Eskilstuna, Sweden
Eskilstuna, Sweden

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Sjoberg D.,Falu Hospital | Larsson M.,Malar Hospital | Nielsen A.-L.,Malar Hospital | Holmquist L.,Uppsala University | And 2 more authors.
Journal of Crohn's and Colitis | Year: 2013

Background and aims: The incidence of ulcerative colitis (UC) increased during the 20th century in Western Europe and the North America, but there are conflicting reports whether the incidence has declined, stabilized or continued to increase. The aim of this study was to evaluate the incidence of UC in the Uppsala Region, Sweden. Methods: All new UC patients in Uppsala County (305,381 inhabitants) were prospectively registered during 2005-2006 and the same for all new UC patients in the Uppsala Region (642,117 inhabitants) during 2007-2009. The extent and severity of disease according to the Montreal classification, relapse rates and surgery were assessed. Results: 526 UC patients were included. The mean overall incidence for the time period was 20.0 (95% CI: 16.1-23.9) cases per 100,000 inhabitants. The incidence among children < 17. years of age was 8.9 per 100,000. The extent at diagnosis was evenly distributed (E1: n = 167, 32%, E2: n = 161, 31%, E3: n = 163, 31%). Half of the cases had moderate to severe symptoms (S1: n = 269, 51%, S2: n = 209, 40%, S3: n = 45, 8.6%). 228 (43%) relapsed and 13 (2.5%) required colectomy during the first year. Children had a higher proportion of extensive disease vs adults (27/42 vs 136/484), but no increased risk for severe symptoms or colectomy. Conclusion: In this prospective population-based study we found one of the highest incidences of UC in the world. The proportion of severe cases is comparable with historical data. The conclusion is that the nature of UC has not changed, only the incidence. © 2013 European Crohn's and Colitis Organisation.

Majeed A.,Karolinska University Hospital | Majeed A.,Malar Hospital | Kim Y.-K.,Soonchunhyang University | Kim Y.-K.,McMaster University | And 5 more authors.
Stroke | Year: 2010

Background and Purpose- The optimum timing of resumption of anticoagulation after warfarin-related intracranial hemorrhage in patients with indication for continued anticoagulation is uncertain. We performed a large retrospective cohort study to obtain more precise risk estimates. Methods- We reviewed charts of 2869 consecutive patients with objectively verified intracranial hemorrhage over 6 years at 3 tertiary centers. We calculated the daily risk of intracranial hemorrhage or ischemic stroke with and without resumption of warfarin; we focused on patients who survived the first week and had cardiac indication for anticoagulation or previous stroke. Using a Cox model, we estimated rates for these 2 adverse events in relation to different time points of resumed anticoagulation. The combined risk of either a new intracranial hemorrhage or an ischemic stroke was calculated for a range of warfarin resumption times. Results- We identified warfarin-associated intracranial hemorrhage in 234 patients (8.2%), of whom 177 patients (76%) survived the first week and had follow-up information available; the median follow-up time was 69 weeks (interquartile range [IQR] 19-144). Fifty-nine patients resumed warfarin after a median of 5.6 weeks (IQR 2.6-17). The hazard ratio for recurrent intracranial hemorrhage with resumption of warfarin was 5.6 (95% CI, 1.8-17.2), and for ischemic stroke it was 0.11 (95% CI, 0.014-0.89). The combined risk of recurrent intracranial hemorrhage or ischemic stroke reached a nadir if warfarin was resumed after approximately 10 to 30 weeks. Conclusion- The optimal timing for resumption of warfarin therapy appears to be between 10 and 30 weeks after warfarin-related intracranial hemorrhage. © 2010 American Heart Association, Inc.

Sjoberg D.,Falu Hospital | Larsson M.,Malar Hospital | Nielsen A.-L.,Malar Hospital | Holmquist L.,Uppsala University | And 2 more authors.
Journal of Crohn's and Colitis | Year: 2014

Background and Aims: As a part of the Swedish ICURE study where the epidemiological results of ulcerative colitis and microscopic colitis recently have been published, we hereby present the corresponding figures for Crohn's disease.Methods: All patients diagnosed with Crohn's disease in Uppsala County (305,381 inhabitants) were prospectively registered during 2005-2006 and the same for all new patients with Crohn's disease in Uppsala Region (642,117 inhabitants) during 2007-2009.Results: 264 patients with Crohn's disease were included. The mean annual incidence was 9.9/100,000/year (95% CI: 7.1-12.6). Incidence among children <. 17. years was 10.0/100,000/year (95% CI: 3.8-16.3). 51% of the patients had ileal involvement (L1: n= 73, 28%. L2: n= 129, 49%. L3: n= 62, 23%, L4: n= 47, 18%) and 23% had a stricturing or penetrating disease (B1: n= 204, 77%. B2: n= 34, 13%. B3: n= 26, 10%. p: n= 27, 10%). Intestinal resection rate during the first year was 12.5%. Patients with complicated disease had longer symptom duration before diagnosis compared to patients with non-complicated disease (median months 12.0, IQR: 3.0-24.0 vs 4.0, IQR: 2.0-12.0, p= 0.0032). Patients 40. years or older had an increased risk for surgery (HR: 2.03, 95% CI: 1.01-4.08, p= 0.0457).Conclusions: The incidence of Crohn's disease in a region of Sweden is one of the highest reported in Europe. Long symptom duration precedes stricturing or penetrating behaviour. Old age is an independent risk factor for surgery. © 2013 European Crohn's and Colitis Organisation.

Bohlen S.,University of Munster | Ekwall C.,Uppsala University Hospital | Hellstrom K.,Uppsala University Hospital | Vesterlin H.,Malar Hospital | And 3 more authors.
European Journal of Neurology | Year: 2013

Background and purpose: Physical therapy is recommended for the treatment of Huntington's disease, but reliable studies investigating its efficacy are almost non-existent. This may in part be due to the lack of suitable outcome measures. Therefore, we investigated the applicability of novel quantitative and objective assessments of motor dysfunction in the evaluation of physical therapy interventions aimed at improving gait and posture. Methods: Twelve patients with Huntington disease received a predefined twice-weekly intervention focusing on posture and gait over 6 weeks. The GAITRite mat and a force plate were used for objective and quantitative assessments. The Unified Huntingtons Disease Rating Scale Total Motor Score, the timed Up &Go test, and the Berg Balance Scale were used as clinical outcome measures. Results: Significant improvements were seen in GAITRite measures after therapy. Improvements were also seen in the Up & Go test and Berg Balance Scale, whereas force plate measures and Total Motor Scores did not change. Conclusions: The results suggest that physical therapy has a positive effect on gait in Huntington's disease. The study shows that objective and quantitative measures of gait and posture may serve as endpoints in trials assessing the efficacy of physical therapy. They should be explored further in larger trials applying a randomized controlled setting. © 2012 The Author(s) European Journal of Neurology © 2012 EFNS.

Lofstrom B.,Karolinska University Hospital | Lofstrom B.,Malar Hospital | Backlin C.,Uppsala University | Pettersson T.,University of Helsinki | And 2 more authors.
Journal of Rheumatology | Year: 2011

Objective. Patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) have an increased risk of diffuse large B cell lymphoma (DLBCL). The cytokine A PRoliferating-Inducing Ligand (APRIL) is strongly expressed in DLBCL in the general population and is detected in high concentrations in sera from subgroups of patients with RA and SLE. To investigate a possible association between APRIL and DLBCL in RA and SLE, we examined APRIL expression in lymphoma biopsies from patients with RA and SLE and from DLBCL patients without inflammatory disease. Methods. Lymphoma tissue from 95 RA, 12 SLE, and 63 comparator DLBCL cases were stained with anti-APRIL antibodies (Aprily-2). The percentage of positively stained cells of the comparator cases were divided into quartiles (1-4, where 4 = most stained) and compared with the results for the RA and SLE lymphomas. APRIL expression was correlated to clinical variables. Results. The odds ratio for high expression of APRIL (quartiles 3 and 4) was elevated in the SLE DLBCL (OR 23.6, 95% CI 2.4-231.2), but not in the RA DLBCL (OR 0.8, 95% CI 0.3-2.0). RA patients in quartile 4 had higher cumulated RA disease activity than those in quartile 1 (p = 0.013). Epstein-Barr virus in the lymphoma tissue was associated with high APRIL expression (p = 0.009). Conclusion. The high expression of APRIL in DLBCL in SLE and in an RA subset might indicate an association between APRIL and lymphoma in these subsets of rheumatic diseases, but could also reflect a dysregulation of APRIL per se in these patient groups. The Journal of Rheumatology Copyright © 2011. All rights reserved.

Forsberg A.,Family Medicine Research Center | Forsberg A.,Örebro University | Andreasson M.,Malar Hospital | Nilsagard Y.E.,Örebro University
Physical Therapy | Year: 2013

Background. Evaluation of walking capacity and risk of falls in people with multiple sclerosis often are performed in rehabilitation. The Dynamic Gait Index (DGI) evaluates walking during different tasks, but the feasibility in identifying people at risk for falls needs to be further investigated. Objective. The objective of this study was to investigate (1) the construct validity (known groups, convergent, and discriminant) of the DGI and (2) the accuracy of predicting falls and establishing a cutoff point to identify fallers. Design. This trial was a multicenter, cross-sectional study. Methods. A convenience sample was composed of 81 people with multiple sclerosis with subjective gait and balance impairment who were able to walk 100 m (comparable to Expanded Disability Status Scale 1-6). Mean age of the participants was 49 years; 76% were women. The 25-Foot Timed Walk Test, Timed "Up & Go" Test, Four Square Step Test, Timed Sit-to-Stand Test, MS Walking Scale, Multiple Sclerosis Impact Scale, and self-reported falls during the previous 2 months were used for validation, to establish cutoff points for identifying fallers, and to investigate predictive values. Results. Significantly lower DGI scores (P<.001) were found for participants reporting falls (n=31). High sensitivity (87%) in identifying fallers was found, with a cutoff score < 19. The positive predictive value was 50%, and the negative predictive value was 87%. The positive likelihood ratio was 1.77, and the negative likelihood ratio was 0.26. The convergent validity was moderate to strong (ρ=0.58-0.80), with the highest correlation coefficient found for the 25-Foot Timed Walk Test. Discriminant validity was shown with low correlation for the psychological subscale of the Multiple Sclerosis Impact Scale. Limitations. The sample included ambulatory people participating in a randomized controlled trial investigating balance training. Conclusions. The DGI is a valid measure of dynamic balance during walking for ambulatory people with multiple sclerosis. With the cutoff point of <19, sensitivity was high in identifying people at risk of falls. © 2013 American Physical Therapy Association.

PubMed | Örebro University and Malar Hospital
Type: | Journal: Physiotherapy research international : the journal for researchers and clinicians in physical therapy | Year: 2017

Sit-to-stand transfers are frequently performed, and transfers have been associated with fall risk among people with multiple sclerosis (PwMS). There is limited research regarding the validity of sit-to-stand tests (STSs) in PwMS. The purpose of this study was to investigate the concurrent, divergent, and discriminant validity and sensitivity to change of the 5 and 10 STSs.A repeated-measurement design was used, with data collected before and directly after a 7-week intervention, as well as prospectively reported near-fall incidents and falls during a 14-week period. One hundred two PwMS with a limited (200m) but retained (20m) walking ability were identified by physiotherapists at outpatient rehabilitation centres in 5 Swedish County Council areas and invited to participate in an intervention study. Of the 52 participants agreeing to participate and fulfilling the inclusion criteria, 47 managed the tests at baseline, and 39 of these returned complete fall diaries. The main outcomes were the Berg Balance Scale (BBS), Timed Up and Go test (TUG), 10-m walk test, 2-min walk test, Fatigue Scale for Motor and Cognitive Function, falls, near-fall incidents, and use of walking aids.Correlations in the total sample were above .60 between the STSs and BBS, TUG, 10-m walk test, and 2-min walk test and above .50 between the STSs and total number of falls. Both tests discriminated between those who did and did not use walking aids for the TUG, but not between fallers and nonfallers. There were no significant correlations between the STSs and number of falls or near-fall incidents. The STSs did not differentiate between participants with changed and unchanged results on the BBS.The 5 and 10 STSs are valid in PwMS with an Expanded Disability Status Scale score 6.0 but do not identify fallers and have limited ability to detect change. Copyright 2017 John Wiley & Sons, Ltd.

Schulman S.,McMaster University | Schulman S.,Karolinska University Hospital | Majeed A.,Karolinska University Hospital | Majeed A.,Malar Hospital
Seminars in Thrombosis and Hemostasis | Year: 2012

Since the quest for a better replacement of warfarin started several decades ago and new compounds were brought forward to clinical trials, the concept of an ideal anticoagulant frequently became presented in lectures and articles. We have here reviewed strengths and weaknesses of the oral thrombin inhibitor dabigatran in terms of pharmacokinetics and clinical data. When strengths clearly exceed the weaknesses for any characteristic, the drug fits into the concept of an ideal anticoagulant in that domain. It is evident that dabigatran does not accomplish that concept for all characteristics but it reaches well above warfarin. We believe it is unlikely that any drug will fulfill all criteria for the ideal anticoagulant. Laboratory testing for dabigatran will not be discussed in any detail in this article, which is instead the focus of other articles from this issue of Seminars in Thrombosis & Hemostasis.© 2012 by Thieme Medical Publishers, Inc.

Sjoberg D.,Falu Hospital | Holmstrom T.,Aland Central Hospital | Larsson M.,Malar Hospital | Nielsen A.-L.,Aland Central Hospital | And 2 more authors.
Inflammatory Bowel Diseases | Year: 2014

Background: Prevalence of anemia in patients with inflammatory bowel disease (IBD) is uncertain because of scarcity of population-based studies. The aim of this study was to evaluate prevalence of anemia in a population-based cohort of newly diagnosed patients with IBD to identify risk factors for anemia and to describe contemporary anemia-specific treatment during the first year. Methods: All patients with ulcerative colitis or Crohn's disease in the IBD Cohort of Uppsala Region cohort (n = 790) and hemoglobin levels at the time of diagnosis were eligible for inclusion. The WHO definition of anemia was used. Results: Seven hundred forty-nine (95%) of the patients with IBD were included. Five hundred eighty of 749 (77%) patients had measured hemoglobin levels at 12-month follow-up. The prevalence of anemia at the time of diagnosis was 227/749 (30%). After 1 year, it was 102/580 (18%). Anemia was more common among newly diagnosed patients with Crohn's disease compared with ulcerative colitis (42% versus 24%, P , 0.0001), but after 1 year, there was no difference (18% versus 18%, P = NS). Children had more often anemia compared with adults, both at diagnosis and after 1 year (diagnosis: 55% versus 27%, P , 0.0001; follow-up: 28% versus 16%, P >0.05). Anemia was associated with colonic engagement in Crohn's disease and the extent of inflammation in ulcerative colitis. Only 46% of patients with anemia were treated with iron supplementation or blood transfusion. Conclusions: The overall prevalence of anemia in patients with IBD at the time of diagnosis was high. A large proportion was still anemic after 1 year. Children were more at risk compared with adults. More efforts are needed to treat patients with anemia. Copyright © 2014 Crohn's Colitis Foundation of America, Inc.

Majeed A.,Karolinska University Hospital | Majeed A.,Malar Hospital | Eelde A.,Karolinska University Hospital | Agren A.,Karolinska University Hospital | And 3 more authors.
Thrombosis Research | Year: 2012

Background: There is uncertainty regarding the efficacy and incidence of thromboembolic events in patients treated with prothrombin complex concentrates (PCC) for the emergency reversal of warfarin effect. Methods: During 2002 to 2010 we prospectively included 160 patients treated with PCC for emergency reversal of warfarin either for bleeding or because of the need of emergency surgery. A possible relationship to PCC was considered if objectively verified thromboembolism occurred within 7 days of PCC administration. Efficacy was adjudicated as good if the bleeding was controlled promptly or if the surgeon did not report excessive perioperative bleeding. Results: We included 160 patients; 72% received PCC for bleeding. The median international normalized ratio (INR) before and after treatment with PCC was 3.5 (interquartile range [IQR] 2.6-5.4) and 1.4 (IQR 1.2-1.6). The mean dose of PCC was 1800 IU (IQR 1200-2000). In addition to PCC, 74% of the patients received vitamin K and 34% received plasma. Six patients (3.8%; 95% confidence interval [CI], 1.4-8.0%) developed thromboembolic events (3 strokes, 1 myocardial infarction, 1 deep vein thrombosis, 1 splenic infarction), possibly related to PCC. The clinical efficacy was good in 146 (91%), moderate in 6 (4%), poor in 4 (2.5%) and non-evaluable in 4 patients. Conclusion: The administration of PCC for the emergency reversal of warfarin may be associated with a low risk of thromboembolism. The contribution of an unmasked thrombotic process by cessation of anticoagulation or of activation of coagulation by the hemorrhagic event should also be considered. © 2011 Elsevier Ltd. All rights reserved.

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