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  • 1.
    Anna, B.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Virologi.
    Hambaeus, M.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Virologi.
    Hambraeus, Johan
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Virologi.
    Wadell, G.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Virologi.
    Animal model of rotavirus infection in rabbits - protection obtained without shedding of viral antigen.1989Ingår i: Archives of Virology, ISSN 0304-8608, E-ISSN 1432-8798, Vol. 107, nr 3-4, s. 237-251Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    A small animal model was developed in order to investigate the pathogenesis and immunology of rotavirus infections and to study the interaction of different virus strains. Seronegative rabbits of the breed French Lop were used. Two rabbit rotavirus strains, belonging to the same serotype, were used: 82/311 F and R-2, both isolated during diarrhoeal outbreaks in commercial rabbitries. The animals were inoculated orally. The viral shedding and the serological response was monitored by ELISA. Initially six weeks old kits were given four different doses of strain R-2. With doses ranging from 1 x 10(3) to 1 x 10(6) TCID50 all animals seroconverted, but for the lowest dose no viral excretion could be detected. No clinical symptoms were observed. Subsequently the age periods during which the animals were susceptible to the strain R-2 was investigated. The rabbits seroconverted and shed rotavirus antigen, independent of age of six or 22 weeks. None of the animals had diarrhoea. Administration of strain 82/311 F did not result in viral shedding, independently of dose, but all the animals seroconverted. It was also shown for the strain R-2 that when challenging with the same strain four weeks post inoculation that the animals were protected; no viral shedding was detected at the second infection. Strain 82/311 F gave protection against R-2 when the rabbits were challenged four weeks post inoculation.

  • 2.
    Hambraeus, Johan
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Ganglion Impar Blocks for More Than Coccygodynia2016Ingår i: Pain medicine, ISSN 1526-2375, E-ISSN 1526-4637, Vol. 17, nr 6, s. 1206-1207Artikel i tidskrift (Refereegranskat)
  • 3.
    Hambraeus, Johan
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Interventional pain management focused on zygapophysial joint pain: a health-economic evaluation2023Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [sv]

    Nästan var 5:e människa i världen (15-20%) har haft ont mer än 3 månader. Utesluter man dem som har smärtor pga cancer, reumatiska sjukdomar, nyligen opererats eller fått frakturer så kvarstår ca hälften. Ländryggsvärk, tätt följd av huvudvärk, är den viktigaste orsaken till funktionsnedsättning i världen enligt de studier WHO genomfört mellan 1990 och 2017. Ca 30-50% av dessa har facettleds-relaterad smärta. Sedan slutet av 1980-talet har mycket arbete skett för att säkerställa hur man på ett evidensbaserat sätt ska kunna diagnostisera och behandla en facettleds-relaterad smärta. Diagnostik och behandling av facettleds-relaterad smärta från halsrygg och ländrygg är väl etablerad så länge man följer de internationella guidelines som finns framtagna, dvs där diagnostik sker med hjälp av exakta nervblockader vid minst två tillfällen och att minst 80% smärtlindring uppnås varje gång, och behandlingen sker så att nerven nås av behandlingen.

    Denna avhandling utgår härifrån.

    Det första steget var att ta fram en metodik för diagnostik och behandling i bröstryggen eftersom detta inte tidigare var bra beskrivet. Behandling i halsrygg och ländrygg användes som referenser att jämföra mot. Men eftersom smärta är en av de viktigaste orsakerna till försämrad livskvalitet ville vi även ta ett steg till, och se om det gick att använda livskvalitets-skattning som utfalls-mått. Så istället för att följa upp hur ont patienter hade 3,6 och 12 månader efter behandling frågade vi efter hur de skattade sin livskvalitet. Vi kunde då se att behandlingsresultaten i bröstryggen var likvärdiga med dem vi såg i ländrygg och halsrygg, och vi kunde se att hos dem som fick en förbättring av behandlingen så beskrev de en i det närmaste normalisering av livskvaliteten, och att förbättringen ofta kvarstod ett år efter behandling.

    Att livskvaliteten förbättrades så kraftigt efter behandling väckte en ny fråga: Vad var det som gjorde detta? Vi genomförde därför en kvalitativ intervju studie där vi frågade efter hur patienterna upplevde utredningen. Det var flera delar som blev tydliga, men det övergripande temat som beskrevs var ökad egenkontroll (Empowerment). Patienterna beskrev att de genom utredningen upplevde att de stärktes i sin egenkontroll. Empowerment är en faktor som lyfts fram både när man pratat om försämrad livskvalitet och om stärkt livskvalitet, och nämns ofta som ett viktigt mål när det gäller smärtbehandling.

    Nästa frågeställning var ifall det var kostnadseffektivt att genomföra denna typ av utredningar. Facettleds-relaterade besvär utgör enbart 30-50% av orsakerna till smärtor, men det är först när vi genomför diagnostiska blockader det går identifiera vilka dessa är, så många patienter måste utredas för att en mindre mängd ska kunna få behandling. Vi genomförde därför en studie där vi inkluderade kostnaderna för alla patienter som utreddes (873 st), och alla blockader och besök dessa genomgick. Vi hämtade uppgifter från socialstyrelsen över medicinering och sjukvårdskonsumtion och lade in förändringarna i kostnadsberäkningarna. Sedan satte vi detta i relation till den genomsnittliga förbättring av livskvaliteten vi såg hos de 331 patienter som behandlades. Det mått man då får fram, kostnad per kvalitets-justerat levnadsår (QALY), använder Socialstyrelsen för bedömning av i princip all sjukvård i Sverige. Vi beräknade kostnaden till 220 tkr/QALY, och det räknas med Socialstyrelsens terminologi som en ”moderat” kostnad.

    Följdfrågan blir naturligtvis hur denna typ av utredning/behandling står sig jämfört med gängse behandling, dvs smärtrehabilitering. Att genomföra en randomiserad studie där patienter slumpmässigt fördelas till smärtrehabilitering respektive interventionell behandling är inte praktiskt genomförbar. Istället har vi efterliknat samma procedur genom att vikta resultaten med hjälp av s.k. propensity score. På det sättet får man jämförbara patientgrupper där de 254 patienter som genomgått behandling för facettleds-smärta jämförs mot 15 357 patienter som genomgått smärtrehabilitering under samma period. Kostnader räknades på samma sätt som i den föregående studien, men den här gången tog vi även in data över sjukskrivning från Försäkringskassan. Interventionell smärtbehandling resulterade i en förbättring av 0.186 kvalitetsjusterade levnadsår (QALY) per individ efter 1 år medan smärtrehabilitering resulterade i 0.164 QALY per person efter 1 år. Kostnaden per QALY var för interventionell behandling 119 tkr (”Moderat” kostnad) och för smärtrehabilitering 1 187 tkr (”Mycket hög” kostnad). Förlängs uppföljningsperioden till 2 år så sjönk kvoten för interventionell smärtbehandling till 49 tkr/QALY (”Låg”) och smärtrehabilitering till 553 tkr/QALY (”Hög”). 

    Idag utgör interventionell smärtbehandling 2% av den specialiserade smärtvården. Om andelen skulle öka till 25% skulle man årligen spara motsvarande 106 millioner kr samtidigt som hälsovinsten skulle bli ca 14 QALY/år. Om en interventionell utredning genomförs tidigt så finns det även förutsättningar för att behandlingsbara patienter kan tas bort från dem som behöver smärtrehabilitering, vilket kan ge ytterligare besparingseffekter.

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  • 4.
    Hambraeus, Johan
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Smartkliniken Eques Indolor, Vallentuna, Sweden.
    Ehsanian, Reza
    Division of Physical Medicine and Rehabilitation, Department of Orthopaedics and Rehabilitation, University of New Mexico School of Medicine, NM, Albuquerque, United States.
    Cheng, David S.
    Department of Neurological Surgery, University of Southern California, CA, Los Angeles, United States.
    McKenna, Michael J.
    Dr. Michael J. Mckenna, MD, NV, Las Vegas, United States.
    McCormick, Zachary L.
    Division of Physical Medicine and Rehabilitation, University of Utah, UT, Salt Lake City, United States.
    Inadequate Selection and Treatment Results in Poor Outcomes and Lack of Cost-Effectiveness2021Ingår i: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 24, nr 8, s. 1234-1235Artikel i tidskrift (Refereegranskat)
  • 5.
    Hambraeus, Johan
    et al.
    Smartkliniken Eques Indolor AB, Vallentuna, Sweden.
    Hambraeus, Kjerstin S.
    Smartkliniken Eques Indolor AB, Vallentuna, Sweden.
    Persson, Jan
    Department of Anesthesia and Intensive Care, Pain Clinic, Karolinska University Hospital, Stockholm, Sweden.
    Radiofrequency denervation improves health-related quality of life in patients with thoracic zygapophyseal joint pain2017Ingår i: Pain medicine, ISSN 1526-2375, E-ISSN 1526-4637, Vol. 19, nr 5, s. 914-919Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To describe a practical approach for the diagnosis and treatment of thoracic zygapophyseal joint pain and to present preliminary clinical data on the effects of this treatment approach on health-related quality of life.

    Design: An observational study.

    Setting: Specialist outpatient pain clinic in northern Sweden.

    Subjects: Patients with long-term thoracic pain.

    Methods: We describe a method of radiofrequency denervation of thoracic zygapophyseal joints. We compared health-related quality of life between patients who underwent radiofrequency denervation of thoracic zygapophyseal joints and patients who underwent radiofrequency denervation for lumbar and cervical zygapophyseal joint pain.

    Results: Treatment according to the Spine Intervention Society Guidelines was performed on the lumbar region in 178 patients and in the cervical region in 55 patients. Another 82 patients were treated in the thoracic region with our proposed technique. A survival plot of improvements in health-related quality of life revealed that all three treatments were effective in 65% or more of patients. The improvement in health-related quality of life was maintained for 12 or more months after treatment in 47% to 51% of patients.

    Conclusions: Our results suggest that radiofrequency denervation of thoracic zygapophyseal joint pain is as effective as radiofrequency denervation, the standard treatment, for lumbar and cervical zygapophyseal joint pain. If these results can be confirmed by other centers, radiofrequency denervation is likely to become more widely available for the treatment of thoracic zygapophyseal joint pain.

  • 6.
    Hambraeus, Johan
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Hambraeus, Kjerstin S.
    Sahlen, Klas-Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Patient perspectives on interventional pain management: thematic analysis of a qualitative interview study2020Ingår i: BMC Health Services Research, E-ISSN 1472-6963, Vol. 20, nr 1, artikel-id 604Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Chronic pain is a widespread problem that is usually approached by focusing on its psychological aspects or on trying to reduce the pain from the pain generator. Patients report that they feel responsible for their pain and that they are disempowered and stigmatized because of it. Here, we explored interventional pain management from the patient’s perspective to understand the process better.

    Methods: A purposive sample of 19 subjects was interviewed by an independent interviewer. The interviews were transcribed into text and thematic analysis was performed.

    Results: The subjects’ perceptions covered three key themes: themselves as objects; the caregivers, including the process of tests and retests, the encounters and interactions with professionals, and the availability of the caregivers; and finally the outcomes, including the results of the tests and treatments and how these inspired them to think of other people with pain. Linking these themes, the subjects reported something best described as “gained empowerment” during interventional pain management; they were feeling heard and seen, they gained knowledge that helped them understand their problem better, they could ask questions and receive answers, and they felt safe and listened to.

    Conclusions: Many of the themes evolved in relation to the subjects’ contact with the healthcare services they received, but when the themes were merged and structured into the model, a cohesive pattern of empowerment appeared. If empowerment is a major factor in the positive effects of interventional pain management, it is important to facilitate and not hinder empowerment.

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  • 7.
    Hambraeus, Johan
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Smartkliniken Eques Indolor AB, Vallentuna, Sweden.
    Norström, Fredrik
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Cost-effectiveness of radiofrequency neurotomy to treat zygapophysial joint pain compared with pain rehabilitation programs2022Ingår i: Interventional Pain Medicine, ISSN 2772-5944, Vol. 1, nr 4, artikel-id 100147Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Chronic pain is a widespread condition that causes much suffering and significant cost to society. Pain rehabilitation programs (REH) have dominated the treatment of chronic pain in Sweden in recent decades. Although radiofrequency neurotomy (RFN) was cost-effective in recent studies, the long-term health and economic effects of REH have not been comprehensively evaluated.

    Design: Observational study with propensity score weighting to compare RFN and REH.

    Methods: Patients assessed and treated between 2010 and 2016 were eligible; 15,357 underwent REH and 254 underwent RFN. Patient data were combined with linked data from national registers. We used propensity score weighting to mimic a randomized controlled trial using baseline gender, age, and baseline health-related quality of life as covariates.

    Results: Health-related quality of life improved significantly in both groups, by 0.164 and 0.352 quality-adjusted life years (QALYs) at 1 and 2 years after REH, and by 0.186 and 0.448 QALYs after RFN. The assessment and diagnostic procedures were slightly more expensive for RFN, but the treatment costs were greater for REH. Sick leave decreased after treatment in both groups, particularly after RFN. The cost per QALY gained 1 year after REH was ∼121,633 USD, which is considered "very expensive" according to the Swedish National Board of Health and Welfare. By comparison, the cost of RFN was ∼13,715 USD, in the "moderate" range. After 2 years the cost per QALY gained was in the "moderate" range for REH and "low" for RFN.

    Conclusions: RFN and REH improved health-related quality of life, with significantly greater improvement with RFN. The treatments were comparable based on propensity score weighting, and RFN was cost-effective in the moderate to low range, whereas REH was considered very expensive to moderate. Expanding RFN from 2% currently to 25% of the treatments given in Sweden could save ∼21.2 million USD annually in healthcare expenditure.

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  • 8.
    Hambraeus, Johan
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Cost-effectiveness of Radiofrequency Denervation for Zygapophyseal Joint Pain2021Ingår i: Pain Physician, ISSN 1533-3159, E-ISSN 2150-1149, Vol. 24, nr 8, s. E1205-E1218Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Chronic pain is a leading cause of disability. Radiofrequency denervation (RFD) is effective when performed according to guidelines for patients with correctly diagnosed zygapophyseal joint pain (ZJP). However, the cost-effectiveness of this method has not been fully explored.

    OBJECTIVE: The aim of this study was to analyze whether RFD is cost-effective for ZJP from a societal perspective.

    STUDY DESIGN: Cost effectiveness study based on an observational study.

    SETTING: An interventional pain management clinic in central Sweden.

    METHODS: Patients - This cost-effectiveness study was performed for all patients (n = 873) assessed between 2010 and 2016 at a specialized interventional pain clinic in Sweden. Those diagnosed with ZJP (n = 331, 37.9%) were treated with RFD and followed up for 1 year after the RFD. Using data collected from national registers, we determined the health care costs, medication costs, the patients' time and travel costs, and the patients' ability to work. The effects of RFD on quality-adjusted life years (QALY) and cost/QALY gained were calculated.

    RESULTS: On average, patients reported very low health-related quality of life (HRQoL; EQ-5D index: 0.212). After RFD, HRQoL increased significantly to 0.530 (P < 0.0001). Drug consumption and specialized health care consumption were reduced by 54% and 81%, respectively, and the cost/QALY gained from a societal perspective was 221,324 Swedish krona (USD ~26,008). The sensitivity analysis showed that the treatment was cost-effective in all scenarios evaluated, using the patients as their own controls. The cost/QALY gained from a health care perspective was 72,749 Swedish krona (USD ~8,548).

    LIMITATIONS: The results are based on data collected at one center. The results need to be compared with those from pain rehabilitation programs and should be confirmed using data from other centers.

    CONCLUSIONS: Patients referred for RFD in Sweden report extremely low HRQoL. HRQoL significantly increased following RFD in patients with ZJP. Medications and health care consumption decreased after RFD. RFD was cost-effective, and the sensitivity analysis yielded stable results in different scenarios. Therefore, RFD is a cost-effective treatment that meets the Swedish National Board of Health and Welfare criteria for a high priority treatment.

    TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (NCT01835704) with Protocol ID SE-Dnr-2012-446-31M-1.  https://clinicaltrials.gov/ct2/show/NCT01835704.

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  • 9.
    Hambraeus, Johan
    et al.
    Smärtkliniken i Umeå, Umeå, Sweden.
    Westergren, Hans
    Section for Specialized Pain Rehabilitation, Department of Rehabilitation Medicine , Skåne University Hospital and Department of Health Sciences, Lund University, Lund, Sweden.
    Treatment of post-traumatic pain, and autonomic and muscular dysfunction by ganglion impar block and medial branch block of the facet joints: A case report2012Ingår i: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 3, nr 4, s. 228-240Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: Patients exposed to whiplash trauma are at risk of developing pain and dysfunction of the neck and shoulder. Although rarely discussed in the literature, some patients also develop autonomic dysfunction.

    Case presentation: A previously healthy 41-year-old woman was involved in a “head-on” car crash. During the following 3 years she developed severe and complex post-traumatic pain syndrome, which consisted of neck pain, lumbar pain, sensory-motor dysfunction, and myoclonic muscular contractions. Despite pharmacotherapy, physiotherapy, and rehabilitation, her condition worsened, resulting in severe disability. Fourteen years after the car crash, an interventional pain therapy program was started, which consisted of sympathetic ganglion impar block and medial branch blocks of facet joints at different levels. These treatment strategies ultimately normalized her sensory-motor dysfunction, reduced her autonomic dysfunction, and stopped the myoclonic muscular contractions.

    Conclusion: This case highlights a possible interaction between the pain-generating facet joints, the somatosensory nervous system, and the autonomic/sympathetic nervous systems. The case also highlights the importance of identifying autonomic dysfunction in patients with persisting pain syndromes.

    Implications: This complex case shows that many clinical phenomena cannot be explained using our present knowledge of pain mechanisms. We hope that readers who have observed similar cases can learn from our case, and are encouraged to publish their observations.

  • 10.
    Li, Quan-Gen
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Virologi.
    Hambraeus, Johan
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Virologi.
    Wadell, Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Virologi.
    Genetic relationship between thirteen genome types of adenovirus 11, 34, and 35 with different tropisms1991Ingår i: Intervirology, ISSN 0300-5526, E-ISSN 1423-0100, Vol. 32, nr 6, s. 338-350Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Eleven genome types of adenovirus serotype 11 (Ad11) were identified among 20 strains isolated from healthy pregnant women and patients with urinary tract infections, respiratory tract infections, or pharyngoconjunctival fever by use of 13 restriction endonucleases: BamHI, BclI, BglI, BglII, BstEII, EcoRI, HindIII, HpaI, PstI, SalI, SmaI, XbaI, and XhoI. All genome types could be grouped into three genomic clusters according to their genetic homology expressed as pairwise comigrating restriction fragments. The genome types within a genomic cluster were very closely related. They shared on an average pairwise comigrating restriction fragments of 91.6-97.7%. The Ad11 strains of genomic clusters 1 and 3 were isolated from urine, whereas all the Ad11 strains isolated from the respiratory tract were identified as members of the genomic cluster 2. One genome type of Ad34 and one genome type of Ad35 were identified from a hemorrhagic cystitis patient and an organ transplant recipient, respectively. Both were closely related to Ad11. The genome type of Ad35 could be located in the Ad11 genomic cluster 1.

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