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  • 1. Adler, Sara
    et al.
    Widerström, Micael
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi.
    Lindh, Johan
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Symptoms and risk factors of Cryptosporidium hominis infection in children: data from a large waterborne outbreak in Sweden2017Ingår i: Parasitology Research, ISSN 0932-0113, E-ISSN 1432-1955, Vol. 116, nr 10, s. 2613-2618Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Cryptosporidium is a major cause of diarrheal disease worldwide. In developing countries, this infection is endemic and in children, associated with growth faltering and cognitive function deficits, with the most severe impact on those aged <2 years. Little has been reported about symptoms and risk factors for children in industrialized countries, although the disease incidence is increasing in such regions. In November 2010, a large waterborne outbreak of C. hominis occurred in the city of Östersund in Sweden. Approximately 27,000 of the 60,000 inhabitants were symptomatic. We aimed to describe duration of symptoms and the risk factors for infection with C. hominis in children aged <15 years in a Western setting. Within 2 months after a boil water advisory, a questionnaire was sent to randomly selected inhabitants of all ages, including 753 children aged <15 years. Those with ≥3 loose stools/day were defined as cases of diarrhoea. The response rate was 70.3%, and 211 children (39.9%) fulfilled the case definition. Mean duration of diarrhoea was 7.5 days (median 6, range 1-80 days). Recurrence, defined as a new episode of diarrhoea after ≥2 days of normal stools, occurred in 52.5% of the cases. Significant risk factors for infection, besides living within the distribution area of the contaminated water plant, included a high level of water consumption, male sex, and a previous history of loose stools. The outbreak was characterized by high attack and recurrence rates, emphasizing the necessity of water surveillance to prevent future outbreaks.

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  • 2.
    Benckert, Martin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Söderberg, Stefan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Eliasson, Mats
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Improved metabolic health among the obesein six population surveys 1986 to 2009: the Northern Sweden MONICA study2015Ingår i: BMC Obesity, ISSN 2052-9538, Vol. 2, nr 7Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background

    The incidence of CVD is decreasing in spite of increasing BMI in the population. We examined trends in metabolic health among overweight and obese individuals and the influence of lifestyle and socioeconomic status. Six cross sectional population surveys in the Northern Sweden MONICA Study between 1986 and 2009. 8 874 subjects 25 to 64 years participated (74% participation rate). Metabolic health was defined as a total cholesterol level below 5.0 mmol/l, blood pressure below 140/90 mmHg and not having diabetes. In 2009 the age span 25 to 74 years was studied.

    Results

    The prevalence of metabolic health among obese subjects increased by 7.9 % per year (95% confidence interval 5.4; 10.5), reaching 21.0% in 2009. The corresponding figures for overweight subjects were 5.9% per year (4.6; 7.3), reaching 18% in 2009, whereas for the normal-weight subjects, the increase was 6.2% per year (5.3; 7.2), reaching 39% in 2009. The prevalence of metabolic health among subjects with abdominal obesity increased by 5.8% (4.6; 7.0) per year, reaching 17.3% in 2009. Among those with no abdominal obesity the increase was 6.2% (5.2; 7.1), reaching 38% in 2009 (p = <0.001 for all groups). Only among non-obese men and obese women did the increase continue between 2004 and 2009. In the other groups a slight decline or levelling off was noted.

    In 2009 women had a 27% higher prevalence of metabolic health than men. The prevalence of metabolic health among the obese was 19.8% which declined to 15.8% if subjects treated for hypertension or hypercholesterolemia were classified as not healthy. Overweight and obese subjects were less often metabolically healthy (odds ratio 0.54 and 0.59 respectively) compared with normal-weight subjects, independent of sex and age as were subjects with abdominal obesity (odds ratio 0.52). Adjustments for smoking, physical activity and education level did not influence any estimates.

    Conclusions

    This report shows a large increase in prevalence of metabolic health from 1986 to 2009 for all anthropometric categories. Metabolic health remains considerably less prevalent among overweight and obese subjects than among those with normal weight.

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  • 3.
    Bergström, Göran
    et al.
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Rosengren, Annika
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medicine Geriatrics and Emergency Medicine, Sahlgrenska University Hospital Östra Hospital, Gothenburg, Sweden.
    Bacsovics Brolin, Elin
    Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden; Department of Radiology, Capio S:t Göran Hospital, Stockholm, Sweden.
    Brandberg, John
    Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Cederlund, Kerstin
    Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
    Engström, Gunnar
    Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden.
    Engvall, Jan E.
    CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden; Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Eriksson, Maria J.
    Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden.
    Gonçalves, Isabel
    Department of Cardiology, Skåne University Hospital, Malmö, Sweden; Cardiovascular Research Translational Studies, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
    Hagström, Emil
    Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
    James, Stefan K.
    Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
    Jernberg, Tomas
    Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Unit of Research, Education, and Development, Östersund Hospital, Umeå University, Umeå, Sweden.
    Magnusson, Martin
    Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden; Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden; Hypertension in Africa Research Team HART, North-West University, Potchefstroom, South Africa.
    Persson, Anders
    CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden; Department of Radiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Clinical Sciences, Huddinge University Hospital, Karolinska Institutet, Stockholm, Sweden.
    Persson, Margaretha
    Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden; Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden.
    Sandström, Anette
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Kardiologi.
    Schmidt, Caroline
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Skoglund Larsson, Linn
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Sundström, Johan
    Department of Medical Sciences, Uppsala University, Uppsala, Sweden; The George Institute for Global Health, University of New South Wales, Sydney, Australia.
    Swahn, Eva
    Department of Cardiology and Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden.
    Söderberg, Stefan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Torén, Kjell
    Section of Occupational and Environmental Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Occupational and Environmental Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Östgren, Carl Johan
    CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Lampa, Erik
    Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
    Lind, Lars
    Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden.
    Body weight at age 20 and in midlife is more important than weight gain for coronary atherosclerosis: Results from SCAPIS2023Ingår i: Atherosclerosis, ISSN 0021-9150, E-ISSN 1879-1484, Vol. 373, s. 46-54Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background and aims: Elevated body weight in adolescence is associated with early cardiovascular disease, but whether this association is traceable to weight in early adulthood, weight in midlife or to weight gain is not known. The aim of this study is to assess the risk of midlife coronary atherosclerosis being associated with body weight at age 20, body weight in midlife and body weight change.

    Methods: We used data from 25,181 participants with no previous myocardial infarction or cardiac procedure in the Swedish CArdioPulmonary bioImage Study (SCAPIS, mean age 57 years, 51% women). Data on coronary atherosclerosis, self-reported body weight at age 20 and measured midlife weight were recorded together with potential confounders and mediators. Coronary atherosclerosis was assessed using coronary computed tomography angiography (CCTA) and expressed as segment involvement score (SIS).

    Results: The probability of having coronary atherosclerosis was markedly higher with increasing weight at age 20 and with mid-life weight (p < 0.001 for both sexes). However, weight increase from age 20 until mid-life was only modestly associated with coronary atherosclerosis. The association between weight gain and coronary atherosclerosis was mainly seen in men. However, no significant sex difference could be detected when adjusting for the 10-year delay in disease development in women.

    Conclusions: Similar in men and women, weight at age 20 and weight in midlife are strongly related to coronary atherosclerosis while weight increase from age 20 until midlife is only modestly related to coronary atherosclerosis.

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  • 4.
    Boks, Marije
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för medicin.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för medicin.
    Widerström, Micael
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi.
    Karling, Pontus
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för medicin.
    Lindam, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Eriksson, Axel
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi.
    Sjöström, Malin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Increased incidence of late-onset inflammatory bowel disease and microscopic colitis after a Cryptosporidium hominis outbreak2022Ingår i: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 57, nr 12, s. 1443-1449Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: In 2010, 27,000 inhabitants (45% of the population) of Östersund, Sweden, contracted clinical cryptosporidiosis after drinking water contaminated with Cryptosporidium hominis. After the outbreak, local physicians perceived that the incidence of inflammatory bowel disease (IBD), including ulcerative colitis (UC), Crohn's disease (CD), and IBD-unclassified, and microscopic colitis (MC) increased. This study assessed whether this perception was correct.

    MATERIALS AND METHODS: This observational study included adult patients (≥18 years old) from the local health care region who were diagnosed with pathology-confirmed IBD or MC during 2006-2019. We collected and validated the diagnosis, date of diagnosis, age at diagnosis, and sex from the Swedish quality register SWIBREG and electronic patient records. Population data were collected from Statistics Sweden. The incidences for 2006-2010 (pre-outbreak) and 2011-2019 (post-outbreak) were evaluated by negative binomial regression analysis and presented as incidence rate ratios (IRRs). Data were analyzed for IBD, for UC and CD separately, and MC.

    RESULTS: During the study period, we identified 410 patients with new onset IBD and 155 new cases of MC. Overall, we found a trend toward an increased incidence of IBD post-outbreak (IRR 1.39, confidence interval (CI) 0.99-1.94). In individuals ≥40 years old, the post-outbreak incidence significantly increased for IBD (IRR 1.69, CI 1.13-2.51) and CD (IRR 2.23, CI 1.08-4.62). Post-outbreak incidence of MC increased 6-fold in all age groups (IRR 6.43, CI 2.78-14.87).

    CONCLUSIONS: The incidence of late-onset IBD and MC increased after the Cryptosporidium outbreak. Cryptosporidiosis may be an environmental risk factor for IBD and MC.

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  • 5.
    Boks, Marije
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Widerström, Micael
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi.
    Karling, Pontus
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lindam, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Sjöström, Malin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Persisting symptoms after Cryptosporidium hominis outbreak: a 10-year follow-up from Östersund, Sweden2023Ingår i: Parasitology Research, ISSN 0932-0113, E-ISSN 1432-1955, Vol. 122, nr 7, s. 1631-1639Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    In late 2010, an outbreak of Cryptosporidium hominis affected 27,000 inhabitants (45%) of Östersund, Sweden. Previous research shows that abdomen and joint symptoms commonly persist up to 5 years post-infection. It is unknown whether Cryptosporidium is associated with sequelae for a longer duration, how persisting symptoms present over time, and whether sequelae are associated with prolonged infection. In this prospective cohort study, a randomly selected cohort in Östersund was surveyed about cryptosporidiosis symptoms in 2011 (response rate 69.2%). A case was defined as a respondent reporting new diarrhoea episodes during the outbreak. Follow-up questionnaires were sent after 5 and 10 years. Logistic regressions were used to examine associations between case status and symptoms reported after 10 years, with results presented as adjusted odds ratios (aOR) with 95% confidence intervals. Consistency of symptoms and associations with case status and number of days with symptoms during outbreak were analysed using X 2 and Mann–Whitney U tests. The response rate after 10 years was 74% (n = 538). Case status was associated with reporting symptoms, with aOR of ~3 for abdominal symptoms and ~2 for joint symptoms. Cases were more likely to report consistent symptoms. Cases with consistent abdominal symptoms at follow-up reported 9.2 days with symptoms during the outbreak (SD 8.1), compared to 6.6 days (SD 6.1) for cases reporting varying or no symptoms (p = 0.003). We conclude that cryptosporidiosis was associated with an up to threefold risk for reporting symptoms 10 years post-infection. Consistent symptoms were associated with prolonged infection.

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  • 6.
    De Luca, Vincenzo
    et al.
    Dipartimento di Sanità Pubblica, Università Degli Studi di Napoli Federico II, via S. Pansini 5, Naples, Italy.
    Lazic, Vanja
    Dom Zdravlja Zagreb–Centar, Runjaninova ul. 4, Zagreb, Croatia.
    Birov, Strahil
    Empirica Gesellschaft für Kommunikations-und Technologieforschung mbH, Oxfordstr. 2, Bonn, Germany.
    Piesche, Klaus
    Empirica Gesellschaft für Kommunikations-und Technologieforschung mbH, Oxfordstr. 2, Bonn, Germany.
    Beyhan, Ozan
    Ministry of Health of Turkey, Üniversiteler Mah. 6001. Cad. No. 9, Ankara, Turkey.
    Pengo, Martino Francesco
    Department of Cardiovascular, Neural and Metabolic Sciences, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano, via Ariosto 13, Milan, Italy.
    Melgara, Marcello
    Azienda Regionale per l’Innovazione e Gli Acquisti S.p.A, Direzione Generale Sanità, Regione Lombardia, Piazza Città di Lombardia 1, Milan, Italy.
    Sherman, Marie Holm
    Research and Development Department, Region Jämtland Härjedalen, Kyrkgatan 12, Östersund, Sweden.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Balenovic, Antonija
    Dom Zdravlja Zagreb–Centar, Runjaninova ul. 4, Zagreb, Croatia.
    Parati, Gianfranco
    Department of Cardiovascular, Neural and Metabolic Sciences, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano, via Ariosto 13, Milan, Italy; Department of Medicine and Surgery, Università Degli Studi di Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, Milan, Italy.
    Triassi, Maria
    Dipartimento di Sanità Pubblica, Università Degli Studi di Napoli Federico II, via S. Pansini 5, Naples, Italy; Azienda Ospedaliera Universitaria Federico II, via S. Pansini 5, Naples, Italy.
    Izzo, Raffaele
    Azienda Ospedaliera Universitaria Federico II, via S. Pansini 5, Naples, Italy; Dipartimento di Scienze Biomediche Avanzate, Università degli Studi di Napoli Federico II, via S. Pansini 5, Naples, Italy.
    Iaccarino, Guido
    Azienda Ospedaliera Universitaria Federico II, via S. Pansini 5, Naples, Italy; Dipartimento di Scienze Biomediche Avanzate, Università degli Studi di Napoli Federico II, via S. Pansini 5, Naples, Italy.
    Illario, Maddalena
    Dipartimento di Sanità Pubblica, Università Degli Studi di Napoli Federico II, via S. Pansini 5, Naples, Italy; Azienda Ospedaliera Universitaria Federico II, via S. Pansini 5, Naples, Italy.
    Digitally enabled health service for the integrated management of hypertension: A participatory user-centred design process2021Ingår i: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 18, nr 23, artikel-id 12442Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This article describes a user-centred approach taken by a group of five procurers to set specifications for the procurement of value-based research and development services for IT-sup-ported integrated hypertension management. The approach considered the unmet needs of patients and health systems of the involved regions. The procurers established a framework for requirements and a solution design consisting of nine building blocks, divided into three domains: service delivery, devices and integration, and health care organisation. The approach included the development of questionnaires, capturing patients’ and professionals’ views on possible system functionalities, and a template collecting information about the organisation of healthcare, professionals involved and existing IT systems at the procurers’ premises. A total of 28 patients diagnosed with hypertension and 26 professionals were interviewed. The interviewees identified 98 functional requirements, grouped in the nine building blocks. A total of nine use cases and their corresponding process models were defined by the procurers’ working group. As result, a digitally enabled integrated approach to hypertension has been designed to allow citizens to learn how to prevent the development of hypertension and lead a healthy lifestyle, and to receive comprehensive, individualised treatment in close collaboration with healthcare professionals.

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  • 7. Despotou, George
    et al.
    Laleci Erturkmen, Gokce B.
    Yuksel, Mustafa
    Sarigul, Bunyamin
    Lindman, Pontus
    Jaulent, Marie-Christine
    Bouaud, Jacques
    Traore, Lamine
    Lim Choi Keung, Sarah N.
    De Manuel, Esteban
    Verdoy, Dolores
    De Blas, Antonio
    Gonzalez, Nicolas
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Unit of Research, Education, and Development, Östersund Hospital.
    Sherman, Marie
    Von Tottleben, Malte
    Beach, Marie
    Marguerie, Christopher
    Karni, Liran
    Klein, Gunnar O.
    Kalra, Dipak
    Chen, Rong
    Arvanitis, Theodoros N.
    Localisation, Personalisation and Delivery of Best Practice Guidelines on an Integrated Care and Cure Cloud Architecture: The C3-Cloud Approach to Managing Multimorbidity2020Ingår i: Digital Personalized Health and Medicine / [ed] Louise B. Pape-Haugaard; Christian Lovis; Inge Cort Madsen; Patrick Weber; Per Hostrup Nielsen; Philip Scott, IOS Press, 2020, Vol. 270, s. 623-627Konferensbidrag (Refereegranskat)
    Abstract [en]

    Background: C3-Cloud is an integrated care ICT infrastructure offering seamless patient-centered approach to managing multimorbidity, deployed in three European pilot sites. Challenge: The digital delivery of best practice guidelines unified for multimorbidity, customized to local practice, offering the capability to improve patient personalization and benefit.

    Method: C3-Cloud has adopted a co-production approach to developing unified multimorbidity guidelines, by collating and reconciling best practice guidelines for each condition. Clinical and technical teams at pilot sites and the C3-Cloud consortium worked in tandem to create the specification and technical implementation.

    Results: C3-Cloud offers CDSS for diabetes, renal failure, depression and congenital heart failure, with over 300 rules and checks that deliver four best practice guidelines in parallel, customized for each pilot site.

    Conclusions: The process provided a traceable, maintainable and audited digitally delivered collated and reconciled guidelines.

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  • 8.
    Fjällström, Petter
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Adopting standardized cancer patient pathways as a policy at different organizational levels in the Swedish health system2023Ingår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 21, nr 1, artikel-id 122Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Standardized cancer patient pathways as a new policy has been adopted in healthcare to improve the quality of cancer care. Within the health systems, actors at different levels manage the adoption of new policies to develop healthcare. The various actors on different levels play an important role and influence the policy adoption process. Thus, knowledge about how these actors use strategies when adopting cancer patient pathways as a policy in the health system becomes central.

    Method: The study's aim was to explore how actors at different organizational levels in the health system adopted cancer patient pathways. Our overarching case was the Swedish health system at the national, regional, and local levels. Constructivist Grounded Theory Method was used to collect and analyze qualitative interviews with persons working in organizations directly involved in adopting cancer patient pathways at each level. Twelve individual and nine group interviews were conducted including 53 participants.

    Results: Organizational actors at three different levels used distinct strategies during the adoption of cancer patient pathways: acting as-missionaries, fixers, and doers. Acting as missionaries consisted of preaching the idea of cancer patient pathways and framing it with a common purpose to agree upon. Acting as fixers entailed creating a space to put cancer patient pathways into practice and overcome challenges to this. Acting as doers comprised balancing breadth and speed in healthcare provision with not being involved in the development of cancer patient pathways for the local context. These strategies were not developed in isolation from the other organizational levels but rather, each level interacted with one another.

    Conclusions: When adopting new policies, it is important to be aware of the different strategies and actors at various organizational levels in health systems. Even when actors on different levels developed separate strategies, if these contribute to fulfilling the four domains of inter-organizational collaboration, they can work well together to adopt new policies. Our study highlighted that the application of two domains was lacking, which meant that local actors were not sufficiently involved in collaboration, thus constricting the local use and optimization of cancer patient pathways in practice.

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  • 9.
    Fjällström, Petter
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Merging existing practices with new ones: the adjustment of organizational routines to using cancer patient pathways in primary healthcare2022Ingår i: BMC Health Services Research, E-ISSN 1472-6963, Vol. 22, nr 1, artikel-id 3Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: The introduction of new tools can bring unintended consequences for organizational routines. Cancer Patient Pathways (CPP) were introduced into the Swedish healthcare system in 2015 to shorten time to diagnosis and treatment. Primary healthcare (PHC) plays a central role since cancer diagnosis often begins in PHC units. Our study aimed to understand how PHC units adjusted organizational routines to utilizing CPPs.

    Method: Six PHC units of varied size from both urban and rural areas in northern Sweden were included. Grounded theory method was used to collect and analyse group interviews at each unit. Nine group interviews with nurses and physicians, for a total of 41 participants, were performed between March and November 2019. The interviews focused on CPPs as tools, the PHC units’ routines and providers’ experiences with using CPPs in their daily work.

    Results: Our analysis captured how PHC units adjusted organizational routines to utilizing CPPs by fusing existing practices with new practices to offer better quality of care. Specifically, three overarching organizational routines within the PHC units were identified. First, Manoeuvring diverse patient needs with easier patient flow, the PHC units handled the diverse needs of the population while simultaneously drawing upon CPPs to ease the patient flow within the healthcare system. Second, (Dis) integrating internal know-how, the PHC units drew upon internal competence even when PHC know-how was not taken into account by those driving the CPP initiative. Third, Coping with unequal relationships toward secondary care, the PHC units dealt with being in an unequal position while adopting CPPs instead further decreased possibilities to influence decision-making between care-levels.

    Conclusion: Adopting CPPs as a tool within PHC units brought various unintended consequences in organizational routines. Our study from northern Sweden illustrates that the PHC know-how needs to be integrated into the healthcare system to improve the use of new tools as CPP. Further, the relationships between different levels of care should be taken in account when introducing new tools for healthcare. Also, when adopting innovations, unintended consequences need to be further explored empirically in diverse healthcare contexts internationally in order to generate deeper knowledge in the research area.

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  • 10.
    Fjällström, Petter
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    CN59 A meeting between existing practices and new ones in primary healthcare: How nurses adjust work routines to using cancer patient pathways2021Ingår i: Annals of Oncology, ISSN 0923-7534, E-ISSN 1569-8041, Vol. 32, nr Supplement 5, s. S1277-S1277, artikel-id CN59Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: The aim was to explore how nurses in primary healthcare (PHC) adjust routines using Cancer Patient Pathways (CPP). CPPs are intended to shorten time to diagnosis but unintended consequences can occur for organizations that utilizes them. Furthermore, in Sweden, PHC is the main entrance into healthcare and nursesas first contact, together with physicians’ are important actors for timely diagnosis.Hence, to explore the unintended consequences when using CPPs in PHC is important since it may impact the process of adaption to CPP.

    Methods: Grounded Theory method was used to collect and analyse qualitative data. Six PHC units were included with a variation in size, staff and location. Data was collected through focus groups with nurses and physicians at each PHC unit, for a total of 41 participants in nine interviews.

    Results: When previous practices meet new ones, three distinct but connected work routines emerged in PHC and encompassed a dimension ranging from continuing working with existing practice to adapting CPPs in their work. However, two of the work routines were mainly related to nurses and depicted how they continued working broadly with patient needs in the population while adapting CPP to speed up patient flows. Additionally, nurses continued to draw upon their longstanding know-how of prioritizing with alarm symptoms while adapting to work with routines in new ways, while physicians were the ones reorganizing adjusted routines in their units. Lastly, the third work routine generally illustrated physicians dealing with unequal relations in communication with secondary care regarding referral criteria and nurses were not involved in these referrals.

    Conclusions: PHC units in our study had not been involved in planning the introduction of CPPs, with nurses excluded in particular. Instead, as our results show, nurses developed their own process to manage using CPPs as a way to adjust to the new procedures, with the unintended consequences influencing their process of adaption. Our study suggests that decision-makers in healthcare could make better use of the know-how within PHC, especially nurses expertise, when developing and introducing new tools such as CPPs.

  • 11.
    Fjällström, Petter
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Reworking routines in primary healthcare: Adapting standarized cancer patient pathways while continuing practice2021Ingår i: Ca-PRI Online Conference 2021: Abstracts, 2021, s. 55-55, artikel-id L27Konferensbidrag (Refereegranskat)
    Abstract [en]

    Background: The aim was to explore how primary healthcare centers (PHC) had adjusted working routines using Cancer Patient Pathways (CPP). CPPs are intended to shorten time to diagnosis, improve access to care and reduce inequality in cancer care. In addition to these intended changes, CPPs have unintended consequences for organizations that utilizes them. In Sweden, PHCs are particularly affected because they are the first and main entrance into healthcare and also important actors of CPP for timely diagnosis. When Sweden in 2015 introduced CPPs, there was an opportunity to explore unintended consequences of using CPPs in PHCs.

    Method: Grounded Theory method was used to collect and analyze qualitative data. Six PHCs were included with a variation in size and location. Data was collected through group interviews with nurses and physicians at each PHC, for a total of 41 participants in nine interviews.

    Results: Our analysis resulted in a process consisting of three distinct but connected work routines. Each routine encompassed a dimension ranging from continuing working as usual to adapting CPPs in their work. The PHCs continued working broadly with patient needs while adapting to speeding up patient flows. Additionally, the PHCs continued to be in a position of dependency on secondary care while adapting to “easier” referral of patients. Lastly, the PHCs continued to draw upon their longstanding know-how while adapting to work with alarm symptoms in new ways.

    Conclusion: PHCs in our study had not been involved in planning the introduction of CPPs. Instead, as our results show, the PHCs developed their own process to manage using CPPs as a tool. The process illuminated their adeptness to deal with new tools and procedures. Our study suggests that decision-makers in healthcare could make better use of the know-how within PHCs when developing and introducing new tools such as CPPs.

  • 12.
    Fjällström, Petter
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hörnsten, Carl
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Psykiatri.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Hultstrand, Cecilia
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Reduction in the diagnostic interval after the introduction of cancer patient pathways for colorectal cancer in northern Sweden2023Ingår i: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 41, nr 3, s. 287-296Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To compare the diagnostic interval for patients with colorectal cancer before and after the introduction of cancer patient pathways in northern Sweden.

    Design: A retrospective study comparing two cohorts (2012 and 2018) of patients diagnosed with colorectal cancer before and after the introduction of cancer patient pathways in 2016.

    Setting: Three counties in northern Sweden with large sparsely populated areas and some cities (637143 residents ∼5.1 residents/km2).

    Subjects: Patients were included from the Swedish Cancer Register. Electronic health records reviews were performed and linked to socioeconomic data from Statistics Sweden.

    Main outcome measures: Differences in the diagnostic intervals, the patient intervals and the characteristics associated with the longest diagnostic intervals and investigations starting at the emergency department.

    Results: The two cohorts included 411 patients in 2012 and 445 patients in 2018. The median diagnostic interval was reduced from 47 days (IQI 18–99) to 29 days (IQI 9–74) (p < 0.001) after the introduction of cancer patient pathways in general. Though for the cases of cancer in the right-side (ascended) colon, the reduction of the diagnostic interval was not observed and it remained associated with investigations starting at the emergency department.

    Conclusion: Our results indicate that cancer patient pathways contributed to an improvement in the diagnostic interval for patients with colorectal cancer in general, yet not for patients with cancer in the right-side colon.

    Implication: In general, cancer patient pathways seem to reduce the diagnostic interval for colorectal cancer but it is not a sufficient solution for all colorectal cancer localisations.

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  • 13.
    Fureman, Anna-Lena
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik. Östersund Hospital.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Östersund Hospital.
    Lind, Torbjörn
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik.
    Särnblad, Stefan
    Department of Pediatrics, Örebro University, Hospital and School of Medical Sciences, Örebro University, Örebro, Sweden.
    Bladh, Marie
    Department of Obstetrics and Gynecology and Biomedical and Clinical Sciences, Linköping University Hospital, Linköping University, Linköping, Sweden.
    Samuelsson, Ulf
    Division of Pediatrics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
    Comparing continuous subcutaneous insulin infusion and multiple daily injections in children with Type 1 diabetes in Sweden from 2011 to 2016: A longitudinal study from the Swedish National Quality Register (SWEDIABKIDS)2021Ingår i: Pediatric Diabetes, ISSN 1399-543X, E-ISSN 1399-5448, Vol. 22, nr 5, s. 766-775Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: This study aimed to compare metabolic control measured as hemoglobin A1c (HbA1c), the risk of severe hypoglycemia, and body composition measured as body mass index standard deviation scores (BMI-SDS) in a nationwide sample of children and adolescents with Type 1 diabetes with continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI), respectively.

    Research Design and Methods: Longitudinal data from 2011 to 2016 were extracted from the Swedish National Quality Register (SWEDIABKIDS) with both cross-sectional (6 years) and longitudinal (4 years) comparisons. Main end points were changes in HbA1c, BMI-SDS, and incidence of severe hypoglycemia.

    Results: Data were available from 35,624 patient-years (54% boys). In general, HbA1c decreased approximately 0.5% (2–5 mmol/mol) from 2011 to 2016 (ptrend < 0.001) and the use of CSII increased in both sexes and all age groups. Mean HbA1c was 0.1% (0.7–1.5 mmol/mol) lower in the CSII treated group. Teenagers, especially girls, using CSII tended to have higher BMI-SDS. There was no difference in the number of hypoglycemias between CSII and MDI over the years 2011–2016.

    Conclusions: There was a small decrease in HbA1c with CSII treatment but of little clinical relevance. Overall, mean HbA1c decreased in both sexes and all age groups without increasing the episodes of severe hypoglycemia, indicating that other factors than insulin method contributed to a better metabolic control.

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  • 14. García-Lorenzo, Borja
    et al.
    Gorostiza, Ania
    González, Nerea
    Larrañaga, Igor
    Mateo-Abad, Maider
    Ortega-Gil, Ana
    Bloemeke, Janika
    Groene, Oliver
    Vergara, Itziar
    Mar, Javier
    Lim Choi Keung, Sarah N.
    Arvanitis, Theodoros N.
    Kaye, Rachelle
    Dahary Halevy, Elinor
    Nahir, Baraka
    Arndt, Fritz
    Dichmann Sorknæs, Anne
    Juul, Natassia Kamilla
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Holm Sherman, Marie
    Laleci Erturkmen, Gokce Banu
    Yuksel, Mustafa
    Robbins, Tim
    Kyrou, Ioannis
    Randeva, Harpal
    Maguire, Roma
    McCann, Lisa
    Miller, Morven
    Moore, Margaret
    Connaghan, John
    Fullaondo, Ane
    Verdoy, Dolores
    de Manuel Keenoy, Esteban
    Assessment of the effectiveness, socio-economic impact and implementation of a digital solution for patients with advanced chronic diseases: the ADLIFE study protocol2023Ingår i: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 20, nr 4, artikel-id 3152Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Due to population ageing and medical advances, people with advanced chronic diseases (ACD) live longer. Such patients are even more likely to face either temporary or permanent reduced functional reserve, which typically further increases their healthcare resource use and the burden of care on their caregiver(s). Accordingly, these patients and their caregiver(s) may benefit from integrated supportive care provided via digitally supported interventions. This approach may either maintain or improve their quality of life, increase their independence, and optimize the healthcare resource use from early stages. ADLIFE is an EU-funded project, aiming to improve the quality of life of older people with ACD by providing integrated personalized care via a digitally enabled toolbox. Indeed, the ADLIFE toolbox is a digital solution which provides patients, caregivers, and health professionals with digitally enabled, integrated, and personalized care, supporting clinical decisions, and encouraging independence and self-management. Here we present the protocol of the ADLIFE study, which is designed to provide robust scientific evidence on the assessment of the effectiveness, socio-economic, implementation, and technology acceptance aspects of the ADLIFE intervention compared to the current standard of care (SoC) when applied in real-life settings of seven different pilot sites across six countries. A quasi-experimental trial following a multicenter, non-randomized, non-concurrent, unblinded, and controlled design will be implemented. Patients in the intervention group will receive the ADLIFE intervention, while patients in the control group will receive SoC. The assessment of the ADLIFE intervention will be conducted using a mixed-methods approach.

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  • 15.
    Hultstrand Ahlin, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    GPs' perspectives of the patient encounter: in the context of standardized cancer patient pathways2020Ingår i: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 38, nr 2, s. 238-247Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: We aim to explore how GPs assign meanings and act upon patients’ symptoms in primary care encounters in the context of standardized cancer patient pathways (CPPs).

    Design, setting and subjects: Thirteen individual interviews were conducted with GPs, at primary healthcare centers (n = 4) in one county in northern Sweden. Interviews were analyzed using grounded theory method. The results were then linked to symbolic interactionism.

    Main outcome measures: GPs’ perspectives about assigning meanings to patients’ presented symptoms and perception about CPPs.

    Results: In the encounter, GPs engaged in two simultaneous interactions, one with patients’ symptoms – and the other with CPPs. The core category Disentangling patients’ care trajectory consists of three categories, interpreted as GPs’ strategies developed to assign meaning to symptoms. These strategies are carried out not in a straightforward manner but rather in a conflicting way, illuminating the complexity of GPs’ daily work.

    Conclusions: Interacting with patients is vital for assigning meaning to presented symptoms. However, nowadays GPs are not only required to interact with patients, they are also required to interact with CPPs. These standardized routines might create pressure and demands on GPs, especially for those experiencing a lack of information about CPPs. Beside of carrying out the challenging patient/person-centered dialogues and interpreting presented symptoms, GPs also need to link the interpreted symptoms to CPPs. Therefore, it is essential that GPs are given opportunities at their workplaces to continuously be informed and be supported in order to practice CPPs and thereby optimize trajectories for patients undergoing cancer diagnostics.

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  • 16.
    Hultstrand Ahlin, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Unit of Research, Education, and Development, Östersund Hospital.
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Negotiating bodily sensations between patients and GPs in the context of standardized cancer patient pathways: an observational study in primary care2020Ingår i: BMC Health Services Research, E-ISSN 1472-6963, Vol. 20, nr 1, artikel-id 46Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: How interactions during patient-provider encounters in Swedish primary care construct access to further care is rarely explored. This is especially relevant nowadays since Standardized Cancer Patient Pathways have been implemented as an organizational tool for standardizing the diagnostic process and increase equity in access. Most patients with symptoms indicating serious illness as cancer initially start their diagnostic trajectory in primary care. Furthermore, cancer symptoms are diverse and puts high demands on general practitioners (GPs). Hence, we aim to explore how presentation of bodily sensations were constructed and legitimized in primary care encounters within the context of Standardized Cancer Patient Pathways (CPPs).

    METHODS: Participant observations of patient-provider encounters (n = 18, on 18 unique patients and 13 GPs) were carried out at primary healthcare centres in one county in northern Sweden. Participants were consecutively sampled and inclusion criteria were i) patients (≥18 years) seeking care for sensations/symptoms that could indicate cancer, or had worries about cancer, Swedish speaking and with no cognitive disabilities, and ii) GPs who met with these patients during the encounter. A constructivist approach of grounded theory method guided the data collection and was used as a method for analysis, and the COREQ-checklist for qualitative studies (Equator guidelines) were employed.

    RESULTS: One conceptual model emerged from the analysis, consisting of one core category Negotiating bodily sensations to legitimize access, and four categories i) Justifying care-seeking, ii) Transmitting credibility, iii) Seeking and giving recognition, and iv) Balancing expectations with needs. We interpret the four categories as social processes that the patient and GP constructed interactively using different strategies to negotiate. Combined, these four processes illuminate how access was legitimized by negotiating bodily sensations.

    CONCLUSIONS: Patients and GPs seem to be mutually dependent on each other and both patients' expertise and GPs' medical expertise need to be reconciled during the encounter. The four social processes reported in this study acknowledge the challenging task which both patients and primary healthcare face. Namely, negotiating sensations signaling possible cancer and further identifying and matching them with the best pathway for investigations corresponding as well to patients' needs as to standardized routines as CPPs.

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  • 17.
    Hultstrand Ahlin, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Hörnsten, Carl
    Psychiatry, University Hospital of Umeå, Umeå, Sweden.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Östersund Hospital.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Fjällström, Petter
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    The association between sociodemographic factors and time to diagnosis for colorectal cancer in northern Sweden2022Ingår i: European Journal of Cancer Care, ISSN 0961-5423, E-ISSN 1365-2354, Vol. 31, nr 6, artikel-id e13687Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: This study examined whether sociodemographic factors, including distance to hospital, were associated with differences in the diagnostic interval and the treatment interval for colorectal cancer in northern Sweden.

    METHODS: Data were retrieved from the Swedish cancer register on patients (n = 446) diagnosed in three northern regions during 2017-2018, then linked to data from Statistics Sweden and medical records. Also, Google maps was used to map the distance between patients' place of residence and nearest hospital. The different time intervals were analysed using Mann-Whitney U-test and Cox regression.

    RESULTS: Differences in time to diagnosis were found between groups for income and distance to hospital, favouring those with higher income and shorter distance. The unadjusted regression analysis showed higher income to be associated with more rapid diagnosis (HR 1.004, CI 1.001-1.007). This association remained in the fully adjusted model for income (HR 1.004, CI 1.000-1.008), but not for distance. No differences between sociodemographic groups were found in the treatment interval.

    CONCLUSION: Higher income and shorter distance to hospital were in the unadjusted models associated with shorter time to diagnosis for patients with CRC in northern Sweden. The association remained for income when adjusting for other variables even though the difference was small.

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  • 18.
    Hultstrand Ahlin, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hörnsten, Åsa
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Wishing to be perceived as a capable and resourceful person: A qualitative study of melanoma patients’ experiences of the contact and interaction with healthcare professionals2019Ingår i: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 28, nr 7–8, s. 1223-1232Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    AIMS AND OBJECTIVES: To explore patients' experiences of contact and interaction with healthcare professionals (HCPs) during the diagnostic process of melanoma.

    BACKGROUND: In Sweden, most patients with suspected skin lesions seek care at the primary level of services in the first instance. Previous research describes the diagnostic process as a complex journey with uncertainty. Nonetheless, the importance of contact and interaction between patient and HCPs during the diagnostic process is rarely explored.

    DESIGN: This study adopted a qualitative design in which semi-structured interviews were conducted and the COREQ-checklist for qualitative studies employed (EQUATOR guidelines).

    METHODS: A sample of 30 patients (15 women, 15 men) diagnosed with melanoma was included. Secondary analysis of interviews was carried out using qualitative content analysis.

    RESULTS: One theme emerged: Wishing to be perceived as a capable and resourceful person that consisted of three categories: (a) The need of being valued, (b) The need of being informed and (c) The need of taking actions.

    CONCLUSIONS: Our results suggest that patients wish to be valued as capable and resourceful persons as well as to be provided with honest and sufficient information about the diagnosis and subsequent procedures. By fulfilling these wishes, HCPs can involve patients in the diagnostic process and reduce patients' uncertainty. A need of supportive and accessible health care to manage the diagnostic process and to reduce patients' struggle for care was also identified.

    RELEVANCE TO THE CLINICAL PRACTICE: Patients are satisfied when health care is organised in a patient-/person-centred manner, that is, in accordance with patients' needs, avoiding gatekeeping, and when HCPs interact respectfully in encounters. Accessible HCPs during the diagnostic process of melanoma are required to inform, support and navigate patients within the healthcare system and through their diagnostic journey.

  • 19.
    Hultstrand, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Shifting between roles of a customer and a seller – patients’ experiences of the encounter with primary care physicians when suspicions of cancer exist2021Ingår i: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 16, nr 1, artikel-id 2001894Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Purpose: Sweden has tried to speed up the process of early cancer detection by standardization of care. This increased focus on early cancer detection provides people with a conflicting norm regarding the importance of recognizing possible cancer symptoms and the responsibility of not delaying seeking care.

    Based on existing norms about patients’ responsibility and care seeking, this study explores how patients experience encounters with primary care physicians when they seek care for symptoms potentially indicating cancer.

    Methods: Thirteen semi-structured interviews were conducted with patients receiving care for symptoms indicative of cancer in one county in northern Sweden. Data was analysed with thematic analysis.

    Results: The common notion of describing patients as customers in a healthcare context does not sufficiently capture all aspects of what counts as being a person seeking care. Instead, people interacting with primary care face a twofold role in where they are required to take the role not only of customer but also of seller. Consequently, people shift between these two roles in order to legitimize their care seeking.

    Conclusions: Standardization oversimplifies the complexity underlying patients’ experience of care seeking and interaction with healthcare. Hence, healthcare must acknowledge the individual person within a standardized system.

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  • 20.
    Hultstrand, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Hörnsten, Carl
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Fjällström, Petter
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hajdarevic, Senada
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Socioeconomic factors do not influence time to diagnosis for colorectal cancer in northern SwedenManuskript (preprint) (Övrigt vetenskapligt)
  • 21.
    Högberg, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Cronberg, Olof
    Department of Clinical Sciences, Lund University, Lund, Malmö, Sweden; Department of R & D, Region Kronoberg, Växjö, Sweden.
    Thulesius, Hans
    Department of Clinical Sciences, Lund University, Lund, Malmö, Sweden; Department of R & D, Region Kronoberg, Växjö, Sweden; Department of Medicine and Optometry, Linnaeus University, Kalmar, Sweden.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Jansson, Stefan
    School of Medical Sciences, University Health Care Research Centre, Örebro University, Örebro, Sweden; Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
    Gunnarsson, Ulf
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Use of faecal immunochemical tests common in patients with suspected colorectal cancer but unrelated to travel distance to secondary care: a population-based study from Swedish primary care2022Ingår i: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 40, nr 4, s. 459-465Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Evidence is increasing for the use of faecal immunochemical tests (FITs) for occult blood as diagnostic tools when colorectal cancer can be suspected. FITs have been used for this purpose in Swedish primary care since around 2005 despite absence of supporting guidelines. To our knowledge, the extent of this use has not been studied.

    Objective: To investigate the use of FITs as diagnostic tools, and if the use was related to patient age, sex and travel time from primary care to diagnostic facilities in secondary care. Design: Population-based retrospective study using data from electronic health records.

    Setting and subjects: Patients ≥18 years that provided FITs in primary care in five Swedish health care regions during 2015. Driving times from their primary care centres to secondary care were calculated. Main outcome measures: The proportion of patients that provided FITs was calculated for each region, different age intervals and grouped driving times. Results: 18,913 patients provided FITs. The proportion of listed patients in the five regions that provided FITs increased with age: 0.86–1.2% for ages <65 years, 3.6–4.1% for ages 65–79 years and 3.8–6.1% for ages ≥80 years. Differences between the regions were small. There was no overall correlation between the proportion of patients that provided FITs and driving time to secondary care.

    Conclusion: FITs were used extensively in Swedish primary care with a higher use in older age groups. There was no tendency towards a higher use of FITs at primary care centres with longer driving times to secondary care.Key Points Evidence is increasing for the use of faecal immunochemical tests (FITs) as diagnostic tools when colorectal cancer can be suspected. We investigated the use of FITs in Sweden. FITs were used extensively in primary care especially in older age groups. There were small differences in the use of FITs between five studied health care regions. There was no tendency towards a higher use of FITs at primary care centres with longer driving times to diagnostic facilities in secondary care.

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  • 22.
    Högberg, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Kardiologi.
    Gunnarsson, Ulf
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Cronberg, Olof
    Department of Clinical Sciences, Lund University, Malmö, Sweden. Department of R & D, Region Kronoberg, Växjö, Sweden..
    Thulesius, Hans
    Department of Clinical Sciences, Lund University, Malmö, Sweden. Department of R & D, Region Kronoberg, Växjö, Sweden. Department of Medicine and Optometry, Linnaeus University, Kalmar, Sweden..
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Jansson, Stefan
    School of Medical Sciences, University Health Care Research Centre, Örebro University, Örebro, Sweden..
    Qualitative faecal immunochemical tests (FITs) for diagnosing colorectal cancer in patients with histories of rectal bleeding in primary care: a cohort study2020Ingår i: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 35, nr 11, s. 2035-2040Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Rectal bleeding is considered an alarm symptom for colorectal cancer (CRC) but it is common and mostly caused by benign conditions. Qualitative faecal immunochemical tests (FITs) for occult blood have been used as diagnostic aids for many years in Sweden when CRC is suspected. The study aimed to evaluate the usefulness of FITs requested by primary care physicians for patients with and without histories of rectal bleeding, in the diagnosis of CRC.

    METHODS: Results of all FITs requested in primary care for symptomatic patients in the Örebro region during 2015 were retrieved. Data on each patient's history of rectal bleeding was gathered from electronic health records. Patients diagnosed with CRC within 2 years were identified from the Swedish Cancer Register. The analysis focused on three-sample FITs, the customary FIT in Sweden.

    RESULTS: A total of 4232 patients provided three-sample FITs. Information about the presence/absence of rectal bleeding was available for 2027 patients, of which 59 were diagnosed with CRC. For 606 patients with the presence of rectal bleeding, the FIT showed sensitivity 96.2%, specificity 60.2%, positive predictive value 9.8% (95% CI 6.1-13.4) and negative predictive value 99.7% (95% CI 99.2-100) for CRC. For 1421 patients without rectal bleeding, the corresponding figures were 100%, 73.6%, 8.3% (95% CI 5.6-10.9) and 100% (95% CI 99.6-100).

    CONCLUSION: The diagnostic performance of a qualitative three-sample FIT provided by symptomatic patients in primary care was similar for those with and without a history of rectal bleeding. FITs seem useful for prioritising patients also with rectal bleeding for further investigation.

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  • 23.
    Högberg, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Gunnarsson, Ulf
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Jansson, Stefan
    University Health Care Research Centre, Örebro University, Örebro..
    Thulesius, Hans
    Department of Clinical Sciences, Lund University, Malmö; professor of primary care, Department of Medicine and Optometry, Linnaeus University, Kalmar.
    Cronberg, Olof
    Department of Clinical Sciences, Lund University, Malmö..
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Diagnosing colorectal cancer in primary care: cohort study in Sweden of qualitative faecal immunochemical tests, haemoglobin levels, and platelet counts2020Ingår i: British Journal of General Practice, ISSN 0960-1643, E-ISSN 1478-5242, Vol. 70, nr 701, s. e843-e851Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Colorectal cancer (CRC) diagnostics are challenging in primary care and reliable diagnostic aids are desired. Qualitative faecal immunochemical tests (FITs) have been used for suspected CRC in Sweden since the mid-2000s, but evidence regarding their effectiveness is scarce. Anaemia and thrombocytosis are both associated with CRC.

    Aim: To evaluate the usefulness of qualitative FITs requested for symptomatic patients in primary care, alone and combined with findings of anaemia and thrombocytosis, in the diagnosis of CRC.

    Design and setting: A population-based cohort study using electronic health records and data from the Swedish Cancer Register, covering five Swedish regions.

    Method: Patients aged ≥18 years in the five regions who had provided FITs requested by primary care practitioners from 1 January 2015 to 31 December 2015 were identified. FIT and blood-count data were registered and all CRC diagnoses made within 2 years were retrieved. Diagnostic measurements were calculated.

    Results: In total, 15 789 patients provided FITs (four different brands); of these patients, 304 were later diagnosed with CRC. Haemoglobin levels were available for 13 863 patients, and platelet counts for 10 973 patients. Calculated for the different FIT brands only, the sensitivities for CRC were 81.6%–100%; specificities 65.7%–79.5%; positive predictive values 4.7%–8.1%; and negative predictive values 99.5%–100%. Calculated for the finding of either a positive FIT or anaemia, the sensitivities increased to 88.9–100%. Adding thrombocytosis did not further increase the diagnostic performance.

    Conclusion: Qualitative FITs requested in primary care seem to be useful as rule-in tests for referral when CRC is suspected. A negative FIT and no anaemia indicate a low risk of CRC.

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  • 24.
    Högberg, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för medicin.
    Karling, Pontus
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för medicin.
    Rutegård, Jörgen
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Diagnosing colorectal cancer and inflammatory bowel disease in primary care: The usefulness of tests for faecal haemoglobin, faecal calprotectin, anaemia and iron deficiency: A prospective study2017Ingår i: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 52, nr 1, s. 69-75Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: Abdominal complaints are common reasons to consult primary care but they are seldom caused by colorectal cancer (CRC), high-risk adenomas (HRAs), or inflammatory bowel disease (IBD). Reliable diagnostic aids would be helpful in deciding which patients to refer for bowel imaging. Our aim was to assess the value of a faecal immunochemical test (FIT) and a faecal calprotectin (FC) test in detecting CRC, HRAs and IBD in primary care, and the value of combining these tests with anaemia and iron-deficiency tests.

    MATERIALS AND METHODS: This prospective study included 373 consecutive patients that received a FIT or a FC test ordered by a primary care physician. We collected samples for FITs, FC tests, full blood counts and iron-deficiency tests. Physicians were instructed to refer patients with a positive FIT or FC test (cut-off ≥100μg/g) for bowel imaging. The patients' presenting symptoms were recorded. Patients were followed for 2 years.

    RESULTS: The best test for detecting CRC and IBD was the combination of the FIT and haemoglobin concentration. This test had a sensitivity, specificity, positive predictive value and negative predictive value of 100%, 61.7%, 11.7% and 100%, respectively. The FIT detected a significantly larger proportion of CRC, HRAs and IBD than the FC test (0.92 versus 0.46, 95% confidence interval 0.22-0.67).

    CONCLUSION: A negative FIT combined with a normal haemoglobin concentration could rule out CRC and IBD with a high degree of safety. This could be useful in prioritising referrals for bowel imaging from primary care.

  • 25.
    Högberg, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Karling, Pontus
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Rutegård, Jörgen
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Diagnosis of colorectal cancer: Patients' symptoms and faecal immunochemical test results in primary care. A prospective studyManuskript (preprint) (Övrigt vetenskapligt)
  • 26.
    Högberg, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Kardiologi.
    Karling, Pontus
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för medicin.
    Rutegård, Jörgen
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Patient-reported and doctor-reported symptoms when faecal immunochemical tests are requested in primary care in the diagnosis of colorectal cancer and inflammatory bowel disease: a prospective study2020Ingår i: BMC Family Practice, E-ISSN 1471-2296, Vol. 21, nr 1, artikel-id 129Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Rectal bleeding and a change in bowel habits are considered to be alarm symptoms for colorectal cancer and they are also common symptoms for inflammatory bowel disease. However, most patients with these symptoms do not have any of these diseases. Faecal immunochemical tests (FITs) for haemoglobin are used as triage tests in Sweden and other countries but little is known about the symptoms patients have when FITs are requested.

    Objective: Firstly, to determine patients’ symptoms when FITs are used as triage tests in primary care and whether doctors record the symptoms that patients report, and secondly to evaluate the association between symptoms, FIT results and possible prediction of colorectal cancer or inflammatory bowel disease.

    Methods and materials: This prospective study included 364 consecutive patients for whom primary care doctors requested a FIT. Questionnaires including gastrointestinal symptoms were completed by patients and doctors.

    Results: Concordance between symptoms reported from patients and doctors was low. Rectal bleeding was recorded by 43.5% of patients versus 25.6% of doctors, FITs were negative in 58.3 and 52.7% of these cases respectively. The positive predictive value (PPV) of rectal bleeding recorded by patients for colorectal cancer or inflammatory bowel disease was 9.9% (95% confidence interval [CI] 5.2–14.7); for rectal bleeding combined with a FIT the PPV was 22.6% (95% CI 12.2–33.0) and the negative predictive value (NPV) was 98.9% (95% CI 96.7–100). For patient-recorded change in bowel habits the PPV was 6.1% (95% CI 2.4–9.8); for change in bowel habits combined with a FIT the PPV was 18.2% (95% CI 9.1–30.9) and the NPV 100% (95% CI 90.3–100).

    Conclusions: Doctors should be aware that, during consultations, they do not record all symptoms experienced by patients. FITs requested in primary care, when found positive, may potentially be of help in prioritising referrals, also when patients present with rectal bleeding or change in bowel habits.

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  • 27.
    Högberg, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Karling, Pontus
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Rutegård, Jörgen
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Ljung, Thomas
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Immunochemical faecal occult blood tests in primary care and the risk of delay in the diagnosis of colorectal cancer2013Ingår i: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 31, nr 4, s. 209-214Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective. To evaluate the value, risks, and shortcomings of immunochemical faecal occult blood tests (iFOBTs) in the diagnosis of colorectal cancer (CRC) and adenomas with high-grade dysplasia (HGD) in patients initially presenting to primary care. Design. A retrospective population-based study. Setting and subjects. All 495 cases of CRC and adenomas with HGD diagnosed in the county of Jamtland, Sweden from 2005 to 2009. Results. Of 495 patients 323 (65%) initially presented to primary care. IFOBTs were performed in 215 of 323 (67%) patients. The sensitivity of iFOBT for CRC and adenomas with HGD was 88% (83% when patients with a history of rectal bleeding were excluded). Of 34 patients with anaemia found en passant, 10 had negative iFOBTs. Time to diagnosis was longer for patients with negative iFOBTs (p < 0.0005). Conclusion. IFOBT might be helpful in selecting which patients to refer for colonoscopy. However, iFOBT has a limited sensitivity as a diagnostic test for CRC and adenomas with HGD. Relying only on iFOBT for colonoscopy referral could delay diagnosis, especially for patients with anaemia found en passant.

  • 28.
    Högberg, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Department of Public Health and Clinical Medicine, Unit of Research, Education and Development - Östersund, Umeå University, Umeå, Sweden .
    Samuelsson, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Department of Public Health and Clinical Medicine, Unit of Research, Education and Development - Östersund, Umeå University, Umeå, Sweden .
    Fhärm, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Could it be colorectal cancer?: general practitioners' use of the faecal occult blood test and decision making - a qualitative study2015Ingår i: BMC Family Practice, E-ISSN 1471-2296, Vol. 16, nr 1, s. 153-161Artikel i tidskrift (Refereegranskat)
    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.

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  • 29.
    Högberg, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för medicin.
    Söderström, Lars
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Faecal immunochemical tests for the diagnosis of symptomatic colorectal cancer in primary care: the benefit of more than one sample2017Ingår i: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 35, nr 4, s. 369-372Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: Faecal immunochemical tests (FITs) are used to screen for colorectal cancer (CRC) and as diagnostic aids in symptomatic patients. However, the number of samples per FIT varies. It is unclear if there is any advantage to analyse multiple-sample FITs in symptomatic patients.

    Design and setting: This is a post hoc analysis of a retrospective study that included all cases of CRC and adenomas with high-grade dysplasia (HGD) between 2005 and 2009 in the county of Jamtland, Sweden.

    Subjects: All patients with CRC and adenomas with HGD that initially presented with symptoms to primary care and delivered FITs.

    Main outcome measure: The likelihood of a positive FIT in cases of CRC and adenomas with HGD; when analysing one, two or three samples.

    Results: Of 195 patients, 160 delivered three-sample FITs. Using the 139 cases in which at least one sample was positive, the likelihood of detecting a positive sample upon analysis of only one of the three samples was 0.91 (95% CI: 0.85-0.95), indicating that 13 positive cases may have been missed.

    Conclusion: Use of a one-sample FIT instead of a three-sample FIT as a diagnostic aid may result in the missing of one tenth of symptomatic CRCs and adenomas with HGD.

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  • 30. Julin, Bettina
    et al.
    Willers, Carl
    Leksell, Janeth
    Lindgren, Peter
    Looström Muth, Karin
    Svensson, Ann-Marie
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Unit of Research, Education, and Development, Östersund.
    Dahlström, Tobias
    Association between sociodemographic determinants and health outcomes in individuals with type 2 diabetes in Sweden2018Ingår i: Diabetes/Metabolism Research Reviews, ISSN 1520-7552, E-ISSN 1520-7560, Vol. 34, nr 4, artikel-id e2984Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Concurrent multifactorial treatment is needed to reduce consequent risks of diabetes, yet most studies investigating the relationship between sociodemographic factors and health outcomes have focused on only one risk factor at a time. Swedish health care is mainly tax-funded, thus providing an environment that should facilitate equal health outcomes in patients, independent of background, socioeconomic status, or health profile. This study aimed at investigating the association between several sociodemographic factors and diabetes-related health outcomes represented by HbA(1c), systolic blood pressure, low-density lipoprotein cholesterol, predicted 5-year risk of cardiovascular disease, and statin use.

    Methods: This large retrospective registry study was based on patient-level data from individuals diagnosed with type 2 diabetes during 2010 to 2011 (n=416,228) in any of 7 Swedish regions (similar to 65% of the Swedish population). Health equity in diabetes care analysed through multivariate regression analyses on intermediary outcomes (HbA(1c), systolic blood pressure, and low-density lipoprotein), predicted 5-year risk of cardiovascular disease and process (i.e., statin use) after 1-year follow-up, adjusting for several sociodemographic factors.

    Results: We observed differences in intermediary risk measures, predicted 5-year risk of cardiovascular disease, and process dependent on place of birth, sex, age, education, and social setting, despite Sweden's articulated vision of equal health care.

    Conclusions: Diabetes patients' health was associated with sociodemographic prerequisites. Furthermore, in addition to demographics (age and sex) and disease history, educational level, marital status, and region of birth are important factors to consider when benchmarking health outcomes, e.g., average HbA(1c) level, and evaluating the level of health equity between organizational units or between different administrative regions.

  • 31.
    Jutterström, Lena
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Stenlund, Anna-Lena
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Otten, Julia
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Unit of Research, Education and Development Department of Public Health and Clinical Medicine, Östersund Hospital, Östersund, Sweden.
    Hellström Ängerud, Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Awareness of cardiovascular risk among persons with type 2 diabetes: a qualitative study2024Ingår i: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 19, nr 1, artikel-id 2294512Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    PURPOSE: To describe the process of becoming aware of and acting on personal cardiovascular (CVD) risk in type 2 diabetes (T2D).

    METHOD: A purposive sample of 14 persons living with T2D participated in semi-structured, open-ended, in-dept interviews. The interviews were analysed with grounded theory.

    RESULT: The analysis identified the core category "Balancing emotions, integrating knowledge and understanding to achieve risk awareness and act on it." Five categories describe the movement from not being aware of the risk of cardiovascular disease (CVD) to becoming aware of this risk and taking action to reduce it. Persons with T2D need to transform their knowledge and experience of CVD risk and incorporate it in their individual situations. Emotional and existential experiences of CVD risk can lead to awareness about the severity of the condition and contribute to increased motivation for self-management. However, an overly high emotional response can be overwhelming and may result in insufficient self-management.

    CONCLUSION: Persons with T2D seemed not to fully grasp their increased risk of CVD or recognize that self-management activities were aimed at reducing this risk. However, their awareness of CVD risk gradually increased as they came to understand the severity of T2D and became more emotionally and existentially engaged.

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  • 32.
    Köpsén, Sofia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Hellgren, Margareta
    The Skaraborg Institute, Sweden; Department of Public Health and Community Medicine/Primary Health Care, The Sahlgrenska Academy, The University of Gothenburg, Gothenburg, Sweden.
    Sandlund, Jonas
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Avdelningen för fysioterapi.
    Sjöström, Rita
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering.
    Midwives' and diabetes nurses' experience of screening and care of women with gestational diabetes mellitus: a qualitative interview study2023Ingår i: Nursing Research and Practice, ISSN 2090-1429, E-ISSN 2090-1437, Vol. 2023, artikel-id 6386581Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Gestational diabetes mellitus (GDM) is increasing and is associated with adverse outcomes for both mother and child. The metabolic demands of pregnancy can reveal a predisposition for type 2 diabetes mellitus (T2DM), and women with a history of GDM are more likely to develop T2DM than women with normoglycemic pregnancies.

    Aim: The aim of this study was to explore midwives' and diabetes nurses' experience of their role in screening, care, and follow-up of women with gestational diabetes mellitus and, further, to explore their opinions and thoughts about existing routines and guidelines.

    Method: Individual interviews were performed with ten diabetes nurses and eight midwives working in primary and special care. Qualitative content analysis was done according to Graneheim and Lundman.

    Results: The analysis of the interviews resulted in the overall theme "An act of balance between normalcy and illness, working for motivation with dilemmas throughout the chain of health care."Difficulties in carrying out the important task of handling GDM while at the same time keeping the pregnancy in focus were central. Women were described as highly motivated to maintain a healthy lifestyle during pregnancy with the baby in mind, but it seemed difficult to maintain this after delivery, and compliance with long-term follow-up with the aim of reducing the risk of T2DM was low. The women came to the first follow-up but did not continue with later contact. This was at a time when the women felt healthy and were focusing on the baby and not themselves. A lack of cooperation and easy access to a dietician and physiotherapist were pointed out as well as a wish for resources such as group activities and multiprofessional teams.

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  • 33. Laleci Erturkmen, Gokce B.
    et al.
    Yuksel, Mustafa
    Sarigul, Bunyamin
    Arvanitis, Theodoros N.
    Lindman, Pontus
    Chen, Rong
    Zhao, Lei
    Sadou, Eric
    Bouaud, Jacques
    Traore, Lamine
    Teoman, Alper
    Lim Choi Keung, Sarah N.
    Despotou, George
    de Manuel, Esteban
    Verdoy, Dolores
    de Blas, Antonio
    Gonzalez, Nicolas
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Unit of Research, Education, and Development, Östersund Hospital, Umeå University, Umeå, Sweden.
    von Tottleben, Malte
    Beach, Marie
    Marguerie, Christopher
    Klein, Gunnar O.
    Kalra, Dipak
    A Collaborative Platform for Management of Chronic Diseases via Guideline-Driven Individualized Care Plans2019Ingår i: Computational and Structural Biotechnology Journal, E-ISSN 2001-0370, Vol. 17, s. 869-885Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals and interventions to be added to the individualized care plans. We also report the results of usability studies carried out in four pilot sites by patients and clinicians.

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  • 34. Laleci Erturkmen, Gokce Banu
    et al.
    Yuksel, Mustafa
    Sarigul, Bunyamin
    Lilja, Mikael
    Chen, Rong
    Arvanitis, Theodoros N
    Personalised Care Plan Management Utilizing Guideline-Driven Clinical Decision Support Systems2018Ingår i: Studies in Health Technology and Informatics, ISSN 0926-9630, E-ISSN 1879-8365, Vol. 247, s. 750-754Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals and interventions to be added to the individualized care plans.

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  • 35. Lekander, I.
    et al.
    Andreasson, S.
    Ekstrand, E.
    von Euler, M.
    Fagervall-Yttling, B.
    Henricson, L.
    Kostulas, K.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Willers, C.
    Pessah-Rasmussen, H.
    Casemix-adjusted comparison of resource use first year following a stroke in Sweden - Results from Sveus2015Ingår i: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, Vol. 10, s. 360-361Artikel i tidskrift (Övrigt vetenskapligt)
  • 36. Lekander, Ingrid
    et al.
    Willers, Carl
    Ekstrand, Elisabeth
    von Euler, Mia
    Fagervall-Yttling, Birgitta
    Henricson, Lena
    Kostulas, Konstantinos
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Sunnerhagen, Katharina S.
    Teichert, Jorg
    Pessah-Rasmussen, Helene
    Hospital comparison of stroke care in Sweden: a register-based study2017Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 7, nr 9, artikel-id e015244Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background and purpose The objective of this study was to estimate the level of health outcomes and resource use at a hospital level during the first year after a stroke, and to identify any potential differences between hospitals after adjusting for patient characteristics (case mix). Method Data from several registries were linked on individual level: seven regional patient administrative systems, Swedish Stroke Register, Statistics Sweden, National Board of Health and Welfare and Swedish Social Insurance Agency. The study population consisted of 14 125 patients presenting with a stroke during 2010. Case-mix adjusted analysis of hospital differences was made on five aspects of health outcomes and resource use, 1 year post-stroke. Results The results indicated that 26% of patients had died within a year of their stroke. Among those who survived, almost 5% had a recurrent stroke and 40% were left with a disability. On average, the patients had 22 inpatient days and 23 outpatient visits, and 13% had moved into special housing. There were significant variations between hospitals in levels of health outcomes achieved and resources used after adjusting for case mix. Conclusion Differences in health outcomes and resource use between hospitals were substantial and not entirely explained by differences in patient mix, indicating tendencies of unequal stroke care in Sweden. Healthcare organisation of regions and other structural features could potentially explain parts of the differences identified.

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  • 37. Lekander, Ingrid
    et al.
    Willers, Carl
    von Euler, Mia
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Sunnerhagen, Katharina S
    Pessah-Rasmussen, Hélène
    Borgström, Fredrik
    Relationship between functional disability and costs one and two years post stroke2017Ingår i: PLOS ONE, E-ISSN 1932-6203, Vol. 12, nr 4, artikel-id e0174861Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND AND PURPOSE: Stroke affects mortality, functional ability, quality of life and incurs costs. The primary objective of this study was to estimate the costs of stroke care in Sweden by level of disability and stroke type (ischemic (IS) or hemorrhagic stroke (ICH)).

    METHOD: Resource use during first and second year following a stroke was estimated based on a research database containing linked data from several registries. Costs were estimated for the acute and post-acute management of stroke, including direct (health care consumption and municipal services) and indirect (productivity losses) costs. Resources and costs were estimated per stroke type and functional disability categorised by Modified Rankin Scale (mRS).

    RESULTS: The results indicated that the average costs per patient following a stroke were 350,000SEK/€37,000-480,000SEK/€50,000, dependent on stroke type and whether it was the first or second year post stroke. Large variations were identified between different subgroups of functional disability and stroke type, ranging from annual costs of 100,000SEK/€10,000-1,100,000SEK/€120,000 per patient, with higher costs for patients with ICH compared to IS and increasing costs with more severe functional disability.

    CONCLUSION: Functional outcome is a major determinant on costs of stroke care. The stroke type associated with worse outcome (ICH) was also consistently associated to higher costs. Measures to improve function are not only important to individual patients and their family but may also decrease the societal burden of stroke.

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  • 38.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Trends in obesity and type 2 diabetes: ethnic aspects and links to adipokines2011Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [en]

    Objective The prevalence of obesity and related diseases such as type 2 diabetes mellitus (T2DM) is increasing worldwide, and the Asian Indian population seems to be particularly susceptible to developing T2DM, even at a low body mass index (BMI). In Sweden, the age-adjusted prevalence of diabetes has not increased despite increasing self-reported obesity. However, modern data on the prevalence of obesity and T2DM in Scandinavia are absent.The biochemical links between obesity and subsequent T2DM are unknown, but the adipocyte-derived hormones leptin and adiponectin (adipokines) have been suggested as potential links because they both are related to insulin and glucose physiology. Some studies have found leptin to be an independent predictor of T2DM in men but not in women, although these results are inconsistent. In contrast, adiponectin has more consistently been linked to development of T2DM in both men and women. Furthermore, the leptin–adiponectin ratio may predict incident T2DM better than either of the two hormones separately.The aims of this thesis were to describe time trends in obesity and T2DM in northern Sweden, to evaluate leptin and adiponectin as predictors of deterioration in glucose metabolism including T2DM, and to evaluate leptin as a risk marker regarding ethnic differences, circ-annual variation, and intra-individual stability.

    Materials and methods Three large population surveys were used, the Northern Sweden MONICA (MONitoring of Trends and Determinants in CArdiovascular Disease) study, the Västerbotten Intervention Programme (VIP), and the Mauritius Non-Communicable Disease Study. Within the MONICA study, six cross-sectional surveys were performed in Sweden’s two northernmost counties, Norrbotten and Västerbotten, between 1986 and 2009. A total of 1000 men and 1000 women ages 25–64 years, also including from 1994 250 men and 250 women ages 65–74 years, were independently chosen for each survey. The overall participation rate was 75%. In 1999, a reinvestigation was performed in 74% of all participants from the three first surveys. Data from the MONICA surveys were used in papers I and IV and data from the reinvestigation survey in paper II. VIP is an ongoing population intervention program that started in the mid-eighties targeting cardiovascular risk factors and has covered the whole county of Västerbotten since 1991. Inhabitants are invited the years they turn 40, 50, and 60 years old, and the annual participation rate has varied between 48% and 67%. A subset (n=1780) from VIP was used in paper II for the circ-annual leptin analysis, and VIP data linked to the diabetes register in Västerbotten (DiabNorr) were used in a case referent study (640 patients with T2DM) in paper III. The Mauritius Non-Communicable Disease Study was performed in 1987 in 10 randomly selected (with probability proportional to size) population clusters. All eligible adults ages 25–74 years were invited, and the participation rate was 86% (n=5083). In 1992, a follow-up survey was performed in 49% of the initial participants. The Mauritius survey data were used in paper II.

    Results

    I. BMI increased in men ages 25–74 years and in women ages 25–44 years in northern Sweden between 1986 and 2004. The prevalence of obesity (BMI 30) increased in men ages 25–44 and 55–74 years and in women ages 25–44 years. The prevalence of obesity increased from 10.4% to 19.1% in men and from 12.9% to 17.9% in women ages 25–64 years. Waist circumference (WC) decreased in women of all ages and in men ages 55–64 years between 1986 and 1990. After 1990, WC increased again, and the prevalence of abdominal obesity rose markedly in women ages 25–64 years.

    II. Differences in circulating levels of leptin, leptin per BMI unit (leptin/BMI), and leptin per cm in WC (leptin/waist) were tested in men and women of Asian Indian, Creole (African), and Caucasian ethnicity. Asian Indian men and women had the highest leptin concentrations and Caucasian men and women the lowest while Creole men and women had intermediate values for leptin, leptin/BMI, and leptin/waist. No circ-annual variation in leptin concentrations was seen in Caucasians. The intra-individual test– retest stability for leptin was equal in men and women of different ethnicities, over 5–13 years, with an intra-class correlation of 0.65–0.82.

    III. High adiponectin concentrations predicted decreased risk of T2DM in both insulin-sensitive and insulin-resistant men and women, whereas high leptin levels predicted increased risk for T2DM only in insulinsensitive men. A high leptin–adiponectin ratio predicted T2DM in both men and women, and men with a high ratio had a shorter time to diagnosis than those with a low ratio.

    IV. In northern Sweden, fasting and post-load glucose increased in women ages 24–65 years with 0.2 mmol/l and 0.7 mmol/l, respectively, between 1990 and 2009. Consequently, the prevalence of impaired fasting glucose and impaired glucose tolerance (IGT) rose from 4.5% to 7.7%, and from 7.8% to 14.5%, respectively. In men, post-load glucose increased at 0.5 mmol/l, and the prevalence of IGT rose from 3.5% to 10.1%. The prevalence of diabetes did not increase. An independent relationship between leptin and changes in fasting and post-load glucose was seen in men but not in women.

    Conclusion An increasing obesity and concomitant deterioration in glucose metabolism was seen in northern Sweden in the period studied. High adiponectin concentrations predicted a decreased risk of T2DM in both men and women, whereas high leptin concentrations predicted an increase in fasting and post-load glucose as well as an increased risk of T2DM in men but not in women. Individual insulin resistance status modified the association between leptin and T2DM, and the leptin–adiponectin ratio may add further predictive information beyond the measures of the separate hormones. In relation to traditional anthropometric measures of obesity, Asian Indian men and women had the highest and Caucasians the lowest concentrations of leptin while Creole (African) men and women had intermediate levels. As a risk marker, leptin has a high intra-individual stability, equal in men and women and among different ethnicities over 5–13 years with no circ-annual variation.

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  • 39.
    Lilja, Mikael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Eliasson, Mats
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Eriksson, Marie
    Umeå universitet, Medicinska fakulteten.
    Söderberg, Stefan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    A right-hand shift of the distribution of fasting and post load glucose in northern Sweden between 1990 and 2009, and its predictorsManuskript (preprint) (Övrigt vetenskapligt)
    Abstract [en]

    Background Recent Swedish studies have shown stable diabetes prevalence despite increasing obesity, but glucose levels may shift upwards below the diagnostic threshold for diabetes. Determinants for this shift are not consistently described, and may include obesity and obesity related factors such as the adipokine leptin.

    Aims To explore secular trends in diabetes prevalence, glucose concentrations and glucose intolerance in northern Sweden, to evaluate if these trends are uniformly distributed throughout the spectrum of glucose concentrations, and to relate trends in glucose concentrations to  traditional risk factors and leptin.

    Methods Four cross-sectional population surveys between 1990 and 2009 with 7069 participants aged 25-64 years with an overall participation rate of 74.4%. Tukey mean-difference plot were used to examine changes in glucose distribution together with trend analyses in each decile of glucose distribution. Linear regression was used to estimate changes in glucose levels in relation to survey year and risk factors including leptin.

    Results Fasting and post load glucose in women (all p<0.001) and post load glucose in men (p=0.004) increased, and the increase was seen in almost all deciles of glucose concentrations, but more pronounced in the upper deciles. In men, fasting glucose remained unchanged, though with an increase in lower deciles. The prevalence of impaired glucose tolerance rose in women from 7.8 to 14.5% and in men from 3.5 to 10.1% (all p=0.004), and the prevalence of impaired fasting glucose rose in women from 4.5 to 7.7% (p<0.001), but was unchanged in men.  The prevalence of diabetes did not change and was 2009 in men 6.4%, and in women 6.5%.  Leptin could, on top of traditional risk factors, in men partly explain the variance in fasting (p=0.008) and post load (p<0.001) glucose. 

    Conclusion The prevalence of diabetes did not increase in northern Sweden between 1986 and 2009, despite increasing fasting and post load glucose levels seen in most deciles of glucose distribution. Leptin is significantly associated with changes in fasting and post load glucose in men.

  • 40.
    Lilja, Mikael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Eliasson, Mats
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin. Department of Public Health and Clinical Medicine, Sunderby Unit, Umeå University, Umeå, Sweden.
    Eriksson, Marie
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet, Statistik.
    Söderberg, Stefan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Kardiologi.
    A rightward shift of the distribution of fasting and post-load glucose in northern Sweden between 1990 and 2009 and its predictors. Data from the Northern Sweden MONICA study2013Ingår i: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491, Vol. 30, nr 9, s. 1054-1062Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Aims

    Most Swedish studies show stable diabetes prevalence despite increasing obesity, but glucose levels may shift upwards below the diagnostic threshold for diabetes. Our aim was to explore trends in glucose distribution in northern Sweden; whether these trends were uniformly distributed throughout the spectrum of glucose concentrations; and to relate trends to traditional risk factors and the obesity-related adipokine leptin.

    Methods

    The project consisted of four cross-sectional surveys between 1990 and 2009, with 7069 participants aged 25–64 years. The overall participation rate was 74.4%. Trend analyses of glucose concentrations along the entire distribution and linear regression in relation to survey years and risk markers were used.

    Results

    Fasting and post-load glucose increased in women (both P < 0.001) and post-load glucose in men (P = 0.004). The increase was seen in most deciles of glucose concentrations. The prevalence of impaired glucose tolerance doubled in women to 14.5% and tripled in men to 10.1% (both P = 0.004). The prevalence of impaired fasting glucose rose in women from 4.5 to 7.7% (P < 0.001). The prevalence of diabetes was unchanged—6.4% in 2009. In men, leptin, together with traditional risk factors, explained 7.8 and 10.8% of the variance in fasting (P = 0.008) and post-load (P < 0.001) glucose, respectively.

    Conclusions

    Increasing fasting and post-load glucose concentrations were seen in most deciles of the glucose distribution, indicating a shift in the entire population. Leptin was significantly associated with fasting and post-load glucose in men.

  • 41.
    Lilja, Mikael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Eliasson, Mats
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Stegmayr, Birgitta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Olsson, Tommy
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Söderberg, Stefan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Trends in obesity and its distribution: data from the Northern Sweden MONICA survey, 1986–20042008Ingår i: Obesity, ISSN 1930-7381, E-ISSN 1930-739X, Vol. 16, nr 5, s. 1120-1128Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

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  • 42.
    Lilja, Mikael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Hellgren, Margareta
    Jansson, Stefan
    Diagnos och behandlingsmål vid diabetes typ 22018Ingår i: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 115, artikel-id EYWXArtikel i tidskrift (Refereegranskat)
    Abstract [en]

    The article presents diagnostic criteria for diabetes and treatment goals for diabetes type 2.

  • 43.
    Lilja, Mikael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Jansson, Stefan
    Alvarsson, Michael
    Aldrimer, Mattias
    Nordin, Gunnar
    Attvall, Stig
    HbA1c blir kompletterande metod för diagnostik av diabetes. Samordnat införande i Sverige januari 2014: [HbA1c will complement other methods in the diagnosis of diabetes. Coordinated introduction in Sweden in January 2014]2013Ingår i: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 110, nr 49-50, s. 2246-2248Artikel i tidskrift (Övrigt vetenskapligt)
  • 44.
    Lilja, Mikael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Julin, B.
    Stockholm, Sweden.
    Andersson, G.
    Stockholm, Sweden.
    Andersson, I. -L
    Nacka, Sweden.
    Axelsen, M.
    Nacka, Sweden.
    Ek, M.
    Stockholm, Sweden.
    Kristiansson, R.
    Uppsala, Sweden.
    Lekell, J.
    Uppsala, Sweden.
    Lindberg, A.
    Malmö, Sweden.
    Lindgren, P.
    Stockholm, Sweden.
    Löndahl, F.
    Stockholm, Sweden.
    Looström Muth, K.
    Gothenburg, Sweden.
    Svensson, A. -M
    Gothenburg, Sweden.
    Dahlström, T.
    Uppsala, Sweden.
    Determinants of HbA1c in patients with type 1 diabetes in seven Swedish county councils2015Ingår i: Diabetologia, ISSN 0012-186X, E-ISSN 1432-0428, Vol. 58, nr Suppl. 1 Abstr. 278, s. S140-S141Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

    Background and aims: In order to make fair comparisons between the results of different health care providers, proper consideration of the casemix of the populations they serve is important. HbA1c is often used as a metric to indicate the quality of diabetes care, it is therefore of value to determine what patient characteristics affect this outcome. As part of the ongoing National Collaboration for Value Based Reimbursement and Monitoring Systems, we therefore set out to investigate what factors are associated with HbA1c in a large retrospective cohort of persons with type 1 diabetes.

    Materials and methods: This was a retrospective register study where we analyzed persons 18 years or older, with a health care contact and a diagnosis of diabetes during 2010-11 in the administrative systems of seven Swedish county councils (Dalarna, Jämtland Härjedalen, Skåne, Stockholm, Uppsala, Västra Götaland and Östergötland), covering ~70% of the Swedish population and linked this data to data from the National Diabetes Register, socioeconomic data from Statistics Sweden and data on filled prescriptions from the Prescribed Drug Register. We estimated a random effect model on HbA1c after one year of follow-up, including socioeconomic, demographic and clinical factors.

    Results: Based on a complete case approach, 13 396 patients were analyzed. Women had on average higher HbA1c than men. Blood sugar control seemed to be better with higher age. Of the socioeconomic factors, higher education was associated with lower levels of HbA1c, as was being married. By contrast, we found no association between HbA1c and being born outside the EU.Ahistory (previous 2 years) of diabetes related complications were associated with higher levels of HbA1c, which is likely due to high levels of HbA1c being an indicator of what is causing the complications in the first place. The exception to this pattern was patients with renal failure.

    Conclusion: Apart from obvious demographic factors such as age and gender as well as disease history, educational and civil status are important factors to take into consideration when comparing obtained HbA1c levels between health care providers. This also raises the question of the need for additional focus on education directed towards these groups to facilitate improved diabetes management.

  • 45.
    Lilja, Mikael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Rolandsson, Olov
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Norberg, Margareta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Söderberg, Stefan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Kardiologi.
    The iImpact of Leptin and Adiponectin on incident type 2 Diabetes is modified by sex and insulin resistance2012Ingår i: Metabolic Syndrome and Related Disorders, ISSN 1540-4196, E-ISSN 1557-8518, Vol. 10, nr 2, s. 143-151Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Adiponectin and leptin and their ratio have been associated with incident type 2 diabetes (T2DM), although the data presented are conflicting and the populations studied have been small. In this large, prospective, nested, case referent study, we hypothesized that these associations are sex specific and may be modified by insulin resistance. Methods: Men and women aged 30-60 years with incident T2DM (n = 640) and a prior health survey within the Vasterbotten Intervention Programme (VIP) and matched referents (n = 1564) were identified. Using conditional logistic regression analyses, we tested whether baseline plasma adiponectin and leptin levels and their ratio independently predicted incident T2DM, stratified for gender and insulin resistance. Results: Adjusted for traditional risk factors, fourth-quartile levels of adiponectin were associated with a reduced risk of T2DM in men [odds ratio (OR) 0.55 (0.36-0.86)] and women [OR 0.47 (0.27-0.83)]. Quartile four of the leptin/adiponectin ratio predicted T2DM in both men [OR 3.08 (1.68-5.67)] and women [OR 3.31 (1.56-7.03)], whereas quartile-four levels of leptin predicted T2DM only in men [OR 2.30 (1.32-4.02)]. When stratified for insulin sensitivity and adjusted for body mass index (BMI), loge-transformed leptin predicted T2DM in insulin-sensitive men [OR 1.56 (1.13-2.17)] but not in insulin-resistant men [OR 1.03 (0.76-1.39)]. The effect of adiponectin and the leptin/adiponectin ratio was not influenced by the insulin sensitivity status. Conclusions: Leptin in men and adiponectin in both sexes were independent predictors of T2DM. The association was modified by the degree of insulin sensitivity. The leptin/adiponectin ratio may add predictive information beyond the separate hormones.

  • 46.
    Lilja, Mikael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Rolandsson, Olov
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Norberg, Margareta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Söderberg, Stefan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    The impact of leptin and adiponectin on incident type 2 diabetes is modified by sex and insulin resistanceManuskript (preprint) (Övrigt vetenskapligt)
    Abstract [en]

    Background Adiponectin and leptin and their ratio have been associated with incident type 2 diabetes (T2DM), although presented data are conflicting and populations studied have been small. In this large prospective nested case referent study, we hypothesised that these associations are sex-specific and may be modified by insulin resistance.

    Methods Men and women aged 30–60 years with incident T2DM (n=640) and a prior health survey within the Västerbotten Intervention Programme (VIP), and matched referents (n=1564) were identified. Using conditional logistic regression analyses, we tested whether baseline plasma adiponectin and leptin levels and their ratio independently predicted incident T2DM, stratified for gender and insulin resistance.

    Results Adjusted for traditional risk factors, fourth-quartile levels of adiponectin were associated with a reduced risk of T2DM in men (OR 0.55 [0.36–0.86]) and women (OR 0.47 [0.27–0.83]). Quartile four of the leptin/adiponectin ratio predicted T2DM in both men (OR 3.08 [1.68–5.67]) and women (OR 3.31 [1.56–7.03]), while quartile-four levels of leptin predicted T2DM only in men (OR 2.30 [1.32–4.02]). When stratified for insulin sensitivity and adjusted for BMI, loge-transformed leptin predicted T2DM in insulin-sensitive men (OR 1.56 [1.13–2.17]) but not in insulin-resistant men (OR 1.03 [0.76–1.39]). The effect of adiponectin and the leptin/adiponectin ratio was not influenced by the insulin sensitivity status.

    Conclusions Leptin in men and adiponectin in both sexes were independent predictors of T2DM. The association was modified by the degree of insulin sensitivity. The leptin/adiponectin ratio may add predictive information beyond the separate hormones

  • 47.
    Lilja, Mikael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Rolandsson, Olov
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Shaw, JE
    Baker IDI Heart and diabetes institute, Melbourne.
    Pauvaday, Vassen
    Ministry of Health and Quality of Life, Port Louis, Mauritiu.
    Cameron, Adrian
    Baker IDI, Heart and diabetes institute, Melbourne.
    Tuomilehto, J
    Department of Public Health, University of Helsinki.
    Alberti, KGMM
    Department of Endocrinology and Metabolic Medicine, Imperial College, London.
    Zimmet, Paul
    Baker IDI, Heart and diabetes institute, Melbourne.
    Söderberg, Stefan
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Higher leptin levels in Asian Indians than Creoles and Europids:  a potential explanation for increased metabolic risk2010Ingår i: International Journal of Obesity, ISSN 0307-0565, E-ISSN 1476-5497, Vol. 34, nr 5, s. 878-885Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND AND PURPOSE:

    Leptin predicts cardiovascular diseases and type 2 diabetes, diseases to which Asian Indians are highly susceptible. As a risk marker, leptin's intra-individual and seasonal stability is unstudied and only small studies have compared leptin levels in Asian Indians with other populations. The aim of this study was to explore ethnicity related differences in leptin levels and its intra-individual and seasonal stability.

    METHODS:

    Leptin and anthropometric data from the northern Sweden MONICA (3513 Europids) and the Mauritius Non-communicable Disease (2480 Asian Indians and Creoles) studies were used. In both studies men and women, 25- to 74-year old, participated in both an initial population survey and a follow-up after 5-13 years. For the analysis of seasonal leptin variation, a subset of 1780 participants, 30- to 60-year old, in the Västerbotten Intervention Project was used.

    RESULTS:

    Asian Indian men and women had higher levels of leptin, leptin per body mass index (BMI) unit (leptin/BMI) or per cm in waist circumference (WC; leptin/waist) than Creoles and Europids when adjusted for BMI (all P<0.0005) or WC (all P<0.005). In men, Creoles had higher leptin, leptin/BMI and leptin/waist than Europids when adjusted for BMI or WC (all P<0.0005). In women, Creoles had higher leptin/BMI and leptin/waist than Europids only when adjusted for WC (P<0.0005). Asian Indian ethnicity in both sexes, and Creole ethnicity in men, was independently associated with high leptin levels. The intra-class correlation for leptin was similar (0.6-0.7), independently of sex, ethnicity or follow-up time. No seasonal variation in leptin levels was seen.

    CONCLUSION:

    Asian Indians have higher levels of leptin, leptin/BMI and leptin/waist than Creoles and Europids. Leptin has a high intra-individual stability and seasonal leptin variation does not appear to explain the ethnic differences observed here

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  • 48.
    Lilja, Mikael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Widerström, Micael
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Klinisk bakteriologi.
    Lindh, Johan
    Persisting post-infection symptoms 2 years after a large waterborne outbreak of Cryptosporidium hominis in northern Sweden2018Ingår i: BMC Research Notes, E-ISSN 1756-0500, Vol. 11, nr 1, artikel-id 625Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: In 2010–2011, a large waterborne outbreak of Cryptosporidium hominis affected the city of Östersund in Sweden. Previous findings had suggested that gastrointestinal symptoms can persist for up to 11 months after the initial infection. Here we investigated whether the parasite could cause sequelae in infected individuals up to 28 months after the outbreak. We compared cases linked to the outbreak and the previous follow-up study with non-cases regarding symptoms present up to 28 months after the initial infection. We investigated whether cases were more likely to report a list of symptoms at follow-up compared to non-cases, calculating odds ratio and 95% confidence interval obtained through logistic regression.

    Results: A total of 559 individuals (215 cases) were included in the study. Forty-eight percent of the outbreak cases reported symptoms at follow-up. Compared to non-cases, cases were more likely to report watery diarrhea, diarrhea, abdominal pain, fatigue, nausea, headache, or joint stiffness/pain/discomfort at follow-up after adjusting for age and sex. Our findings suggest that gastrointestinal symptoms and joint pain can persist several years after the initial Cryptosporidium infection and should be regarded as a potential cause of unexplained gastrointestinal symptoms or joint pain in people who have had this infection.

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  • 49.
    Lindroth, Martin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Lundqvist, Robert
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Eliasson, Mats
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
    Cardiovascular risk factors differ between rural and urban Sweden: the 2009 Northern Sweden MONICA cohort2014Ingår i: BMC Public Health, E-ISSN 1471-2458, Vol. 14, artikel-id 825Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Rural communities have a higher burden of cardiovascular risk factors than urban communities. In Sweden, socioeconomic transition and urbanization have led to decreased populations in rural areas and changing characteristics of the remaining inhabitants. We investigated the risk factors in urban and rural populations in Northern Sweden.

    METHODS: The 2009 Northern Sweden MONICA Study invited a random sample of 2,500 people, 25 to 74 years and 69.2% participated. Community size was classified as rural = <1,000 inhabitants, town = 1,000-15,000, or urban/city= >15,000. We adjusted our analysis for age, gender and education.

    RESULTS: The rural population was older and the proportion of men was higher than in the urban areas. Having only primary education was more common in rural areas than in urban areas (26.2% vs. 12.3%). Waist and hip circumference, body mass index (BMI), and total cholesterol levels were higher in rural areas than in urban areas, even after adjusting for differences in age and gender. The largest differences between rural and urban dwellers were seen in waist circumference of women (4.8 cm), BMI of women (1.8 units) and cholesterol of men (0.37 mmol/l). Blood pressure was higher in rural areas, but not after adjusting for age and gender.Participants in rural areas were more often treated for hypertension and hyperlipidaemia, hospitalized for myocardial infarction and diagnosed with diabetes. However, after adjusting for age and gender, there were no differences. The odds ratio for being physically active comparing rural areas to urban areas was 0.73 (95% CI 0.53; 1.01). Smoking, snuff use and the prevalence of pathological glucose tolerance did not differ between community sizes. Middle-sized communities often had values in between those found in rural and urban communities, but overall they were more similar to the rural population. Further adjustment for education did not change the results for any variable.

    CONCLUSIONS: In 2009 the rural population in northern Sweden was older, with less education, higher BMI, more sedentary lifestyle, and had higher cholesterol levels than the urban population. The rural population should be considered targets for focused preventive interventions, but with due consideration of the socioeconomic and cultural context.

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  • 50.
    Lööv, Anna
    et al.
    Department of Medical Sciences, Örebro University, Örebro, Sweden; Skebäck Primary Care Centre, Region Örebro län, Örebro, Sweden.
    Högberg, Cecilia
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lilja, Mikael
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Theodorsson, Elvar
    Department of Biomedical and Clinical Science, Clinical Chemistry, Linköping University, Linköping, Sweden.
    Hellström, Per
    Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
    Metsini, Alexandra
    Department of Medical Sciences, Örebro University, Örebro, Sweden; Department of Knowledge Management and Patient Safety Unit, Region Värmland, Karlstad, Sweden.
    Olsson, Louise
    Department of Medical Sciences, Örebro University, Örebro, Sweden; Centre for Assessment of Medical Technology, Örebro University Hospital, Örebro, Sweden.
    Diagnostic accuracy for colorectal cancer of a quantitative faecal immunochemical test in symptomatic primary care patients: a study protocol2022Ingår i: Diagnostic and prognostic research, ISSN 2397-7523, Vol. 6, nr 1, artikel-id 16Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: There is increasing evidence supporting the use of faecal immunochemical tests (FIT) in patients reporting symptoms associated with colorectal cancer (CRC), but most studies until now have focused on selected subjects already referred for investigation. We therefore set out to determine the accuracy and predictive values of FIT in a primary care population.

    METHOD: A prospective, multicentre, single-gated comparative diagnostic study on quantitative FIT in patients aged 40 years and above presenting in primary care with symptoms associated with CRC will be conducted. Patients representing the whole spectrum of severity of such symptoms met with in primary care will be eligible and identified by GPs. Participants will answer a short form on symptoms during the last month. They will provide two faecal samples from two separate days. Analyses will be performed within 5 days (QuikRead go®, Aidian Oy). The analytical working range is 10-200 μg Hb/g faeces. Reference test will be linked to the Swedish Colorectal Cancer Registry up to 2 years after inclusion. Accuracy, area under ROC curves, and predictive values will be calculated for one FIT compared to the highest value of two FIT and at cutoff < 10, 10-14.9, 15-19.9 and ≥ 20 μg Hb/g faeces. Subgroup analyses will be conducted for patients with anaemia and those reporting rectal bleeding. A model-based cost-effectiveness analysis based on the clinical accuracy study will be performed. Based on previous literature, we hypothesized that the sensitivity of the highest value of two FIT at cutoff 10 μg Hb/g faeces will be 95% (95% CI + / - 15%). The prevalence of CRC in the study population was estimated to be 2%, and the rate of non-responders to be 1/6. In all, 3000 patients will be invited at 30 primary care centres.

    DISCUSSION: This study will generate important clinical real-life structured data on accuracy and predictive values of FIT in the most critical population for work-up of CRC, i.e. patients presenting with at times ambiguous symptoms in primary care. It will help establish the role of FIT in this large group.

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