| 1. |
- Blom Johansson, Monica, 1965-
(författare)
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Aphasia and Communication in Everyday Life : Experiences of persons with aphasia, significant others, and speech-language pathologists
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aims of this thesis were to describe the experiences of persons with aphasia and their significant others of their conversations and use of communication strategies, examine current practice of family-oriented speech-language pathology (SLP) services, and test a family-oriented intervention in the early phase of rehabilitation.The persons with aphasia valued having conversations despite perceiving their aphasia as a serious social disability. They acknowledged the importance of the communication partners’ knowledge and understanding of aphasia and their use of supporting conversation strategies. Their own use of communication strategies varied considerably. The persons with aphasia longed to regain language ability and to be active participants in society.A majority of the significant others perceived their conversations with the person with aphasia as being less stimulating and enjoyable than conversations before stroke onset. Aphasia was considered a serious problem. The significant others took on increased communicative responsibility, where two thirds had changed their communicative behaviour to facilitate conversations. Type and severity of aphasia were especially related to the communicative experiences of the significant others and their motivation to be involved in SLP services.Thirty percent of the speech-language pathologists worked with people with aphasia and typically met with their families. They considered the involvement of significant others in SLP services as very important, especially in providing information about aphasia and communication partner training (CPT). However, involvement of significant others was restricted because of a time shortage and perceived limited skills and knowledge. In addition, there were national differences regarding aphasia rehabilitation services.The intervention consisted of three sessions directed to significant others (primarily emotional support and information) and three directed to the dyads (a person with aphasia and a significant other) (primarily CPT). All six participants (three dyads) felt that their knowledge and understanding of aphasia had increased and that their conversations had improved. These improvements were also evident to some extent with formal assessments.These results suggest the following: CPT should be an integral part of SLP services, national clinical guidelines are needed, and further education of speech-language pathologists and implementation of new knowledge into clinical practice requires consideration.
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| 2. |
- Hägglund, Patricia, 1989-
(författare)
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Swallowing dysfunction among older people in short-term care : prevalence, effect of intervention, and risk of mortality
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives: Swallowing dysfunction (dysphagia) is a common, but often neglected condition among geriatric patients that can cause severe complications such as malnutrition, aspiration pneumonia and death. The aims of this thesis were to (i) describe the study design and method of the multidisciplinary and multicenter project SOFIA (Swallowing function, Oral health, and Food Intake in old Age), (ii) study the prevalence of and the relationship between swallowing dysfunction and risk of undernutrition among older individuals in short-term care, (iii) study the effect of oral neuromuscular training on swallowing dysfunction among older individuals, and (iv) to investigate the association between poor oral health, swallowing dysfunction and mortality.Methods: This thesis includes four original papers that are all part of the SOFIA project. Paper Iis the study protocol. In total, 391 individuals aged 65 or older, from 36 short-term care units were included in the project. At baseline the participants’ status regarding swallowing function (assessed with the Timed Water Swallow Test, TWST), oral health (using the Revised Oral Assessment Guide, ROAG) and nutrition (assessed with the Minimal Eating Observation and Nutrition Form-version II, MEONF-II) were assessed and collected by calibrated professionals. Clinical data were also collected. Paper IIwas a cross-sectional study where the baseline assessments of the participants’ swallowing function and nutritional status were obtained and the relationship analyzed. Paper IIIwas a cluster randomized, controlled trial (cRCT) that included 116 participants identified with swallowing dysfunction in paper II. These participants were randomly assigned to either usual care (control group) or oral neuromuscular training (intervention group). All participants were assessed at baseline, after five weeks’ training and six months after end-of-treatment, regarding swallowing function and swallowing-related quality of life (QOL). Paper IVwas a prospective cohort study where all participants were followed-up 1-year after inclusion to investigate risk factors for mortality by analysis of the associations between swallowing dysfunction, poor oral health, and 1-year survival. Results: Paper II:The median age of the 391 participants was 84 years (Interquartile range [IQR] 11) and 209 (53%) were females. In total, 248 of the 385 (64%) participants showed swallowing dysfunction, and risk of undernutrition was observed in 91 of 390 (23%) participants. The adjusted logistics regression model revealed that participants with swallowing dysfunction had significantly higher odds of undernutrition than those with normal swallowing (Odds ratio [OR]: 1.74, 95% Confidence interval [CI] 1.04 to 2.92, P=0.034).Paper III: At end-of-treatment, a linear mixed model showed significant between-group differences of changes in swallowing efficacy between baseline and after completed treatment period (Ratio 1.60, 95% CI 1.15 to 2.29, P=0.007); indicating a 60% higher swallowing efficacy in the intervention group compared with the control group. Paper IV: A mixed effects Cox model showed that swallowing dysfunction and poor oral health were both independently associated with 1-year mortality (adjusted Hazard Ratio [aHR]: 1.67, 95% CI 1.02 to 2.75,P=0.041 and aHR: 1.98, 95% CI 1.07 to 3.65, P=0.029, respectively). In addition, swallowing dysfunction and poor oral health in combination predicted the highest mortality rate (35%, P<0.001).Conclusion: Swallowing dysfunction is highly prevalent and a risk factor for undernutrition among older people in short-term care. Oral neuromuscular training improves swallowing dysfunction and is thus a promising method of swallowing rehabilitation for older people with impaired swallowing. Swallowing dysfunction and poor oral health are independent risk factors for 1-year morality among older people in short-term care. Therefore, systematic screening and intervention to improve swallowing dysfunction and poor oral health are important to achieve healthy aging and to prevent undernutrition and early death.
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| 3. |
- Arnell, Kai, 1945-
(författare)
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Cerebrospinal Fluid Shunts in Children : Technical Considerations and Treatment of Certain Complications
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Ventriculo-peritoneal shunting is the most commonly used method for the treatment of paediatric hydrocephalus. Despite improved shunts and surgical techniques there are still complications. This retrospective study focuses on diagnoses and treatment of shunt malfunction and infections. Cost/benefit of using an adjustable shunt was assessed. Two adjustable cerebrospinal fluid shunts and their compatible antisiphon devices were compared in-vitro. In 21 of 46 children the standard shunt was changed to an adjustable one due to over-drainage. Adjustment of the shunt was performed in 73% of the children thereby avoiding surgery in several cases. This was a financial advantage. Ascites or an abdominal pseudocyst without infection was detected in eight children due to resorption difficulties. A ventriculo-atrial shunt was inserted for a period of time. In three children it could successfully be reverted to a ventriculo-peritoneal. In six children papilloedema was the only sign of shunt dysfunction. At revision the intracranial pressure ranged from 25 to 52 cm H2O. Fundoscopic examination in children older than 8 years may detect symptomless shunt malfunction. During a 13-year period 39 shunt infections were diagnosed. Skin bacteria were found in 80%. Prolonged and anaerobic cultures increased the detection rate by more than one third. The intraventricular infections were treated with intraventricular and systemic antibiotics resulting in quick sterilisation. No relapses were encountered. In five older children with distal catheter infection Propionibacterium acne was found. These were treated with intravenous antibiotics and exchanging of the shunt system. Strata NSCTM and Codman HakimTM worked according to the manufacturers except at the lowest setting. The resistance was below and in the lower range of the physiological one respectively. The antisiphon device of Strata shunt had to be placed in line with shunt to function properly.
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| 4. |
- Bengtsson, Anna, 1973-
(författare)
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Pictorial presentation of subclinical atherosclerosis : a measure to reduce the risk for cardiovascular disease
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim was improved cardiovascular disease (CVD) prevention through the VIPVIZA intervention. This includes the provision of pictorial information of subclinical atherosclerosis to participants and their general practitioners (GPs), follow-up phone call, and written information to the participant. VIPVIZA is a Prospective Randomized Open Blinded End-point (PROBE) trial nested within VIP, a CVD prevention program in primary health care in Västerbotten county, Sweden. Middle-aged individuals at low/intermediate CVD risk were enrolled to VIPVIZA and randomized 1:1 to an intervention (n=1749) or control group (n=1783 who received no pictorial or other information). Preventive measures were managed within primary health care.At baseline, clinical risk factors were measured and carotid ultrasound examination was performed. The prevalence of subclinical atherosclerotic disease was assessed as intima media thickness and presence of plaque. The association between clinical risk factors and measures of subclinical atherosclerosis was investigated. In addition to conventional risk factor-based risk evaluation, the impact of the VIPVIZA intervention on CVD risk, traditional risk factors and pharmacological treatment was evaluated after 1 and 3 years. Individual interviews were conducted with 15 GPs to explore how a pictorial representation of subclinical atherosclerosis affects physicians in their perception and communication of CVD risk. The interviews were analyzed by qualitative content analysis.The plaque prevalence was 44.7% in this population. Clinical risk factors explained more of the variation in a combined ultrasound measurement than single measurements. The results up to three years showed a VIPVIZA intervention effect, with lower and sustained CVD risk in the intervention as compared to the control group. The effect was partly mediated by differences in intake of lipid-lowering medication and partly by lifestyle behaviour. The GPs described their risk assessment and patients’ risk perception as more accurate with the VIPVIZA intervention. Informing patients about examination results prior to a consultation can facilitate shared decision-making and enhance adherence to preventive measures.The results show that the VIPVIZA intervention reduces CVD risk over three years. In the long run this has the potential to reduce the incidence of CVD events.
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| 5. |
- Björck, Fredrik, 1974-
(författare)
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Warfarin treatment quality in stroke prevention
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundIschemic stroke is a serious condition often associated to presence of atrial fibrillation (AF). Use of anticoagulants for AF patients greatly reduces the risk of stroke. Warfarin is the most commonly used anticoagulant in Sweden. The aim of this thesis was to study the impact of warfarin treatment quality in Swedish stroke prevention.MethodsStudy I, II and IV were relatively large multicentre, retrospective, cohort studies based on Swedish registries, especially AuriculA, a quality register for AF and anticoagulation. Background data as well as bleeding and thromboembolic complications were retrieved from the National Patient Register. The Cause of Death Register was used in study II and IV. The Swedish Prescribed Drug Register was used in study IV, for data on concomitant acetylsalicylic acid (ASA) use. Study period was January 1, 2006, to December 31, 2011. Study III enrolled all warfarin treated AF patients in Sundsvall, registered in AuriculA on January 1, 2010. This smaller cohort was followed until discontinuation or study-stop December 31, 2013. All used data were collected from each patient’s medical record.ResultsThe annual risk of major bleedings and thromboembolic events for warfarin treated patients, including all different indications for warfarin, was relatively low (2.24% and 2.66%), with incidence of intracranial bleeding of 0.37% per treatment year. The overall mean time in therapeutic range (TTR) was 76.5%. Patients started on warfarin due to AF had a mean TTR of 68.6%, with an annual risk of major bleeding and thromboembolic events of 2.23% and 2.95%, and with 0.44% annual risk of intracranial bleeding. No significant differences in overall complications were found when comparing treatment monitored in anticoagulation clinics (ACC) with treatment monitored in primary health care centers (PHCC). There were significantly increased risk of both overall major bleedings and thromboembolic events for those warfarin treated AF patients receiving additional ASA treatment, having individual TTR (iTTR) below 70%, or having high international normalized ratio (INR) variability. AF patients with low INR variability had generally lower complication rates, compared with patients with high INR variability. There were however no alteration on cumulative incidence of complications due to INR variability, for AF patients with iTTR ≥70%. The overall proportion of persistence to warfarin treatment for stroke patients with AF was found to be 0.69 after 2 years treatment and 0.47 after 5 years. Stroke patients with diagnosed dementia at baseline were more than two-times likely of discontinuing warfarin than others. Excessive alcohol use, chronic obstructive pulmonary disease, cancer and chronic heart failure were baseline diagnoses each associated with over 20% increased risk of treatment discontinuation. Lower persistence to treatment was linked to increasing start-age and CHA2DS2-VASc scores. As documented reasons for warfarin treatment discontinuation in AF patients, we found regained sinus rhythm as the most common addressed cause (31.2%), followed by problematic monitoring and bleedings. We estimated that only half (49.5%) of the treatment discontinuations were clinically well motivated.ConclusionsQuality of Swedish warfarin treatment in initiated stroke prevention is high, with generally low rates of complications and high TTRs, no matter treatment in ACC or PHCC, including high long time persistence to warfarin in secondary stroke prevention. For better outcome in future warfarin stroke prophylactic treatment clinicians should aim for iTTRs above 70%, avoid additional ASA therapy, support fragile patients like those with excessive alcohol use and dementia, and base decisions on treatment discontinuations on solid medical arguments.
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| 6. |
- Bråndal, Anna, 1966-
(författare)
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Rehabilitation after stroke with focus on early supported discharge and post-stroke fatigue
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Stroke is a major cause of disability worldwide. After treatment in a specialized stroke unit, early supported discharge (ESD) followed by home rehabilitation has shown to be an effective way to improve patient outcome and quality of care for persons with mild to moderate stroke. ESD service is recommended in the national and international guidelines for stroke care, but has only partially been implemented in Sweden. Following stroke, fatigue is a common consequence that often becomes more evident when the patient comes home. Currently, there is insufficient evidence about how to measure, treat and handle post-stroke fatigue. The overall aim of this thesis was to evaluate and implement early supported discharge (ESD) based on stroke patients experience after discharge from the stroke unit and local conditions. The aim was also to evaluate post-stroke fatigue with a potentially valid and reliable scale and finally to prepare for a study to evaluate cardiorespiratory training as a part of ESD service for patients with post-stroke fatigue.Methods In paper I, nine strategically chosen patients were interviewed of their experience of falling ill, the hospital stay, discharge, contact with health care after discharge and their request of support. Papers II-III describe and evaluate the development, content, implementation and effects of a locally adopted method for early supported discharge (Umeå Stroke Center ESD) in modern stroke care. Paper II included 153 consecutive patients and paper III, 30 232 patients with first-ever stroke registered in the Riksstroke registry in Sweden. Paper II evaluated number of patients/year, clinical and functional health status, satisfaction in relation to needs, accidental falls/other injuries and resources with the result summarized in a value compass. The implementation process was evaluated retrospectively by means of Consolidated Framework for Implementation (CFIR). Paper III evaluated patient reported outcome measurements (PROMs) at 3 months. The primary outcome in paper III was satisfaction with the rehabilitation after discharge. Secondary outcomes were information about stroke provided, tiredness/fatigue, pain, dysthymia/depression, general health status and dependence in activities of daily living (mobility, toilet hygiene and dressing). Multivariable logistic regression models for each PROM was used to analyze associations between PROMs and ESD/no ESD. In Paper IV, the Fatigue Assessment scale (FAS) was translated into Swedish and evaluated regarding psychometric properties when self-administered by persons with mild to moderate stroke. 72 consecutively patients selected from the stroke unit admission register received a letter including three questionnaires: the FAS, the Short Form Health Survey (SF-36) subscale for vitality and the Geriatric Depression Scale GDS-15. A second letter with FAS was sent within 2 weeks, for re-test evaluation. Paper V is a study protocol for a planned randomized controlled trial (RCT) of 50 consecutive stroke patients will who receive stroke unit care followed by ESD-service at Umeå Stroke Center, University Hospital, Umeå, Sweden. Paper V will investigate if a structured cardiorespiratory interval training program (CITP) added to the ESD-service may result in relieved post-stroke fatigue and increased oxygen uptake.Results The interviews in Paper I revealed three main categories with subcategories: “Responsible and implicated”, “Depersonalized object for caring measures” and “The striving for repersonalization and autonomy”. The findings indicate that coming home gave the informants’ important insights and understanding of the stroke, its consequences and was also an important factor for the recovery. Paper II-III showed that it is possible to develop and implement an adapted ESD service for stroke patients based on the patients’ experiences and requests, evidence-based recommendations and local conditions. The ESD service reduced dependence of activity, increased mobility with seemingly no increased risk of accidental falls or other injuries. The patient satisfaction in relation to needs regarding the ESD was high. Paper III showed that patients that received ESD were more satisfied with rehabilitation after discharge, had less need for assistance with ADL and less dysthymia/depression compared to patients that did not receive ESD. Study IV showed that the Swedish FAS used at home as a selfadministered questionnaire is a reliable and valid questionnaire for measuring fatigue in persons with mild to moderate stroke. The internal consistency was good, the agreement between the test and retest reliability for individual items (weighted kappa) was for the majority of items good or moderate. The relative reliability for total scores was good and the absolute reliability was 9 points. The Swedish FAS had no floor nor ceiling effects and correlated both with the SF-36, subscale for vitality and the GDS-15 indicating convergent construct validity, but not divergent construct validity.Conclusion It is possible to develop and implement ESD care for stroke patients based on patients’ experience and needs, evidence-based principles and local conditions. Early supported discharge (ESD) in the setting of modern stroke unit care appears to have positive effects on rehabilitation in the subacute phase. The Swedish FAS used at home as a self-administered questionnaire is reliable and valid for measuring fatigue in persons with mild to moderate stroke.
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| 7. |
- Garoff, Maria, 1979-
(författare)
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Carotid calcifications in panoramic radiographs in relation to carotid stenosis
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Calcifications in carotid atheromas can be detected in a panoramic radiograph (PR) of the jaws. A carotid artery calcification (CAC) can indicate presence of significant (≥ 50%) carotid stenosis (SCS). The aim of this thesis was to (1) determine the prevalence of SCS and burden of atherosclerotic disease among patients revealing CACs in PRs, (2) determine the prevalence of CACs in PRs among patients with SCS, (3) analyze whether the amount of calcium and/or (4) the radiographic appearance of the CACs, can improve the positive predictive value (PPV) for SCS detection among patients with CACs in PRs.The thesis is based on four cross-sectional studies. Two patient groups were prospectively and consecutively studied. Group A represented a general adult patient population in dentistry examined with PR presenting incidental findings of CACs. These patients were examined with carotid ultrasound for presence or absence of SCS and their medical background regarding atherosclerotic related diseases and risk factors was reviewed. An age and gender matched reference group was included for comparisons. Group B comprised patients with ultrasound verified SCS, examined with PR prior to carotid endarterectomy. The PRs were analysed regarding presence of CACs. The extirpated plaques were collected and examined with cone-beam computed tomography (CBCT) to determine the amount of calcium. The radiographic appearance of CACs in PRs from Group A and B were evaluated for possible association with presence of SCS.In Group A, 8/117 (7%) of patients with CAC in PRs revealed SCS in the ultrasound examination, all were found in men (8/64 (12%)). Patients with CACs in PRs revealed a higher burden of atherosclerotic disease compared to participants in the reference group (p <0.001). In Group B, where all patients had SCS, 84% revealed CACs in PRs and 99% of the extirpated plaques revealed calcification. CACs with volumes varying between 1 and 509 mm3 were detected in the PRs. The variation in volume did not correlate to degree of carotid stenosis. The radiographic appearance that was most frequently seen in neck sides with SCS (65%) was also frequently found in neck sides without SCS (47%) and therefore the PPV did not improve compared to the PPV solely based on presence of CACs.CACs in PRs are more associated with SCS in men than in a general population and patients with CACs in PRs have a higher burden of atherosclerotic disease. The majority of patients with SCS show CACs in PRs and the majority of extirpated carotid plaques reveal calcification. The volume of CAC and specified radiographic appearance does not increase the PPV for SCS in patients with CACs in PRs. In conclusion patients with CACs in PRs, and without previous record of cardiovascular disease, should be advised to seek medical attention for screening of cardiovascular risk factors.
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| 8. |
- Gustafsson, Nils, 1990-
(författare)
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Calcified carotid artery atheromas in panoramic radiographs : diagnostic reliability and association to cardiovascular disease, diabetes and periodontitis
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objective: Incidental findings of Calcified Carotid Artery Atheromas (CCAA) on Panoramic Radiographs (PRs) of the jaws can be a risk marker for cardiovascular disease. The objectives for the thesis were to investigate the association between CCAA and 1) Myocardial Infarction (MI), 2) periodontitis, 3) diabetes and 4) estimated cardiovascular risk. Also 5) if patients with both CCAA and periodontitis have a higher risk of MI. The final objective was to study 6) General Dental Practitioners (GDPs) ability to detect CCAA on PRs and if a short training programme can improve their diagnostic accuracy.Materials and methods: Paper I-III were part of the Swedish, multicentre (17 hospitals) case- control study Periodontitis and Its Relation to Coronary Artery Disease (PAROKRANK). The study included 1610 individuals, 805 cases (151 women) diagnosed with first acute MI, and 805 controls matched for age, sex and residential area. Seventeen participants were not examined with PR and an additional 111 were excluded due to inadequate quality. As a result, 90 participants lost their match. Paper I and II had a case-control design that only included matched cases (n = 696) and controls (n = 696). Paper II and III used a cross-sectional design to evaluate all included cases (n = 738) and controls (n = 744) separately. All participants in PAROKRANK went through a detailed medical and oral health examination, including e.g., oral glucose tolerance, an extensive blood panel, and 4-point pocket probing. All PRs were assessed both for the presence of CCAA and signs of poor oral health, including marginal bone loss. The results from the medical examination were used to estimate risk of future cardiovascular events and death using Systematic COronary Risk Evaluation (SCORE) and Framingham Risk Score (FRS). The results from the oral health examination were used to classify the degree of periodontitis both according to bone loss and clinical periodontal disease index (CPDI). Paper IV used a pre-post design to evaluate 14 GDPs diagnostic accuracy regarding assessment of CCAA on PR before and after participation in a short training programme. The GDPs were evaluated at baseline, 2 weeks and 1 year after training. Comparisons were made with the consensus of 2 experienced oral and maxillofacial radiologists.Results: Paper I: CCAA on PRs was more common among cases with recent first MI, (33.8% with CCAA), compared to controls (27.6%; P = 0.012). Paper II: CCAA and CPDI were associated among cases (OR 1.51; 95% CI, 1.09 to 2.10; P = 0.02) and controls (OR 1.70; 95% CI, 1.22 to 2.38; P < 0.01). No association was found between CCAA and the degree of bone loss on PR. MI had a stronger association to CCAA combined with periodontitis, than to either condition alone (OR 1.75; 95% CI, 1.11 to 2.74; P = 0.01). Paper III: Elevated risk of a future cardiovascular event estimated with FRS was associated with CCAA, both among cases (OR 1.89; 95% CI: 1.31–2.73, P = 0.001) and controls (OR 1.64; 95% CI: 1.03–2.64, P = 0.04). Elevated risk of cardiovascular death according to SCORE was associated with CCAA among controls (OR 1.58; 95% CI: 1.12–2.23, P < 0.01) but not among cases. Diabetes was more common among controls with than without CCAA (18.0% vs. 11.7%), but this association was not statistically significant after adjustments. Paper I-III included a sex- stratified analysis revealing that the results were mainly applicable on men. Paper IV: An improvement in diagnostic accuracy was observed among GDPs after a short training programme for diagnosing CCAA on PR. The sensitivity increased (41.8% to 55.7%, P = 0.02) without a decrease in specificity. The kappa values also increased (0.66 to 0.71, P = 0.04). At 1 year follow up, the improvements compared to baseline remained.Conclusions: There is an association between CCAA on PR and MI. Clinically diagnosed periodontitis is associated with CCAA on PR, and among participants with both periodontitis and CCAA there is a higher probability of having had MI than among participants with either condition alone. An increased estimated risk of future cardiovascular events and death according to FRS and SCORE is associated with CCAA on PR. These conclusions are mainly applicable on men. Diabetes was not independently associated with CCAA on PR, possibly due to selection bias. A short training programme can significantly and sustainably improve GDPs diagnostic accuracy regarding CCAA. This indicate that GDPs could contribute to prevention of cardiovascular events and death by detecting CCAA on PR and, should be encouraged to refer patients without previous treatment of cardiovascular disease for further medical attention, and if other cardiovascular risk factors are identified, necessary treatment.
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| 9. |
- Hendrikx, Tijn, 1975-
(författare)
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Catch Atrial Fibrillation, Prevent Stroke : Detection of atrial fibrillation and other arrhythmias with short intermittent ECG
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Atrial fibrillation (AF) is the most common arrhythmia in the adult population, affecting about 5% of the population over 65 years. Occurrence of AF is an independent risk factor for stroke, and together with other cardiovascular risk factors (CHADS2/CHA2DS2- VASc), the stroke risk increases. Since AF is often paroxysmal and asymptomatic (silent) it may remain undiagnosed for a long time and many AF patients are not discovered before suffering a stroke.Aims: To estimate the prevalence of previously undiagnosed AF in an out-of-hospital population with CHADS2 ≥1, in patients with an enlarged left atrium (LA) and of total AF prevalence in sleep apnea (SA) patients, conditions that have been associated with AF. To compare the efficacy of short intermittent ECG with continuous 24h Holter ECG in detecting arrhythmias.Methods: Patients without known AF recorded 10−30 second handheld ECG (Zenicor-EKG®) registrations during 14−28 days at home, both regular, asymptomatic registrations twice daily and when having cardiac symptoms. Recordings were transmitted through the in-built SIM card to an internet-based database. Patients with palpitations or dizziness/presyncope referred for 24h Holter ECG were asked to additionally record 30-second handheld ECG registrations during 28 days at home.Results: In the out-of-hospital population with increased stroke risk, previously unknown AF was diagnosed in 3.8% of 928 patients. Comparing AF detection in patients with an enlarged LA versus normal LA showed that eleven of 299 patients had AF. Five of these had an enlarged LA (volume/BSA). No statistical difference in AF prevalence was found between patients with enlarged and normal LA, 3.3% and 3.2% respectively, (p = 0.974). AF occurred in 7.6% of 170 patients with sleep apnea, in 15% of patients with sleep apnea ≥60 years, and in 35% of patients with central sleep apnea. AF prevalence was also associated with severity of sleep apnea, male gender and diabetes. Comparing the efficacy of arrhythmia detection in 95 patients with palpitations or dizziness/presyncope with continuous 24h Holter and short intermittent ECG, 24h Holter found AF in two and AV-block II in one patient, resulting in 3.2% relevant arrhythmias detected. Short intermittent ECG diagnosed nine patients with AF, three with PSVT and one with AV-block II, in total 13.7% relevant arrhythmias. (p = 0.0094).Conclusions: Screening in the out-of-hospital patient population (mean age 69.8 years) yielded almost 4% AF, making it seem worthwhile to screen older patients with increased stroke risk for AF with this method. Screening patients with LA enlargement (mean age 73.1 years) did not result in higher detection rates compared with the general out-of-hospital population. AF occurred in 7.6% of patients with sleep apnea, (mean age 57.6 years) and was associated with severity of sleep apnea, presence of central sleep apnea, male gender, age ≥60 years, and diabetes. Short intermittent ECG is more effective in detecting relevant arrhythmias than 24h Holter ECG in patients with palpitations or dizziness/presyncope.
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| 10. |
- Holmgren, Eva, 1972-
(författare)
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Getting up when falling down : reducing fall risk factors after stroke through an exercise program
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The purpose of this thesis was to identify fall risk individuals (+55) after stroke by validating a fall risk index and in post-stroke individuals with high risk of falls evaluate the impact of an intervention program on fall risk factors.A previously developed fall risk index was validated, modified and re-validated. The validation showed a sensitivity of 97% and a specificity of 26%. This result was not considered sufficiently accurate. Therefore a modified index was created in the Validation sample and re-validated back in the Model fit sample. The modified index was reduced to three items and included postural stability + visuospatial hemi-inattention + male sex.The randomized controlled trial contained an intervention program (IP) with High-Intensity Functional Exercises as well as implementation these exercises in to real life situations together with educational group discussions. The participants were enrolled and randomized three to six months after their stroke. The assessments were performed at the Clinical Research Center at Norrlands University Hospital. The Intervention Group (IG) received a program of 35 sessions (exercise and group discussions) and the Control Group (CG) received five group discussions.Performing daily activities at 6 months follow-up and falls-efficacy post-intervention and at the 3 months follow-up showed significant improvement in the IG compared with the CG (p<0.05). The IP did not have a statistically significant impact on Balance or Lifestyle activities. When evaluating gait, step time variability for the paretic leg and the variability in Cycle Time for the paretic and non-paretic leg were improved for the IG. The time spent on the non –paretic leg in the gait cycles’ most stable phase, Double Support, was reduced by almost half (0.9 sec to 0.4 sec) since baseline for the IG after the intervention and remained reduced to the three month follow-up. Quality of Life showed an improvement in the CG compared with the IG for the mental scales, Mental Component Scale and Mental Health subscale at the 3 month follow-up (p=.02).In conclusion, this intervention program significantly improved performance of everyday life activities, falls-efficacy and the variability in gait. These are three major fall risk factors and might in the long run have an impact on decreasing falls in persons that had a stroke.
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