| 1. |
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| 2. |
- Johnsson, Linus, et al.
(author)
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Patients' refusal to consent to storage and use of samples in Swedish biobanks : cross sectional study
- 2008
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In: BMJ. British Medical Journal. - : BMJ. - 0959-8146 .- 0959-535X. ; 337:7663, s. a345-
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Journal article (peer-reviewed)abstract
- ObjectivesTo estimate how many people object to storage of biological samples collected in health care in Sweden and to their use in research and how many withdraw previous consent.DesignCross sectional study of register data.SettingBiobanks used in Swedish health care, 2005-6.PopulationData on refusal to consent were obtained for 1.4 million biobank samples per year from 20 of 21 counties.Main outcome measuresRates of preliminary refusal to consent, confirmed refusal, and withdrawal of consent.ResultsPatients refused consent to either storage or use of their samples in about 1 in 690 cases, about 1 in 1600 confirmed their decision by completing a dissent form. Rather than having the samples destroyed, about 1 in 6200 patients wanted to restrict their use. Of those who had previously consented, about 1 in 19 000 withdrew their consent.ConclusionsRefusal to consent to biobank research in Sweden is rare, and the interests of individuals and research interests need not be at odds. The Swedish healthcare organisation is currently obliged to obtain either consent or refusal to each potential use of each sample taken, and tack of consent to research is used as the default position. A system of presumed consent with straightforward opt out;would correspond with people's attitudes, as expressed in their actions, towards biobank research.
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| 3. |
- Neovius, Martin, et al.
(author)
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Combined effects of overweight and smoking in late adolescence on subsequent mortality : nationwide cohort study
- 2009
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In: BMJ. British Medical Journal. - : BMJ. - 0959-8146 .- 0959-535X. ; 338, s. b496-
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To investigate the combined effects on adult mortality of overweight and smoking in late adolescence. DESIGN: Record linkage study with Cox proportional hazard ratios adjusted for muscle strength, socioeconomic position, and age. SETTING: Swedish military service conscription register, cause of death register, and census data. PARTICIPANTS: 45 920 Swedish men (mean age 18.7, SD 0.5) followed for 38 years. MAIN OUTCOME MEASURES: Body mass index (underweight (BMI <18.5), normal weight (18.5-24.9), overweight (25-29.9), and obesity (>or=30)), muscle strength, and self reported smoking (non-smoker, light smoker (1-10 cigarettes/day), heavy smoker (>10/day)) at mandatory military conscription tests in 1969-70. All cause mortality. RESULTS: Over 1.7 million person years, 2897 men died. Compared with normal weight men (incidence rate 17/10 000 person years, 95% confidence interval 16 to 18), risk of mortality was increased in overweight (hazard ratio 1.33, 1.15 to 1.53; incidence rate 23, 20 to 26) and obese men (hazard ratio 2.14, 1.61 to 2.85; incidence rate 38, 27 to 48), with similar relative estimates in separate analyses of smokers and non-smokers. No increased risk was detected in underweight men (hazard ratio 0.97, 0.86 to 1.08; incidence rate 18, 16 to 19), though extreme underweight (BMI <17) was associated with increased mortality (hazard ratio 1.33, 1.07 to 1.64; incidence rate 24, 19 to 29). The relative excess risk due to interaction between BMI and smoking status was not significant in any stratum. Furthermore, all estimates of interaction were of small magnitude, except for the combination of obesity and heavy smoking (relative excess risk 1.5, -0.7 to 3.7). Compared with non-smokers (incidence rate 14, 13 to 15), risk was increased in both light (hazard ratio 1.54, 1.41 to 1.70; incidence rate 15, 14 to 16) and heavy smokers (hazard ratio 2.11, 1.92 to 2.31; incidence rate 26, 24 to 27). CONCLUSIONS: Regardless of smoking status, overweight and obesity in late adolescence increases the risk of adult mortality. Obesity and overweight were as hazardous as heavy and light smoking, respectively, but there was no interaction between BMI and smoking status. The global obesity epidemic and smoking among adolescents remain important targets for intensified public health initiatives.
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| 4. |
- Osika, Walter, et al.
(author)
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Physical control and coordination in childhood and adult obesity : longitudinal birth cohort study
- 2008
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In: BMJ. British Medical Journal. - : BMJ. - 0959-8146 .- 0959-535X. ; 337, s. a699-
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To identify whether measures of childhood physical control and coordination as markers of neurological function are associated with obesity in adults. DESIGN: Longitudinal birth cohort study. SETTING: National child development study in Great Britain. PARTICIPANTS: 11,042 people born during one week in 1958. MAIN OUTCOME MEASURE: Obesity at age 33 years defined as body mass index >or=30. RESULTS: Among 7990 cohort members at age 7 years, teachers reported that poor hand control, poor coordination, and clumsiness "certainly applied" more often among those who would be obese adults, producing adjusted odds ratios of 1.57 (95% confidence interval 1.13 to 2.20; P=0.008) for poor hand control, 2.30 (1.52 to 3.46; P<0.001) for poor coordination, and 3.91 (2.61 to 5.87; P<0.001) for clumsiness. Among 6875 participants who had doctor administered assessments with continuous scores at age 11 years, poorer function was associated with later obesity, indicated by adjusted odds ratios (change in risk per unit increase in score) of 0.88 (0.81 to 0.96; P=0.003) for copying designs, 0.84 (0.78 to 0.91; P<0.001) for marking squares, and 1.14 (1.06 to 1.24; P<0.001) for picking up matches (a higher score indicates poor function in this test). Further adjustment for contemporaneous body mass index at age 7 or 11 years did not eliminate statistical significance for any of the associations. CONCLUSION: Some aspects of poorer neurological function associated with adult obesity may have their origins in childhood.
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| 5. |
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| 6. |
- Auvinen, A, et al.
(author)
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Indoor radon and deaths from lung cancer
- 2009
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In: BMJ (Clinical research ed.). - : BMJ. - 1756-1833 .- 0959-8138 .- 1468-5833. ; 338, s. a3128-
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Journal article (other academic/artistic)
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| 7. |
- Boman, Magnus
(author)
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Commentary : The joy of mesh
- 2009
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In: BMJ. British Medical Journal. - : BMJ. - 0959-8146 .- 0959-535X. ; 337, s. a2500-
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Journal article (peer-reviewed)
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| 8. |
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| 10. |
- Byberg, Liisa, et al.
(author)
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Total mortality after changes in leisure time physical activity in 50 year old men : 35 year follow-up of population based cohort
- 2009
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In: British Journal of Sports Medicine. - : BMJ Publishing Group Ltd. - 0306-3674 .- 1473-0480. ; 338, s. b688-
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Journal article (peer-reviewed)abstract
- Objective: To examine how change in level of physical activity after middle age influences mortality and to compare it with the effect of smoking cessation.Design: Population based cohort study with follow-up over 35 years.Setting: Municipality of Uppsala, Sweden.Participants: 2205 men aged 50 in 1970-3 who were reexamined at ages 60, 70, 77, and 82 years.Main Outcome Measure: Total (all cause) mortality.Results: The absolute mortality rate was 27.1, 23.6, and 18.4 per 1000 person years in the groups with low, medium, and high physical activity, respectively. The relative rate reduction attributable to high physical activity was 32% for low and 22% for medium physical activity. Men who increased their physical activity level between the ages of 50 and 60 continued to have a higher mortality rate during the first five years of follow-up (adjusted hazard ratio 2.64, 95% confidence interval 1.32 to 5.27, compared with unchanged high physical activity). After 10 years of follow-up their increased physical activity was associated with reduced mortality to the level of men with unchanged high physical activity (1.10, 0.87 to 1.38). The reduction in mortality associated with increased physical activity (0.51, 0.26 to 0.97, compared with unchanged low physical activity) was similar to that associated with smoking cessation (0.64, 0.53 to 0.78, compared with continued smoking).Conclusions: Increased physical activity in middle age is eventually followed by a reduction in mortality to the same level as seen among men with constantly high physical activity. This reduction is comparable with that associated with smoking cessation
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| 11. |
- Byberg, Liisa, et al.
(author)
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Total mortality after changes in leisure time physical activity in 50 year old men : 35 year follow-up of population based cohort
- 2009
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In: The BMJ. - : BMJ. - 1756-1833 .- 0959-8138 .- 1468-5833. ; 43:7, s. 482-
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To examine how change in level of physical activity after middle age influences mortality and to compare it with the effect of smoking cessation. DESIGN: Population based cohort study with follow-up over 35 years. SETTING: Municipality of Uppsala, Sweden. PARTICIPANTS: 2205 men aged 50 in 1970-3 who were re-examined at ages 60, 70, 77, and 82 years. MAIN OUTCOME MEASURE: Total (all cause) mortality. RESULTS: The absolute mortality rate was 27.1, 23.6, and 18.4 per 1000 person years in the groups with low, medium, and high physical activity, respectively. The relative rate reduction attributable to high physical activity was 32% for low and 22% for medium physical activity. Men who increased their physical activity level between the ages of 50 and 60 continued to have a higher mortality rate during the first five years of follow-up (adjusted hazard ratio 2.64, 95% confidence interval 1.32 to 5.27, compared with unchanged high physical activity). After 10 years of follow-up their increased physical activity was associated with reduced mortality to the level of men with unchanged high physical activity (1.10, 0.87 to 1.38). The reduction in mortality associated with increased physical activity (0.51, 0.26 to 0.97, compared with unchanged low physical activity) was similar to that associated with smoking cessation (0.64, 0.53 to 0.78, compared with continued smoking). CONCLUSIONS: Increased physical activity in middle age is eventually followed by a reduction in mortality to the same level as seen among men with constantly high physical activity. This reduction is comparable with that associated with smoking cessation.
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| 14. |
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| 15. |
- Dillner, Joakim, et al.
(author)
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Long term predictive values of cytology and human papillomavirus testing in cervical cancer screening: joint European cohort study.
- 2008
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In: BMJ: British Medical Journal. - : BMJ. - 1756-1833 .- 0959-8138 .- 1468-5833. ; 337
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To obtain large scale and generalisable data on the long term predictive value of cytology and human papillomavirus (HPV) testing for development of cervical intraepithelial neoplasia grade 3 or cancer (CIN3+). DESIGN: Multinational cohort study with joint database analysis. SETTING: Seven primary HPV screening studies in six European countries. PARTICIPANTS: 24,295 women attending cervical screening enrolled into HPV screening trials who had at least one cervical cytology or histopathology examination during follow-up. MAIN OUTCOME MEASURE: Long term cumulative incidence of CIN3+. RESULTS: The cumulative incidence rate of CIN3+ after six years was considerably lower among women negative for HPV at baseline (0.27%, 95% confidence interval 0.12% to 0.45%) than among women with negative results on cytology (0.97%, 0.53% to 1.34%)). By comparison, the cumulative incidence rate for women with negative cytology results at the most commonly recommended screening interval in Europe (three years) was 0.51% (0.23% to 0.77%). The cumulative incidence rate among women with negative cytology results who were positive for HPV increased continuously over time, reaching 10% at six years, whereas the rate among women with positive cytology results who were negative for HPV remained below 3%. CONCLUSIONS: A consistently low six year cumulative incidence rate of CIN3+ among women negative for HPV suggests that cervical screening strategies in which women are screened for HPV every six years are safe and effective.
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| 16. |
- Eliasson, E
(author)
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Ethnicity and adverse drug reactions
- 2006
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In: BMJ (Clinical research ed.). - : BMJ. - 1756-1833 .- 0959-8138 .- 1468-5833. ; 332:7551, s. 1163-1164
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Journal article (other academic/artistic)
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| 17. |
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| 18. |
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| 19. |
- Godbolt, Alison K.
(author)
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Scandinavian solution
- 2008
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In: BMJ. British Medical Journal. - : BMJ. - 0959-8146 .- 0959-535X. ; 337, s. a2586-
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Journal article (peer-reviewed)
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| 20. |
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| 21. |
- Head, Jenny, et al.
(author)
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Diagnosis-specific sickness absence as a predictor of mortality : the Whitehall II prospective cohort study.
- 2008
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In: BMJ (Clinical research ed.). - : BMJ. - 1468-5833 .- 0959-8138 .- 1756-1833. ; 337, s. a1469-
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To investigate whether knowing the diagnosis for sickness absence improves prediction of mortality. DESIGN: Prospective cohort study established in 1985-8. Sickness absence records including diagnoses were obtained from computerised registers. SETTING: 20 civil service departments in London. PARTICIPANTS: 6478 civil servants aged 35-55 years. MAIN OUTCOME MEASURES: All cause, cardiovascular, and cancer mortality until 2004, average follow-up 13 years. RESULTS: After adjustment for age, sex, and employment grade, employees who had one or more medically certified spells of sickness absence (>7 days) in a three year period had a mortality 1.7 (95% CI 1.3 to 2.1) times greater than those with no medically certified spells. Inclusion of diagnoses improved the prediction of all cause mortality (P=0.03). The hazard ratio for mortality was 4.7 (2.6 to 8.5) for absences with circulatory disease diagnoses, 2.2 (1.4 to 3.3) for surgical operations, and 1.9 (1.2 to 3.1) for psychiatric diagnoses. Psychiatric absences were also predictive of cancer mortality (2.5 (1.3 to 4.7)). Associations of infectious, respiratory, and injury absences with overall mortality were less marked (hazard ratios from 1.5 to 1.7), and there was no association between musculoskeletal absences and mortality. CONCLUSIONS: Major diagnoses for medically certified absences were associated with increased mortality, with the exception of musculoskeletal disease. Data on sickness absence diagnoses may provide useful information to identify groups with increased health risk and a need for targeted interventions.
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| 22. |
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| 23. |
- Hoff, Geir, et al.
(author)
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Risk of colorectal cancer seven years after flexible sigmoidoscopy screening : randomised controlled trial
- 2009
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In: BMJ. British Medical Journal. - : BMJ. - 0959-8146 .- 0959-535X. ; 338, s. b1846-
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To determine the risk of colorectal cancer after screening with flexible sigmoidoscopy. DESIGN: Randomised controlled trial. SETTING: Population based screening in two areas in Norway-city of Oslo and Telemark county (urban and mixed urban and rural populations). PARTICIPANTS: 55 736 men and women aged 55-64 years. INTERVENTION: Once only flexible sigmoidoscopy screening with or without a single round of faecal occult blood testing (n=13 823) compared with no screening (n=41 913). MAIN OUTCOME MEASURES: Planned end points were cumulative incidence and mortality of colorectal cancer after 5, 10, and 15 years. This first report from the study presents cumulative incidence after 7 years of follow-up and hazard ratio for mortality after 6 years. RESULTS: No difference was found in the 7 year cumulative incidence of colorectal cancer between the screening and control groups (134.5 v 131.9 cases per 100 000 person years). In intention to screen analysis, a trend towards reduced colorectal cancer mortality was found (hazard ratio 0.73, 95% confidence interval 0.47 to 1.13, P=0.16). For attenders compared with controls, a statistically significant reduction in mortality was apparent for both total colorectal cancer (hazard ratio 0.41, 0.21 to 0.82, P=0.011) and rectosigmoidal cancer (0.24, 0.08 to 0.76, P=0.016). CONCLUSIONS: A reduction in incidence of colorectal cancer with flexible sigmoidoscopy screening could not be shown after 7 years' follow-up. Mortality from colorectal cancer was not significantly reduced in the screening group but seemed to be lower for attenders, with a reduction of 59% for any location of colorectal cancer and 76% for rectosigmoidal cancer in per protocol analysis, an analysis prone to selection bias. TRIAL REGISTRATION: Clinical trials NCT00119912.
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| 24. |
- Håkansson, Krister, 1952-, et al.
(author)
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Association between mid-life marital status and cognitive function in later life : population based cohort study
- 2009
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In: The BMJ. - : BMJ. - 1756-1833 .- 0959-8138 .- 1468-5833. ; 339:July, s. Article number: b2462-
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Journal article (peer-reviewed)abstract
- Objectives To evaluate whether mid-life marital status is related to cognitive function in later life. Design Prospective population based study with an average follow-up of 21 years. Setting Kuopio and Joensuu regions in eastern Finland. Participants Participants were derived from random, population based samples previously investigated in 1972, 1977, 1982, or 1987; 1449 individuals (73%), aged 65-79, underwent re-examination in 1998. Main outcome measures Alzheimer's disease and mild cognitive impairment. Results People cohabiting with a partner in mid-life (mean age 50.4) were less likely than all other categories (single, separated, or widowed) to show cognitive impairment later in life at ages 65-79. Those widowed or divorced in mid-life and still so at follow-up had three times the risk compared with married or cohabiting people. Those widowed both at mid-life and later life had an odds ratio of 7.67 (1.6 to 40.0) for Alzheimer's disease compared with married or cohabiting people. The highest increased risk for Alzheimer's disease was in carriers of the apolipoprotein E e4 allele who lost their partner before mid-life and were still widowed or divorced at follow-up. The progressive entering of several adjustment variables from mid-life did not alter these associations. Conclusions Living in a relationship with a partner might imply cognitive and social challenges that have a protective effect against cognitive impairment later in life, consistent with the brain reserve hypothesis. The specific increased risk for widowed and divorced people compared with single people indicates that other factors are needed to explain parts of the results. A sociogenetic disease model might explain the dramatic increase in risk of Alzheimer's disease for widowed apolipoprotein E e4 carriers.
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| 25. |
- Johansson, Kari, et al.
(author)
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Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men : a randomised controlled trial.
- 2009
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In: The BMJ. - : BMJ. - 1756-1833 .- 0959-8138 .- 1468-5833. ; 339
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To assess the effect of weight loss induced by a very low energy diet on moderate and severe obstructive sleep apnoea in obese men. Design Single centre, two arm, parallel, randomised, controlled, open label trial. Blocked randomisation procedure used for treatment allocation. Setting Outpatient obesity clinic in a university hospital in Stockholm, Sweden. Participants 63 obese men (body mass index 30-40, age 30-65 years) with moderate to severe obstructive sleep apnoea (apnoea-hypopnoea index (AHI) >or=15), treated with continuous positive airway pressure.INTERVENTIONS: The intervention group received a liquid very low energy diet (2.3 MJ/day) for seven weeks to promote weight loss, followed by two weeks of gradual introduction of normal food, reaching 6.3 MJ/day at week 9. The control group adhered to their usual diet during the nine weeks of follow-up.MAIN OUTCOME MEASURE: AHI, the major disease severity index for obstructive sleep apnoea. Data from all randomised patients were included in an intention to treat analysis (baseline carried forward for missing data). Results Of the 63 eligible patients, 30 were randomised to intervention and 33 to control. Two patients in the control group were dissatisfied with allocation and immediately discontinued. All other patients completed the trial. Both groups had a mean AHI of 37 events/h (SD 15) at baseline. At week 9, the intervention group's mean body weight was 20 kg (95% confidence interval 18 to 21) lower than that of the control group, while its mean AHI was 23 events/h (15 to 30) lower. In the intervention group, five of 30 (17%) were disease free after the energy restricted diet (AHI <5), with 15 of 30 (50%) having mild disease (AHI 5-14.9), whereas the AHI of all patients in the control group except one remained at 15 or higher. In a subgroup analysis of the intervention group, baseline AHI significantly modified the effectiveness of treatment, with a greater improvement in AHI in patients with severe obstructive sleep apnoea (AHI >30) at baseline compared with those with moderate (AHI 15-30) sleep apnoea (AHI -38 v -12, P<0.001), despite similar weight loss (-19.2 v -18.2 kg, P=0.55). Conclusion Treatment with a low energy diet improved obstructive sleep apnoea in obese men, with the greatest effect in patients with severe disease. Long term treatment studies are needed to validate weight loss as a primary treatment strategy for obstructive sleep apnoea.TRIAL REGISTRATION: Current Controlled Trials ISRCTN70090382.
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| 26. |
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| 27. |
- Kivipelto, M, et al.
(author)
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Cerebral embolism and Alzheimer's disease
- 2006
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In: BMJ (Clinical research ed.). - : BMJ. - 1756-1833 .- 0959-8138 .- 1468-5833. ; 332:7550, s. 1104-1105
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Journal article (other academic/artistic)
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| 28. |
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| 29. |
- Lager, Anton, et al.
(author)
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The association of early IQ and education with mortality : 65 year longitudinal study in Malmö, Sweden
- 2009
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In: The BMJ. - : BMJ. - 1756-1833 .- 0959-8138 .- 1468-5833. ; 339, s. b5282-
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Journal article (peer-reviewed)abstract
- Objectives To establish whether differences in early IQ explain why people with longer education live longer, or whether differences in father’s or own educational attainment explain why people with higher early IQ live longer.Design Population based longitudinal study. Mortality risks were estimated with Cox proportional hazards regressions.Setting Malmö, Sweden.Participants 1530 children who took IQ tests at age 10 and were followed up until age 75.Results Own educational attainment was negatively associated with all cause mortality in both sexes, even when early IQ and father’s education were adjusted for (hazard ratio (HR) for each additional year in school 0.91 (95% CI 0.85 to 0.97) for men and HR 0.88 (95 % CI 0.78 to 0.98) for women). Higher early IQ was linked with a reduced mortality risk in men, even when own educational attainment and father’s education were adjusted for (HR for one standard deviation increase in IQ 0.85 (95 % CI 0.75 to 0.96)). In contrast, there was no crude effect of early IQ for women, and women with above average IQ had an increased mortality risk when own educational attainment was adjusted for, but only after the age of 60 (HR 1.60 (95 % CI 1.06 to 2.42)). Adding measures of social career over and above educational attainment to the model (for example, occupational status at age 36 and number of children) only marginally affected the hazard ratio for women with above average IQ (<5%).Conclusions Mortality differences by own educational attainment were not explained by early IQ. Childhood IQ was independently linked, albeit differently, to male adult mortality and to female adult mortality even when father’s education and own educational attainment was adjusted for, thus social background and own social career seem unlikely to be responsible for mortality differences by childhood IQ. The clear difference in the effect of IQ between men and women suggests that the link between IQ and mortality involves the social and physical environment rather than simply being a marker of a healthy body to begin with. Cognitive skills should, therefore, be addressed in our efforts to create childhood environments that promote health.
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| 30. |
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| 31. |
- Nordin, Pär, et al.
(author)
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Volume of procedures and risk of recurrence after repair of groin hernia : national register study
- 2008
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In: BMJ. British Medical Journal. - : BMJ Group. - 0959-8146 .- 0959-535X. ; 336:7650, s. 934-937
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To determine whether the association between volume and outcome found in major surgery also holds true for a minor operation. DESIGN: Review of outcomes after hernia surgery in Sweden.SETTING: Surgical units registered with the Swedish hernia register, which in 2004 covered about 95% of all hernia operations in Sweden.PARTICIPANTS: 86,409 patients over 15 years, who underwent 96,601 unilateral or bilateral groin hernia repairs (94,077 inguinal and 2524 femoral) in 1996-2004 at the participating surgical units.MAIN OUTCOME MEASURE: Re-operation for recurrence.RESULTS: There was a significantly higher rate of re-operation in surgeons who carried out 1-5 repairs a year than in surgeons who carried out more repairs. There was no association between outcome and further increases in volume. Although about half of surgeons in Sweden who repair hernias are low volume operators, they performed only 8.4% of all repairs.CONCLUSIONS: Sweden's numerous low volume hernia surgeons perform such a small proportion of all operations that the impact of their inferior results on the nationwide re-operation rate is minimal. Volume indicates an approximate minimum value for the number of hernia repairs a surgeon should do each year but the outcome in surgeons who carry out more than that number disqualifies volume as an indicator of proficiency.
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| 35. |
- Tannsjo, T
(author)
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Moral dimensions
- 2005
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In: BMJ (Clinical research ed.). - : BMJ. - 1756-1833 .- 0959-8138 .- 1468-5833. ; 331:7518, s. 689-691
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Journal article (peer-reviewed)
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| 45. |
- Butler, C.C., et al.
(author)
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Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care : Prospective study in 13 countries
- 2009
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In: BMJ. - : BMJ. - 0959-8146 .- 0959-8138 .- 1468-5833. ; 338:7710, s. 1545-
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Journal article (peer-reviewed)abstract
- Objective: To describe variation in antibiotic prescribing for acute cough in contrasting European settings and the impact on recovery. Design: Cross sectional observational study with clinicians from 14 primary care research networks in 13 European countries who recorded symptoms on presentation and management. Patients followed up for 28 days with patient diaries. Setting: Primary care. Participants: Adults with a new or worsening cough or clinical presentation suggestive of lower respiratory tract infection. Main outcome measures: Prescribing of antibiotics by clinicians and total symptom severity scores over time. Results: 3402 patients were recruited (clinicians completed a case report form for 99% (3368) of participants and 80% (2714) returned a symptom diary). Mean symptom severity scores at presentation ranged from 19 (scale range 0 to 100) in networks based in Spain and Italy to 38 in the network based in Sweden. Antibiotic prescribing by networks ranged from 20% to nearly 90% (53% overall), with wide variation in classes of antibiotics prescribed. Amoxicillin was overall the most common antibiotic prescribed, but this ranged from 3% of antibiotics prescribed in the Norwegian network to83% in the English network. While fluoroquinolones were not prescribed at all in three networks, they were prescribed for 18% in the Milan network. After adjustment for clinical presentation and demographics, considerable differences remained in antibiotic prescribing, ranging from Norway (odds ratio 0.18, 95% confidence interval 0.11 to 0.30) to Slovakia (11.2, 6.20 to 20.27) compared with the overall mean (proportion prescribed: 0.53). The rate of recovery was similar for patients who were and were not prescribed antibiotics (coefficient -0.01, Pless than0.01) once clinical presentation was taken into account. Conclusions: Variation in clinical presentation does not explain the considerable variation in antibiotic prescribing for acute cough in Europe. Variation in antibiotic prescribing is not associated with clinically important differences in recovery. Trial registration: Clinicaltrials.gov NCT00353951.
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| 46. |
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| 47. |
- Frisch, Morten, et al.
(author)
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Appendicitis, mesenteric lymphadenitis, and subsequent risk of ulcerative colitis : cohort studies in Sweden and Denmark
- 2009
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In: BRITISH MEDICAL JOURNAL. - : BMJ. - 0959-8146. ; 338:b716
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Journal article (peer-reviewed)abstract
- Objective To determine whether the repeatedly observed low risk of ulcerative colitis after appendicectomy is related to the appendicectomy itself or the underlying morbidity, notably appendicitis or mesenteric lymphadenitis. Design Nationwide cohort studies. Setting Sweden and Denmark. Participants 709 353 Swedish (1964-2004) and Danish (1977-2004) patients who had undergone appendicectomy were followed up for subsequent ulcerative colitis. The impact of appendicectomy on risk was also studied in 224 483 people whose parents or siblings had inflammatory bowel disease. Main outcome measures Standardised incidence ratios and rate ratios as measures of relative risk. Results During 11.1 million years of follow-up in the appendicectomy cohort, 1192 patients developed ulcerative colitis (10.8 per 100 000 person years). Appendicectomy without underlying inflammation was not associated with reduced risk (standardised incidence ratio 1.04, 95% confidence interval 0.95 to 1.15). Before the age of 20, however, appendicectomy for appendicitis (0.45, 0.39 to 0.53) or mesenteric lymphadenitis (0.65, 0.46 to 0.90) was associated with significant risk reduction. A similar pattern was seen in those with affected relatives, whose overall risk of ulcerative colitis was clearly higher than the background risk (1404 observed v 446 expected; standardised incidence ratio 3.15, 2.99 to 3.32). In this cohort, appendicectomy without underlying appendicitis did not modify risk (rate ratio 1.04, 0.66 to 1.55, v no appendicectomy), while risk after appendicectomy for appendicitis was halved (0.49, 0.31 to 0.74). Conclusions In individuals with or without a familial predisposition to inflammatory bowel disease, appendicitis and mesenteric lymphadenitis during childhood or adolescence are linked to a significantly reduced risk of ulcerative colitis in adulthood. Appendicectomy itself does not protect against ulcerative colitis.
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| 48. |
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| 49. |
- Lund, Soren S., et al.
(author)
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Combining insulin with metformin or an insulin secretagogue in non-obese patients with type 2 diabetes: 12 month, randomised, double blind trial
- 2009
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In: BMJ (International Edition). - : BMJ. - 0959-8146 .- 0959-8138 .- 1468-5833. ; 339
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Journal article (peer-reviewed)abstract
- Objectives To study the effect of insulin treatment in combination with metformin or an insulin secretagogue, repaglinide, on glycaemic regulation in non-obese patients with type 2 diabetes. Design Randomised, double blind, double dummy, parallel trial. Setting Secondary care in Denmark between 2003 and 2006. Participants Non-obese patients (BMI <= 27) with preserved beta cell function. Interventions After a four month run-in period with repaglinide plus metformin combination therapy, patients with a glycated haemoglobin (HbA(1c)) concentration of 6.5% or more were randomised to repaglinide 6 mg or metformin 2000 mg. All patients also received biphasic insulin aspart 70/30 (30% soluble insulin aspart and 70% intermediate acting insulin aspart) 6 units once a day before dinner for 12 months. Insulin dose was adjusted aiming for a fasting plasma glucose concentration of 4.0-6.0 mmol/l. The target of HbA(1c) concentration was less than 6.5%. Treatment was intensified to two or three insulin injections a day if glycaemic targets were not reached. Main outcome measure HbA(1c) concentration. Results Of the 459 patients who were eligible, 102 were randomised, and 97 completed the trial. Patients had had type 2 diabetes for approximately 10 years. At the end of treatment, HbA(1c) concentration was reduced by a similar amount in the two treatment groups (insulin plus metformin: mean (standard deviation) HbA(1c) 8.15% (1.32) v 6.72% (0.66); insulin plus repaglinide: 8.07% (1.49) v 6.90% (0.68); P=0.177). Total daily insulin dose and risk of hypoglycaemia were also similar in the two treatment groups. Weight gain was less with metformin plus biphasic insulin aspart 70/30 than with repaglinide plus biphasic insulin aspart 70/30 (difference in mean body weight between treatments -2.51 kg, 95% confidence interval -4.07 to -0.95). Conclusions In non-obese patients with type 2 diabetes and poor glycaemic regulation on oral hypoglycaemic agents, overall glycaemic regulation with insulin in combination with metformin was equivalent to that with insulin plus repaglinide. Weight gain seemed less with insulin plus metformin than with insulin plus repaglinide.
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