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  • Abbott, A, et al. (författare)
  • What biopsychosocial factors are associated with work ability in conservatively managed patients with cervical radiculopathy? A cross-sectional analysis
  • 2020
  • Ingår i: PM&R. - John Wiley & Sons. - 1934-1482. ; 12:1, s. 64-72
  • Tidskriftsartikel (refereegranskat)abstract
    • BackgroundNo previous studies have investigated what biopsychosocial factors are associated with self‐reported work ability in conservatively managed patients with cervical radiculopathy.ObjectiveTo develop a theoretical model of factors and potential processes associated with variation in work ability based on a thorough assessment of biopsychosocial variables in conservatively managed patients with cervical radiculopathy.DesignCross‐sectional observational study.SettingTertiary neurosurgery clinic.PatientsA total of 144 conservatively managed patients with cervical pain and radiculopathy participated in the study.MethodsFrom 64 biopsychosocial candidate variables, significant (P < .05) bivariate correlators with Work Ability Index (WAI) were entered as independent variables in a categorical regression. Elastic net regularization maintained the most parsimonious set of independent variables significantly associated with variation in WAI as the dependent variable. Process analysis of significant independent variable associations with WAI was performed.Main Outcome MeasurementWAI.ResultsFrom 42 bivariate correlates of WAI, multivariate regression displayed a total of seven variables that were significantly (F [25,98] = 5.74, P < .05) associated with 65.8% of the variation in WAI. The Neck Disability Index (NDI) and Fear‐Avoidance Beliefs Questionnaire Work subscale (FABQ‐W) were significant individual factors within the final regression model. Process analysis displayed FABQ‐W having a significant specific indirect association with the direct association between NDI and WAI, with the model associated with 77% of the variability in WAI (F [2,84] = 141.17, P < .001).ConclusionOf 64 candidate biopsychosocial factors, NDI and FABQ‐W were the most significant multivariate correlates with work ability. FABQ‐W has a significant indirect association with baseline NDI scores and perceived work ability. This warrants future research trialing work‐related fear avoidance interventions in conservatively managed patients with cervical radiculopathy.Level of EvidenceIII
  • Abé, Christoph, et al. (författare)
  • Longitudinal Cortical Thickness Changes in Bipolar Disorder and the Relationship to Genetic Risk, Mania, and Lithium Use.
  • 2020
  • Ingår i: Biological psychiatry. - 1873-2402. ; 87:3, s. 271-281
  • Tidskriftsartikel (refereegranskat)abstract
    • Bipolar disorder (BD) is a highly heritable psychiatric disorder characterized by episodes of manic and depressed mood states and associated with cortical brain abnormalities. Although the course of BD is often progressive, longitudinal brain imaging studies are scarce. It remains unknown whether brain abnormalities are static traits of BD or result from pathological changes over time. Moreover, the genetic effect on implicated brain regions remains unknown.Patients with BD and healthy control (HC) subjects underwent structural magnetic resonance imaging at baseline (123 patients, 83 HC subjects) and after 6 years (90 patients, 61 HC subjects). Cortical thickness maps were generated using FreeSurfer. Using linear mixed effects models, we compared longitudinal changes in cortical thickness between patients with BD and HC subjects across the whole brain. We related our findings to genetic risk for BD and tested for effects of demographic and clinical variables.Patients showed abnormal cortical thinning of temporal cortices and thickness increases in visual/somatosensory brain areas. Thickness increases were related to genetic risk and lithium use. Patients who experienced hypomanic or manic episodes between time points showed abnormal thinning in inferior frontal cortices. Cortical changes did not differ between diagnostic BD subtypes I and II.In the largest longitudinal BD study to date, we detected abnormal cortical changes with high anatomical resolution. We delineated regional effects of clinical symptoms, genetic factors, and medication that may explain progressive brain changes in BD. Our study yields important insights into disease mechanisms and suggests that neuroprogression plays a role in BD.
  • Ahl, Rebecka, 1987-, et al. (författare)
  • β-Blockade in Rectal Cancer Surgery : A Simple Measure of Improving Outcomes
  • 2020
  • Ingår i: Annals of Surgery. - Lippincott Williams & Wilkins. - 0003-4932. ; 271:1, s. 140-146
  • Tidskriftsartikel (refereegranskat)abstract
    • OBJECTIVE: To ascertain whether regular β-blocker exposure can improve short- and long-term outcomes after rectal cancer surgery.BACKGROUND: Surgery for rectal cancer is associated with substantial morbidity and mortality. There is increasing evidence to suggest that there is a survival benefit in patients exposed to β-blockers undergoing non-cardiac surgery. Studies investigating the effects on outcomes in patients subjected to surgery for rectal cancer are lacking.METHODS: All adult patients undergoing elective abdominal resection for rectal cancer over a 10-year period were recruited from the prospectively collected Swedish Colorectal Cancer Registry. Patients were subdivided according to preoperative β-blocker exposure status. Outcomes of interest were 30-day complications, 30-day cause-specific mortality, and 1-year all-cause mortality. The association between β-blocker use and outcomes were analyzed using Poisson regression model with robust standard errors for 30-day complications and cause-specific mortality. One-year survival was assessed using Cox proportional hazards regression model.RESULTS: A total of 11,966 patients were included in the current study, of whom 3513 (29.36%) were exposed to regular preoperative β-blockers. A significant decrease in 30-day mortality was detected (incidence rate ratio = 0.06, 95% confidence interval: 0.03-0.13, P < 0.001). Deaths of cardiovascular nature, respiratory origin, sepsis, and multiorgan failure were significantly lower in β-blocker users, as were the incidences in postoperative infection and anastomotic failure. The β-blocker positive group had significantly better survival up to 1 year postoperatively with a risk reduction of 57% (hazard ratio = 0.43, 95% confidence interval: 0.37-0.52, P < 0.001).CONCLUSIONS: Preoperative β-blocker use is strongly associated with improved survival and morbidity after abdominal resection for rectal cancer.
  • Ahmed, Sayem (författare)
  • Healthcare financing challenges and opportunities to achieving universal health coverage in the low- and middle-income country context
  • 2020
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • Background: In Bangladesh, on an average 62% of total healthcare spending was borne by households through out-of-pocket (OOP) payments annually during 2000- 2015. Because of such high OOP payments, a sizable proportion of households (15.7%) faced catastrophic health expenditure (CHE) and a number of them fell into poverty in 2010. Protecting households from such payments and consequently, the risk of impoverishment are desirable objectives of health systems worldwide. The Sustainable Development Goals (SDGs) resolution emphasized ensuring quality and affordable essential health services through Universal Health Coverage (UHC) by 2030. In order to achieve UHC, the World Health Organization (WHO) recommends to ensure the protection against the risk of large healthcare payments or CHE by spreading the risk among the population through pre-payments e.g., tax, social security contribution, insurance premium. Informal workers in the agricultural and non-agricultural sectors including readymade garments (RMG) workers constitute a large proportion of the total labor force (88%), who contribute to 64% of the total Gross Domestic Products of Bangladesh. Efforts should, therefore, be made to ensure sustainable quality healthcare for this group of workers by bringing them under pre-payment health schemes. Community-Based health insurance (CBHI) and employer-sponsored health insurance (ESHI) schemes were thus piloted among selected informal workers with an aim to increase utilization of medically trained healthcare providers (MTPs) at an affordable price. Objectives: The main objective of this dissertation is twofold: firstly, to study the effect of the current healthcare financing system on the financial risk of households and secondly, to explore potential solutions through pre-payments schemes (CBHI and ESHI) for mitigating such challenges. Methods: Based on both primary and/or secondary data, five studies were conducted. In study I, nationally representative Household Income and Expenditure Survey, 2016 has been used which provide data on household consumption expenditure including health expenses. We calculated the incidence of CHE, which was later predicted by demographic and socio-economic characteristics of the households using multiple regression analysis. The incidence of CHE was defined as the proportion of households having healthcare expenditure of more than a threshold level such as 10% of their total consumption expenditure or 40% of their non-food consumption expenditure. We estimated the impoverishment effect of OOP payments using both the national (cost of basic need approach) and the international (1.90 International dollar per person per day) poverty line. For study II, 557 informal workers were surveyed during 2010-11 in three geographic locations (a metropolitan city, a district town and a sub-district area) to estimate the willingness-to-pay (WTP) for CBHI, using the contingent valuation method. The association between WTP and demographic characteristics was measured by employing the log-normal regression model. Study III adopted a case-control design to estimate the effect of the CBHI scheme on healthcare utilization from MTPs. We, therefore, surveyed 1,292 (646 insured and 646 uninsured) households after 1 year of implementation of the scheme. In order to minimise the unobserved baseline differences between the insured and uninsured groups, a propensity score matching was performed. A multilevel logistic regression model was applied to measure the association between MTP healthcare use and CBHI membership, in comparison to uninsured. Using the same design in study IV, a two-part regression model was applied to assess the relationship between CBHI membership and the OOP expenditure (probability and magnitude) when adjusted for other confounding factors (demographic and socio-economic). Study V utilized a case-control design with cross-sectional pre-and post-intervention surveys among workers from 7 purposely selected RMG factories (6 intervention and 1 comparison factories) in Safipur of Gazipur, Bangladesh. Randomly selected RMG workers were interviewed in pre-(October 2013) and post-intervention phases (April 2015) from insured and uninsured RMG factories. In total, 1,924 workers were interviewed (480 from the insured group and 482 from the uninsured group in pre- and post-intervention periods). We estimated the difference-in-difference (DiD) of the utilization of healthcare and OOP expenditure. The DiD is a counterfactual estimate derived by measuring the change in outcomes in the intervention group, which is deducted from the change in outcomes in the comparison group between the pre- and post-intervention periods. Beside DiD estimation, we used a two-part regression model to measure the association between OOP payments and membership of the ESHI scheme while controlling for workers’ demographic and socio-economic characteristics. Results: Study I found that CHE were faced by 24.6% of households at the 10% threshold level, the incidence was 25.3% and 22.0% among the poorest and the richest households, respectively. The poverty rate rose by 5.5% (9.0 million individuals) due to OOP payments. In study II, we observed that approximately 87% of the informal workers were willing to pay for the CBHI. The average weekly WTP was 22.8 BDT [95% confidence interval (CI): 20.9–24.8] or 0.32 USD. Monthly income, occupation, geographic location and educational level were the main determinants of WTP. Study III suggested that the insured of CBHI were 2.111 (95% CI: 1.458- 3.079) times more likely than uninsured to use MTP for healthcare. Applying the two-part regression model in study IV, we found that in comparison with the uninsured, the average OOP payment was 6.4% (p<0.001) smaller among the insured for such healthcare utilization. Nonetheless, no significant difference was observed in OOP payments for the health service utilization from all types of providers, i.e., both MTPs and non-trained providers though the latter one was not included in the benefit package of the scheme. Study V showed that the ESHI scheme has resulted in a significant 26.1% escalation in the utilization of healthcare (DiD=26.1; p<0.01) from MTPs among the insured relative to uninsured. When accounting for covariates, such utilization fell to 18.4% (p<0.05). The DiD calculation showed that OOP spending for insured group decreased by -3,700 BDT and -1,100 BDT in comparison to uninsured group while utilized MTPs or all types of providers respectively, although not statistically significant. Conclusions: Reliance on OOP payments for healthcare leads to financial hardship and a challenge for securing financial protection to achieve UHC in low- and middle-income country settings with a large informal sector, like in Bangladesh. To mitigate the challenge of healthcare utilization at lower OOP payments, preppayment schemes such as CBHI and ESHI, are useful for increasing utilization of healthcare from MTPs by both informal and RMG workers. These schemes are in considerable demand that was supported by the WTP findings. However, the insured of the CBHI scheme had a significantly lower OOP payment, while worker insured by ESHI did not experience such reduction. Broader healthcare provider networks of ESHI schemes would reduce dependency on external providers (not contracted by ESHI) and consequently reduce OOP payments while increasing utilization of services. In summary, the studies in this dissertation describe the challenges of the current healthcare financing system in Bangladesh and the substantial potential of CBHI and ESHI schemes to mitigate such challenges among the informal and RMG workers.
  • Alder, Susanna, et al. (författare)
  • Incomplete excision of cervical intraepithelial neoplasia as a predictor of the risk of recurrent disease : a 16-year follow-up study
  • 2020
  • Ingår i: American Journal of Obstetrics and Gynecology. - Elsevier. - 0002-9378. ; 222:2, s. 172.e1-172.e12
  • Tidskriftsartikel (refereegranskat)abstract
    • BACKGROUND: Women treated for high-grade cervical intraepithelial neoplasia (CIN, grade 2 or 3) are at elevated risk of developing cervical cancer. Suggested factors identifying women at highest risk for recurrence post-therapeutically include incomplete lesion excision, lesion location, size and severity, older age, treatment modality and presence of high-risk human papilloma virus (hrHPV) after treatment. This question has been intensively investigated over decades, but there is still substantial debate as to which of these factors or combination of factors most accurately predict treatment failure.OBJECTIVES: In this study, we examine the long-term risk of residual/recurrent CIN2+ among women previously treated for CIN2 or 3 and how this varies according to margin status (considering also location), as well as comorbidity (conditions assumed to interact with hrHPV acquisition and/or CIN progression), post-treatment presence of hrHPV and other factors.STUDY DESIGN: This prospective study included 991 women with histopathologically-confirmed CIN2/3 who underwent conization in 2000-2007. Information on the primary histopathologic finding, treatment modality, comorbidity, age and hrHPV status during follow-up and residual/recurrent CIN2+ was obtained from the Swedish National Cervical Screening Registry and medical records. Cumulative incidence of residual/recurrent CIN2+ was plotted on Kaplan-Meier curves, with determinants assessed by Cox regression.RESULTS: During a median of 10 years and maximum of 16 years follow-up, 111 patients were diagnosed with residual/recurrent CIN2+. Women with positive/uncertain margins had a higher risk of residual/recurrent CIN2+ than women with negative margins, adjusting for potential confounders (hazard ratio (HR)=2.67; 95% confidence interval (CI): 1.81-3.93). The risk of residual/recurrent CIN2+ varied by anatomical localization of the margins (endocervical: HR=2.72; 95%CI: 1.67-4.41) and both endo- and ectocervical (HR=4.98; 95%CI: 2.85-8.71). The risk did not increase significantly when only ectocervical margins were positive/uncertain. The presence of comorbidity (autoimmune disease, human immunodeficiency viral infection, hepatitis B and/or C, malignancy, diabetes, genetic disorder and/or organ transplant) was also a significant independent predictor of residual/recurrent CIN2+. In women with positive hrHPV findings during follow-up, the HR of positive/uncertain margins for recurrent/residual CIN2+ increased significantly compared to women with hrHPV positive findings but negative margins.CONCLUSIONS: Patients with incompletely excised CIN2/3 are at increased risk of residual/recurrent CIN2+. Margin status combined with hrHPV results and consideration of comorbidity may increase the accuracy for predicting treatment failure.
  • Bergman, Ida (författare)
  • Female pelvic floor disorders : clinical aspects on surgical treatments
  • 2020
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • Background and aims: The life-time risk for a woman to undergo pelvic floor reconstructive surgery due to prolapse or incontinence is 20% and the high risk for recurrence after prolapse surgery is a major challenge. Surgical reconstruction of the perineal body is commonly performed, although studies assessing results of this procedure are scarce. Mid-urethral sling surgery has a cure rate of 80%, but whether the sling endures a subsequent delivery is largely unknown. In this thesis we aimed to investigate whether the choice of suture material has an impact on vaginal wall prolapse repair; whether cervical amputation results in similar cure rates in comparison to vaginal hysterectomy in women with uterine prolapse; if a subsequent delivery jeopardizes results from incontinence surgery; if physiotherapy and surgical treatment is equally effective in women with symptoms related to a poorly healed second-degree perineal tear. Methods and main results: Study I and II are both register-based cohort studies based on data from the Swedish National Quality Register for Gynecological Surgery (GynOp). In Study I, 731 women who underwent primary anterior colporrhaphy and 384 women who underwent primary posterior colporrhaphy were included. We found a significantly lower rate of women reporting vaginal bulging symptoms one year after anterior colporrhaphy if a slowly absorbable monofilament suture was used compared to a more rapidly absorbable multifilament suture, 22% vs 30% (aOR 1.6, 95% CI 1.1-2.3). There was no difference between the suture groups in the posterior colporrhaphy cohort. In Study II, women with uterine prolapse who had undergone either cervical amputation (n=1979) or vaginal hysterectomy (n=1195) were analyzed. There were no differences between the two groups regarding neither symptom relief nor patient satisfaction at one year after surgery. Vaginal hysterectomy was associated with a higher rate of severe complications compared to cervical amputation, 1.9 % vs 0.2 % (p < 0.001). Study III is a cross-sectional, survey-based study. National registers were used to identify women with a delivery subsequent to a mid-urethral sling procedure (n=207) and a matched control-group including women without childbirth after a mid-urethral sling procedure (n=521). Validated questionnaires investigating urinary symptoms were mailed to the study participants. Patient reported stress urinary incontinence was present in 22% of the women with a delivery after a mid-urethral sling procedure and in 17% of the women in the control group (aOR 1.2, 95% CI 0.7-2.0). Vaginal childbirth after mid-urethral sling surgery did not increase the risk of stress urinary incontinence compared to cesarean delivery. Study IV is a randomized controlled trial where 70 women with a poorly healed second degree perineal tear, minimum six months post-partum, were randomized to either surgery or tutored pelvic floor muscle therapy. In an intention-to-treat analysis with worst case outcome imputation, treatment success at 6 months followup was significantly more frequent in the surgery group, 71% vs 11%, p<0.001. Conclusions: In conclusion, the use of slowly absorbable monofilament sutures in anterior colporrhaphy was associated with a lower risk of symptomatic prolapse at one year postoperatively, compared to more rapidly absorbable multifilament sutures. In women with uterine prolapse, cervical amputation seems to result in similar patient reported outcomes as compared to vaginal hysterectomy, but comes with a lower risk of severe complications. Childbirth after a mid-urethral sling procedure does not increase the risk for recurrent stress urinary incontinence and the mode of a subsequent delivery does not seem to impact continence status. Finally, surgical treatment was superior to pelvic floor muscle therapy in providing symptom relief in women with poorly healed second-degree perineal tears.
  • Bokrantz, Tove, et al. (författare)
  • Antihypertensive drug classes and the risk of hip fracture: results from the Swedish primary care cardiovascular database.
  • 2020
  • Ingår i: Journal of hypertension. - 1473-5598. ; 38:1
  • Tidskriftsartikel (refereegranskat)abstract
    • Hypertension and fractures related to osteoporosis are major public health problems that often coexist. This study examined the associations between exposure to different antihypertensive drug classes and the risk of hip fracture in hypertensive patients.We included 59 246 individuals, 50 years and older, diagnosed with hypertension during 2001-2008 in the Swedish Primary Care Cardiovascular Database. Patients were followed from 1 January 2006 (or the date of diagnosis of hypertension) until they had their first hip fracture, died, or reached the end of the study on 31 December 2012. Cox proportional hazards models were used to calculate the risk of hip fracture across types of antihypertensive medications, adjusted for age, sex, comorbidity, medications, and socioeconomic factors.In total, 2593 hip fractures occurred. Compared to nonusers, current use of bendroflumethiazide or hydrochlorothiazide was associated with a reduced risk of hip fracture (hazard ratio 0.86; 95% CI 0.75-0.98 and hazard ratio 0.84; 95% CI 0.74-0.96, respectively), as was use of fixed drug combinations containing a thiazide (hazard ratio 0.69; 95% CI 0.57-0.83). Current use of loop diuretics was associated with an increased risk of hip fracture (hazard ratio 1.23; 95% CI 1.11-1.35). No significant associations were found between the risk of hip fracture and current exposure to beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone-receptor blockers or calcium channel blockers.In this large observational study of hypertensive patients, the risk of hip fracture differed across users of different antihypertensive drugs, results that could have practical implications when choosing antihypertensive drug therapy.
  • Carlsson, Axel C, et al. (författare)
  • Endostatin predicts mortality in patients with acute dyspnea – A cohort study of patients seeking care in emergency departments
  • 2020
  • Ingår i: Clinical Biochemistry. - Elsevier. - 0009-9120. ; 75, s. 35-39
  • Tidskriftsartikel (refereegranskat)abstract
    • Background: Increased levels of circulating endostatin predicts cardiovascular morbidity and impaired kidney function in the general population. The utility of endostatin as a risk marker for mortality in the emergency department (ED) has not been reported. Aim: Our main aim was to study the association between plasma endostatin and 90-day mortality in an unselected cohort of patients admitted to the ED for acute dyspnea. Design Circulating endostatin was analyzed in plasma from 1710 adults and related to 90-day mortality in Cox proportional hazard models adjusted for age, sex, body mass index, oxygen saturation, respiratory rate, body temperature, C-reactive protein, lactate, creatinine and medical priority according to the Medical Emergency Triage and Treatment System–Adult score (METTS-A). The predictive value of endostatin for mortality was evaluated with receiver operating characteristic (ROC) analysis and compared with the clinical triage scoring system and age. Results: Each one standard deviation increment of endostatin was associated with a HR of 2.12 (95% CI 1.31–3.44 p < 0.01) for 90-day mortality after full adjustment. Levels of endostatin were significantly increased in the group of patients with highest METTS-A (p < 0.001). When tested for the outcome 90-day mortality, the area under the ROC curve (AUC) was 0.616 for METTS-A, 0.701 for endostatin, 0.708 for METTS -A and age and 0.738 for METTS-A, age and levels of endostatin. Conclusions: In an unselected cohort of patients admitted to the ED with acute dyspnea, endostatin had a string association to 90-day mortality and improved prediction of 90-day mortality in the ED beyond the clinical triage scoring system and age with 3%.
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