. The incidence of VTE during pregnancy was only slightly higher than during COC use. It was considered that a significant part of COC-related VTE might have been avoided.

  • 37.
    Samuelsson, Eva
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Krokoms Health Centre and the Research & Development Unit, The County Council of Jämtland.
    Månsson, L
    The Administrative Department, Östersund Hospital, Östersund.
    Milsom, I
    The Department of Obstetrics & Gynaecology, Sahlgrenska University Hospital, Göteborg.
    Incontinence aids in Sweden: users and costs2001In: BJU International, ISSN 1464-4096, E-ISSN 1464-410X, Vol. 88, no 9, p. 893-8Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To study age- and sex-specific use and costs of incontinence aids distributed free of charge in Sweden.

    SUBJECTS AND METHODS: The study was conducted in the county of Jämtland, Sweden (132,000 inhabitants). The use and cost of incontinence aids for people living in their homes and the total cost of incontinence aids for residents of special accommodation (e.g. nursing homes, homes for the elderly and sheltered housing) was obtained from a central database constructed for the purpose. Individual usage of incontinence aids by those in special accommodation was studied in two districts of Jämtland, representing 18% of the population.

    RESULTS: Free incontinence products were used by 6.4% of all women and 2.4% of all men in the county. There was a sharp increase in usage from the age of 75 years. Of the users, 21% lived in special accommodation. If the data from Jämtland are extrapolated nationally, then 274,000 women and 93,000 men in Sweden (total population 8.8 million) are using free incontinence products. The total cost of incontinence aids for Jämtland during 1999 was 15.4 million Swedish krona (SK), and those in special accommodation accounted for 46% of these costs. This corresponds to an estimated total cost in Sweden of approximately 925 million SK. Although 75% of the users were women, women only contributed 61% of the total costs. The mean annual cost of incontinence aids for an incontinent man was twice that of an incontinent woman. More than half of the costs were attributable to those aged >or=80 years.

    CONCLUSIONS: The estimated national costs of free incontinence aids accounts for 0.5% of the total costs of Swedish healthcare, including the care and nursing of older and disabled people, and for 0.05% of the gross national product.

  • 38.
    Samuelsson, Eva
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Nyström, Emma
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Söderstrom, L.
    TREATMENT FOR STRESS URINARY INCONTINENCE WITH THE SUPPORT OF A MOBILE APPLICATION IS EFFECTIVE WHEN IMPLEMENTED FOR FREE USE2016In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 35, no S4, p. S92-S94Article in journal (Other academic)
  • 39.
    Samuelsson, Eva
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Odeberg, Jenny
    Stenzelius, Karin
    Molander, Ulla
    Hammarström, Margareta
    Franzen, Karin
    Andersson, Gunnel
    Midlöv, Patrik
    Effect of pharmacological treatment for urinary incontinence in the elderly and frail elderly: A systematic review2015In: Geriatrics & Gerontology International, ISSN 1444-1586, E-ISSN 1447-0594, Vol. 15, no 5, p. 521-534Article, review/survey (Refereed)
    Abstract [en]

    Aim: The prevalence and severity of urinary incontinence (UI) increase with age and comorbidity. The benefits of pharmacotherapy for UI in the elderly are questionable. The aim of the present study was to systematically review the efficacy of pharmacological treatment for UI in the elderly and frail elderly. Methods: We searched PubMed, EMBASE, Cochrane library and Cinahl databases through October 2013 to identify prospective controlled trials that evaluated pharmacological treatment for UI in persons aged >= 65 years. Elderly persons living in nursing homes were regarded as frail elderly. Outcomes were urinary leakage, quality of life and adverse events. Results: We screened 1038 abstracts and assessed 309 full-text articles. We identified 13 trials of high or moderate quality; 11 evaluated anticholinergic drugs and two evaluated duloxetine. Oxybutynin, the only drug studied in the frail elderly population, had no effect on urinary leakage or quality of life in elderly with urgency UI (UUI). Seven trials evaluated the effects of darifenacin, fesoterodine, solifenacin, tolterodine or trospium. Urinary leakage decreased (standard mean difference: -0.24, 95% confidence interval -0.32-0.15), corresponding to a reduction of half a leakage per 24 h. Common side-effects of treatment were dry mouth and constipation. Data were insufficient for evaluation of the effect on quality of life or cognition. The evidence was insufficient to evaluate the effects of duloxetine. No eligible studies on mirabegron and estrogen were found. Conclusions: Anticholinergics have a small, but significant, effect on urinary leakage in older adults with UUI. Treatment with drugs for UUI in the frail elderly is not evidence based.

  • 40.
    Samuelsson, Eva
    et al.
    Uppsala University, Uppsala and Mid Sweden University, Östersund.
    Victor, Arne
    Mid Sweden University, Östersund.
    Svärdsudd, Kurt
    Uppsala University.
    Determinants of urinary incontinence in a population of young and middle-aged women2000In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 79, no 3, p. 208-15Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Urinary incontinence and genital prolapse are prevalent conditions in the female population. The aim of this study was to study possible determinants of female urinary incontinence in a population-based sample of young and middle-aged women.

    METHODS: Of 641 eligible women aged 20-59 years in a primary health care district, 487 (76%) responded to a questionnaire and accepted an invitation to a gynecological examination. The examination included digital assessment of the pelvic floor muscle strength (PFMS). Genital prolapse presence (cystocele, rectocele, uterine prolapse or absence of the urethrovesical crease) was graded in relation to the vaginal introitus.

    RESULTS: The prevalence of urinary incontinence was 28%, 3.5% having daily leakage. Stress urinary incontinence was the dominant type. The odds ratio (OR) of having incontinence increased from 1 to 3.5 with increasing age and from 1 to 2.7 with increasing parity. The OR also increased with decreasing PFMS; from 1 in the group with the best PFMS to 3.4 in the group unable to contract their pelvic musculature. In addition, women with cystocele and/or absence of the urethrovesical crease had a 2.5-fold increased OR of incontinence (95% CI 1.5-4.2), smoking increased the OR 1.9 times (95% CI 1.1-3.2) and estrogen replacement therapy (ERT) increased the OR 2.9 times (95% CI 1.4-5.9). There were no significant correlations with the presence of chronic disease, episiotomy or the birth weights of children but small non-significant correlations with performed hysterectomy and the woman's weight.

    CONCLUSIONS: Urinary incontinence is a frequent symptom in the female general population and related to age, pelvic floor muscle strength, genital prolapse, smoking, parity and estrogen replacement therapy.

  • 41.
    Samuelsson, Eva
    et al.
    Uppsala University, Uppsala and Zätägrands Primary Health Care, Center, Östersund.
    Victor, Arne
    Tibblin, Gösta
    A population study of urinary incontinence and nocturia among women aged 20-59 years: prevalence, well-being and wish for treatment1997In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 76, no 1, p. 74-80Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim was to study urinary incontinence (UI) and nocturia in a female population; prevalence, effect on well-being, wish for treatment and result of treatment in primary health care.

    METHODS: A postal questionnaire was sent to all women aged 20-59 years who were scheduled for gynecological health examination by midwives in a primary health care district during one year. Questions concerning well-being were based on the Gothenburg QOL instrument. All women with incontinence were offered treatment by a midwife and a family doctor.

    RESULTS: Of the included 641 women, 491 (77%) answered the questionnaire. The prevalence of urinary incontinence was 27.7%, 3.5% having daily leakage. Nocturia occurred in 32 women (6.5%), 12 of whom were also incontinent. Self-assessed health, sleep, fitness and satisfaction with work situation decreased significantly with increased frequency of incontinence. Well-being was not correlated to type of incontinence. Nocturia correlated to poor health and sleep. About a quarter of the incontinent women started treatment when offered and 80% of those who completed the treatment program were subjectively improved. Wish for treatment was directly correlated to frequency of incontinence but not to type.

    CONCLUSIONS: Urinary incontinence and nocturia affect well-being in a negative way. Well-being and wish for treatment correlate to frequency of incontinence but not to type of incontinence. Most women with UI accept it, only about a quarter of incontinent women, or 6-7% of all women in the studied age group, want treatment. Treatment of female urinary incontinence in primary health care is successful.

  • 42.
    Sjöström, M
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Umefjord, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Stenlund, H
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Carlbring, Per
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Andersson, G
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Internet-based treatment of stress urinary incontinence: a randomised controlled study2012In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 31, no 6, p. 734-736Article in journal (Other academic)
  • 43.
    Sjöström, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Mobile App for Treatment of Stress Urinary Incontinence: A Cost-Effectiveness Analysis2017In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 19, no 5, article id e154Article in journal (Refereed)
    Abstract [en]

    Background: Mobile apps can increase access to care, facilitate self-management, and improve adherence to treatment. Stress urinary incontinence (SUI) affects 10-35% of women and, currently, an app with instructions for pelvic floor muscle training (PFMT) is available as first-line treatment. A previous randomized controlled study demonstrated that the app benefitted symptom severity and quality of life (QoL); in this study we investigate the cost-effectiveness of the app. Objective: The objective of this study was to evaluate the health economy of the app for treating SUI. Methods: This deterministic cost-utility analysis, with a 1-year societal perspective, compared the app treatment with no treatment. Health economic data were collected alongside a randomized controlled trial performed in Sweden from March 2013 to October 2014. This study included 123 community-dwelling women participants of 18 years and above, with stress urinary incontinence >= 1 time per week. Participants were self-assessed with validated questionnaires and 2-day leakage diaries, and then randomized to 3 months of treatment (app group, n=62) or no treatment (controls, n=61). The app focused on pelvic floor muscle training, prescribed 3 times daily. We continuously registered treatment delivery costs. Data were collected on each participant's training time, incontinence aids, and laundry at baseline and at a 3-month follow-up. We measured quality of life with the International Consultation on Incontinence Modular Questionnaire on Lower Urinary Tract Symptoms and Quality of Life, and calculated the quality-adjusted life years (QALYs) gained. Data from the 3-month follow-up were extrapolated to 1 year for the calculations. Our main outcome was the incremental cost-effectiveness ratios compared between app and control groups. One-way and multiway sensitivity analyses were performed. Results: The mean age of participants was 44.7 years (SD 9.4). Annual costs were (sic)547.0 for the app group and (sic)482.4 for the control group. Annual gains in quality-adjusted life years for app and control groups were 0.0101 and 0.0016, respectively. Compared with controls, the extra cost per quality-adjusted life year for the app group ranged from -(sic) 2425.7 to (sic) 14,870.6, which indicated greater gains in quality-adjusted life years at similar or slightly higher cost. Conclusions: The app for treating stress urinary incontinence is a new, cost-effective, first-line treatment with potential for increasing access to care in a sustainable way for this patient group.

  • 44.
    Sjöström, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Jämtland Cty Council, Res Unit, S-83157 Östersund, Sweden.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Johansson, S
    Jämtland Cty Council, Res Unit, S-83157 Östersund, Sweden.
    Umefjord, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Stress urinary incontinence and quality of life: a reliability study of a condition-specific instrument in paper and web-based versions2012In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 31, no 8, p. 1242-1246Article in journal (Refereed)
    Abstract [en]