Danderyds Hospital

Stockholm, Sweden

Danderyds Hospital

Stockholm, Sweden
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Nystrom T.,Karolinska Institutet | Holzmann M.J.,Karolinska University Hospital | Holzmann M.J.,Karolinska Institutet | Eliasson B.,Sahlgrenska University Hospital | And 4 more authors.
Journal of the American College of Cardiology | Year: 2015

Background Patients with type 1 diabetes mellitus (T1DM) have a high risk of cardiovascular events. Objectives The aim of this study was to investigate whether preoperative hemoglobin A1c (HbA1c) levels could predict cardiovascular events or death after coronary artery bypass grafting (CABG). Methods This was a nationwide population-based observational cohort study that included all patients with T1DM who underwent primary isolated nonemergency CABG in Sweden between 1997 and 2012, according to the Swedish National Diabetes Register and the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) register. We calculated the crude incidence rates and 95% confidence intervals (CIs) and used Cox regression and multivariable hazard ratios (HRs) to estimate the risk of both all-cause mortality and major adverse cardiovascular events (MACE), defined as myocardial infarction, stroke, heart failure, or repeat revascularization, in relation to HbA1c levels. Results In total, 764 patients with T1DM were included. During a median follow-up of 4.7 years, 334 (44%) patients died or had MACE (incidence rate: 82 events/1,000 person-years). After multivariable adjustment, the HR (95% CI) for death or MACE in patients with HbA1c levels of 7.1% to 8.0%, 8.1% to 9.0%, 9.1% to 10.0%, and >10.0% were 1.34 (0.82 to 2.21), 1.59 (1.00 to 2.54), 1.73 (1.03 to 2.90), and 2.25 (1.29 to 3.94), respectively, compared with the reference category. When HbA1c was used as a continuous variable, the HR for a 1% increase in HbA1c level was 1.18, and the 95% CI was 1.06 to 1.32. Conclusions In patients with T1DM, poor glycemic control before CABG was associated with increased long-term risk of death or MACE. (HeAlth-data Register sTudies of Risk and Outcomes in Cardiac Surgery [HARTROCS]; NCT02276950) © 2015 American College of Cardiology Foundation.


Caudwell P.,University of Leeds | Finlayson G.,University of Leeds | Gibbons C.,University of Leeds | Hopkins M.,University of Leeds | And 4 more authors.
American Journal of Clinical Nutrition | Year: 2013

Background: There are strong logical reasons why energy expended in metabolism should influence the energy acquired in food-intake behavior. However, the relation has never been established, and it is not known why certain people experience hunger in the presence of large amounts of body energy. Objective: We investigated the effect of the resting metabolic rate (RMR) on objective measures of whole-day food intake and hunger. Design: We carried out a 12-wk intervention that involved 41 overweight and obese men and women [mean ± SD age: 43.1 ± 7.5 y; BMI (in kg/m2): 30.7 ± 3.9] who were tested under conditions of physical activity (sedentary or active) and dietary energy density (17 or 10 kJ/g). RMR, daily energy intake, meal size, and hunger were assessed within the same day and across each condition. Results: We obtained evidence that RMR is correlated with meal size and daily energy intake in overweight and obese individuals. Participants with high RMRs showed increased levels of hunger across the day (P < 0.0001) and greater food intake (P < 0.00001) than did individuals with lower RMRs. These effects were independent of sex and food energy density. The change in RMR was also related to energy intake (P < 0.0001). Conclusions: We propose that RMR (largely determined by fat-free mass) may be a marker of energy intake and could represent a physiologic signal for hunger. These results may have implications for additional research possibilities in appetite, energy homeostasis, and obesity. This trial was registered under international standard identification for controlled trials as ISRCTN47291569. © 2013 American Society for Nutrition.


Segelman J.,Karolinska Institutet | Segelman J.,Danderyds Hospital | Nygren J.,Ersta Hospital
World Journal of Gastroenterology | Year: 2014

Repeated surveys from Europe, the United States, Australia, and New Zealand have shown that adherence to an evidence-based perioperative care protocol, such as Enhanced Recovery After Surgery (ERAS), has been generally low. It is of great importance to support the implementation of the ERAS protocol as it has been shown to improve outcomes after a number of surgical procedures, including major abdominal surgery. However, despite an increasing awareness of the importance of structured perioperative management, the implementation of this complex protocol has been slow. Barriers to implementation involve both patient- and staff-related factors as well as practice-related issues and resources. To support efficient and successful implementation, further educational and structural measures have to be made on a national or regional level to improve the standard of general health care. Besides postoperative morbidity, biological and physiological variables have been quite commonly reported in previous ERAS studies. Little information, however, has been obtained on cost-effectiveness, long-term outcomes, quality of life and patient-related outcomes, and these issues remain important areas of research for future studies. © 2014 Baishideng Publishing Group Inc. All rights reserved.


Eriksson L.,Karolinska Institutet | Czene K.,Karolinska Institutet | Rosenberg L.,Karolinska Institutet | Rosenberg L.,Danderyds Hospital | And 2 more authors.
Breast Cancer Research and Treatment | Year: 2012

Mammographic density (MD) is a well-established risk factor for breast cancer. Whether MD influences the tumor phenotype remains to be clarified. Previous studies are highly inconsistent and most lack important covariate information. This is a case-only study within a populationbased case-control study. Cases were all postmenopausal women, aged 50-74 years, with incident breast cancer, diagnosed 1993-1995, and with no history of previous cancer (n = 2,720). 1,747 women with mammograms and information on tumor characteristics were included in analyses. MD was assessed using a computer-assisted thresholding technique. We used linear, logistic, and multinomial logistic regression, adjusting for possible confounders, to study density and tumor characteristics. PD was only statistically significantly associated with tumor size in our study (regression coefficient 0.031, p = 0.017). The effect of PD on tumor size was greater when mode of detection was excluded from the model (regression coefficient 0.043, p = 0.001). No other associations between PD and the tumor characteristics studied (lymph node metastasis, ER-status, PR-status, grade, and histopathological classification) were observed. In summary, PD was positively associated with tumor size in postmenopausal women. However, the relationship was at least partially confounded by mode of detection. Although there may be a true biological relationship between MD and more highly proliferative tumors, it also seems that part of this relationship is due to masking delaying diagnosis. In conclusion, PD does not seem to be differentially associated with tumor phenotype, except for tumor size, after taking mode of detection into consideration. © Springer Science+Business Media, LLC. 2012.


Eriksson L.,Karolinska Institutet | Czene K.,Karolinska Institutet | Rosenberg L.,Danderyds Hospital | Humphreys K.,Karolinska Institutet | Hall P.,Karolinska Institutet
Breast Cancer Research | Year: 2013

Introduction: It is debated whether mammographic density gives rise to more aggressive cancers. We therefore aimed to study the influence of mammographic density on prognosis.Methods: This is a case-only study within a population-based case-control study. Cases were all postmenopausal women in Sweden with incident breast cancer, diagnosed 1993-1995, and aged 50-74 years. Women with pre-diagnostic/diagnostic mammograms were included (n = 1774). Mammographic density of the unaffected breast was assessed using a computer-assisted thresholding technique. The Cox proportional hazards model was used to study recurrence and survival with and without stratification on surgical procedure (breast-conserving surgery vs. mastectomy).Results: Percentage density (PD) was associated with both local and locoregional recurrence even after adjustment for established prognosticators; hazards ratio (HR) 1.92, p = 0.039, for local recurrence and HR 1.67, p = 0.033, for locoregional recurrence for women with PD≥25% compared to PD<25%. Stratification on surgical procedure showed that the associations were also present in mastectomized women. PD was neither associated with distant recurrence nor survival.Conclusions: High mammographic density is an independent risk factor of local and locoregional recurrence but is neither associated with distant metastasis nor survival. The relationships with local and locoregional recurrences were also present in women treated with mastectomy, indicating that they are not merely explained by density masking residual disease in women treated with breast-conserving surgery. Rather there appears to be a true association. Thus, mammographic density should possibly influence adjuvant therapy decisions in the future. © 2013 Eriksson et al.; licensee BioMed Central Ltd.


Doliwa Sobocinski P.,Danderyds Hospital | Anggardh Rooth E.,Danderyds Hospital | Frykman Kull V.,Danderyds Hospital | Von Arbin M.,Danderyds Hospital | And 2 more authors.
Europace | Year: 2012

ObjectivesTo what extent silent paroxysmal atrial fibrillation (AF) is present in ischaemic stroke patients has not been established. We hypothesized that brief intermittent long-term electrocardiogram (ECG) recordings at regular time intervals are more effective than short-term continuous ECG monitoring in detecting silent AF episodes. Methods and ResultsConsecutive patients who had suffered an ischaemic stroke/transient ischaemic attack (TIA) and were without known AF underwent a 24 h continuous ECG recording and performed 10 s rhythm registrations using a hand-held ECG recorder twice daily for 30 days and when arrhythmia symptoms occured. Two hundred and forty-nine stroke patients were included. Mean National Institute of Health Stroke Scale (NIHSS) score was 0.9 (010). In total, 17 patients were diagnosed with AF. One hundred and eight AF episodes were diagnosed in 15 patients using intermittent recording, out of which 22 where unscheduled symptom triggered episodes. In three patients AF was diagnosed with both methods and in two patients AF was detected exclusively with 24 h Holter monitoring. A significant difference in favour of the hand-held ECG was shown between the two methods (P=0.013). The total prevalence of AF was 6.8 and increased to 11.8 in patients <75 years. No AF was found in patients <65 years. ConclusionsProlonged brief intermittent arrhythmia screening substantially improves the detection of silent paroxysmal AF in patients with a recent ischaemic stroke/TIA, and thus facilitates the detection of patients who should receive oral anticoagulant treatment. © 2012 The Author.


Kadir R.A.,Royal Free Hospital | Edlund M.,Danderyds Hospital | Von Mackensen S.,University of Hamburg
Haemophilia | Year: 2010

Menorrhagia, heavy menstrual bleeding, is a common condition that has a substantial impact on the lives of many women. The objective measurement of menorrhagia is often impractical; therefore diagnosis and treatment are usually based on the direct perception of the woman. Menstrual problems are likely to be worse in women with bleeding disorders, as they are more likely to have heavy and painful menstrual periods and ovulation bleeding and pain. These can have a major impact on the quality of women's lives, especially those who suffer heavy menstruation. These problems can also lead to limitations at work and school and hinder educational and academic achievements. Only few studies describe how quality of life (QOL) changes in women with an underlying haemostatic defect; poorer QOL being associated with more frequent bleeding symptoms. Early recognition, accurate diagnosis and appropriate management of bleeding disorders should improve not only the quality of care for affected women but also their QOL. Increased awareness of the high prevalence of menstrual problems especially menorrhagia is essential for early diagnosis and provision of appropriate treatments without any delay. Accurate knowledge of the impact of menorrhagia on health-related quality of life (HRQOL) and its adequate assessment help individualize treatment and assess the magnitude of changes in HRQOL. An ideal situation would be to use a generic and a disease-specific measure together so that comparisons can be made on a general and disease-specific level. © 2010 Blackwell Publishing Ltd.


Nekludov M.,Karolinska University Hospital | Mobarrez F.,Danderyds Hospital | Gryth D.,Karolinska University Hospital | Bellander B.-M.,Karolinska University Hospital | Wallen H.,Danderyds Hospital
Journal of Neurotrauma | Year: 2014

The potential pathophysiological role of circulating microparticles (MPs) has been recognized in various conditions, such as cardiovascular and thrombotic diseases. Traumatic brain injury (TBI) has a complex pathophysiology that involves coagulopathy and inflammation. We investigated endothelial-, platelet-, and leukocyte-derived microparticles (EMPs, PMPs, and LMPs, respectively) in 16 patients with severe isolated TBI. Arterial and cerebrovenous samples were taken repeatedly, during 1-72 h after injury. Subpopulations of MPs, exposing tissue factor (TF) and P-selectin, were also studied. MP counts in cerebrovenous samples, irrespective of cellular origin, were higher in TBI cases, compared to healthy controls (peak levels of EMPs were approximately 7 times higher, PMPs 1.4 times higher, and LMPs 2 times higher, respectively; p < 0.001 for all). MP counts declined sharply from high levels shortly after the trauma toward slightly elevated levels 72 h later. EMPs and PMPs exposing TF, as well as PMPs exposing P-selectin, showed a transcranial gradient with higher concentration in cerebrovenous, compared to arterial, samples. In contrast, LMPs exposing TF were higher in arterial samples, suggesting accumulation of LMPs in the brain. We conclude that the pattern of circulating MPs is altered after TBI. PMPs exposing P-selectin and EMPs exposing TF seem to be generated in the injured brain, whereas LMPs exposing TF are accumulated. The pathophysiological significance of these changes in MP pattern in TBI should be further investigated. Including MPs exposing brain-specific antigens in the assessment of brain injury would give further information of origin and likely give additional information of the size of the injury, given that the MP phenotypes investigated in the present study are not brain-specific markers. © Mary Ann Liebert, Inc.


Edlund M.,Danderyds Hospital
Journal of Women's Health | Year: 2011

Background: The purpose of this review is to identify and compare nonhormonal medications for the treatment of idiopathic heavy menstrual bleeding (HMB) or menorrhagia. Methods: Clinical trials were identified through a PubMed literature search. Titles and abstracts of identified studies were reviewed. Controlled clinical trials that evaluated nonhormonal medications in women with HMB in the absence of anatomic abnormalities other than small fibroids were selected for retrieval. Additional studies were identified from the reference lists of selected articles. Selected articles were comprehensively reviewed. Results: All medications evaluated reduced menstrual blood loss (MBL); however, mean reductions in MBL were greatest with the hemostatic agents, tranexamic acid (TA) and ε-aminocaproic acid. Several TA studies also included evidence of improvement in health-related quality of life (HRQOL). Reductions in MBL were generally smaller and less consistent with nonsteroidal anti-inflammatory drug (NSAID) treatment. All medications reviewed were well tolerated. Conclusions: Nonhormonal medications used for HMB treatment differ in the extent of MBL reduction. TA was notable for consistent MBL reductions and improvement in HRQOL; other agents reviewed indicated less reduction in MBL or sufficient data were lacking for comparison. © Copyright 2011, Mary Ann Liebert, Inc.


Olson J.,South Hospital Sodersjukhuset | Samad B.A.,Danderyds Hospital | Alam M.,Danderyds Hospital
Heart | Year: 2012

Objectives: To investigate the value of tissue Doppler imaging (TDI) measurements of right ventricular (RV) systolic and diastolic function as a predictor of long term cardiovascular outcomes in patients with left ventricular (LV) systolic heart failure. Background: In patients with LV systolic heart failure, RV function has been shown to be an important predictor of outcome. TDI is probably a clinically useful method for assessing RV function. The studies published so far have had a rather short follow-up period and have excluded patients with atrial fibrillation. Methods: 156 patients admitted to the cardiology department due to decompensated heart failure were included in this observational cohort study. 19% had atrial fibrillation. An echocardiographic examination was performed at entry to the study. The patients were then followed for a mean of 829 days. The primary endpoint was cardiovascular mortality or hospitalisation for decompensated heart failure. Results: 43 patients (28%) died from cardiovascular causes and 55 patients (35%) patients were hospitalised. 80 patients (51%) reached the study endpoint. Only age and a combined systolic and diastolic TDI parameter (s′r + e′r < 18.5 cm/s) of the right ventricle were independent predictors of cardiovascular outcome (HR 1.99, p=0.007). Conclusion: A combined measure of RV systolic and diastolic function, using TDI, can be used as an independent predictor of outcome in patients with LV systolic heart failure.

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