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41.
  • Andersson, Jonas, 1977- (författare)
  • Inflammation and lifestyle in cardiovascular medicine
  • 2010
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • <p>Despite major advances in the treatment and prevention of atherosclerosis the last several decades, cardiovascular disease still accounts for the majority of deaths in Sweden. With the population getting older, more obese and with rising numbers of diabetics, the cardiovascular disease burden may increase further in the future.</p> <p>The focus in cardiovascular disease has shifted with time from calcification and narrowing of arteries to the biological processes within the atherosclerotic plaque. C-reactive protein (CRP) has emerged as one of many proteins that reflect a low grade systemic inflammation and is suitable for analysis as it is more stable and easily measured than most other inflammatory markers. Several large prospective studies have shown that CRP is not only an inflammatory marker, but even a predictive marker for cardiovascular disease. C-reactive protein is associated with several other risk factors for cardiovascular disease including obesity and the metabolic syndrome.</p> <p>Our study of twenty healthy men during a two week endurance cross country skiing tour demonstrated a decline in already low baseline CRP levels immediately after the tour and six weeks later.</p> <p>In a study of 200 obese individuals with impaired glucose tolerance randomised to a counselling session at their health care centre or a one month stay at a wellness centre, we found decreased levels of CRP in subjects admitted to the wellness centre. The effect remained at one, but not after three years of follow-up.</p> <p>In a prospective, nested, case-referent study with 308 ischemic strokes, 61 intracerebral haemorrhages and 735 matched referents, CRP was associated with ischemic stroke in both uni- and multivariate analyses. No association was found with intracerebral haemorrhages. When classifying ischemic stroke according to TOAST criteria, CRP was associated with small vessel disease. The CRP 1444 (CC/CT vs. TT) polymorphism was associated with plasma levels of CRP, but neither with ischemic stroke nor with intracerebral haemorrhage.</p> <p>A study on 129 patients with atrial fibrillation was used to evaluate whether inflammation sensitive fibrinolytic variables adjusted for CRP could predict recurrence of atrial fibrillation after electrical cardioversion. In multivariate iv models, lower PAI-1 mass was associated with sinus rhythm even after adjusting for CRP and markers of the metabolic syndrome.</p> <p>In conclusion, lifestyle intervention can be used to reduce CRP levels, but it remains a challenge to maintain this effect. CRP is a marker of ischemic stroke, but there are no significant associations between the CRP1444 polymorphism and any stroke subtype, suggesting that the CRP relationship with ischemic stroke is not causal. The fibrinolytic variable, PAI-1, is associated with the risk of recurrence of atrial fibrillation after electrical cardioversion after adjustment for CRP. Our findings suggest a pathophysiological link between atrial fibrillation and PAI-1, but the relation to inflammation remains unclear.</p>
42.
  • Andersson, Jonas, 1975- (författare)
  • Ion recombination in liquid ionization chambers development of an experimental method to quantify general recombination
  • 2013
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • <p>An experimental method (the two-dose-rate method) for the correction of general recombination losses in liquid ionization chambers has been developed and employed in experiments with different liquids and radiation qualities. The method is based on a disassociation of initial and general recombination, since an ionized liquid is simultaneously affected by both of these processes.</p><p>The two-dose-rate method has been compared to an existing method for general recombination correction for liquid ionization chambers, and has been found to be the most robust method presently available.</p><p>The soundness of modelling general recombination in liquids on existing theory for gases has been evaluated, and experiments indicate that the process of general recombination is similar in a gas and a liquid. It is thus reasonable to employ theory for gases in the two-dose-rate method to achieve experimental corrections for general recombination in liquids. There are uncertainties in the disassociation of initial and general recombination in the two-dose-rate method for low applied voltages, where initial recombination has been found to cause deviating results for different liquids and radiation qualities.</p><p>Sensitivity to ambient electric fields has been identified in the microLion liquid ionization chamber (PTW, Germany). Experimental data may thus be perturbed if measurements are conducted in the presence of ambient electric fields, and the sensitivity has been found to increase with an increase in the applied voltage. This can prove to be experimentally limiting since general recombination may be too severe for accurate corrections if the applied voltage is low.</p>
43.
  • Andersson, Kennet, 1979- (författare)
  • Assessment of cerebrospinal fluid system dynamics novel infusion protocol, mathematical modelling and parameter estimation for hydrocephalus investigations
  • 2011
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • <p>Patients with idiopathic normal pressure hydrocephalus (INPH) have a disturbance in the cerebrospinal fluid (CSF) system. The treatment is neurosurgical – a shunt is placed in the CSF system. The infusion test is used to assess CSF system dynamics and to aid in the selection of patients that will benefit from shunt surgery. The infusion test can be divided into three parts: a mathematical model, an infusion protocol and a parameter estimation method. A non-linear differential equation is used to mathematically describe the CSF system, where two important parameters are the outflow conductance (<em>C</em><sub>out</sub>) and the Pressure Volume Index (PVI). These are used both for clinical and research purposes. The analysis methods for the non-linear CSF system have limited the infusion protocols of presently used infusion investigations. They come with disadvantages such as long investigation time, no estimation of PVI and no measure of the reliability of the estimates.</p><p>The aim of this dissertation was to develop and evaluate novel methods for infusion protocols, mathematical modelling and parameter estimation methods for assessment of CSF system dynamics.</p><p>The infusion protocols and parameter estimation methods in current use, constant pressure infusion (CPI), constant infusion and bolus infusion, were investigated. The estimates of <em>C</em><sub>out</sub> were compared, both on an experimental set-up and on 20 INPH patients. The results showed that the bolus method produced a significantly higher <em>C</em><sub>out</sub> than the other methods. The study suggested a method with continuous infusion for estimating <em>C</em><sub>out</sub> and emphasized that standardization of <em>C</em><sub>out</sub> measurement is necessary.</p><p>The non-linear model of the CSF system was further developed. The ability to model physiological variations that affect the CSF system was incorporated into the model and it was transformed into a linear time-invariant system. This enabled the use of methods developed for identification of such systems. The underlying model for CSF absorption was discussed and the effect of baseline resting pressure (<em>P</em><sub>r</sub>) in the analysis on the estimation of <em>C</em><sub>out</sub> was explored using two different analyses, with and without <em>P</em><sub>r</sub>.</p><p>A novel infusion protocol with an oscillating pressure pattern was introduced. This protocol was theoretically better suited for the CSF system characteristics. Three new parameter estimation methods were developed. The adaptive observer was developed from the original non-linear model of the CSF system and estimated <em>C</em><sub>out</sub> in real time. The prediction error method (PEM) and the robust simulation error (RSE) method were based on the transformed linear system, and they estimated both <em>C</em><sub>out</sub> and PVI with confidence intervals in real time. Both the oscillating pressure pattern and the reference CPI protocol were performed on an experimental set-up of the CSF system and on 47 hydrocephalus patients. The parameter estimation methods were applied to the data, and the RSE method produced estimates of <em>C</em><sub>out</sub> that were in good agreement with the reference method and allowed for an individualized and considerably reduced investigation time.</p><p><strong>In summary</strong>, current methods have been investigated and a novel approach for assessment of CSF system dynamics has been presented. The Oscillating Pressure Infusion method, which includes a new infusion protocol, a further developed mathematical model and new parameter estimation methods has resulted in an improved way to perform infusion investigations and should be used when assessing CSF system dynamics. The advantages of the new approach are the pressure-regulated infusion protocol, simultaneous estimation of <em>C</em><sub>out</sub> and PVI and estimates of reliability that allow for an individualized investigation time.</p>
44.
  • Andersson, Karin (författare)
  • Prefibrillar oligomeric Transthyretin mutants - amyloid conformation, toxicity and association with Serum amyloid P component
  • 2005
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • <p>Amyloidoses represent a heterogeneous group of diseases characterized by abnormal protein metabolism leading to extracellular deposition of fibrillar, proteinaceous amyloid in various tissues and organs of the body. To date more than 20 different proteins have been linked to diseases with amyloid depositions, of which Alzheimer’s disease and the prion-associated diseases are the most well known. Despite the origin of protein in the amyloid, the fibrils share some common biochemical and biophysical properties such as a diameter of 8-13 nm, a β-pleated sheet secondary structure packed in an ordered crystal-like way, Congo red and thioflavin binding with characteristic spectroscopic patterns and decoration of the fibrils with Serum amyloid P component and glycoseaminoglycans.</p><p>The plasma protein transthyretin (TTR) is associated with familial amyloidosis with polyneuropathy (FAP) and senile systemic amyloidosis (SSA). FAP is a lethal, autosomal inherited disorder caused by point mutations in the TTR-gene. More than 80 different mutations have been associated with amyloid formation and linked to FAP. The interpretation is that amino acid replacements at different sites of the polypeptide lead to reduced stability. Mutant TTR were constructed that have a strong tendency to self-aggregate under physiological conditions. The precipitates were shown to be amyloid by staining with thioflavin T and Congo red. As the mutants were sensitive to trypsin cleavage compared to plasma TTR, we suggest that the mutants represent amyloid precursors or that they may share structural properties with intermediates on a pathway leading to amyloid deposition. Monoclonal antibodies were generated that exclusively recognize the amyloidogenic folding of TTR providing direct biochemical evidence for a structural change in amyloidogenic intermediates. Two cryptic epitopes were mapped to a domain of TTR, where most mutations associated with amyloidosis occur and is proposed to be displaced at the initial phase of amyloid formation. Amyloidogenic intermediates of TTR were shown to induce a toxic, free radical dependent, response in cultured neuroblastoma cells. Morphological studies revealed a correlation between toxicity (apoptosis) and the presence of immature amyloid suggesting that mature full-length fibrils represent an inert end stage, which might serve as a rescue mechanism.</p><p>Serum amyloid P component (SAP) is a highly conserved plasma glycoprotein universally found associated with amyloid depositions independently of protein origin. SAP’s role in amyloid formation is contradictory since both inhibition and promotion of aggregation have been shown in the case of fibril formation from the Aβ peptide of Alzheimer’s disease. Amyloidogenic prefibrils of TTR were shown to bind SAP and no interference with aggregation was detected. SAP co-localize in patches with mutant TTR on the surface of neuroblastoma cells and prevent apoptosis induced by mutant TTR and Aβ peptide, while several other molecules known to decorate amyloid fibrils were without effect.</p>
45.
  • Andersson, Liselott, 1961- (författare)
  • Implications of psychiatric disorders during pregnancy and the postpartum period - A population-based study
  • 2004
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • <p>Background: Depressive and anxiety disorders are common health problems, affecting women at least twice as often as men. Although some studies have been made on pregnant women or, especially, in the postpartum period, most of these studies have been performed on small samples, mainly specific risk groups such as teenage mothers, women of low socioeconomic status and certain ethnic groups. Also, there is a lack of studies on antenatal and postpartum depression and/or anxiety using diagnostic criteria adhering to the Diagnostic and Statistical Manual of Mental disorders, fourth edition (DSM-IV).</p> <p>Aims and methods: The aims were to estimate the point prevalence of mood, anxiety and eating disorders, based on DSM-IV criteria, in an unselected population during the second trimester of pregnancy, and to assess the obstetric and neonatal outcome, as well as the health care consumption during pregnancy, delivery and the early postpartum period among women with a psychiatric disorder, compared to healthy subjects. Finally, we aimed to investigate depression and anxiety, and associated maternal characteristics and events through pregnancy and the postpartum period in the same group of women. The Primary Care Evaluation of Mental Disorders (PRIME-MD) was used for assessment of psychiatric disorders during the second trimester of pregnancy and three to six months after delivery. From October 2nd, 2000, to October 1st, 2001 all women attending the second trimester routine ultrasound-screening at two different hospitals in northern Sweden (at Umeå University Hospital and at Sunderby Central Hospital) were approached for participation in the study. After delivery, data were extracted from the medical records of the mothers and their offspring to evaluate obstetric and neonatal outcome. Three to six months after delivery, the women who had an antenatal depression and/or anxiety were contacted for an assessment using the PRIME-MD. The same procedure was made in a control group, consisting of 500 women, randomly selected among those who did not have any psychiatric diagnosis according to the PRIME-MD investigation during the second trimester of pregnancy.</p> <p>Results and conclusions: Of the 1555 women in the study population, 220 (14.1%) had one or more PRIME-MD diagnoses. Living single, low socioeconomic status, smoking, multiparity and a body mass index of 30 or more were significantly associated with a psychiatric diagnosis in the second trimester of pregnancy. Women with antenatal depression and/or anxiety more often suffered from nausea and vomiting during pregnancy were more often on sick leave, and they visited their obstetrician more often than healthy subjects, specifically because of fear of childbirth and premature contractions. Also, they were more commonly delivered by elective caesarean section, had an increased use of epidural analgesia and reported a longer self-experienced duration of labor. Severe complications of pregnancy, delivery, and the early postpartum period were not affected by antenatal depression and/or anxiety. There was no significant difference in neonatal outcome depending on antenatal depressive or anxiety disorder. Fewer cases of depressive and/or anxiety disorders were prevalent postpartum, but there was a significant shift from a majority of sub-threshold diagnoses during pregnancy to full DSM-IV diagnoses during the postpartum period. Previous psychiatric disorder and living singly were significantly associated with both a new-onset and a postpartum continuation/recurrence of depression and/or anxiety. Postpartum continuation/recurrence of a psychiatric disorder was additionally associated with smoking, obesity, and adverse obstetric events.</p>
46.
  • Andersson, Martin, 1979- (författare)
  • Asthma in school age prevalence, incidence and remission in relation to environmental determinants
  • 2013
  • Ingår i: OLIN-studierna. - Umeå : Umeå Universitet. - 978-91-7459-595-6
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • <p><strong>Background </strong>In the past half-century, the prevalence of asthma among children and adolescents has risen and asthma has become an important public health challenge in Sweden as well as in many other countries, necessitating further studies on this complex disease and its risk factor pattern. The studies included in this thesis aimed to investigate the clinical expression of childhood asthma over time, to describe the determinants of new-onset and remission of asthma, and to evaluate possible environmental risk factors in northern Sweden.</p><p><strong>Methods </strong>As the result of a repeated questionnaire survey among primary school children aged 7-8 years in three municipalities in the north of Sweden, two pediatric cohorts were formed, one in 1996 (<em>n</em>=3430) and one in 2006 (<em>n</em>=2585). The cohort created in 1996 was followed annually until the age of 19 years. Skin prick testing was performed on children in both cohorts. Lung function and bronchial hyperreactivity testing were carried out in children with asthma in the first cohort. The study participation and retention rates were very high in both cohorts. Among children in the second cohort living in Luleå, the home addresses were assigned to coordinates in a geographical information system (GIS) to evaluate the impact on respiratory health of living near roads with much traffic, which was measured as the number of vehicles daily. We used a validated reported diagnosis of asthma and International Study of Asthma and Allergies in Childhood (ISAAC) questions were incorporated into the questionnaire. A cross-sectional study of children of the same age ten years apart, longitudinal studies on asthma incidence and remission as well as a cross-sectional study on vehicle traffic were performed.</p><p><strong>Results </strong>While children aged 7-8 years in 2006 more often had a physician-diagnosed asthma compared to children of the same age in 1996 (7.4% vs 5.7%, p&lt;0.001), they had less asthma symptoms, especially severe symptoms. In parallel, a more beneficial environment and a more intense treatment with inhaled corticosteroids (ICS) were observed. The explanation for this change in clinical expression probably includes also an increased awareness and diagnosing of asthma. From age 12 years to age 19 years, the cumulative incidence of physician-diagnosed asthma was 7.2% and of current wheeze 22.0%. The risk of new-onset asthma in adolescence was increased among girls, sensitized and those with heredity for asthma. Smoking and home dampness increased the risk for incident wheeze. The risk for both incident asthma and wheeze was inversely related to number of siblings. Among children with current asthma at age 7-8 years, 21% were in remission, 38% had periodic asthma and 41% had persistent asthma at a follow-up at age 19 years. Subjects in remission and with periodic asthma had significantly less airway obstruction and showed less bronchial hyperreactivity compared to subjects with persistent asthma. The probability of asthma remission from childhood to early adulthood was significantly increased by absence of allergic sensitization, male gender and a low asthma severity scoring at age 7-8 years. Sensitization to furred animals was more important as a determinant of both incidence and remission than sensitization to pollen. Living close to roads with high traffic flows, especially with heavy vehicles, was associated with an increased risk for current wheeze. Stratified analyses showed that the effect of traffic on asthma and wheeze was restricted to non-sensitized subjects.</p><p><strong>Conclusion </strong>Asthma onset in adolescence was more common among girls and remission was more common among boys. Children sensitized to furred animals and children with a more severe asthma were risk groups for persistence of asthma. Environmental factors such as smoking and dampness were associated to onset of asthma symptoms during adolescence, and vehicle traffic was associated with asthma symptoms among children also in a small city with relatively low traffic flows. Preventive measures like smoking reduction programs, improvement of damp housing conditions and separation of areas where many children live from heavily trafficked roads could prove to be beneficial.</p>
47.
  • Andersson, Marie, 1962- (författare)
  • Immunopathogenesis of relapsing fever borreliosis
  • 2008
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • <p>Relapsing fever (RF) is caused by different species of Borrelia transmitted by soft ticks or by the human body louse. Illness is characterized by reappearing peaks of high concentrations of spirochetes in blood, concordant with fever peaks separated by asymptomatic periods. Neuroborreliosis is one of the most severe manifestations of RF borreliosis. To understand the immune response during early RF, we analyzed immune cells in brain and kidney of mice infected with B. crocidurae during the acute infection. Our results indicate that brain defense is comprised primarily of innate immune cells. Despite the infiltration of innate immune cells, Borrelia was not completely eradicated. A failure of the host brain to clear the bacteria may give the pathogen a niche where it can persist. Using our mouse model, we revealed that Borrelia duttonii could persist in the mouse brain for up to 270 days, without being present in the circulation. The infection was silent with no change in host gene expression, and the spirochetes could re-enter the circulation after immunosuppression. We propose that the brain is used by the pathogen to evade host immunity and serves as a possible natural reservoir for B. duttonii, a spirochete that has rarely been found in any mammalian host other than man. Borrelia-induced complications during pregnancy have been reported, and are especially common in RF. In our established mouse model of gestational RF, we could show that the fetuses suffered from severe pathology and growth retardation, probably as a consequence of placental destruction. We could also show trans-placental transmission of the bacteria leading to neonatal RF. Surprisingly, pregnant dams had a lower bacterial load and less severe disease, showing that pregnancy has a protective effect during RF. We have used the gestational RF model to investigate host factors favoring disease resolution. Because the spleen is the primary organ responsible for trapping and removing blood-borne pathogens, we have compared temporal changes in spleen immune cell populations and cytokine/chemokine induction during the infection. Spleens of pregnant mice had earlier neutrophil infiltration, as well as faster and higher production of pro-inflammatory mediators. This rapid, robust response suggests a more effective host defense. Thus, an enhanced pro-inflammatory response during pregnancy imparts a distinct advantage in controlling the severity of relapsing fever infection.</p>
48.
  • Andersson, Nina, 1976- (författare)
  • Cerebrospinal fluid infusion methods development and validation on patients with idiopathic normal pressure hydrocephalus
  • 2007
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • <p>Cerebrospinal fluid (CSF) infusion tests can be used to estimate the dynamic properties of the CSF system. Idiopathic normal pressure hydrocephalus (INPH) is a syndrome signified by a disturbance to the CSF system, where the cause is unknown and the diagnosis is difficult to determine. As an aid in identifying patients with INPH who will improve after shunt surgery, infusion tests are commonly used to determine the outflow conductance (C<sub>out</sub>), or outflow resistance (R<sub>out</sub>=1/C<sub>out</sub>), of the CSF system. The tests are also used to determine shunt function in vivo. The general aim of this thesis was to develop and validate CSF infusion methods, to investigate the dynamics of the CSF system. The methods should be applicable to patients with INPH, to aid in the quest to further improve the diagnosis and management of this syndrome.</p><p>An existing mathematical model describing the dynamics of the CSF system was further developed. The characteristics of the model were verified and the effect of expanding intracranial air on the intracranial pressure (ICP) was simulated. The simulations supported the recommendation to maintain sea-level pressure during air ambulance transportation of patients with suspected intracranial air.</p><p>A recently developed infusion apparatus was evaluated, on an experimental model as well as on a patient material. The repetitiveness in estimating C<sub>out</sub> was found to be good. A statistically significant difference was found between the repeated C<sub>out</sub> estimations in the patient group, indicating that there might have been a small physiological change introduced during the infusion test. A parameter, ∆C<sub>out</sub>, was proposed and evaluated. It proved to reflect the reliability of individual C<sub>out</sub> investigations in a clinically useful way, as well as to provide easily interpreted information.</p><p>An adaptive algorithm for assessment of C<sub>out</sub> was developed and evaluated on a patient group. The new algorithm was shown to reduce the investigation time, from 60 minutes, by 14.3 ± 5.9 minutes (mean ± SD), p&lt;0.01, without reducing the reliability of the estimated C<sub>out</sub> below clinically relevant levels.</p><p>The relationship between ICP and CSF outflow was studied in a group of patients investigated for INPH. It was found that in the range of moderate increase from baseline pressure, the assumption of a pressure independent R<sub>out</sub> was confirmed (p=0.5). However, at larger pressure increments, the relationship had a non-linear tendency (p&lt;0.05). This indicates that the traditional view of a pressure independent R<sub>out</sub> might have to be questioned in the region where ICP exceeds baseline pressure too much.</p><p>Infusion tests can be performed in different ways, where three main categories may be distinguished. The bolus infusion method was compared to the constant pressure and constant flow infusion methods, on an experimental model as well as on a patient material. When physiological pressure fluctuations were added to the model, significant differences were found in the determination of C<sub>out</sub> in the range of clinical importance, i.e. low C<sub>out</sub> (p&lt;0.05). The finding was supported by the patient investigations, the difference was however not significant.</p><p>With the application of the new methods developed in this thesis, and the increased knowledge concerning relationships between CSF dynamic parameters, the CSF infusion test was further improved with the ability to increase measurement reliability in a reduced time. This constitutes a good basis to perform a large multi-centre study with the main goal to determine the predictive value of the parameter C<sub>out</sub>.</p>
49.
50.
  • Andersson, Sven-Olof, 1943- (författare)
  • Time and general practice consultations aspects of length, attendance and quality
  • 1995
  • Ingår i: digitalisering@umu. - Umeå : Umeå universitet. - 91-7191-085-9
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • <p>The consultation is the GP’s form of work. How long a consultation should be, and what short/long consultations imply with regard to the satisfaction of patient and doctor has been much debated. The aim of this thesis was to study consultations with regard to content and time consumption in a short term and long term perspective. Three studies were carried out.</p><p>1. Consultations with the members of a group of GPs were investigated, where patients and doctors separately assessed different aspects of the consultation, and their ratings were related to the real length of the consultations. The following questions were posed: Was there time enough? Could the patient tell the doctor about her/his problems? Were the problems physical or psychological? 2. Nurses at the primary care health centres were interviewed about their considerations in booking short or long appointments for the patients. 3. Patients who frequently attended one health centre during one year and consumed much time were studied. Quantitative and qualitative methods were used.</p><p>The results of the first study (Papers I-III) show that the average length of the consultations was 21 minutes; there was considerable variation (ranging from 3 to 60 minutes). (About 600 consultations with 7 male doctors were registered in two batches). The doctors’ mean consultation length also varied widely, from 13-28 minutes. Consultations dealing with psychological problems were longer than those dealing with physical problems. Older patients had longer consultations than younger patients, and female patients had somewhat longer consultations than male patients. The patients were generally more satisfied with the consultations than the doctors were, and there were no clear affinities between long consultations and high satisfaction. Male patients and patients with physical problems mainly received short consultations, whereas patients with ”mixed" problems and older patients received long consultations.</p><p>The single factors most decisive for the length of a consultation were ‘the doctor factor’, the character of the problem and the age of the patient. "Good” consultations (operational definition) were associated primarily with ‘the doctor factor’, and the real length of the consultations was less important.</p><p>The interviews with ten experienced primary care nurses (Paper IV) showed that the nurses worked in two perspectives: in the ”immediate” perspective, appointments were booked according to rules which directly impacted the length of the visit, and in the "reflective" perspective, appointments were booked with a view to the quality of the work at the health centre and the long-term time consumption. Other factors of importance were the patient’s age and problem(s), the doctor’s experience and working style, and the current situation at the health centre.</p><p>Frequent attenders (FAs) at one health centre (Paper V) were compared with a contrast group of matched patients (CPs). The FAs represented 1.7% of the population of the catchment area and made 15% of the visits. The FAs were a heterogeneous group where small boys, women of working age and pensioners of both sexes were overrepresented. The FAs had higher consultation frequency than the CPs during the year of investigation, but few remained FAs for longer periods. The FAs had more problems and more complex problems than the CPs. Complaints regarding the musculo-skeletal organs, and psychosocial problems were common among these patients, often in combination.</p><p>The present work thus shows that longer consultations do not naturally imply higher patient satisfaction. Other factors than the time factor, in particular ‘the doctor factor’ seem to be more important. ‘The doctor factor’, the characteristics of the patients, the type of problem and the situation at the health centre also have a bearing on consultation length and time consumption in a short-term as well as long-term perspective. The implications of these factors and their relative importance are discussed, but further studies of certain issues, such as ‘the doctor factor’, are necessary.</p>
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