Östersund, Sweden
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Zhang L.,Grande Rio University | Axelsson I.,Ostersund Hospital | Axelsson I.,Mid Sweden University | Chung M.,Institute for Clinical Research and Health Policy Studies | Lau J.,Institute for Clinical Research and Health Policy Studies
Pediatrics | Year: 2011

OBJECTIVE: To assess the dose-response relationship (benefits and harms) of inhaled corticosteroids (ICSs) in children with persistent asthma. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared ≥2 doses of ICSs in children aged 3 to 18 years with persistent asthma. Medline was searched for articles published between 1950 and August 2009. Main outcomes of our analyses included morning and evening peak expiratory flow, forced expiratory volume in 1 second, asthma symptom score, β2-agonist use, withdrawal because of lack of efficacy, and adverse events. Meta-analyses were performed to compare moderate (300-400 μg/day) with low (≤200 μg/day beclomethasone-equivalent) doses of ICSs. RESULTS: Fourteen RCTs (5768 asthmatic children) that evaluated 5 ICSs were included. The pooled standardized mean difference from 6 trials revealed a small but statistically significant increase of moderate over low doses in improving forced expiratory volume in 1 second (standardized mean difference: 0.11 [95% confidence interval: 0.01-0.21]) among children with mild-to-moderate asthma. There was no significant difference between 2 doses in terms of other efficacy outcomes. Local adverse events were uncommon, and there was no evidence of dose-response relationship at low-to-moderate doses. CONCLUSIONS: Compared with low doses, moderate doses of ICSs may not provide clinically relevant therapeutic advantage in children with mild-to-moderate persistent asthma. Additional RCTs are needed to clarify the dose-response relationship of ICSs in persistent childhood asthma. Copyright © 2011 by the American Academy of Pediatrics.


Rosemar A.,Sahlgrenska University Hospital | Angeras U.,Sahlgrenska University Hospital | Rosengren A.,Sahlgrenska University Hospital | Nordin P.,Ostersund Hospital | Nordin P.,Umeå University
Annals of Surgery | Year: 2010

Objective: To analyze the effect of underweight, overweight, and obesity in relation to clinical characteristics, the risk of postoperative complications, 30-day mortality, and reoperations for recurrence after groin hernia surgery. Summary of background data: Groin hernia surgery is one of the most frequent operations performed in general surgery. Several studies have demonstrated a protective effect of overweight and obesity on the risk of developing primary groin hernia. However, obesity has also been suggested to increase the risk for recurrence of groin hernia. Methods: Through the Swedish Hernia Register, 49,094 primary groin hernia operations were identified between January 1, 2003 and December 31, 2007. Patients were divided into 4 body mass index (BMI) groups: BMI 1, <20 kg/m; BMI 2, 20 to 25 kg/m; BMI 3, 25-30 kg/m; and BMI 4, >30 kg/m. Results: Of the 49,094 patients, 3.5% had a BMI <20 kg/m and 5.2% were obese. Altogether, women constituted only 7.7% of the studied group, but among patients with BMI <20 kg/m that had surgical procedures for femoral hernia, 81.4% were women. The relation between BMI and postoperative complications was U-shaped and after adjustment for age, gender, and emergency procedure, patients with BMI <20 and >25 had a significant increased risk when compared with patients with BMI from 20 to 25. Reoperation for recurrence of groin hernia has an increased hazard ratio of 1.20 (95% confidence interval, 1.00-1.40) in overweight, which was particularly evident after open suture and preperitoneal mesh techniques. Conclusions: In this large and unselected population of patients with a first surgical procedure for groin hernia a relative dominance of female and femoral hernias presented as an emergency condition was observed in the low BMI group. The prevalence of obesity was markedly low. Both lean and obese patients had an increased risk for postoperative complications. Copyright © 2010 by Lippincott Williams & Wilkins.


Olsson K.S.,Sahlgrenska University Hospital | Ritter B.,Ostersund Hospital | Raha-Chowdhury R.,University of Cardiff
European Journal of Haematology | Year: 2010

Background: The haemochromatosis mutation C282Y occurred once in a person who lived in Ireland or Scandinavia and carried either human leucocyte antigen (HLA)-A3-B7 or A3-B14. With time, recombinations are believed to have taken place introducing new HLA haplotypes. This evolution is mainly unknown. In this study, we tried to find a founder, possible recombination events and effect on the phenotype in descendants. Setting: A Swedish mountain population close to Norway, n = 3529, population density <1/km2. Methods: Retrospective genealogy study of HLA haplotypes followed by extended haplotype studies. Results: There were 34 probands (22 men, 12 women) where 31 (91%) shared a common founder origin 12 generations ago. The A3-B14 haplotype was the most common, 39%, in strong linkage disequilibrium (P < 0.0005) with controls, followed by A3-B7, 20% (P < 0.005), probably resulting from a centromeric recombination replacing the B14 allele with the common B7. Possible telomeric recombinations took place close to HLA-A and introduced the haplotypes AW19-B7 (n = 4), AW19-B27 (2), A1-B17 (5) and A2-B12 (4) supported by pedigree studies. Male homozygotes with two copies of HLA-A3 had significantly (P 0.001) higher mean serum ferritin values than those with one, and liver damage (fibrosis and cirrhosis) was also more common (P < 0.001) than in a population with a recombinant (A1-B8) haplotype. Conclusions: A3-B14 may well be the ancestral haplotype with A3B7, the result of centromeric recombinations introducing the common B7 allele. Telomeric recombinations were more common than expected. The ancestral HLA-A3 haplotype may be associated with a more severe phenotypic expression. © 2009 John Wiley & Sons A/S.


Widerstrom M.,Ostersund Hospital | Widerstrom M.,Umeå University | Wistrom J.,Umeå University | Sjostedt A.,Umeå University | Monsen T.,Umeå University
European Journal of Clinical Microbiology and Infectious Diseases | Year: 2012

Coagulase-negative staphylococci (CoNS), originally described as ubiquitous commensals of the healthy human skin and mucosa, have emerged as important opportunistic pathogens primarily causing healthcareassociated infections in patients with indwelling medical devices. Recent studies, utilizing new molecular typing methods, particularly on Staphylococcus epidermidis, have increased our understanding of the mechanisms that contribute to the evolutionary success of these extremely versatile microorganisms. In the following mini-review, we summarize recent research in this area focusing on the molecular methods and epidemiology of S. epidermidis and S. saprophyticus. © Springer-Verlag 2011.


Melin B.S.,Umeå University | Nordfjall K.,Ostersund Hospital | Andersson U.,Umeå University | Roos G.,Umeå University
Genetic Epidemiology | Year: 2012

Telomere biology is associated with cancer initiation and prognosis. Collected data suggest that blood cell telomere length (TL) can change over time, which may be related to development of common disorders, such as cardiovascular diseases and cancer. Recently, single nucleotide polymorphisms in the region of the human telomerase reverse transcriptase (hTERT) gene were associated with various malignancies, including glioma, lung and urinary bladder cancer, and telomerase RNA gene hTERC genotypes were recently linked to TL. In the present study a hypothetical association between identified genotypes in hTERT and hTERC genes and TL were investigated. We analyzed 21 polymorphisms, covering 90% of the genetic variance, in the hTERT gene, two genetic variants in hTERC, and relative TL(RTL) at average age 50 and 60 in 959 individuals with repeated blood samples. Mean RTL at age 60 was associated with four genetic variants of the hTERT gene (rs2736100, rs2853672, rs2853677, and rs2853676), two of which reported to be associated with cancer risk. Two alleles (rs12696304, rs16847897) near the hTERC gene were confirmed as also being associated with RTL at age 60. Our data suggest that hTERT and hTERC genotypes have an impact on TL of potential relevance and detectable first at higher ages, which gives us further insight to the complex regulation of TL. © 2012 Wiley Periodicals, Inc.


Van Der Linden W.,Ostersund Hospital | Warg A.,Ostersund Hospital | Nordin P.,Ostersund Hospital | Nordin P.,Umeå University
Archives of Surgery | Year: 2011

Objectives: To examine the relationship between operating time and reoperation for recurrence and other complications in groin hernia repairs. Design: Observational population-based register study. Setting: Data from the nationwide Swedish Hernia Register, which prospectively collects data from almost all groin hernia repairs performed in Sweden. Patients: There were 123 917 primary groin hernia repairs recorded in the Swedish Hernia Register from January 1, 1998, through December 31, 2007. Main Outcome Measures: Relative risk of reoperation for recurrence and odds ratios for postoperative complications in 4 operating time groups.Results: The relative risk of reoperation for recurrence of all patients operated on in less than 36 minutes was 26% higher than that of all patients with an operating time of more than 66 minutes (1.26; 95% CI, 1.11-1.43). Because the Lichtenstein procedure is the standard procedure in Sweden today, its results were also analyzed separately. In this homogeneous group, the difference was even more striking with an increased relative risk of 45% (1.45; 95% CI, 1.21-1.75). The odds ratio for infection and other postoperative complications increased with increasing operating time. Conclusion: A significant decrease in reoperation for recurrence with increasing operating time exhorts the hernia surgeon to avoid speed and to maintain thoroughness throughout the procedure. ©2011 American Medical Association. All rights reserved.


Stenfors N.,Ostersund Hospital | Stenfors N.,Umeå University
Respiratory Medicine | Year: 2010

Introduction: Respiratory symptoms in relationship to exercise, bronchial hyperresponsiveness (BHR), and exercise-induced asthma (EIA) are very common in elite winter athletes. Symptom-based screening for BHR would facilitate selection of athletes with possible EIA. Objectives: The aim of the present study was to evaluate the diagnostic accuracy of self-reported symptoms as predictors of BHR in an unselected population of adult elite cross-country skiers. Methods: Forty-six Swedish adult skiers competing at national or international level were included. They had a mean (SD) training volume in the past 12 months of 593 (122) hours. Twenty-four subjects had previous physician-diagnosed asthma. The European Community Respiratory Health Survey questionnaire was used to evaluate the presence of respiratory symptoms. BHR was defined as bronchoconstriction to either eucapnic voluntary hyperventilation, dry powder mannitol or methacholine provocation. Results: The "classical" EIA symptom of shortness of breath post-exercise was reported by 17% of all skiers. Eight subjects (17%) had BHR. None of the self-reported respiratory symptoms had high positive predictive values. However, symptoms caused by grass or pollen had high negative predictive values. Discussion: EIA in elite winter athletes cannot accurately be based only on self-reported symptoms but requires verification with objective testing of BHR. Bronchoprovocation of elite winter athletes reporting respiratory symptoms in rest or because of exercise will probably reveal a high proportion of athletes without BHR. Clinical trial: EUDRA-CT number 2006-005822-21. © 2010 Elsevier Ltd. All rights reserved.


Brammas A.,Umeå University | Jakobsson S.,Umeå University | Ulvenstam A.,Ostersund Hospital | Mooe T.,Umeå University | Mooe T.,Ostersund Hospital
Stroke | Year: 2013

Background and Purpose: Acute myocardial infarction (AMI) increases the risk of ischemic stroke, and mortality among these patients is high. Here, we aimed to estimate the 1-year mortality reliably after AMI complicated by ischemic stroke. We also aimed to identify trends over time for mortality during 1998-2008, as well as factors that predicted increased or decreased mortality. Methods: Data for 173 233 unselected patients with AMI were collected from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions registry for 1998-2008. Specifically, we analyzed 1-year follow-up and mortality data for patients with AMI with and without ischemic stroke. Kaplan-Meyer analysis was used to analyze mortality trends over time, and Cox regression analysis was used to identify uni- and multivariate predictors of mortality. Results: The 1-year mortality was 36.5% for AMI complicated by ischemic stroke and 18.3% for AMI without stroke. Mortality decreased over time in patients with and without ischemic stroke. The absolute decreases in mortality were 9.4% and 7.5%, respectively. Reperfusion and secondary preventive therapies were associated with a decreased mortality rate. Conclusions: Mortality after AMI complicated by an ischemic stroke is very high but decreased from 1998 to 2008. The increased use of evidence-based therapies explains the improved prognosis. © 2013 American Heart Association, Inc.


Nappa U.,Ostersund Hospital | Nappa U.,Umeå University | Lindqvist O.,Umeå University | Lindqvist O.,Karolinska Institutet | And 4 more authors.
Annals of Oncology | Year: 2011

Background: This study analyses the potential discriminative characteristics for patients with incurable cancer who received palliative chemotherapy during their last month of life. Patients and methods: The study includes all patients with epithelial cancer treated with palliative chemotherapy who died in 2008 in northern Sweden. Demographic parameters and care utilization data were registered. Data were analyzed using nonparametric methods. Results: Of 374 included patients, 87 (23%) received chemotherapy during the last month of life. These patients had a significantly shorter survival time from first palliative treatment to death, were admitted more frequently to hospital, more often lacked a documented decision to cease treatment, and died less frequently at home. Conclusions: The results indicate covariations between palliative chemotherapy treatments in the last month of life and unfavorable patient outcomes. As almost one of four patients with incurable cancer received their last round of palliative chemotherapy <31 days before death, there is a potential for improved routines. © The Author 2011. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved.


Sevonius D.,Skåne University Hospital | Gunnarsson U.,Karolinska Institutet | Nordin P.,Ostersund Hospital | Nilsson E.,Umeå University | Sandblom G.,Karolinska Institutet
British Journal of Surgery | Year: 2011

Background: The reoperation rate after recurrent groin hernia surgery is more than twice that recorded for primary groin hernia procedures. The aim was to define the outcome from routine redo hernia surgery by analysing a large population-based cohort from a national hernia register. Methods: All recurrent groin hernia operations registered in the Swedish Hernia Register from 1992 to 2008 were analysed using multivariable analysis with stratification for preceding repair. Results: Altogether 174 527 hernia operations were recorded in the Swedish Hernia Register between 1992 and 2008, including 19 582 reoperations. The preceding repair was included in the register for 5565 of these recurrent repairs. With laparoscopic repair as reference standard, the hazard ratio for recurrence was 2·55 (95 per cent confidence interval 1·66 to 3·93) after sutured repair, 1·53 (1·20 to 1·95) after Lichtenstein repair, 2·31 (1·76 to 3·03) after plug repair, 1·36 (0·95 to 1·94) after open preperitoneal mesh and 3·08 (2·22 to 4·29) after other repairs. Laparoscopic and open preperitoneal repair were associated with a lower risk of reoperation following a preceding open repair (P < 0·001), but no technique differed significantly from the others following a preceding preperitoneal repair. Conclusion: The laparoscopic and the open preperitoneal mesh methods of repair for recurrent groin hernias were associated with the lowest risk of reoperation. Although the method of repair in previous surgery must be considered, these techniques are the preferred methods for recurrent groin hernia surgery. © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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