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  • 1. Califf, RM
    et al.
    Boolell, M
    Sandström, Herbert et al
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Prevention of diabetes and cardiovascular disease in patients with impaired glucose tolerance: rationale and design of the Nateglinide And Valsartan in impaired Glucose Tolerance Outcomes Research (NAVIGATOR)2008In: Trial Am heart J, Vol. 156, no 4, p. 623-632Article in journal (Refereed)
  • 2.
    Escher, Cecilia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    [Substantial blood glucose control differences at Swedish surgery departments. Common guidelines required]2006In: Lakartidningen, ISSN 0023-7205, Vol. 103, no 48, p. 3811-4Article in journal (Refereed)
  • 3.
    Hendrikx, Tijn
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hörnsten, Rolf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Clinical Physiology.
    Rosenqvist, Mårten
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Screening for atrial fibrillation with baseline and intermittent ECG recording in an out-of-hospital population2013In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 13, p. 41-, article id 41Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: the objective of this study is to investigate the detection rate of undiagnosed atrial fibrillation (AF) with short intermittent ECG recordings during four weeks among out-of-hospital patients, having at least one additional risk factor (CHADS2) for stroke.

    METHOD: Design: Cross-sectional study. Setting: Eight family practice centres and two hospital-based out-patient clinics in Sweden. Subjects: 989 out-of-hospital patients, without known AF, having one or more risk factors associated with stroke (CHADS2). Interventions: All individuals were asked to perform 10-second handheld ECG recordings during 28 days, twice daily and when having palpitations. Main outcome measures: Episodes of AF on handheld ECG recordings were defined as irregular supraventricular extrasystoles in series with a duration of 10 seconds.

    RESULTS: 928 patients completed registration. AF was found in 35 of 928 patients; 3.8% (95% confidence interval [CI] 2.7--5.2). These 35 patients had a mean age of 70.7 years (SD +/- 7.7; range 53--85) and a median CHADS2 of 2 (range 1--4).

    CONCLUSIONS: Intermittent handheld ECG recording over a four week period had a detection rate of 3.8% newly diagnosed AF, in a population of 928 out-of-hospital patients having at least one additional risk factor for stroke. Intermittent handheld ECG registration is a feasible method to detect AF in patients with an increased risk of stroke in whom oral anticoagulation (OAC) treatment is indicated.

  • 4.
    Hendrikx, Tijn
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Mårten, Rosenqvist
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hörnsten, Rolf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Clinical Physiology.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Screening for atrial fibrillation in patients with left atrial enlargementIn: Article in journal (Other academic)
  • 5.
    Hendrikx, Tijn
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Rosenqvist, Mårten
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Persson, Mats
    Hörnsten, Rolf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Identifiering av paroxysmala, kortvariga arytmier: intermittent registrering mer effektiv än 24-timmars Holter-EKG2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112, no 1-2, article id C6SEArticle in journal (Refereed)
    Abstract [en]

    Many patients suffer from palpitations or dizziness/presyncope. These patients are often referred for Holter ECG (24 hour), although the sensitivity for detecting arrhythmias is low. A new method, short intermittent regular and symptomatic ECG registrations at home, might be a convenient and more sensitive alternative also suitable for primary health care. In this case report we present a patient who had contacted health care several times during a seven year period for paroxysmal palpitations. Routine examination with 24 hour Holter ECG and event recorder did not result in a diagnosis. Using intermittent handheld ECG registration at home, a paroxysmal supraventricular arrhythmia was diagnosed. Further investigation revealed that the patient had a concealed Wolff-Parkinson-White (WPW) syndrome.

  • 6.
    Hendrikx, Tijn
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Rosenqvist, Mårten
    Department of Clinical Sciences, Danderyds Sjukhus, Karolinska Institutet, SE-182 88 Stockholm, Sweden.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hörnsten, Rolf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Clinical Physiology.
    Intermittent short ECG recording is more effective than 24-hour Holter ECG in detection of arrhythmias2014In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 14, p. 41-Article in journal (Refereed)
    Abstract [en]

    Background: Many patients report symptoms of palpitations or dizziness/presyncope. These patients are often referred for 24-hour Holter ECG, although the sensitivity for detecting relevant arrhythmias is comparatively low. Intermittent short ECG recording over a longer time period might be a convenient and more sensitive alternative. The objective of this study is to compare the efficacy of 24-hour Holter ECG with intermittent short ECG recording over four weeks to detect relevant arrhythmias in patients with palpitations or dizziness/presyncope.

    Methods:

    Design: prospective, observational, cross-sectional study. Setting: Clinical Physiology, University Hospital. Patients: 108 consecutive patients referred for ambiguous palpitations or dizziness/presyncope.

    Interventions: All individuals underwent a 24-hour Holter ECG and additionally registered 30-second handheld ECG (Zenicor EKG ((R)) thumb) recordings at home, twice daily and when having cardiac symptoms, during 28 days.

    Main outcome measures: Significant arrhythmias: atrial fibrillation (AF), paroxysmal supraventricular tachycardia (PSVT), atrioventricular (AV) block II-III, sinus arrest (SA), wide complex tachycardia (WCT).

    Results: 95 patients, 42 men and 53 women with a mean age of 54.1 years, completed registrations. Analysis of Holter registrations showed atrial fibrillation (AF) in two patients and atrioventricular (AV) block II in one patient (= 3.2% relevant arrhythmias [95% CI 1.1-8.9]). Intermittent handheld ECG detected nine patients with AF, three with paroxysmal supraventricular tachycardia (PSVT) and one with AV-block-II (= 13.7% relevant arrhythmias [95% CI 8.2-22.0]). There was a significant difference between the two methods in favour of intermittent ECG with regard to the ability to detect relevant arrhythmias (P = 0.0094). With Holter ECG, no symptoms were registered during any of the detected arrhythmias. With intermittent ECG, symptoms were registered during half of the arrhythmia episodes.

    Conclusions: Intermittent short ECG recording during four weeks is more effective in detecting AF and PSVT in patients with ambiguous symptoms arousing suspicions of arrhythmia than 24-hour Holter ECG.

  • 7.
    Hendrikx, Tijn
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sundqvist, Martin
    Hörnsten, Rolf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Clinical Physiology.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sahlin, Carin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Rohani, Morteza
    Al-Khalili, Faris
    Blomberg, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Rosenqvist, Mårten
    Franklin, Karl A
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Atrial fibrillation in patients with sleep apneaManuscript (preprint) (Other academic)
  • 8.
    Hendrikx, Tijn
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sundqvist, Martin
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sahlin, Carin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Rohani, Morteza
    Al-Khalili, Faris
    Hörnsten, Rolf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Clinical Physiology.
    Blomberg, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Rosenqvist, Mårten
    Franklin, Karl A
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Atrial fibrillation among patients under investigation for suspected obstructive sleep apnea2017In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 12, no 2, article id e0171575Article in journal (Refereed)
    Abstract [en]

    STUDY OBJECTIVES: Obstructive sleep apnea is common among patients with atrial fibrillation, but the prevalence and risk factors for atrial fibrillation among patients who are being investigated on suspicion of sleep apnea are not well known. The aim of the study was to estimate the prevalence of atrial fibrillation among patients investigated for suspected obstructive sleep apnea and to identify risk factors for atrial fibrillation among them.

    METHODS: The prevalence of atrial fibrillation was investigated among 201 patients referred for suspected obstructive sleep apnea. Patients without known atrial fibrillation were investigated with a standard 12-lead ECG at hospital and short intermittent handheld ECG recordings at home, during 14 days.

    RESULTS: Atrial fibrillation occurred in 13 of 201 subjects (6.5%), and in 12 of 61 men aged 60 years and older (20%). The prevalence of atrial fibrillation increased with sleep apnea severity (p = 0.038). All patients with atrial fibrillation were men and all had sleep apnea. Age 60 or older, the occurrence of central sleep apnea and diabetes mellitus were independent risk factors for atrial fibrillation after adjustments for body mass index, gender, sleep apnea and cardiovascular disease.

    CONCLUSIONS: Atrial fibrillation is common among subjects referred for sleep apnea investigation and the prevalence of atrial fibrillation increases with sleep apnea severity. Independent risk factors for atrial fibrillation among patients investigated for suspected obstructive sleep apnea include the occurrence of coexisting central sleep apnea, age 60 years or older and diabetes mellitus.

  • 9. Holman, Rury R.
    et al.
    Haffner, Steven M.
    McMurray, John J.
    Bethel, M. Angelyn
    Holzhauer, Bjoern
    Hua, Tsushung A.
    Belenkov, Yuri
    Boolell, Mitradev
    Buse, John B.
    Buckley, Brendan M.
    Chacra, Antonio R.
    Chiang, Fu-Tien
    Charbonnel, Bernard
    Chow, Chun-Chung
    Davies, Melanie J.
    Deedwania, Prakash
    Diem, Peter
    Einhorn, Daniel
    Fonseca, Vivian
    Fulcher, Gregory R.
    Gaciong, Zbigniew
    Gaztambide, Sonia
    Giles, Thomas
    Horton, Edward
    Ilkova, Hasan
    Jenssen, Trond
    Kahn, Steven E.
    Krum, Henry
    Laakso, Markku
    Leiter, Lawrence A.
    Levitt, Naomi S.
    Mareev, Viacheslav
    Martinez, Felipe
    Masson, Chantal
    Mazzone, Theodore
    Meaney, Eduardo
    Nesto, Richard
    Pan, Changyu
    Prager, Rudolf
    Raptis, Sotirios A.
    Rutten, Guy E. H. M.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Schaper, Frank
    Scheen, Andre
    Schmitz, Ole
    Sinay, Isaac
    Soska, Vladimir
    Stender, Steen
    Tamas, Gyula
    Tognoni, Gianni
    Tuomilehto, Jaako
    Villamil, Alberto S.
    Vozar, Juraj
    Califf, Robert M.
    Effect of Nateglinide on the Incidence of Diabetes and Cardiovascular Events2010In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 362, no 16, p. 1463-1476Article in journal (Refereed)
    Abstract [en]

    BACKGROUND The ability of short-acting insulin secretagogues to reduce the risk of diabetes or cardiovascular events in people with impaired glucose tolerance is unknown. METHODS In a double-blind, randomized clinical trial, we assigned 9306 participants with impaired glucose tolerance and either cardiovascular disease or cardiovascular risk factors to receive nateglinide (up to 60 mg three times daily) or placebo, in a 2-by-2 factorial design with valsartan or placebo, in addition to participation in a lifestyle modification program. We followed the participants for a median of 5.0 years for incident diabetes (and a median of 6.5 years for vital status). We evaluated the effect of nateglinide on the occurrence of three coprimary outcomes: the development of diabetes; a core cardiovascular outcome that was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure; and an extended cardiovascular outcome that was a composite of the individual components of the core composite cardiovascular outcome, hospitalization for unstable angina, or arterial revascularization. RESULTS After adjustment for multiple testing, nateglinide, as compared with placebo, did not significantly reduce the cumulative incidence of diabetes (36% and 34%, respectively; hazard ratio, 1.07; 95% confidence interval [CI], 1.00 to 1.15; P = 0.05), the core composite cardiovascular outcome (7.9% and 8.3%, respectively; hazard ratio, 0.94, 95% CI, 0.82 to 1.09; P = 0.43), or the extended composite cardiovascular outcome (14.2% and 15.2%, respectively; hazard ratio, 0.93, 95% CI, 0.83 to 1.03; P = 0.16). Nateglinide did, however, increase the risk of hypoglycemia. CONCLUSIONS Among persons with impaired glucose tolerance and established cardiovascular disease or cardiovascular risk factors, assignment to nateglinide for 5 years did not reduce the incidence of diabetes or the coprimary composite cardiovascular outcomes. (ClinicalTrials.gov number, NCT00097786.)

  • 10.
    Hörnsten, Åsa
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lundman, Berit
    Umeå University, Faculty of Medicine, Department of Nursing.
    Almberg, Agneta
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Nurses' experiences of conflicting encounters in diabetes care2008In: European Diabetes Nursing, ISSN 1551-7853, E-ISSN 1551-7861, Vol. 5, no 2, p. 64-69Article in journal (Refereed)
    Abstract [en]

    Aim: To describe nurses' experiences of encounters with patients in diabetes care.Methods: Focus-group interviews with 17 nurses about their experiences of caring for patients with diabetes. Interviews were analysed by qualitative content analysis.Results: Four themes described conflicts in their encounters with patients, disclosing a complex professional role as a diabetes nurse. Implementing guidelines at the same time as being patient-centred was found to be problematic. Nurses further viewed medical knowledge as being more important than life experience of diabetes. The nurses' comments were distanced from, and judgemental about, patients as a collective. Finally, the nurses felt comfortable in expert roles, but not in equal and mutual relationships with patients.Conclusion: The interviews identified a feeling of frustration over conflicting demands between different goals and ideologies for diabetes care. These conflicts may also arise from the difficulty of integrating medical goals and patients' life experiences of illness.

  • 11.
    Hörnsten, Åsa
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lundman, Berit
    Umeå University, Faculty of Medicine, Department of Nursing.
    Selstam, Eva Kihl
    Umeå University, Faculty of Medicine, Department of Nursing.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Patient satisfaction with diabetes care2005In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 51, no 6, p. 609-617Article in journal (Refereed)
    Abstract [en]

    Aim. The aim of this paper is to report the findings of a study that elucidated the experiences and reflections of people with type 2 diabetes about clinical encounters.

    Background. Several patient satisfaction surveys have focused on privacy, cheerfulness and amenities rather than on how the care was delivered. A great deal of research has also focused on communication and various consultation styles, particularly within health promotion and diabetes care, but how these factors tie up with patient satisfaction has rarely been discussed. This study was performed in order to elucidate patients' perspectives about clinical encounters in diabetes care.

    Method. Interviews were carried out during 2001 with 44 patients with diabetes. The transcribed interviews were analysed using qualitative content analysis.

    Results. Five themes were connected to patient satisfaction and dissatisfaction, namely 'being in agreement vs. in disagreement about the goals'; 'autonomy and equality vs. feeling forced into adaptation and submission'; 'feeling worthy as a person vs. feeling worthless'; 'being attended to and feeling welcome vs. ignored'; and, lastly, 'feeling safe and confident vs. feeling unsafe and lacking confidence'.

    Conclusion. Despite efforts to individualize diabetes care and find ways to communicate with patients, many people have experiences of clinical encounters that they find dissatisfying. Experiences of dissatisfying encounters have elements that may threaten their perception of self and identity, while elements included in satisfying encounters are those characterizing patient-centred care.

  • 12.
    Hörnsten, Åsa
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lundman, Berit
    Umeå University, Faculty of Medicine, Department of Nursing.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Metabolic improvement after intervention focusing on personal understanding in type 2 diabetes.2005In: Diabetes Research and Clinical Practice, ISSN 0168-8227, E-ISSN 1872-8227, Vol. 68, no 1, p. 65-74Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to evaluate, whether an educational intervention, focusing on patients' personal understanding of their illness, was more effective than care given according to national guidelines for diabetes care. METHODS: An intervention group (n = 44), with type 2 diabetes was compared with a control group (n = 60), with HbA1c as the primary outcome. The intervention included ten group sessions addressing themes related to the patients' personal understanding of their illness. The diabetes nurses involved were educated in theories about illness/wellness experiences and participated in group sessions where various caring strategies related to the patients' individual needs and understanding were reflected upon. RESULTS: At 1-year follow-up the intervention group showed lower HbA1c levels (mean difference 0.94%; P < 0.001), lower triglycerides (mean difference 0.52 mmol/l; P = 0.002) and higher high-density lipoprotein (mean difference 0.15 mmol/l; P = 0.029) and treatment satisfaction than did the control group. The differences remained when adjusting for age, gender, body mass index or changed treatment during the intervention period. Within the intervention group, BMI and treatment satisfaction were also improved. CONCLUSION: The intervention, which focused on patients' personal understanding of illness, was found to be effective in terms of metabolic control and treatment satisfaction.

  • 13.
    Hörnsten, Åsa
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lundman, Berit
    Umeå University, Faculty of Medicine, Department of Nursing.
    Personal understandings of illness among people with type 2 diabetes2004In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 47, no 2, p. 174-182Article in journal (Refereed)
    Abstract [en]

    Background. Professionals and patients understand the experience of illness from different worlds. Professionals' explanatory models focus on aetiology, diagnosis, pathophysiology and treatment, while patients' explanatory models are more focused on consequences and influences on daily life. The differences between patients and professionals in their understanding often result in conflicting expectations about treatment, priorities and outcomes of care.

    Aim. The aim of this study was to describe personal understandings of illness among people with type 2 diabetes in Sweden.

    Method. A sample of 44 patients, 47–80 years, diagnosed with type 2 diabetes within the last 2 years, was recruited from four health care centres. Narrative thematic interviews were used covering the areas of developing, coping with and living with diabetes. Qualitative content analysis was performed.

    Findings. The findings were formulated into six categories: image of the disease, meaning of the diagnosis, integration of the illness, space for the illness, responsibility for care and future prospects.

    Conclusions. The findings demonstrate that patients' personal understanding of illness is an important complement to the traditional professional view of diabetes. They could serve as a foundation for development of health history interviewing, as well as development of systems of documentation. Patients' personal understandings of diabetes in their daily lives are considered to be an important shared source of information for planning meaningful care.

  • 14.
    Hörnsten, Åsa
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lundman, Berit
    Umeå University, Faculty of Medicine, Department of Nursing.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Allmänmedicin.
    Improvements in HbA1c remain after 5 years--a follow up of an educational intervention focusing on patients' personal understandings of type 2 diabetes2008In: Diabetes Research and Clinical Practice, ISSN 0168-8227, E-ISSN 1872-8227, Vol. 81, no 1, p. 50-5Article in journal (Refereed)
    Abstract [en]

    This paper reports a 5-year follow-up from a study aimed at evaluating whether an intervention which focused on patients’ personal understanding of their illness was more effective than conventional diabetes care with regard to metabolic control among patients with type 2 diabetes mellitus (DM2). The study was conducted within Swedish primary health care and included 102 patients (mean age 63 years). At clinic level they were randomised into control or intervention groups. The intervention directed at patients consisted of ten two-hour group sessions over 9 months, focusing on patients’ own needs and questions. The mean HbA1c at baseline was 5.71% (S.D. 0.76) in the intervention group and 5.78% (S.D. 0.71) in the control group. At the 5-year follow-up, the mean HbA1c in the intervention group still was 5.71% (S.D. 0.85) while among the controls it had increased to 7.08% (S.D. 1.71). The adjusted difference was 1.37 (p < 0.0001). Treatment upgrade, BMI, total cholesterol, HDL, LDL and triglycerides at baseline did not influence the difference in HbA1c. These findings indicate that group sessions in patients with DM2 focusing on patients’ personal understanding of their illness are more effective than conventional diabetes care with regard to metabolic control.

  • 15.
    Jutterström, Lena
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Hörnsten, Åsa
    Umeå University, Faculty of Medicine, Department of Nursing.
    Sandström, Herbert
    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.
    Isaksson, Ulf
    Umeå University, Faculty of Medicine, Department of Nursing.
    Nurse-led patient-centered self-management support improves HbA1c in patients with type 2 diabetes: A randomized study2016In: Patient Education and Counseling, ISSN 0738-3991, E-ISSN 1873-5134, Vol. 99, no 11, p. 1821-1829Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The aim of this study was to evaluate the effect of a patient-centered self-management support, in type 2 diabetes (T2D) with regard to metabolic changes.

    METHODS: 182 patients were randomized into group intervention (GI), individual intervention (II) or internal controls (IC). An external control (EC) group was recruited from another county council. The intervention consisted of six sessions that featured themes, which regarded different views of their illness experiences. Data were collected in 2010 and 2011.

    RESULTS: HbA1c was significantly decreased at 12-month follow-up with 5mmol/mol in the GI and 4mmol/mol in the II. In the IC group, the HbA1c was close to baseline. The EC group had increased HbA1c, though not significantly. When the HbA1c difference at baseline was adjusted, there was a significant difference between intervention groups and the EC-group.

    CONCLUSION: Patient-centered self-management support, led by nurses, can lower HbA1c among patients with type 2 diabetes.

    PRACTICE IMPLICATIONS: It is possible to train diabetes specialist nurses in clinical patient-centered care, and simultaneously influence patients' metabolic balance positively.

  • 16.
    Jutterström, Lena
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Isaksson, Ulf
    Umeå University, Faculty of Medicine, Department of Nursing.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hörnsten, Åsa
    Umeå University, Faculty of Medicine, Department of Nursing.
    Turning points in self-management of type 2 diabetes2012In: European Diabetes Nursing, ISSN 1551-7853, E-ISSN 1551-7861, Vol. 9, no 2, p. 46-50Article in journal (Refereed)
    Abstract [en]

    A turning point is described in the literature as a powerful emotional experience or insight leading to a fundamental change in a person’s life, and requires a new way of managing the illness. However, turning points are not sufficiently described in the literature, particularly not with respect to diabetes.

    The aim of this study was to throw light on turning points in self-management asdescribed by people with type 2 diabetes.

    Eighteen participants diagnosed with type 2 diabetes within the previous two years, and who received treatment in primary health care, were invited to participate. Semi-structured interviews were analysed using qualitative content analysis.

    The findings demonstrated that the turning point in self-management among individuals living with type 2 diabetes included four themes: being in a life and death struggle, being at a crossroads with no return, being the one who decides, and being the one who can change the outcome.

    Turning point transitions include existential and emotional aspects that can increase inner motivation and power for changed behaviour. Turning points are possible to identify, and self-management could be facilitated if more attention is paid to the emotional and existential aspects of having an illness.

  • 17.
    Jutterström, Lena
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Isaksson, Ulf
    Umeå University, Faculty of Medicine, Department of Nursing.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hörnsten, Åsa
    Umeå University, Faculty of Medicine, Department of Nursing.
    Diabetes control by patient-centred self-management support: a randomised controlled trialArticle in journal (Refereed)
  • 18.
    Liljeholm, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Grönlund, Elisabeth
    Umeå University, Faculty of Medicine, Department of Medical Biosciences.
    Golovleva, Irina
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wahlin, Anders
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Erythrocyte Flow Cytometric Analysis in Congenital Dyserythropoietic Anemia Type III-Evaluation of Eosin-5´-Maleimide, CD55, and CD592013In: Journal of Blood Disorders & Transfusion, ISSN 2155-9864, Vol. 121, no 23, p. 4791-4799Article in journal (Refereed)
    Abstract [en]

    Introduction: Flow cytometry with eosin-5´-maleimide (EMA), anti-CD55 and anti-CD59 is commonly used when investigating non-autoimmune hemolytic anemias. Reduced fluorescence of EMA, typically detected in hereditary spherocytosis is also seen in congenital dyserythropoietic anemia type II (CDA II). Reduction of CD55 and CD59 characterizes paroxysmal nocturnal hemoglobinuria (PNH). We studied the flow cytometric profile of EMA, CD55 and CD59 on erythrocytes in congenital dyserythropoietic anemia type III (CDA III). 

    Methods: Erythrocytes from 16 CDA III positive individuals, 14 CDA III negative relatives and three normal controls per assay were studied with flow cytometry after EMA staining. Flow cytometry after anti-CD55 and anti- CD59 was performed on erythrocytes from 12 CDA III positive and 7 CDA III negative relatives with one normal control per assay. 

    Results: CDA III - erythrocytes exhibited marginally stronger fluorescence after EMA-staining than normal controls. Correlation between EMA fluorescence and erythrocyte volume was confirmed. CDA III subjects did not differ from normal controls concerning CD55 and CD59. 

    Conclusion: The results of the present study indicate no abnormality of the erythrocyte membrane in CDA III and show that standard flow cytometry cannot be used to discriminate between CDA III and normal controls. 

  • 19.
    Liljeholm, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Irvine, Andrew F
    Vikberg, Ann-Louise
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Norberg, Anna
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Month, Stacy
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wahlin, Anders
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Mishima, Masanori
    Golovleva, Irina
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Congenital dyserythropoietic anemia type III (CDA III) is caused by a mutation in kinesin family member, KIF23.2013In: Blood, ISSN 0006-4971, E-ISSN 1528-0020Article in journal (Refereed)
    Abstract [en]

    Haplotype analysis and targeted next-generation resequencing allowed us to identify a mutation in the KIF23 gene and to show its association with an autosomal dominant form of congenital dyserythropoietic anemia type III (CDA III). The region at 15q23 where CDA III was mapped in a large Swedish family was targeted by array-based sequence capture in a female diagnosed with CDA III and her healthy sister. Prioritization of all detected sequence changes revealed 10 variants unique for the CDA III patient. Among those variants, a novel mutation c.2747C>G (p.P916R) was found in KIF23, which encodes mitotic kinesin-like protein 1 (MKLP1). This variant segregates with CDA III in the Swedish and American families but was not found in 356 control individuals. RNA expression of the 2 known splice isoforms of KIF23 as well as a novel one lacking the exons 17 and 18 was detected in a broad range of human tissues. RNA interference-based knock-down and rescue experiments demonstrated that the p.P916R mutation causes cytokinesis failure in HeLa cells, consistent with appearance of large multinucleated erythroblasts in CDA III patients. We conclude that CDA III is caused by a mutation in KIF23/MKLP1, a conserved mitotic kinesin crucial for cytokinesis.

  • 20.
    Liljeholm, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Vikberg, Ann-Louise
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Golovleva, Irina
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wahlin, Anders
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Congenital Dyserythropoietic Anemia Type III and Primary Hemochromatosis; Coexistence of Mutations in KIF23 and HFE.2016In: Journal of Hematology and Blood Disorders, Vol. 1, no 2, article id 203Article in journal (Refereed)
    Abstract [en]

    Background: Congenital dyserythropoietic anemia type III (CDA III) can be caused by mutation in KIF23. CDA III differs from CDA I and II in the sense that secondary hemochromatosis has not been reported. However, we have observed elevated serum ferritin in a CDA III family. Since primary hemochromatosis is common in Northern Europe we decided to screen the family for HFE mutations.

    Aim: Study clinical appearance and prevalence of HFE gene mutations, C282Y and H63D, in a CDA III family. 

    Methods: DNA from 37 CDA III patients and 21 non-affected siblings was genotyped. Iron status from EDTA plasma was measured in 32 of the CDA III patients and 18 of the non-affected siblings.

    Results: Out of 37 CDA III patients, 18 carried heterozygous HFE mutations and six were compound heterozygotes. Out of 21 CDA III negative siblings, nine had heterozygous HFE mutations, two were homozygous (one H63D and one C282Y), and two were compound heterozygous. None of the patients with wt HFE, regardless of CDA III status, suffered from iron overload. Four patients with HFE mutations needed treatment with phlebotomy to normalize ferritin and transferrin iron saturation; one CDA III negative patient with homozygous C282Y, two CDA III patients with heterozygous HFE mutations and one CDA III case with compound heterozygosity.

    Conclusion: HFE mutations were found in 65 % of CDA III patients and in 62 % of their CDA III negative siblings. Heterozygous HFE mutation, C282Y and even H63D, can cause iron overload when occurring concomitantly with CDA III.

  • 21. Lind, L
    et al.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wahlin, A
    Eriksson, M
    Nilsson-Sojka, B
    Sikström, C
    Holmgren, G
    Localization of the gene for congenital dyserythropoietic anemia type III, CDAN3, to chromosome 15q21-q25.1995In: Human Molecular Genetics, ISSN 0964-6906, E-ISSN 1460-2083, Vol. 4, no 1, p. 109-12Article in journal (Refereed)
    Abstract [en]

    Congenital dyserythropoietic anemia, type III (CDA III) is a rare autosomal dominant disorder characterized by macrocytic anemia, bone marrow erythroid hyperplasia and giant multinucleate erythroblasts. We have genetically characterized a large Swedish family in which the concurrence of CDA III and myeloma or benign monoclonal gammopathy is significantly higher than expected and have found that the causative genetic defect for CDA III maps to an 11 cM interval within 15q21-q25.

  • 22.
    Lundberg, Thorbjörn
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Biagio, Leigh
    Univ Pretoria, Dept Speech Language Pathol & Audiol, ZA-0002 Pretoria, South Africa.
    Laurent, Claude
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Otorhinolaryngology. Univ Pretoria, Dept Speech Language Pathol & Audiol, ZA-0002 Pretoria, South Africa.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Swanepoel, De Wet
    Univ Pretoria, Dept Speech Language Pathol & Audiol, ZA-0002 Pretoria, South Africa.
    Remote evaluation of video-otoscopy recordings in an unselected pediatric population with an otitis media scale2014In: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 78, no 9, p. 1489-1495Article in journal (Refereed)
    Abstract [en]

    Background: A recently validated image-based grading scale for acute otitis media (OMGRADE) can be used to assess tympanic membrane (TM) status. The aim of this study was to evaluate the validity and reliability of this scale for remote assessments of TM status using video-otoscopy recordings in an unselected pediatric population.

    Method: Children 2-16 years attending a South African primary health clinic were offered an ear examination by an otologist using otomicroscopy. An ear and hearing telehealth facilitator then made video-otoscopy recordings (9 – 33 seconds) of the ears and uptakes were uploaded to a secure server for remote assessments in Sweden by an otologist and general practitioner at four- and eight-weeks post onsite assessment. TM appearance was judged according to the OMGRADE scale. Concordance between onsite otomicroscopy and asynchronous assessments of video-otoscopy recordings was calculated together with intra- and inter-rater agreements.

    Results: One hundred and eighty ears were included. Concordance of TM classifications using the OMGRADE scale was found to be substantial (weighted kappa range 0,66-0,79). Intra- and inter-rater agreement (test-retest) was found to be substantial to almost perfect (weighted kappa range 0,85-0,88 and 0,69-0,72, respectively).

    Conclusion: The OMGRADE scale can be used to accurately assess the normal TM and secretory otitis media (SOM) remotely using video-otoscopy recordings in an unselected pediatric population.

  • 23.
    Lundberg, Thorbjörn
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hellström, Sten
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Development and Validation of a New Grading Scale for Otitis Media2013In: The Pediatric Infectious Disease Journal, ISSN 0891-3668, E-ISSN 1532-0987, Vol. 32, no 4, p. 341-345Article in journal (Refereed)
    Abstract [en]

    Background: Grading of acute otitis media (AOM) is important in clinical situations as well as in research. Current grading scales for AOM have used a 6 to 9 point scoring system primarily based on variation of redness and bulging of the tympanic membrane (TM). This study aimed to develop and validate a new scale for grading AOM. Method: The scale was developed in 3 stages based on 32 patients with images taken of the TM when a child attended healthcare centre with othalgia and at follow-up visits. Content validity was used as the method for the first 2 stages. An expert panel reviewed the scale and repeated the process on a revised scale. Reliability was tested with a different expert panel that used the final scale on a sample of TM images in a test-retest and inter-rater and intra-rater agreements were calculated. Results: The scale was developed in 3 steps using expert committees. During the process the description of vascularization was judged to be of insufficient importance for our scale. Inter-rater agreement was moderate (kappa = 0.52) and intra-rater agreement was good (kappa = 0.66 to 0.89) in the test-retest of the final scale. Conclusions: The developed AOM image-based grading scale demonstrates substantial inter- and intra-rater reliability with potential use in clinical research and telemedicine applications. Furthermore, the parameter "redness of TM" is of less importance in our scale as compared with other available grading systems.

  • 24.
    Lundberg, Thorbjörn
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Laurent, Claude
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Otorhinolaryngology.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hellström, Sten
    Department of Audiology and Neurotology Karolinska University Hospital, Stockholm, Sweden.
    What does otalgia in children represent?: A study of acute otitis media in general practice related to symptoms and tympanic membrane status over time.Manuscript (preprint) (Other academic)
    Abstract [en]

    Background

    Otalgia is an important symptom leading children to seek health care in general practice and it can be a symptom of acute otitis media (AOM). The course of AOM can be of importance when grading severity of AOM.

    The aim of this study was to assess tympanic membrane TM appearance in children aged 2–16 years with otalgia in general practice and to follow their signs and symptoms over time.

    Method

    The children were examined at four rural health care centers in Lapland, Sweden. Symptoms such as otalgia, fever and the general condition were recorded together with endoscopic TM images and tympanometry results and stored in a central database. The same procedures were applied at follow-up visits after 3 days, 7 days and 3 months. The symptoms were given scores 0–2, the tympanograms were labeled as type A, type C and type B (scores 0–4–8) whereas TM images were graded according to the OMGRADE scale for TM´s (score 0–8). An assessment group set a diagnosis asynchronously after a consensus discussion. Diagnoses: normal, otitis media with effusion, AOM, bullous myringitis without AOM (BM), bullous myringitis with AOM (bAOM) and AOM with perforation or a wet and chagrinated appearance of the TM (pAOM). The diagnoses were scrutinized for any difference in presentation of symptoms. The course of signs and symptoms was followed up at return visits.

    Results

    The children showed a normal TM and tympanogram in 19%, otitis media with effusion in 32% and AOM in 49% at first visit. The majority of children reported no symptoms after 3 days. The children with bilateral AOM reported slightly more symptoms and the BM/bAOM groups reported fewer symptoms than children with AOM. A pAOM with a chagrinated TM was found in 19% and showed a prolonged return to normal tympanograms. Forty percent of the children who presented with a chagrinated TM (pAOM) at first visit still had type-B tympanograms after 3 months.

    Conclusions Half of the children with otalgia were diagnosed with AOM. Symptoms resolved faster than signs. The chagrinated TM appeared to be associated with prolonged middle ear effusion. 

  • 25.
    Lundberg, Thorbjörn
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Westman, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hellström, Sten
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Otorhinolaryngology.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Digital imaging and telemedicine as a tool for studying inflammatory conditions in the middle ear: evaluation of image quality and agreement between examiners2008In: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 72, no 1, p. 73-79Article in journal (Other academic)
    Abstract [en]

    Objective: To evaluate digital imaging of the tympanic membrane by telemedicine technology and study interpersonal agreement in assessing image quality.

    Methods: In an open consecutive study, 64 children aged 2-16 years who attended three rural health care centres in Northern Sweden with otalgia were examined with video endoscopic photography of their tympanic membrane in a telemedical environment. One hundred and twenty-four images were stored in a central database and Later assessed independently regarding image quality by an ENT specialist, a general practitioner and a registrar in general practice. The overall image quality was graded (0-2) regarding assessment of signs of tympanic membrane inflammation. ALL images were also assessed regarding 8 different components, four image-related components and four anatomically related components.

    Results: Overall image quality was good, with 82.3% of acceptable or excellent quality. The position and thickness of the TM were found to be the most important factors of the images to be able to assess inflammatory disease. Image quality tended to be higher later in the study as a sign of improved skills of examiners. Interpersonal agreement between examiners was acceptable. Overall grade showed k 0.56, 0.49 and 0.66 respectively, and focus, light and existence of obscuring objects were the components with the highest agreement.

    Conclusions: The image quality of video endoscopy of the tympanic membrane was good overall. Interpersonal agreement in evaluating image quality was acceptable but not excellent. The use of digital imaging of good quality in clinical studies can offer an objective clinical evaluation of the TM in retrospect by independent reviewers using strict criteria.

  • 26.
    Lundqvist, Anette
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology, Cariology.
    Wennberg, Anna-Lena
    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.
    Högberg, Ulf
    Uppsala, Sweden.
    Hamberg, Katarina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Reported dietary intake in early pregnant compared to non-pregnant women: a cross-sectional study2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, no 373Article in journal (Refereed)
    Abstract [en]

    Background: A woman's nutritional status before conception and during pregnancy is important for maternal health and the health of the foetus. The aim of the study was to compare diet intake in early pregnant women with non-pregnant women. Methods: Between September 2006 and March 2009, 226 women in early pregnancy were consecutively recruited at five antenatal clinics in Northern Sweden. Referent women (n = 211) were randomly selected from a current health screening project running in the same region (the Vasterbotten Intervention Program; VIP). We collected diet data with a self-reported validated food frequency questionnaire with 66 food items/food aggregates, and information on portion size, alcohol consumption, and supplement intake. Data were analysed using descriptive, comparative statistics and multivariate partial least square modelling. Results: Intake of folate and vitamin D from foods was generally low for both groups. Intake of folate and vitamin D supplements was generally high in the pregnant group and led to significantly higher total estimated intake of vitamin D and folate in the pregnant group. Iron intake from foods tended to be lower in pregnant women although iron supplement intake evened out the difference with respect to iron intake from foods only. Energy intake was slightly lower in pregnant women but not significant, a reflection of that they reported consuming significantly less of potatoes/rice/pasta, meat/fish, and vegetables (grams/day) than the women in the referent group. Conclusions: In the present study, women in early pregnancy reported less intake of vegetables, potatoes, meat, and alcohol than non-pregnant women. As they also had a low intake (below the Nordic Nutritional Recommendations) of folate, vitamin D, and iron from foods, some of these women and their unborn children are possibly at risk for adverse effects on the pregnancy and birth outcome.

  • 27.
    Lundqvist, Anette
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Bäckström, Torbjörn
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    The relationship between weight gain during pregnancy and allopregnanolone levels: a longitudinal study2017In: Endocrine Connections, ISSN 2049-3614, E-ISSN 2049-3614, Vol. 6, no 4, p. 253-259Article in journal (Refereed)
    Abstract [en]

    Objective: Large weight gain during pregnancy is a risk factor for complications for mother and fetus. Hunger and satiety are regulated in the hypothalamus, where the gamma-amino-butyric acid system (GABA) has an important role. Allopregnanolone, a progesterone metabolite, increases during pregnancy and is a potent GABA-A receptor modulating steroid. Allopregnanolone has been shown to induce overeating in rodents. The aim was to investigate whether there is a relationship between weight gain and allopregnanolone concentrations during pregnancy in humans. Design: A longitudinal, cohort study. Methods: Pregnant women (n = 56) were recruited in primary care in northern Sweden. Allopregnanolone concentrations in plasma were measured using radioimmunoassay and weight was measured in gestational weeks 12 and 35. Results: Weight increase correlated significantly to allopregnanolone in late pregnancy increase (r(s) = 0.320; P = 0.016), indicating a positive relationship between weight increase and allopregnanolone increase. A positive relationship was also noted between allopregnanolone in the 35th gestational week and weight increase. Women who gained = 11 kg during pregnancy showed higher allopregnanolone concentrations in week 35 and higher increase compared to women who increased < 11 kg (P = 0.006 and P = 0.009 resp.). There was no difference in weight or allopregnanolone concentrations at the onset of pregnancy. Conclusions: The results show a relationship between weight gain during pregnancy and increase in allopregnanolone concentrations.

  • 28.
    Lundqvist, Anette
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sandström, Herbert
    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.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Vitamin D Status during Pregnancy: a Longitudinal Study in Swedish Women from Early Pregnancy to Seven Months Postpartum2016In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 3, article id e0150385Article in journal (Refereed)
    Abstract [en]

    Low vitamin D levels during pregnancy may have negative consequences for the health of both the mother and child. Cross-sectional studies in childbearing women suggest that vitamin D levels are low during pregnancy, but few studies have followed the same women during pregnancy and postpartum. The aims of this study were to longitudinally assess vitamin D status during pregnancy and postpartum and identify the factors associated with vitamin D status in pregnant women in northern Sweden. Between September 2006 and March 2009, 184 women were consecutively recruited at five antenatal primary care clinics. Blood was sampled, and dietary intake was estimated using a food frequency questionnaire with 66 food items/food aggregates and questions on the intake of vitamin supplements at gestational weeks 12, 21, and 35, as well as at 12 and 29 weeks after birth. Plasma 25(OH) vitamin D levels were analyzed using liquid chromatography tandem-mass spectrometry. At least one-third of the women had 25(OH) vitamin D levels <50 nmol/L on at least one sampling occasion. Plasma levels increased slightly over the gestation period and peaked in late pregnancy. The levels reverted to the baseline levels after birth. Multivariate analysis showed that gestational and postpartum week, season, dietary intake of vitamin D, and vitamin supplementation were significantly related to plasma levels. There was also an influence of season on the longitudinal concentration patterns. In conclusion, more than one-third of the women studied had low 25(OH) vitamin D levels, and gestational and postpartum week was related to 25(OH) vitamin D levels after adjustment for season and vitamin D intake.

  • 29.
    Lundqvist, Anette
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Wennberg, Anna-Lena
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lövgren, Gunvor
    Umeå University, Faculty of Medicine, Department of Nursing.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    8 av 10 barnmorskor gav information om folsyra: de flesta ansåg sig ha otillräckliga kunskaper2004In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 101, no 15-16, p. 1380-1386Article in journal (Other academic)
    Abstract [en]

    Deficiency of folic acid increases the risk for neural tube defects among newborn children and megaloblastic anaemia in the mother. The aim of this study was to make a survey of how midwives working in maternity health care, family planning guidance, and specialist prenatal care in a Swedish county inform women of childbearing age about folic acid. The questionnaire study showed that 79% of the midwives informed the women about folic acid. Usually, the women received information first when they asked for it and midwifes were less prone to inform young women about folic acid. 87% of the midwives felt that they did not know enough about folic acid. Conclusions: Midwives play an important role in information about the need of folic acid intake for women in childbearing age. Changes in local routines, guidelines and further education of midwifes would subsequently provide information about the importance of folic acid to women in childbearing age.

  • 30.
    Lundqvist, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Öhman, Ann
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Patterns of tobacco use: a 10-year follow-up study of smoking and snus habits in a middle-aged Swedish population2009In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 37, no 2, p. 161-167Article in journal (Refereed)
    Abstract [en]

    Aims: To study longitudinal patterns of tobacco use over a 10-year period among middle-aged men and women in Västerbotten County, Northern Sweden.

    Methods: The study is based on data from the 16,486 (8800 women and 7686 men) in the Västerbotten Intervention Programme (VIP) where people were invited to a health screening and counselling programme at 30, 40, 50 and 60 years of age.

    Results: Smoking decreased from 22.3% to 15.6% among women and from 18.5% to 12.7% among men. Use of snus (Swedish moist snuff) increased from 3.1% to 6.0% among women and from 24.6% to 26.3% among men. The number of people who used both snus and cigarettes was stable: 0.5% to 0.8% from baseline to follow-up for women, and 4.1% to 3.3% for men. The number of tobacco-free adults increased from 75.2% to 79.2% for women and from 61.1% to 64.3% for men. Of those who became smoke-free during the 10-year follow-up period, 80% of the women and 66% of the men quit smoking without transitioning to snus use.

    Conclusions: The majority of middle-aged Swedish men and women in this cohort that quit smoking did so without becoming snus dependent. In spite of an increasing use of snus, overall there was a decline in the number of people using tobacco products.

  • 31.
    Lundqvist, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Öhman, Ann
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Smokers becoming tobacco-free: a study of success factors among 513 middle aged smoking Swedes, who quit tobaccoManuscript (preprint) (Other academic)
  • 32. Lökk, Johan
    et al.
    Nilsson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Norberg, Bo
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Westman, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Shifts in B12 opinions in primary health care of Sweden.2001In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 29, no 2, p. 122-128Article in journal (Refereed)
    Abstract [en]

    AIMS: The diagnosis and management of vitamin B12 deficiency varies between countries and within countries. The aim of the study was to map current attitudes and values behind clinical decision-making in Swedish primary health care, which has a unique B12 tradition: two patients out of three are treated with oral high-dose cyanocobalamin. Most patients with B12-associated problems are managed in primary health care by general practitioners (GPs). METHODS: The study was designed to elucidate possible opinion shifts among GPs during the period 1996-1998. GPs (n=499), stratified and randomized, received a questionnaire with 24 statements on B12-associated clinical and laboratory problems, to be evaluated by a visuo-analogue scale. RESULTS: The majority of GPs in primary health care in Sweden accepted homocysteine and methylmalonic acid (MMA) as markers for functional deficiency of vitamin B12. The evaluation of classical markers of B12 deficiency was wary and balanced. There was a consensus of the need for B12 therapy to risk groups such as patients with atrophic gastritis or previous gastric surgery. The answers also appeared to reflect an improvement of professional knowledge and competence concerning B12-associated problems among Swedish GPs between 1996 and 1998. CONCLUSIONS: The overriding conclusion was that B12-associated opinions of Swedish GPs were stable within the period studied, with marginal improvements of knowledge and competence.

  • 33. Lökk, Johan
    et al.
    Nilsson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Norberg, Bo
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Westman, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Vitamin B12 in primary health care and geriatrics - attitudes, knowledge, competence.2001In: International Journal of Geriatric Psychiatry, ISSN 0885-6230, E-ISSN 1099-1166, Vol. 16, no 10, p. 987-992Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The objective of the study was to test attitudes, knowledge and competence of Swedish general practitioners and geriatricians concerning B12-associated problems in 1998. METHODS: Postal questionnaires were sent to a random sample of 485 GPs and a total sample of 613 geriatricians. The response rates were 70% in the GP group and 69% in the geriatrician group. The questionnaire contained 24 statements to be evaluated by a visuo-analogue scale. RESULTS: There were small numerical differences between the two physician groups. The geriatricians were more aware of risk groups for B12 deficiency. GPs were less categorical concerning low hit rate in the laboratory testing of clinical conclusions. There were statistical differences in both directions for statements on pitfalls in laboratory diagnostics. GPs were somewhat less prone to give risk groups prophylactic B12 therapy. CONCLUSIONS: GPs and geriatricians appeared to be familiar with the current debate on B12-associated problems, suggesting that health care quality will be unaffected by patient transfer from hospital care to primary health care. Copyright 2001 John Wiley & Sons, Ltd.

  • 34. Lökk, Johan
    et al.
    Nilsson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Norberg, Bo
    Rudolphi, Olle
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Westman, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Controversies around vitamin B12 in Sweden.: Attitudes and values behind clinical decision-making in primary health care 19961997In: Hematology, ISSN 1024-5332, E-ISSN 1607-8454, Vol. 2, no 4, p. 341-350Article in journal (Refereed)
    Abstract [en]

    Over a five-year period, 1991-1995, the vitamin B12 market in Sweden increased three-fold, from approximatelyy 2 million U.S. dollars to approximately 6 million U.S. dollars. Most prescriptions, approximately 60%, originated from primary health care. The attitudes, values and knowledge of the family physicians/general practitioners were elucidated by a questionnaire study with visuo-analogue opinion scales, evaluating 24 basic statements on problems associated with the management of vitamin B12 deficiency. The questionnaire was sent to a representative sample of 506 family physicians/general practitioners. Response rate was 74%. Dropout analysis supported the view that responders provided a representative sample of Swedish FP/GPs. Analysis of the answers was compatible with the hypothesis that the mentioned increase in Swedish B12 market reflected increased awareness in primary health care about the biochemical, pathophysiological and social problems associated with vitamin B12 deficiency.

  • 35. McMurray, John J
    et al.
    Holman, Rury R
    Haffner, Steven M
    Bethel, M Angelyn
    Holzhauer, Björn
    Hua, Tsushung A
    Belenkov, Yuri
    Boolell, Mitradev
    Buse, John B
    Buckley, Brendan M
    Chacra, Antonio R
    Chiang, Fu-Tien
    Charbonnel, Bernard
    Chow, Chun-Chung
    Davies, Melanie J
    Deedwania, Prakash
    Diem, Peter
    Einhorn, Daniel
    Fonseca, Vivian
    Fulcher, Gregory R
    Gaciong, Zbigniew
    Gaztambide, Sonia
    Giles, Thomas
    Horton, Edward
    Ilkova, Hasan
    Jenssen, Trond
    Kahn, Steven E
    Krum, Henry
    Laakso, Markku
    Leiter, Lawrence A
    Levitt, Naomi S
    Mareev, Viacheslav
    Martinez, Felipe
    Masson, Chantal
    Mazzone, Theodore
    Meaney, Eduardo
    Nesto, Richard
    Pan, Changyu
    Prager, Rudolf
    Raptis, Sotirios A
    Rutten, Guy E H M
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Schaper, Frank
    Scheen, Andre
    Schmitz, Ole
    Sinay, Isaac
    Soska, Vladimir
    Stender, Steen
    Tamás, Gyula
    Tognoni, Gianni
    Tuomilehto, Jaako
    Villamil, Alberto S
    Vozár, Juraj
    Califf, Robert M
    Effect of valsartan on the incidence of diabetes and cardiovascular events2010In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 362, no 16, p. 1477-1490Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: It is not known whether drugs that block the renin-angiotensin system reduce the risk of diabetes and cardiovascular events in patients with impaired glucose tolerance.

    METHODS: In this double-blind, randomized clinical trial with a 2-by-2 factorial design, we assigned 9306 patients with impaired glucose tolerance and established cardiovascular disease or cardiovascular risk factors to receive valsartan (up to 160 mg daily) or placebo (and nateglinide or placebo) in addition to lifestyle modification. We then followed the patients for a median of 5.0 years for the development of diabetes (6.5 years for vital status). We studied the effects of valsartan on the occurrence of three coprimary outcomes: the development of diabetes; an extended composite outcome of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, hospitalization for heart failure, arterial revascularization, or hospitalization for unstable angina; and a core composite outcome that excluded unstable angina and revascularization.

    RESULTS: The cumulative incidence of diabetes was 33.1% in the valsartan group, as compared with 36.8% in the placebo group (hazard ratio in the valsartan group, 0.86; 95% confidence interval [CI], 0.80 to 0.92; P<0.001). Valsartan, as compared with placebo, did not significantly reduce the incidence of either the extended cardiovascular outcome (14.5% vs. 14.8%; hazard ratio, 0.96; 95% CI, 0.86 to 1.07; P=0.43) or the core cardiovascular outcome (8.1% vs. 8.1%; hazard ratio, 0.99; 95% CI, 0.86 to 1.14; P=0.85).

    CONCLUSIONS: Among patients with impaired glucose tolerance and cardiovascular disease or risk factors, the use of valsartan for 5 years, along with lifestyle modification, led to a relative reduction of 14% in the incidence of diabetes but did not reduce the rate of cardiovascular events. (ClinicalTrials.gov number, NCT00097786.)

  • 36. Modin, K
    et al.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Blomquist, H K
    Nilsson, M
    [No clinical rachitis in spite of incomplete AD-supplementation. Should the national recommendations be re-evaluated?].1998In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 95, no 8, p. 745-8Article in journal (Refereed)
  • 37.
    Nilsson, Mats
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Lökk, Johan
    Norberg, Bo
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Westman, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Sex differences in cobalamin (vitamin B12) opinions of Swedish physicians.2002In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 56, no 4, p. 299-303Article in journal (Refereed)
    Abstract [en]

    The aim of the study was to elucidate possible sex differences in knowledge, competence and attitudes behind decision-making on cobalamin-associated problems (vitamin B(12)). The study was conducted by postal questionnaires to Swedish physicians in 1996-98. The participants were recruited by random sampling of general practitioners (1996, 1998), and a total sampling of geriatricians (1998). The overall response rate was 71%. The study group comprised 480 female physicians and 526 male physicians. The responses to 24 statements in the questionnaire were measured by means of visual analogue scales. Group differences were evaluated by medians and shapes of distributions. The female doctors appeared to value patient-related symptoms and signs more than male doctors. Conversely, male doctors relied on laboratory tests more than female doctors. As reflected by questionnaire answers, female doctors appeared to be more informed than male doctors on cobalamin-associated clinical problems. Group differences between the sexes were marginal from a numerical point of view. It is suggested that the statistical differences observed should be regarded as negligible until confirmed by further studies.

  • 38.
    Nilsson, Mats
    et al.
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Family Medicine.
    Norberg, Bo
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Medical Biosciences, Clinical chemistry.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Family Medicine.
    Westman, Göran
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Family Medicine.
    Lökk, Johan
    Medical intelligence in Sweden. Vitamin B12: oral compared with parenteral?2005In: Postgraduate medical journal, ISSN 0032-5473, E-ISSN 1469-0756, Vol. 81, no 953, p. 191-193Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Sweden is the only country in which oral high dose vitamin B12 has gained widespread use in the treatment of deficiency states. OBJECTIVE: The aim of the study was to describe prescribing patterns and sales statistics of vitamin B12 tablets and injections in Sweden 1990-2000.Design, setting, and sources: Official statistics of cobalamin prescriptions and sales were used. RESULTS: The use of vitamin B12 increased in Sweden 1990-2000, mainly because of an increase in the use of oral high dose vitamin B12 therapy. The experience, in statistical terms a "total investigation", comprised 1,000,000 patient years for tablets and 750,000 patient years for injections. During 2000, 13% of residents aged 70 and over were treated with vitamin B12, two of three with the tablet preparation. Most patients in Sweden requiring vitamin B12 therapy have transferred from parenteral to oral high dose vitamin B12 since 1964, when the oral preparation was introduced. CONCLUSION: The findings suggest that many patients in other post-industrial societies may also be suitable for oral vitamin B12 treatment.

  • 39.
    Sandström, Herbert
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    More than 1 out of 100 will have myocardial infarction and stroke because of enalapril--effect of drug package inserts?2006In: Läkartidningen, Vol. 103, no 8, p. 564-567Article in journal (Refereed)
  • 40.
    Sandström, Herbert
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wahlin, A
    Congenital dyserythropoietic anemia type III.2000In: Haematologica, ISSN 0390-6078, E-ISSN 1592-8721, Vol. 85, no 7, p. 753-7Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND OBJECTIVES: Congenital dyserythropoietic anemia type III (CDA-III) is a group of very rare disorders characterized by similar bone marrow morphology. The clinical picture is characterized by hemolytic anemia and dramatic bone marrow changes dominated by active erythropoiesis with big multinucleated erythroblasts. The aim of this review is to describe the clinical manifestations, laboratory findings, and management CDA-III.

    EVIDENCE AND INFORMATION SOURCES: The present review critically examines relevant articles and abstracts published in journals covered by the Science Citation Index and Medline. The authors have performed several studies on CDA-III.

    STATE OF ART AND PERSPECTIVES: The clinical and laboratory manifestations of CDA-III indicate that the gene responsible for it, which has been mapped to chromosome 15q22, is expressed not only in erythroblasts during mitosis but also in B-cells, and in cells of the retina. Preliminary results indicate genetic and phenotypic similarities between a Swedish and an American family, both with an autosomally dominant inherited form of CDA-III. It is possible that the genetic lesion is identical in these families, but the different phenotypes and modes of inheritance reported among some other cases of CDA-III are probably the results of other genetic lesions. At present, the function of the gene responsible for the Swedish (V sterbotten) variant of CDA-III (CDAN3) is unknown and it is an important goal to characterize and clone this gene in order to study its function.

  • 41.
    Sandström, Herbert
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wahlin, A
    [Localized gene of the rare "Norrland disease". CDA-III blood disease with dominant heredity].1999In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 96, no 4, p. 343-7Article in journal (Refereed)
    Abstract [sv]

    The article consists in a review of available knowledge of the rare blood disorder, congenital dyserythropoietic anaemia, type III (CDA-III), a disease characterised by autosomal dominant heredity, and mild to moderate haemolytic anaemia. The gene causing CDA-III has been localised on chromosome 15q22. Most patients are adapted to their disease, and have few or no overt manifestations. Bone marrow examination yields a characteristic picture of erythroid hyperplasia and multinucleate erythroblasts. A Swedish family affected with CDA-III has been reported to be characterised by a high prevalence of monoclonal gammopathy and angioid streaks, a triad suggested by the authors to represent a hitherto unreported syndrome.

  • 42.
    Sandström, Herbert
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wahlin, A
    Eriksson, M
    Bergström, I