| 1. |
- Ahlström, Monica, et al.
(författare)
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Ett praktiskt försök : nationell prioriteringsmodell tillämpad i Landstinget i Kalmar Län
- 2008
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Rapport (övrigt vetenskapligt/konstnärligt)abstract
- Idag finns en nationell modell för hur öppna vertikala prioriteringar kan genomföras. Den är resultatet av de samlade erfarenheterna av att omsätta riksdagens riktlinjer för prioriteringar i praktiskt prioriteringsarbete. Modellen är framtagen av Socialstyrelsen, PrioriteringsCentrum samt flera vårdförbund och landsting gemensamt. Också FSA och LSR har ställt sig bakom den. Fram tills nu har det dock saknats praktisk erfarenhet av att tillämpa modellen inom arbetsterapi och sjukgymnastik. Men sedan drygt två år tillbaka har de båda rehabiliteringsenheterna Samrehab och Rehab Söder i Landstinget i Kalmar län med stöd av PrioriteringsCentrum bedrivit ett prioriteringsarbete i enlighet med modellen. Det är deras erfarenheter denna rapport handlar om.Prioriteringsarbetet har med nära stöd av verksamhetsledningarna letts av en projektgrupp bestående av arbetsterapeuter och sjukgymnaster från de båda enheterna som fungerat som handledare, ansvarat för metodutveckling och utbildning samt kontinuerligt utvärderat arbetet. Själva tillämpningen av den nationella modellen har ett antal utvecklingsgrupper inom olika specialistområden stått för. De har valt ut och rangordnat tillstånd och olika åtgärder som de ansett angelägna att ta fram prioriteringar för.Ett av syftena med prioriteringsarbetet i Samrehab och Rehab Söder var att få till stånd länsövergripande prioriteringar inom vissa verksamheter och/eller för vissa sjukdomstillstånd för en mer likvärdig vård. Idag finns elva sådana prioriteringsordningar presenterade på landstingets intranät och ytterligare ett tiotal är under bearbetning. Utöver vinsterna med det förbättrade samarbetet mellan länsdelarna har alltså den interna öppenheten i prioriteringarna ökat. Alla anställda kan lätt få fram prioriteringsordningarna via basenheternas hemsidor när man behöver det. Andra vinster av prioriteringsarbetet är att kännedomen och kunskapen om riksdagens riktlinjer för prioriteringar har ökat, att en större del av basenheternas verksamhet idag är faktabaserad än innan prioriteringsarbetet startade samt att den kliniska erfarenheten har tillvaratagits och dokumenterats på ett mer systematiskt sätt än tidigare. Det har dessutom skett en utveckling av den nationella modellen som har blivit mer konkret vad det gäller svårighetsgrad och nytta. En majoritet av deltagarna i utvecklingsgrupperna har haft en positiv inställning till att arbeta med prioriteringar utifrån modellen och upplever också att de erhållit ett språk som gör det möjligt att kommunicera prioriteringar med politiker och landstingsledning.I rapporten presenteras också de frågor kring modellens olika steg som dykt upp under arbetets gång. Tre frågor har dominerat; syftet med prioriteringsarbetet, tolkningen av modellen samt dokumentationen av prioriteringsarbetet. Syftet har inte alltid upplevts som helt klart och sambandet mellan prioriteringsarbetet och annat kvalitetsarbete som t ex framtagande av behandlingsriktlinjer har varit otydligt. När det gäller tolkningen av modellen har t ex graderingen av svårighetsgrad och patientnytta gett upphov till frustration. Också den skriftliga presentationen av prioriteringsordningarna har stundtals upplevts som krånglig och svår att förmedla till övriga medarbetare på ett användbart sätt.Alla de åtgärder som projektgruppen vidtagit för att underlätta de svårigheter som dykt upp delar de här med sig av i rapporten. Likaså pekar de ut viktiga förutsättningar för ett prioriteringsarbete (som t ex tid, kompetens, kontinuitet och legitima deltagare). Syftet med att pröva om den nationella modellen för öppna vertikala prioriteringar är användbar i Samrehabs och Rehab Söders prioriteringsarbete är uppnådd och det har inte framkommit något som ger anledning att ifrågasätta modellens grundstruktur. Förslag har dock givits bl a avseende bedömning av svårighetsgrad och patientnytta för att ytterligare underlätta tillämpningen.Nu planerar enheterna att gå vidare med sitt prioriteringsarbete, dels genom att fortsätta att ta fram behandlingsriktlinjer som kombineras med prioriteringar men också genom att ytterligare utveckla prioriteringsstödet för de enskilda medarbetarna i deras dagliga patientarbete. Om andra verksamheter i Sverige följer efter detta exempel från Kalmar län med att öppet redovisa hur de hanterar prioriteringar i sin verksamhet kommer ytterligare nya erfarenheter att hjälpa metodutvecklingen på traven.
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| 2. |
- Albagha, O M E, et al.
(författare)
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Association of oestrogen receptor alpha gene polymorphisms with postmenopausal bone loss, bone mass, and quantitative ultrasound properties of bone.
- 2005
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Ingår i: Journal of Medical Genetics. - : BMJ. - 0022-2593 .- 1468-6244. ; 42:3, s. 240-6
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The gene encoding oestrogen receptor alpha (ESR1) appears to regulate bone mineral density (BMD) and other determinants of osteoporotic fracture risk. OBJECTIVE: To investigate the relation between common polymorphisms and haplotypes of the ESR1 gene and osteoporosis related phenotypes in a population based cohort of 3054 Scottish women. RESULTS: There was a significant association between a common haplotype "px", defined by the PvuII and XbaI restriction fragment length polymorphisms within intron 1 of the ESR1 gene, and femoral neck bone loss in postmenopausal women who had not received hormone replacement therapy (n = 945; p = 0.009). Annual rates of femoral neck bone loss were approximately 14% higher in subjects who carried one copy of px and 22% higher in those who carried two copies, compared with those who did not carry the px haplotype. The px haplotype was associated with lower femoral neck BMD in the postmenopausal women (p = 0.02), and with reduced calcaneal broadband ultrasound attenuation (BUA) values in the whole study population (p = 0.005). There was no association between a TA repeat polymorphism in the ESR1 promoter and any phenotype studied, though on long range haplotype analysis subjects with a smaller number of TA repeats who also carried the px haplotype had reduced BUA values. CONCLUSIONS: The ESR1px haplotype is associated with reduced hip BMD values and increased rates of femoral neck bone loss in postmenopausal women. An association with BUA may explain the fact that ESR1 intron 1 alleles predict osteoporotic fractures by a mechanism partly independent of differences in BMD.
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| 3. |
- Bergström, Ulrica, 1970-
(författare)
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Fragility fractures in fragile people : epidemiology of the age quake
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Osteoporosis-related fracture is already today a major public health problem and the number of hip fractures is expected to double to 2030. Sweden has one of the highest hip fracture incidences worldwide. This may be explained by several factors: e.g. age, genetic, climatologic, geographic and a relative vitamin D deficiency, secondary to the limited sunlight exposure especially during winter months. Intrinsic and extrinsic factors contribute to a fracture, although a prior low energy fracture is one of the strongest predictors for a subsequent one and this should be a target for secondary fracture prevention in an orthopaedic setting. Since 1993 all injured patients admitted to the emergency floor and all in-hospital fractures at Umeå University Hospital, Sweden, were registered according to the Injury Data Base, former EHLASS. There were 31,173 fracture events (one or more fractures at the same time), of which 13,931 were in patients’ ≥ 50 years old. The fracture database was co analyzed with the Northern Sweden Health and Disease Study cohort in a nested case-control study for investigations of associations between osteoporotic fracture and serum markers, lifestyle data, nutrition etc. We found that there were differences in fracture pattern depending on age and sex. Both injury mechanism and fracture site were strongly dependent of age. The most severe fragility fracture, hip fracture, had a decreasing incidence. However, the incidence curve was right-shifting leading to an increase, both in numbers and in incidence of hip fractures among the oldest female. To identify people at high risk for fractures, re-fracture patients are useful. No less than 21% of the fracture patients had suffered more than one fracture event, accounting for 38% of all fracture events. The total risk ratio for a subsequent fracture was 2.2 (2.1-2.3 95% CI). In males the highest risk for re fracture was in the age cohort 70-79 years (RR 2.7, 2.3-3.2 95% CI), in females > 90 years (RR 3.9, 3.2-4.8 95% CI). Another possible risk factor in this subarctic population is the lack of sunlight, leading to a vitamin D deficit. The overall adjusted risk of sustaining a hip fracture in this population was 2.7 (95%CI:1.3-5.4) in subjects with a serum 25 hydroxyvitamin D below 50 nmol/l. The association was, however, different according to age at baseline. Thus in subjects aged 60 years and above at baseline, the adjusted odds ratio of sustaining a hip fracture was 6.2 (1.2-32.5 95%CI) for the group of individuals with a serum 25OHD below 50 nmol/l, whereas no significant association was found in the youngest age group. In the next 30 years the ongoing demographic changes will accelerate. The World War II baby boomers will cause an age quake. We can already see signs heralding a new fracture pattern: an increasing cohort of mobile but fragile elderly, with considerable co-morbidity is now at risk for fragility fractures. In fracture patients, clinical information is sufficient to pinpoint patients with a high risk for re-fractures. It is therefore clinically important to use the information provided by the fracture event. We suggest that trauma units and primary care units should screen for risk factors and inform patients about the treatment options, and to organize fracture liaison services. This seems to be especially cost-efficient for our oldest and frailest patients. Secondary prophylaxis and follow-up treatment after cardiovascular disorders are now a matter of course worldwide, but the screening for risk factors, in order to prevent a second fracture, is often neglected. This is one of the most important issues of fracture care in the future in order to improve general health.
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| 4. |
- Bergström, Ulrica, 1970-, et al.
(författare)
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The hip fracture incidence curve is shifting to the right : a forecast of the age-quake
- 2009
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Ingår i: Acta Orthopaedica. - : Medical Journals Sweden AB. - 1745-3674 .- 1745-3682. ; 80:5, s. 520-524
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Tidskriftsartikel (refereegranskat)abstract
- Background The number of hip fractures has doubled in the last 30–40 years in many countries. Age-adjusted incidence has been reported to be decreasing in Europe and North America, but is there a decreasing trend in all age groups? Patients and methods This population-based study included all hip-fracture patients over 50 years of age (a total of 2,919 individuals, 31% of whom were men) admitted to Umeå University Hospital, Sweden, from 1993 through 2005. Results The incidence of hip fracture declined between the periods 1993–1996 and 2001–2005: from 706 to 625 hip fractures per 105 women and from 390 to 317 hip fractures per 105 men. However, there was a 114% increase in the number of fractures in women aged 90 or older (12 and 25 hip fractures/year, respectively, in the two time periods). For the period 2001–05, women ≥ 90 years of age accounted for almost the same numbers of hip fractures as women aged 75–79 (27 fractures/year). The rate increased during this period, from 2,700 per 105 women to 3,900 per 105 women > 90 years. In men there were declining trends for both relative and absolute numbers. Interpretation Although age-adjusted incidence declined in the population > 50 years of age, absolute fracture rate and incidence increased in the very old. Women over 90 now have the same absolute number of hip fractures every year as women aged 75–79 years. There was a right-shift in hip fracture distribution towards the oldest old, probably due to an increased number of octo/nonagenarians, a new population of particularly frail old people that hardly existed earlier. Better health among septuagenarians may also have delayed the age at which fractures occurred. This changing pattern will strain orthopedic and geriatric resources even more.
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| 5. |
- Blomberg, Anders, 1956, et al.
(författare)
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Establishing the barnacle Balanus improvisus as a potent invertebrate monitoring system in marine ecotoxicogenomics
- 2009
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Ingår i: SETAC Europe 19th Annual Meeting Abstract Book, Göteborg 31 May - 4 June, 2009.
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Konferensbidrag (övrigt vetenskapligt/konstnärligt)abstract
- There is a need for potent invertebrate systems for assessing the impacts of environmental contaminants on marine ecosystems. Balanus improvisus, a marine athropod, has a number of promising characteristics that make it a good candidate in such efforts. We have conducted sequencing of a cDNA library from the cyprid larval stage and identified several detoxification systems as well as novel B. improvisus specific genes. To investigate the toxicological gene expression response in this organism, we performed a short-term exposure experiment of the cyprid larvae to two different biofouling substances. From a natural population of B. improvisus, 300 - 1000 cyprids were treated for 23 hours with 390nM CuO or with two different concentrations (10nM or 10μM) of meditomidine. Protein expression changes were studied by 2D-PAGE analysis after DIGE labelling. For gene expression analysis by DNA miroarrays total RNA was extracted and used for cDNA and cRNA/aRNA templates. Roughly 2000 B. improvisus genes were studied represented by 3000 different probes on the arrays (each in duplicates). Candidate genes were confirmed by qPCR. A number of protein expression changes were detected on the 2D gels as a result of the different treatments. Interestingly, the response to the different treatments clearly formed distinct groups in principle component analysis. The DNA microarray analysis revealed several genes as toxicity indicators, e.g. various heat shock proteins, some proteases and factors involved in regulatory processes (transcription factors). Our data indicate that B. improvisus may serve as a tool to evaluate the impacts of marine pollution, and thus to fill the niche as an important invertebrate marine model organism for ecotoxicology and environmental genomics.
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| 6. |
- Conaway, H Herschel, et al.
(författare)
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Retinoids inhibit differentiation of hematopoietic osteoclast progenitors.
- 2009
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Ingår i: The FASEB journal. - Bethesda, Md. : Wiley. - 1530-6860 .- 0892-6638. ; 23:10, s. 3526-38
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Tidskriftsartikel (refereegranskat)abstract
- Whether vitamin A promotes skeletal fragility, has no effect on fracture rate, or protects against bone loss is unclear. In the present study, effects of retinoids on osteoclast differentiation in cultured mouse bone marrow cells (BMCs), bone marrow macrophages (BMMs), spleen cells, and RAW264.7 cells were evaluated by analyzing osteoclast formation and expression of genes important in signal transduction and osteoclast function. All-trans-retinoic acid (ATRA) did not stimulate osteoclastogenesis in BMCs, but inhibited hormone and RANKL-induced gene expression and formation of osteoclasts. In BMMs, spleen cells, and RAW264.7 cells, osteoclast differentiation and formation stimulated by M-CSF/RANKL were inhibited (IC(50) = 0.3 nM) by ATRA. The effect was exerted at an early step of RANKL-induced differentiation. ATRA also abolished increases of the transcription factors c-Fos and NFAT2 stimulated by RANKL and suppressed down-regulation of the antiosteoclastogenic transcription factor MafB. By comparing effects of several compounds structurally related to ATRA, as well as by using receptor antagonists, evaluation pointed to inhibition being mediated by RARalpha, with no involvement of PPARbeta/delta. The results suggest that activation of RARalpha by retinoids in myeloid hematopoietic precursor cells decreases osteoclast formation by altering expression of the transcription factors c-Fos, NFAT2, and MafB.
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| 7. |
- Englund, Undis, 1957-, et al.
(författare)
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A 1-year combined weight-bearing training program is beneficial for bone mineral density and neuromuscular function in older women
- 2005
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Ingår i: Osteoporosis International. - : Springer. - 0937-941X .- 1433-2965. ; 16:9, s. 1117-1123
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Tidskriftsartikel (refereegranskat)abstract
- Forty-eight community living women 66–87 years old volunteered to participate in a 12-month prospective, randomized, controlled, trial. The aim was to determine if a combined weight-bearing training program twice a week would be beneficial to bone mineral density and neuromuscular function. The participants were pairwise age-matched and randomly assigned to either an exercise group (n=24) or a control group (n=24). Twenty-one subjects in the intervention group and 19 in the control group completed the study. The exercise program lasted for 50 min and consisted of a combination of strengthening, aerobic, balance and coordination exercises. The mean percentage of scheduled sessions attended for the exercise group was 67%. At the completion of the study, the intervention group showed significant increments in bone mineral density of the Wards triangle (8.4%, P<0.01) as well as improvement in maximum walking speed (11.4%, P<0.001) and isometric grip strength (9.9%, P<0.05), as compared to the control group. The conclusion was that a combined weight-bearing training program might reduce fracture risk factors by improving bone density as well as muscle strength and walking ability. This program could be suitable for older community living women in general, and might, therefore, have important implications for fracture prevention.
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| 8. |
- Englund, Undis, 1957-
(författare)
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Physical activity, bone density, and fragility fractures in women
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Scandinavia has among the highest incidence of fragility fractures in the world. The reasons for this are unknown, but might involve differences in genetic and/or environmental factors, such as sunlight exposure and levels of physical activity. Weight-bearing exercise is thought to have a beneficial effect on bone health in the young, but few studies have evaluated whether exercise in older subjects affects bone density and protects against fragility fractures. The initial objective of this thesis was to evaluate whether a combined weight-bearing training programme twice a week would be beneficial as regards bone mineral density (BMD) and neuromuscular function in older women. Forty-eight community living women with a mean age of 73 years were recruited for this 12-month prospective, randomised controlled trial, and were randomly assigned to an intervention group (n=24) or a control group (n=24). The intervention group displayed significant increments in BMD at the Ward’s triangle, maximum walking speed, and isometric grip strength compared to the control group. The second objective was to investigate if training effects were retained in older women five years after the cessation of training. The 40 women who completed the first study included in this thesis were invited to take part in a follow-up assessment five years later, and 34 women (~79 years) agreed to participate. During these five years both groups had sustained significant losses in hip BMD and in all neuromuscular function tests, and the previous exercise-induced intergroup differences were no longer seen. The third and fourth objective of this thesis was to investigate whether exercise and weight-bearing leisure activities in middle-aged women are associated with a decreased risk of sustaining hip or wrist fractures at a later stage. A cohort of women participating in the Umeå Fracture and Osteoporosis (UFO) study, a longitudinal, nested case-control study investigating associations between bone markers, lifestyle, and osteoporotic fractures, was used for the purpose of this investigation. Eighty-one hip fracture cases and 376 wrist fracture cases, which had reported lifestyle data before they sustained their fracture, were identified. These cases were compared with age-matched controls identified from the same cohort. Using conditional logistic regression analysis with adjustments for height, BMI, smoking, and menopausal status, results showed that moderate frequency of leisure physical activities such as gardening and berry/mushroom picking, were associated with reduced hip fracture risk (OR 0.28; 95% CI 0.12 – 0.67), whereas active commuting (especially walking) along with dancing and snow shoveling in leisure time, reduced the wrist fracture risk (OR 0.48; 95% CI 0.27 – 0.88, OR 0.42; 95% CI 0.22 – 0.80 and OR 0.50; 95% CI 0.32 – 0.79 respectively). In summary, this thesis suggests that weight-bearing physical activity is beneficial for BMD and neuromuscular functions such as muscle strength and gait in older women, and that a physically active lifestyle, with outdoor activities, in middle age is associated with reduced risk of both hip and wrist fractures. Possible mechanisms underlying this association include improved muscle strength, coordination, and balance, resulting in a decreased risk of falling and perhaps also direct skeletal benefits.
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| 9. |
- Englund, Undis, 1957-, et al.
(författare)
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The beneficial effects of exercise on BMC are lost after cessation : a 5-year follow-up in older post-menopausal women
- 2009
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Ingår i: Scandinavian Journal of Medicine and Science in Sports. - Copenhagen : Munksgaard. - 0905-7188 .- 1600-0838. ; 19:3, s. 381-388
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Tidskriftsartikel (refereegranskat)abstract
- This study investigates whether the positive effects on bone mineral density (BMD, g/cm2) and neuromuscular function following a combined weight-bearing program are sustained in older women, a longer period after cessation of training. Thirty-four women (18 exercisers and 16 controls) aged 73–88 years, who completed a 12-month randomized-controlled trial, were invited to a 5-year follow-up assessment of BMD and neuromuscular function. Both groups sustained significant losses in BMD of the femoral neck, trochanter, and Ward's triangle during the follow-up period. Significant losses were also seen in all neuromuscular function tests. The inter-group change was, however, significant only for maximal walking speed where the exercise group had a significantly greater loss. In conclusion, this study suggests that gains in bone density and neuromuscular functions achieved by training are lost after cessation of training. Continuous high-intensity weight-loading physical activity is probably necessary to preserve bone density and neuromuscular function in older women.
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| 10. |
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