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- Brand, Judith, 1984-, et al.
(författare)
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Maternal smoking during pregnancy and fractures in offspring : national register based sibling comparison study
- 2020
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Ingår i: The BMJ. - : BMJ Publishing Group Ltd. - 1756-1833. ; 368
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To study the impact of maternal smoking during pregnancy on fractures in offspring during different developmental stages of life.DESIGN: National register based birth cohort study with a sibling comparison design.SETTING: Sweden.PARTICIPANTS: 1 680 307 people born in Sweden between 1983 and 2000 to women who smoked (n=377 367, 22.5%) and did not smoke (n=1 302 940) in early pregnancy. Follow-up was until 31 December 2014.MAIN OUTCOME MEASURE: Fractures by attained age up to 32 years.RESULTS: During a median follow-up of 21.1 years, 377 970 fractures were observed (the overall incidence rate for fracture standardised by calendar year of birth was 11.8 per 1000 person years). The association between maternal smoking during pregnancy and risk of fracture in offspring differed by attained age. Maternal smoking was associated with a higher rate of fractures in offspring before 1 year of age in the entire cohort (birth year standardised fracture rates in those exposed and unexposed to maternal smoking were 1.59 and 1.28 per 1000 person years, respectively). After adjustment for potential confounders the hazard ratio for maternal smoking compared with no smoking was 1.27 (95% confidence interval 1.12 to 1.45). This association followed a dose dependent pattern (compared with no smoking, hazard ratios for 1-9 cigarettes/day and >= 10 cigarettes/day were 1.20 (95% confidence interval 1.03 to 1.39) and 1.41 (1.18 to 1.69), respectively) and persisted in within-sibship comparisons although with wider confidence intervals (compared with no smoking, 1.58 (1.01 to 2.46)). Maternal smoking during pregnancy was also associated with an increased fracture incidence in offspring from age 5 to 32 years in whole cohort analyses, but these associations did not follow a dose dependent gradient. In within-sibship analyses, which controls for confounding by measured and unmeasured shared familial factors, corresponding point estimates were all close to null. Maternal smoking was not associated with risk of fracture in offspring between the ages of 1 and 5 years in any of the models.CONCLUSION: Prenatal exposure to maternal smoking is associated with an increased rate of fracture during the first year of life but does not seem to have a long lasting biological influence on fractures later in childhood and up to early adulthood.
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- Britten, Nicky, et al.
(författare)
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Learning from Gothenburg model of person centred healthcare.
- 2020
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Ingår i: BMJ. - : BMJ. - 0959-8138 .- 1756-1833. ; 370
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Tidskriftsartikel (refereegranskat)abstract
- Systematik och en tydlig struktur – det är faktorer som är avgörande i omställningen till personcentrerad vård. I en studie från Göteborgs universitet, publicerad i tidskriften BMJ, speglas nu ett decennium av erfarenheter och forskning i fältet. Förväntningarna växer sig allt starkare på att hälso- och sjukvården ska vara personcentrerad, och därmed ta avstamp i ett partnerskap mellan personal, patient och anhöriga. Samtidigt är det på många håll trögt att införa och upprätthålla detta arbetssätt. Att personcentrerad vård kan minska antalet vårddagar på sjukhus och skapa ökad tilltro till vården är redan känt. Nu gäller det istället att fokusera på hur man går tillväga, menar författarna bakom den övergripande artikeln i BMJ. Studien ger tips och verktyg för fortsatt forskning och utveckling av personcentrering i hälso- och sjukvården. Korresponderande författare är Axel Wolf, docent i vårdvetenskap vid institutionen för vårdvetenskap och hälsa på Sahlgrenska akademin, Göteborgs universitet, och verksam vid Centrum för personcentrerad vård, GPCC. Hela organisationen ska med – Ett av de viktigaste råden är att personcentrerad etik måste praktiseras på ett systematiskt sätt i vardagen. Det innebär att skapa organisatoriska och individuella förutsättningar för utvecklingen av ett partnerskap mellan patient, anhöriga om det är aktuellt, och personal vid varje möte, inte bara när det passar i schemat, säger han, och fortsätter: – För att få bästa kliniska effekt är det viktigt att frågan om personcentrering inte enbart blir något mellan patienten och den enskilde yrkesföreträdaren, utan återfinns i hela organisationen. Det ligger också en stor utmaning i att öka förståelsen för hur personcentrerad vård skiljer sig från nuvarande vårdpraktik. Grundläggande är att representanter från hälso- och sjukvården tar sig tid att lyssna in patientens erfarenheter och mål, som kan handla om att till exempel återgå i arbete eller kunna ta en promenad, och låter dessa mål vara vägledande i den gemensamt överenskomna hälsoplanen. Patientens prioriteringar ska speglas i planen som också ska utvärderas kontinuerligt. Dokumentationen ska sedan följa patienten, även vid övergång från exempelvis sjukhusvård till primärvård eller kommunal omsorg. Hierarkier och låsta roller Sedan starten för tio år sedan har den nationella centrumbildningen GPCC varit ledande aktör i att utveckla, testa, utvärdera och implementera personcentrerad vård i många olika hälso- och sjukvårdssammanhang, nationellt och internationellt. Tillsammans med kollegan Nicky Britten, professor vid University of Exeter, England, har Axel Wolf lett en internationell forskargrupp som har undersökt förutsättningar och hinder som forskare, kliniker och patienter upplevt under kliniska studier inom ramen för GPCC, och vid implementering av forskningsresultat i vardagen. Bland de hinder som beskrivs i den aktuella studien finns hierarkiska vårdstrukturer, låsta yrkesroller och övertygelsen om att man redan jobbar personcentrerat. – I och med omställningen till nära vård, som genomsyras av ett personcentrerat arbetssätt, måste den personcentrerade etiken praktiseras konstant för att få optimala förutsättningar. Det kräver en systematik gällande utbildning, livslångt lärande och verktyg som underlättar partnerskapet, avslutar Axel Wolf.
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- Crump, Casey, et al.
(författare)
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Preterm delivery and long term mortality in women : National cohort and co-sibling study
- 2020
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Ingår i: The BMJ. - : BMJ. - 0959-8146. ; 370
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Tidskriftsartikel (refereegranskat)abstract
- Objectives To examine the long term mortality associated with preterm delivery in a large population based cohort of women, and to assess for potential confounding by shared familial factors. Design National cohort study. Setting Sweden. Participants All 2 189 477 women with a singleton delivery in 1973-2015. Main outcome measures All cause and cause specific mortality up to 2016, identified from nationwide death records. Cox regression was used to calculate hazard ratios while adjusting for confounders, and co-sibling analyses assessed the potential influence of unmeasured shared familial (genetic and environmental) factors. Results In 50.7 million person years of follow-up, 76 535 (3.5%) women died (median age at death was 57.6). In the 10 years after delivery, the adjusted hazard ratio for all cause mortality associated with preterm delivery (<37 weeks) was 1.73 (95% confidence interval 1.61 to 1.87), and when further stratified was 2.20 (1.63 to 2.96) for extremely preterm delivery (22-27 weeks), 2.28 (2.01 to 2.58) for very preterm delivery (28-33 weeks), 1.52 (1.39 to 1.67) for late preterm delivery (34-36 weeks), and 1.19 (1.12 to 1.27) for early term delivery (37-38 weeks) compared with full term delivery (39-41 weeks). These risks declined but remained significantly raised after longer follow-up times: for preterm versusfull term births, 10-19 years after delivery, the adjusted hazard ratio was 1.45 (95% confidence interval 1.37 to 1.53); 20-44 years after delivery, the adjusted hazard ratio was 1.37 (1.33 to 1.41). These findings did not seem to be attributable to shared genetic or environmental factors within families. Several causes were identified, including cardiovascular and respiratory disorders, diabetes, and cancer. Conclusions In this large national cohort of women, the findings suggested that preterm and early term delivery were independent risk factors for premature mortality from several major causes. These associations declined over time but remained raised up to 40 years later.
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- Delicano, Rachel Ann, et al.
(författare)
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The shared risk of diabetes between dog and cat owners and their pets : register based cohort study
- 2020
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Ingår i: The BMJ. - : BMJ. - 1756-1833. ; 371
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To investigate whether dog and cat owners and their pets share a risk of developing diabetes.DESIGN: Cohort study.SETTING: Register based longitudinal study, Sweden.PARTICIPANTS: 208 980 owner-dog pairs and 123 566 owner-cat pairs identified during a baseline assessment period (1 January 2004 to 31 December 2006).MAIN OUTCOME MEASURES: Type 2 diabetes events in dog and cat owners and diabetes events in their pets, including date of diagnosis during the follow-up period (1 January 2007 to 31 December 2012). Owners with type 2 diabetes were identified by combining information from the National Patient Register, the Cause of Death Register, and the Swedish Prescribed Drug Register. Information on diabetes in the pets was extracted from veterinary care insurance data. Multi-state models were used to assess the hazard ratios with 95% confidence intervals and to adjust for possible shared risk factors, including personal and socioeconomic circumstances.RESULTS: The incidence of type 2 diabetes during follow-up was 7.7 cases per 1000 person years at risk in dog owners and 7.9 cases per 1000 person years at risk in cat owners. The incidence of diabetes in the pets was 1.3 cases per 1000 dog years at risk and 2.2 cases per 1000 cat years at risk. The crude hazard ratio for type 2 diabetes in owners of a dog with diabetes compared with owners of a dog without diabetes was 1.38 (95% confidence interval 1.10 to 1.74), with a multivariable adjusted hazard ratio of 1.32 (1.04 to 1.68). Having an owner with type 2 diabetes was associated with an increased hazard of diabetes in the dog (crude hazard ratio 1.28, 1.01 to 1.63), which was attenuated after adjusting for owner's age, with the confidence interval crossing the null (1.11, 0.87 to 1.42). No association was found between type 2 diabetes in cat owners and diabetes in their cats (crude hazard ratio 0.99, 0.74 to 1.34, and 1.00, 0.78 to 1.28, respectively).CONCLUSIONS: Data indicated that owners of a dog with diabetes were more likely to develop type 2 diabetes during follow-up than owners of a dog without diabetes. It is possible that dogs with diabetes could serve as a sentinel for shared diabetogenic health behaviours and environmental exposures.
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- Deschasaux, Melanie, et al.
(författare)
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Association between nutritional profiles of foods underlying Nutri-Score front-of-pack labels and mortality : EPIC cohort study in 10 European countries
- 2020
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Ingår i: The BMJ. - : BMJ Publishing Group Ltd. - 1756-1833. ; 370
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE To determine if the Food Standards Agency nutrient profiling system (FSAm-NPS), which grades the nutritional quality of food products and is used to derive the Nutri-Score front-of-packet label to guide consumers towards healthier food choices, is associated with mortality. DESIGN Population based cohort study. SETTING European Prospective Investigation into Cancer and Nutrition (EPIC) cohort from 23 centres in 10 European countries. PARTICIPANTS 521 324 adults; at recruitment, country specific and validated dietary questionnaires were used to assess their usual dietary intakes. A FSAm-NPS score was calculated for each food item per 100 g content of energy, sugars, saturated fatty acids, sodium, fibre, and protein, and of fruit, vegetables, legumes, and nuts. The FSAm-NPS dietary index was calculated for each participant as an energy weighted mean of the FSAm-NPS score of all foods consumed. The higher the score the lower the overall nutritional quality of the diet. MAIN OUTCOME MEASURE Associations between the FSAm-NPS dietary index score and mortality, assessed using multivariable adjusted Cox proportional hazards regression models. RESULTS After exclusions, 501 594 adults (median follow-up 17.2 years, 8 162 730 person years) were included in the analyses. Those with a higher FSAm-NPS dietary index score (highest versus lowest fifth) showed an increased risk of all cause mortality (n=53 112 events from non-external causes; hazard ratio 1.07, 95% confidence interval 1.03 to 1.10, P(0.001 for trend) and mortality from cancer (1.08, 1.03 to 1.13, P(0.001 for trend) and diseases of the circulatory (1.04, 0.98 to 1.11, P=0.06 for trend), respiratory (1.39, 1.22 to 1.59, P(0.001), and digestive (1.22, 1.02 to 1.45, P=0.03 for trend) systems. The age standardised absolute rates for all cause mortality per 10 000 persons over 10 years were 760 (men=1237; women=563) for those in the highest fifth of the FSAm-NPS dietary index score and 661 (men=1008; women=518) for those in the lowest fifth. CONCLUSIONS In this large multinational European cohort, consuming foods with a higher FSAm-NPS score (lower nutritional quality) was associated with a higher mortality for all causes and for cancer and diseases of the circulatory, respiratory, and digestive systems, supporting the relevance of FSAm-NPS to characterise healthier food choices in the context of public health policies (eg, the Nutri-Score) for European populations. This is important considering ongoing discussions about the potential implementation of a unique nutrition labelling system at the European Union level.
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- Fu, EL, et al.
(författare)
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Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease: nationwide cohort study
- 2021
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Ingår i: BMJ (Clinical research ed.). - : BMJ. - 1756-1833. ; 375, s. e066306-
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Tidskriftsartikel (refereegranskat)abstract
- ObjectiveTo identify the optimal estimated glomerular filtration rate (eGFR) at which to initiate dialysis in people with advanced chronic kidney disease.DesignNationwide observational cohort study.SettingNational Swedish Renal Registry of patients referred to nephrologists.ParticipantsPatients had a baseline eGFR between 10 and 20 mL/min/1.73 m2and were included between 1 January 2007 and 31 December 2016, with follow-up until 1 June 2017.Main outcome measuresThe strict design criteria of a clinical trial were mimicked by using the cloning, censoring, and weighting method to eliminate immortal time bias, lead time bias, and survivor bias. A dynamic marginal structural model was used to estimate adjusted hazard ratios and absolute risks for five year all cause mortality and major adverse cardiovascular events (composite of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) for 15 dialysis initiation strategies with eGFR values between 4 and 19 mL/min/1.73 m2in increments of 1 mL/min/1.73 m2. An eGFR between 6 and 7 mL/min/1.73 m2(eGFR6-7) was taken as the reference.ResultsAmong 10 290 incident patients with advanced chronic kidney disease (median age 73 years; 3739 (36%) women; median eGFR 16.8 mL/min/1.73 m2), 3822 started dialysis, 4160 died, and 2446 had a major adverse cardiovascular event. A parabolic relation was observed for mortality, with the lowest risk for eGFR15-16. Compared with dialysis initiation at eGFR6-7, initiation at eGFR15-16was associated with a 5.1% (95% confidence interval 2.5% to 6.9%) lower absolute five year mortality risk and 2.9% (0.2% to 5.5%) lower risk of a major adverse cardiovascular event, corresponding to hazard ratios of 0.89 (95% confidence interval 0.87 to 0.92) and 0.94 (0.91 to 0.98), respectively. This 5.1% absolute risk difference corresponded to a mean postponement of death of 1.6 months over five years of follow-up. However, dialysis would need to be started four years earlier. When emulating the intended strategies of the Initiating Dialysis Early and Late (IDEAL) trial (eGFR10-14veGFR5-7) and the achieved eGFRs in IDEAL (eGFR7-10veGFR5-7), hazard ratios for all cause mortality were 0.96 (0.94 to 0.99) and 0.97 (0.94 to 1.00), respectively, which are congruent with the findings of the randomised IDEAL trial.ConclusionsVery early initiation of dialysis was associated with a modest reduction in mortality and cardiovascular events. For most patients, such a reduction may not outweigh the burden of a substantially longer period spent on dialysis.
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