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Bonander C, Holmberg R, Gustavsson J, Svensson M. Model-based economic evaluation of ice cleat distribution programmes for the prevention of outdoor falls among adults from a Swedish societal perspective. Inj Prev 2021; 28:125-130. [PMID: 34183438 PMCID: PMC8938667 DOI: 10.1136/injuryprev-2021-044203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/14/2021] [Indexed: 11/15/2022]
Abstract
Background Slipping on snow or ice poses a significant health risk among older adults in Sweden. To combat this problem, about 80 Swedish municipalities have distributed ice cleats to older citizens (65+ years old) over the last decade. This paper details a cost–benefit analysis of such programmes. Materials and methods We developed a decision-analytical model to estimate the costs and benefits of ice cleat programmes in Swedish municipalities compared with a business-as-usual scenario. The modelled benefits of the programme were based on effect estimates from previous research, data from population and healthcare registers and a survey of attitudes to and actual ice cleat use. The modelled costs of the programme were based on resource use data collected from 34 municipalities with existing ice cleat programmes. We assessed heterogeneity in the potential impact and benefit-to-cost ratios across all Swedish municipalities as a function of the average number of days with snow cover per year. Uncertainty in the cost–benefit results was assessed using deterministic and probabilistic sensitivity analyses. Results The average benefit-to-cost ratio was 87, ranging from about 40 in low-risk municipalities to 140 in high-risk municipalities, implying that the potential benefits of ice cleat programmes greatly outweigh their costs. Probabilistic and deterministic sensitivity analyses support the robustness of this conclusion to parameter uncertainty and large changes in assumptions about the magnitude of the impact on ice cleat use and injuries. Conclusion The benefits of distributing ice cleats to older adults appear to outweigh the costs from a Swedish societal perspective.
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Affiliation(s)
- Carl Bonander
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden .,Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden
| | - Robin Holmberg
- Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden.,Department of Political, Historical and Cultural Studies, Karlstad University, Karlstad, Sweden
| | - Johanna Gustavsson
- Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden.,Department of Political, Historical and Cultural Studies, Karlstad University, Karlstad, Sweden
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Erdogan S, Erlandsson M, Oparina N, Lundquist C, Wasen C, Svensson M, Bemark M, Andersson KM, Bokarewa MI. OP0026 IGF1R DEPENDENT CELL INTERACTION AND REGULATION OF AUTOANTIBODY PRODUCTION IN RHEUMATOID ARTHRITIS. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.2440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:The insulin-like growth factor 1 receptor (IGF1R) signalling mediates numerous developmental processes acting through downstream adaptor molecules IRS1/2, which activate Akt and inhibit the family of forkhead box class O (FoxO). Inhibition of IGF1R signalling alleviates rheumatoid arthritis (RA) (Erlandsson et al., 2017), however, the role of IGF1R signalling in the regulation of immune function is poorly understood.Objectives:To investigate the link between IGF1R signalling and antigen presentation in experimental arthritis.Methods:Arthritis was induced by immunising Balb/c mice with methylated bovine serum albumin (mBSA, n=18) and DBA/1 mice with type II collagen (CII, n=18). The mice were treated with a synthetic IGF1R inhibitor NT157 or with short hairpin RNA targeting IGF1R (shIGF1R) from the day prior to immunisation. Controls were treated with cyclodextrine vehicle/ non-targeting (nt)RNA, respectively. Flow cytometry was used for spleen cell phenotype. Antibody levels were measured by ELISA. Immunohistochemistry (IHC) of spleen was performed for assessment of marginal zone (MZ) and location of pS612IRS1+ and pS256FoxO1+ cells. IHC images were acquired by fluorescent confocal microscopy, and analysed using ZEN2009 and Cell Profiler soft ware.Results:The inhibition of IGF1R resulted in an 80% increase in MZ area in NT157-treated mice compared to controls (p=0.0001). This was supported by a significant increase of CD21+ (p=0.034) and CD23+ cell populations (p=0.00059), both among the CD19+ B cells and antigen-presenting MHCII+CD19- cells, implying that IGF1R expression regulates the populations of MZ and follicular cells. Additionally, there was a strong positive correlation between the decrease of IGF1R+ and ICOSL+ population on CD21+ cells (r=0.70, p=0.0071), which retained them in the MZ and prolonged communication with macrophages. Insufficient feedback from ICOSL- B cells limited expression of CXCR5 on CD4 cells. The IHC analysis displayed that, IGF1R inhibition led to abundance of inactivate pS612IRS1+ and pS256FoxO1+ cells within the MZ, compared with controls (p=0.0002). Alongside the increase of IgM+ B cell population (p=0.0022), we observed significant increase in number of antigen-presenting F4/80+ cells (p=0.043) and MARCO expression (p=0.043) after IGF1R intervention. Finally, the NT157- treated mice displayed a significant pleiotropic increase in IgM autoantibody production, with anti-CCP IgM (p=0.027), RF-IgM (p=0.0085), anti-DNA IgM (p=0.066) and in total IgM (p=0.027) levels, which correlated positively with pS256FoxO1+ cells (r=0.51, p=0.03). Levels of IgG were not changed.Conclusion:We show that IGF1R signalling is important for immune cell communication after antigen challenge. IGF1R controls ICOSL dependent trafficking of B cells through the MZ and facilitates interaction with T cells. Retention of B cells in the MZ tips the balance from T cell to macrophage-dependent processes, which permits the formation of autoantibody producing B cells.References:[1]Erlandsson, M., et.al., 2017. IGF-1R signalling contributes to IL-6 production and T cell dependent inflammation in rheumatoid arthritis. Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease, 1863(9), pp.2158-2170.Disclosure of Interests:None declared
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Andersson H, Svensson M, Bergh H. The cost-effectiveness of a two-step blood pressure screening programme in a dental health-care setting. PLoS One 2021; 16:e0252037. [PMID: 34033664 PMCID: PMC8148372 DOI: 10.1371/journal.pone.0252037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 05/10/2021] [Indexed: 11/18/2022] Open
Abstract
Background Hypertension is one of the largest contributors to the disease burden and a major economic challenge for health-care systems. Early detection of persons with high blood pressure can be achieved through screening and has the potential to reduce morbidity and mortality. We evaluate the cost-effectiveness of an opportunistic hypertension screening programme in a dental-care facility for individuals aged 40–75 in comparison to care as usual (the no-screening baseline scenario). Methods A cost-effectiveness analysis (CEA) was carried out from the payer and societal perspectives, and the short-term (from screening until diagnosis has been established) cost per identified case of hypertension and long-term (20 years) cost per quality-adjusted life year (QALY) were reported. Data on the short-term cost were based on a real-world screening programme in which 2025 healthy individuals were screened for hypertension. Data on the long-term cost were based on the short-term outcomes combined with modelling in a Markov cohort model. Deterministic and probabilistic sensitivity analyses were carried out to assess uncertainty. Results The short-term analysis showed an additional cost of 4,800 SEK (€470) per identified case of hypertension from the payer perspective and from the societal perspective 12,800 SEK (€1,240). The long-term analysis showed a payer cost per QALY of 2.2 million SEK (€210,000) and from the societal perspective 2.8 million SEK per QALY (€270,000). Conclusion The long-term model results showed that the screening model is unlikely to be cost-effective in a country with a well-developed health-care system and a relatively low prevalence of hypertension.
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Affiliation(s)
- Helen Andersson
- Hallands Hospital Varberg, Varberg, Sweden
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Håkan Bergh
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Dept. of Research & Development Unit, Hospital Varberg, Region Halland, Varberg, Sweden
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Fletcher-Sandersjöö A, Thelin EP, Maegele M, Svensson M, Bellander BM. Time Course of Hemostatic Disruptions After Traumatic Brain Injury: A Systematic Review of the Literature. Neurocrit Care 2021; 34:635-656. [PMID: 32607969 PMCID: PMC8128788 DOI: 10.1007/s12028-020-01037-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Almost two-thirds of patients with severe traumatic brain injury (TBI) develop some form of hemostatic disturbance, which contributes to poor outcome. While the initial head injury often leads to impaired clot formation, TBI is also associated with an increased risk of thrombosis. Most likely there is a progression from early bleeding to a later prothrombotic state. In this paper, we systematically review the literature on the time course of hemostatic disruptions following TBI. A MEDLINE search was performed for TBI studies reporting the trajectory of hemostatic assays over time. The search yielded 5,049 articles, of which 4,910 were excluded following duplicate removal as well as title and abstract review. Full-text assessment of the remaining articles yielded 33 studies that were included in the final review. We found that the first hours after TBI are characterized by coagulation cascade dysfunction and hyperfibrinolysis, both of which likely contribute to lesion progression. This is then followed by platelet dysfunction and decreased platelet count, the clinical implication of which remains unclear. Later, a poorly defined prothrombotic state emerges, partly due to fibrinolysis shutdown and hyperactive platelets. In the clinical setting, early administration of the antifibrinolytic agent tranexamic acid has proved effective in reducing head-injury-related mortality in a subgroup of TBI patients. Further studies evaluating the time course of hemostatic disruptions after TBI are warranted in order to identify windows of opportunity for potential treatment options.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden.
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Marc Maegele
- Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
- Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
| | - Mikael Svensson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden
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Dorjdagva J, Batbaatar E, Svensson M, Dorjsuren B, Togtmol M, Kauhanen J. Does social health insurance prevent financial hardship in Mongolia? Inpatient care: A case in point. PLoS One 2021; 16:e0248518. [PMID: 33788865 PMCID: PMC8011747 DOI: 10.1371/journal.pone.0248518] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 02/27/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Protecting people from financial hardship and impoverishment due to health care costs is one of the fundamental purposes of the Mongolian health system. However, the inefficient, oversized hospital sector is considered one of the main shortcomings of the system. The aim of this study is to contribute to policy discussions by estimating the extent of catastrophic health expenditure and impoverishment due to inpatient care at secondary-level and tertiary-level public hospitals and private hospitals. METHODS Data were derived from a nationally representative survey, the Household Socio-Economic Survey 2012, conducted by the National Statistical Office of Mongolia. A total of 12,685 households were involved in the study. "Catastrophic health expenditure" is defined as out-of-pocket payments for inpatient care that exceed a threshold of 40% of households' non-discretionary expenditure. The "impoverishment" effect of out-of-pocket payments for inpatient care was estimated as the difference between the poverty level before health care payments and the poverty level after these payments. RESULTS At the threshold of 40% of capacity to pay, 0.31%, 0.07%, and 0.02% of Mongolian households suffered financially as a result of their member(s) staying in tertiary-level and secondary-level public hospitals and private hospitals respectively. About 0.13% of the total Mongolian population was impoverished owing to out-of-pocket payments for inpatient care at tertiary-level hospitals. Out-of-pocket payments for inpatient care at secondary-level hospitals and private hospitals were responsible for 0.10% and 0.09% respectively of the total population being pushed into poverty. CONCLUSIONS Although most inpatient care at public hospitals is covered by the social health insurance benefit package, patients who utilized inpatient care at tertiary-level public hospitals were more likely to push their households into financial hardship and poverty than the inpatients at private hospitals. Improving the hospital sector's efficiency and financial protection for inpatients would be a crucial means of attaining universal health coverage in Mongolia.
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Affiliation(s)
- Javkhlanbayar Dorjdagva
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Enkhjargal Batbaatar
- Department of Social Sciences, Faculty of Social Sciences and Business Studies, University of Eastern Finland, Kuopio, Finland
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | | | - Jussi Kauhanen
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Lindblad C, Pin E, Just D, Al Nimer F, Nilsson P, Bellander BM, Svensson M, Piehl F, Thelin EP. Fluid proteomics of CSF and serum reveal important neuroinflammatory proteins in blood-brain barrier disruption and outcome prediction following severe traumatic brain injury: a prospective, observational study. Crit Care 2021; 25:103. [PMID: 33712077 PMCID: PMC7955664 DOI: 10.1186/s13054-021-03503-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/10/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Severe traumatic brain injury (TBI) is associated with blood-brain barrier (BBB) disruption and a subsequent neuroinflammatory process. We aimed to perform a multiplex screening of brain enriched and inflammatory proteins in blood and cerebrospinal fluid (CSF) in order to study their role in BBB disruption, neuroinflammation and long-term functional outcome in TBI patients and healthy controls. METHODS We conducted a prospective, observational study on 90 severe TBI patients and 15 control subjects. Clinical outcome data, Glasgow Outcome Score, was collected after 6-12 months. We utilized a suspension bead antibody array analyzed on a FlexMap 3D Luminex platform to characterize 177 unique proteins in matched CSF and serum samples. In addition, we assessed BBB disruption using the CSF-serum albumin quotient (QA), and performed Apolipoprotein E-genotyping as the latter has been linked to BBB function in the absence of trauma. We employed pathway-, cluster-, and proportional odds regression analyses. Key findings were validated in blood samples from an independent TBI cohort. RESULTS TBI patients had an upregulation of structural CNS and neuroinflammatory pathways in both CSF and serum. In total, 114 proteins correlated with QA, among which the top-correlated proteins were complement proteins. A cluster analysis revealed protein levels to be strongly associated with BBB integrity, but not carriage of the Apolipoprotein E4-variant. Among cluster-derived proteins, innate immune pathways were upregulated. Forty unique proteins emanated as novel independent predictors of clinical outcome, that individually explained ~ 10% additional model variance. Among proteins significantly different between TBI patients with intact or disrupted BBB, complement C9 in CSF (p = 0.014, ΔR2 = 7.4%) and complement factor B in serum (p = 0.003, ΔR2 = 9.2%) were independent outcome predictors also following step-down modelling. CONCLUSIONS This represents the largest concomitant CSF and serum proteomic profiling study so far reported in TBI, providing substantial support to the notion that neuroinflammatory markers, including complement activation, predicts BBB disruption and long-term outcome. Individual proteins identified here could potentially serve to refine current biomarker modelling or represent novel treatment targets in severe TBI.
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Affiliation(s)
- Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Elisa Pin
- Division of Affinity Proteomics, Department of Protein Science, SciLifeLab, KTH-Royal Institute of Technology, Stockholm, Sweden
| | - David Just
- Division of Affinity Proteomics, Department of Protein Science, SciLifeLab, KTH-Royal Institute of Technology, Stockholm, Sweden
| | - Faiez Al Nimer
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Neurology, Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
| | - Peter Nilsson
- Division of Affinity Proteomics, Department of Protein Science, SciLifeLab, KTH-Royal Institute of Technology, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Neurology, Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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Ojwang DO, Svensson M, Njel C, Mogensen R, Menon AS, Ericsson T, Häggström L, Maibach J, Brant WR. Moisture-Driven Degradation Pathways in Prussian White Cathode Material for Sodium-Ion Batteries. ACS Appl Mater Interfaces 2021; 13:10054-10063. [PMID: 33599484 PMCID: PMC8026098 DOI: 10.1021/acsami.0c22032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The high-theoretical-capacity (∼170 mAh/g) Prussian white (PW), NaxFe[Fe(CN)6]y·nH2O, is one of the most promising candidates for Na-ion batteries on the cusp of commercialization. However, it has limitations such as high variability of reported stable practical capacity and cycling stability. A key factor that has been identified to affect the performance of PW is water content in the structure. However, the impact of airborne moisture exposure on the electrochemical performance of PW and the chemical mechanisms leading to performance decay have not yet been explored. Herein, we for the first time systematically studied the influence of humidity on the structural and electrochemical properties of monoclinic hydrated (M-PW) and rhombohedral dehydrated (R-PW) Prussian white. It is identified that moisture-driven capacity fading proceeds via two steps, first by sodium from the bulk material reacting with moisture at the surface to form sodium hydroxide and partial oxidation of Fe2+ to Fe3+. The sodium hydroxide creates a basic environment at the surface of the PW particles, leading to decomposition to Na4[Fe(CN)6] and iron oxides. Although the first process leads to loss of capacity, which can be reversed, the second stage of degradation is irreversible. Over time, both processes lead to the formation of a passivating surface layer, which prevents both reversible and irreversible capacity losses. This study thus presents a significant step toward understanding the large performance variations presented in the literature for PW. From this study, strategies aimed at limiting moisture-driven degradation can be designed and their efficacy assessed.
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Affiliation(s)
- Dickson O. Ojwang
- Department
of Chemistry—Ångström Laboratory, Ångström
Advanced Battery Centre, Uppsala University, Box 538, SE-751 21 Uppsala, Sweden
| | - Mikael Svensson
- Department
of Chemistry—Ångström Laboratory, Ångström
Advanced Battery Centre, Uppsala University, Box 538, SE-751 21 Uppsala, Sweden
| | - Christian Njel
- Institute
for Applied Materials (IAM) and Karlsruhe Nano Micro Facility (KNMF), Karlsruhe Institute of Technology (KIT) Hermann-von-Helmholtz-Platz
1, 76344 Eggenstein-Leopoldshafen, Germany
| | - Ronnie Mogensen
- Department
of Chemistry—Ångström Laboratory, Ångström
Advanced Battery Centre, Uppsala University, Box 538, SE-751 21 Uppsala, Sweden
| | - Ashok S. Menon
- Department
of Chemistry—Ångström Laboratory, Ångström
Advanced Battery Centre, Uppsala University, Box 538, SE-751 21 Uppsala, Sweden
| | - Tore Ericsson
- Department
of Chemistry—Ångström Laboratory, Ångström
Advanced Battery Centre, Uppsala University, Box 538, SE-751 21 Uppsala, Sweden
| | - Lennart Häggström
- Department
of Chemistry—Ångström Laboratory, Ångström
Advanced Battery Centre, Uppsala University, Box 538, SE-751 21 Uppsala, Sweden
| | - Julia Maibach
- Institute
for Applied Materials (IAM) and Karlsruhe Nano Micro Facility (KNMF), Karlsruhe Institute of Technology (KIT) Hermann-von-Helmholtz-Platz
1, 76344 Eggenstein-Leopoldshafen, Germany
| | - William R. Brant
- Department
of Chemistry—Ångström Laboratory, Ångström
Advanced Battery Centre, Uppsala University, Box 538, SE-751 21 Uppsala, Sweden
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Grevfors N, Lindblad C, Nelson DW, Svensson M, Thelin EP, Rubenson Wahlin R. Delayed Neurosurgical Intervention in Traumatic Brain Injury Patients Referred From Primary Hospitals Is Not Associated With an Unfavorable Outcome. Front Neurol 2021; 11:610192. [PMID: 33519689 PMCID: PMC7839281 DOI: 10.3389/fneur.2020.610192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/03/2020] [Indexed: 01/29/2023] Open
Abstract
Background: Secondary transports of patients suffering from traumatic brain injury (TBI) may result in a delayed management and neurosurgical intervention, which is potentially detrimental. The aim of this study was to study the effect of triaging and delayed transfers on outcome, specifically studying time to diagnostics and neurosurgical management. Methods: This was a retrospective observational cohort study of TBI patients in need of neurosurgical care, 15 years and older, in the Stockholm Region, Sweden, from 2008 throughout 2014. Data were collected from pre-hospital and in-hospital charts. Known TBI outcome predictors, including the protein biomarker of brain injury S100B, were used to assess injury severity. Characteristics and outcomes of direct trauma center (TC) and those of secondary transfers were evaluated and compared. Functional outcome, using the Glasgow Outcome Scale, was assessed in survivors at 6–12 months after trauma. Regression models, including propensity score balanced models, were used for endpoint assessment. Results: A total of n = 457 TBI patients were included; n = 320 (70%) patients were direct TC transfers, whereas n = 137 (30%) were secondary referrals. In all, n = 295 required neurosurgery for the first 24 h after trauma (about 75% of each subgroup). Direct TC transfers were more severely injured (median Glasgow Coma Scale 8 vs. 13) and more often suffered a high energy trauma (31 vs. 2.9%) than secondary referrals. Admission S100B was higher in the TC transfer group, though S100B levels 12–36 h after trauma were similar between cohorts. Direct or indirect TC transfer could be predicted using propensity scoring. The secondary referrals had a shorter distance to the primary hospital, but had later radiology and surgery than the TC group (all p < 0.001). In adjusted multivariable analyses with and without propensity matching, direct or secondary transfers were not found to be significantly related to outcome. Time from trauma to surgery did not affect outcome. Conclusions: TBI patients secondary transported to a TC had surgical intervention performed hours later, though this did not affect outcome, presumably demonstrating that accurate pre-hospital triaging was performed. This indicates that for selected patients, a wait-and-see approach with delayed neurosurgical intervention is not necessarily detrimental, but warrants further research.
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Affiliation(s)
- Niklas Grevfors
- Division of Perioperative Medicine and Intensive Care (PMI), Department of Anesthesiology, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David W Nelson
- Division of Perioperative Medicine and Intensive Care (PMI), Department of Anesthesiology, Karolinska University Hospital, Stockholm, Sweden.,Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden.,Ambulance Medical Service in Stockholm (Ambulanssjukvården i Storstockholm AB), Stockholm, Sweden.,Academic EMS, Stockholm, Sweden
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Díez-Del-Molino D, von Seth J, Gyllenstrand N, Widemo F, Liljebäck N, Svensson M, Sjögren-Gulve P, Dalén L. Population genomics reveals lack of greater white-fronted introgression into the Swedish lesser white-fronted goose. Sci Rep 2020; 10:18347. [PMID: 33110153 PMCID: PMC7591532 DOI: 10.1038/s41598-020-75315-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 09/21/2020] [Indexed: 11/09/2022] Open
Abstract
Interspecific introgression is considered a potential threat to endangered taxa. One example where this has had a major impact on conservation policy is the lesser white-fronted goose (LWfG). After a dramatic decline in Sweden, captive breeding birds were released between 1981-1999 with the aim to reinforce the population. However, the detection of greater white-fronted goose (GWfG) mitochondrial DNA in the LWfG breeding stock led to the release program being dismantled, even though the presence of GWfG introgression in the actual wild Swedish LWfG population was never documented. To examine this, we sequenced the complete genomes of 21 LWfG birds from the Swedish, Russian and Norwegian populations, and compared these with genomes from other goose species, including the GWfG. We found no evidence of interspecific introgression into the wild Swedish LWfG population in either nuclear genomic or mitochondrial data. Moreover, Swedish LWfG birds are genetically distinct from the Russian and Norwegian populations and display comparatively low genomic diversity and high levels of inbreeding. Our findings highlight the utility of genomic approaches in providing scientific evidence that can help improve conservation management as well as policies for breeding and reinforcement programmes.
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Affiliation(s)
- David Díez-Del-Molino
- Department of Bioinformatics and Genetics, Swedish Museum of Natural History, Box 50007, 10405, Stockholm, Sweden. .,Department of Zoology, Stockholm University, 10691, Stockholm, Sweden.
| | - Johanna von Seth
- Department of Bioinformatics and Genetics, Swedish Museum of Natural History, Box 50007, 10405, Stockholm, Sweden.,Department of Zoology, Stockholm University, 10691, Stockholm, Sweden
| | - Niclas Gyllenstrand
- Centre for Genetic Identification, Department of Environmental Research and Monitoring, Swedish Museum of Natural History, Box 50007, 10405, Stockholm, Sweden
| | - Fredrik Widemo
- Department of Wildlife, Fish and Environmental Studies, Swedish University of Agricultural Sciences, 90183, Umeå, Sweden
| | - Niklas Liljebäck
- Grimsö Wildlife Research Station, Department of Ecology, Swedish University of Agricultural Sciences, 73091, Riddarhyttan, Sweden
| | - Mikael Svensson
- Swedish Species Information Centre, SLU ArtDatabanken, Box 7007, 750 07, Uppsala, Sweden
| | - Per Sjögren-Gulve
- The Wildlife Analysis Unit, Swedish Environmental Protection Agency, 106 48, Stockholm, Sweden
| | - Love Dalén
- Department of Bioinformatics and Genetics, Swedish Museum of Natural History, Box 50007, 10405, Stockholm, Sweden.
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Wolff E, Larsson S, Svensson M. Willingness to Pay for Health Improvements Using Stated Preferences: Prevention Versus Treatment. Value Health 2020; 23:1384-1390. [PMID: 33032783 DOI: 10.1016/j.jval.2020.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 06/11/2020] [Accepted: 06/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES This study aimed to investigate whether there was a difference in willingness to pay (WTP) between prevention and treatment for health benefits of equal magnitude. METHODS We used a web-based survey instrument in a sample of the Swedish general population to perform a contingent valuation study assessing the WTP for prevention and treatment. We analyzed the WTP as a continuous variable using a two-part regression model to adjust for a mass point around 0 and a skewed distribution among respondents with a positive WTP. RESULTS The study found that people were less willing, on average, to pay at all for prevention than treatment, but those who were willing to pay for prevention had a higher WTP than for treatment. The latter effect was more substantial, and in total mean WTP for prevention was about 85% higher than for treatment. CONCLUSIONS The findings from this study contribute to the ongoing discussion on the appropriate cost-effectiveness thresholds by adding prevention as a parameter affecting the demand-side value of health improvements. As such, it can provide support to decision makers in healthcare and in health promotion priority setting.
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Affiliation(s)
- Ellen Wolff
- Public Health Analysis and Data Management, Public Health Agency of Sweden, Solna, Sweden; Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
| | - Sofie Larsson
- Public Health Analysis and Data Management, Public Health Agency of Sweden, Solna, Sweden; Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- Public Health Analysis and Data Management, Public Health Agency of Sweden, Solna, Sweden; Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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Nilsson N, Nilsson Helander K, Hamrin Senorski E, Holm A, Karlsson J, Svensson M, Westin O. The economic cost and patient-reported outcomes of chronic Achilles tendon ruptures. J Exp Orthop 2020; 7:60. [PMID: 32748273 PMCID: PMC7399724 DOI: 10.1186/s40634-020-00277-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/23/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose While most Achilles tendon ruptures are dramatic and diagnosed quickly, some are missed, with a risk of becoming chronic. A chronic Achilles tendon rupture is defined as a rupture that has been left untreated for more than 4 weeks. By mapping the health economic cost of chronic Achilles tendon ruptures the health-care system might be able to better distribute resources to detect these ruptures at an earlier time. Method All patients with a chronic Achilles tendon rupture who were treated surgically at Sahlgrenska University Hospital or Kungsbacka Hospital between 2013 and 2018 were invited to participate in the study. The patients were evaluated postoperatively using the validated Achilles tendon Total Rupture Score (ATRS). The health-care costs were assessed using clinical records. The production-loss costs were extracted from the Swedish Social Insurance Agency. The cost of chronic Achilles tendon ruptures was then compared with the cost of acute ruptures in a previous study by Westin et.al. Results Forty patients with a median (range) age of 66 (28–86) were included in the study. The mean total cost (± SD) for the patients with a chronic Achilles tendon rupture was 6494 EUR ± 6508, which is 1276 EUR higher than the mean total cost of acute ruptures. Patients with chronic Achilles tendon ruptures reported a mean (min-max) postoperative ATRS of 73 (14–100). Conclusion Missing an Achilles tendon rupture will entail higher health-care costs compared with acute ruptures. Health-care resources can be saved if Achilles tendon ruptures are detected at an early stage.
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Affiliation(s)
- Niklas Nilsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Holm
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jón Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Mikael Svensson
- Health Metrics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Olof Westin
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Djerf H, Millinger J, Falkenberg M, Jivegard L, Svensson M, Nordanstig J. Absence of Long-term Benefit of Revascularization in Patients With Intermittent Claudication: Five-Year Results From the IRONIC Randomized Controlled Trial. J Vasc Surg 2020. [PMCID: PMC7374115 DOI: 10.1016/j.jvs.2020.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Djerf H, Millinger J, Falkenberg M, Jivegård L, Svensson M, Nordanstig J. Response to Letter Regarding Article, "Absence of Long-Term Benefit of Revascularization in Patients With Intermittent Claudication: Five-Year Results From the IRONIC Randomized Controlled Trial". Circ Cardiovasc Interv 2020; 13:e009385. [PMID: 32519878 DOI: 10.1161/circinterventions.120.009385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Henrik Djerf
- Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Millinger
- Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mårten Falkenberg
- Department of Radiology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sweden (M.F.)
| | - Lennart Jivegård
- HTA Centrum (Health Technology Assessment Center) Västra Götaland (L.J.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (M.S.)
| | - Joakim Nordanstig
- Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden
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Zachrisson K, Krupic F, Svensson M, Wigelius A, Jonsson A, Dimopoulou A, Stenborg A, Jensen G, Herlitz H, Gottsäter A, Falkenberg M. Results of renal artery revascularization in the post-ASTRAL era with 4 years mean follow-up. Blood Press 2020; 29:285-290. [PMID: 32363961 DOI: 10.1080/08037051.2020.1756740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Purpose: To investigate contemporary results of percutaneous transluminal renal angioplasty (PTRA).Materials and Methods: A multicentre retrospective study analysing all patients treated with PTRA for primary symptomatic renal artery stenosis (RAS) between 2010 and 2013 at four tertiary centres. Procedures during the preceding four years were counted to evaluate for change in PTRA frequency.Results: The number of PTRA procedures decreased by approximately 50% from 2006 to 2013. Patients treated in the post-ASTRAL period (n = 224) had a significant reduction in mean systolic pressure (168 to 146 mmHg, p < 0.01), diastolic pressure (84 to 76 mmHg, p < 0.01), number of anti-hypertensive drugs (3.54 to 3.05, p < 0.01), and anti-hypertensive treatment index (21.75 to 16.92, p < 0.01) compared to before PTRA. These improvements were maintained at one year and at the last clinical evaluation after a mean follow-up of 4.31 years. Renal function increased transiently without sustained improvement, or deterioration, during later follow-up. Thirteen patients (5.8%) eventually required dialysis, nine of these had eGFR <20 ml/min/1.73 m2 before PTRA. There was no difference in outcomes between subgroups differentiated by different indications for PTRA.Conclusion: The frequency of PTRA has decreased, indicating a higher threshold for invasive treatment of RAS in recent years. The reduction in blood pressures, the reduced need for anti-hypertensive medication, and stabilization of renal function over time suggest a clinical benefit for most patients who are now being treated with PTRA.
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Affiliation(s)
- Karin Zachrisson
- Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ferid Krupic
- Department of Orthopedics and Anesthesiology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- Health Metrics Unit, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ann Wigelius
- Diagnostic Radiology, Department of Radiation Sciences, Umeå University Hospital, Umeå, Sweden
| | - Andreas Jonsson
- Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden
| | | | - Anna Stenborg
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Gert Jensen
- Department of Molecular and Clinical Medicine/Nephrology, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Herlitz
- Department of Molecular and Clinical Medicine/Nephrology, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Gottsäter
- Vascular Center, Clinical Vascular Disease Research, Skåne University Hospital, Malmö, Sweden
| | - Mårten Falkenberg
- Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Perlander A, Jivegård L, Nordanstig J, Svensson M, Österberg K. Amputation-free survival, limb symptom alleviation, and reintervention rates after open and endovascular revascularization of femoropopliteal lesions in patients with chronic limb-threatening ischemia. J Vasc Surg 2020; 72:1987-1995. [PMID: 32276010 DOI: 10.1016/j.jvs.2020.03.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/05/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The optimal strategy for revascularization in chronic limb-threatening ischemia (CLTI) is not yet completely known and is still under debate. Endovascular treatment methods predominate despite limited evidence for their advantage. In this concurrent, prospective observational cohort study, we investigated outcomes after open and endovascular revascularization in the femoropopliteal segment for CLTI. METHODS Between March 2011 and January 2015, there were 190 patients presenting with CLTI with the principal target lesion in the superficial femoral or popliteal segment who underwent endovascular intervention (n = 117) or bypass surgery (n = 73) and were observed prospectively. The choice of revascularization technique was based on international and local guidelines. All patients were observed for 2 years. The primary end point was amputation-free survival (AFS) assessed with Kaplan-Meier estimates; secondary end points included CLTI symptom alleviation rates and reintervention rates. A Cox proportional hazards regression model was used to investigate risk factors for amputation and death. RESULTS AFS at 2 years was 59% in the endovascular group and 76% in the bypass group (P = .020). Kaplan-Meier survival analysis confirmed a significant difference in AFS, with mortality rate as the main driver for the observed intergroup AFS difference. In sequential multivariable regression analysis, the observed difference in AFS between the groups favored bypass surgery and remained significant after controlling for covariates of known prognostic importance (hazard ratio, 2.38; 95% confidence interval, 1.14-4.96). At 2 years, a higher proportion of patients subjected to bypass surgery remained free from ischemic rest pain, wounds, and gangrene (65% vs 45%; P = .009). The proportions of patients who underwent reintervention within 2 years were similar in the two groups (38% vs 39%; P = .90), but repeated reinterventions were more frequent in the bypass group. CONCLUSIONS At 2 years, bypass surgery was associated with higher AFS than endovascular intervention, a finding that could not be explained only by differences in case mix. More patients who had bypass surgery were free from CLTI symptoms at both 1 year and 2 years after revascularization. Reinterventions to maintain patency were equally common after bypass and endovascular intervention.
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Affiliation(s)
- Angelica Perlander
- Department of Vascular Surgery, Sahlgrenska University Hospital, and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Lennart Jivegård
- Health Technology Assessment Centre (HTA-centrum) Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joakim Nordanstig
- Department of Vascular Surgery, Sahlgrenska University Hospital, and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Klas Österberg
- Department of Vascular Surgery, Sahlgrenska University Hospital, and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Lindblad C, Nelson DW, Zeiler FA, Ercole A, Ghatan PH, von Horn H, Risling M, Svensson M, Agoston DV, Bellander BM, Thelin EP. Influence of Blood-Brain Barrier Integrity on Brain Protein Biomarker Clearance in Severe Traumatic Brain Injury: A Longitudinal Prospective Study. J Neurotrauma 2020; 37:1381-1391. [PMID: 32013731 PMCID: PMC7249468 DOI: 10.1089/neu.2019.6741] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Brain protein biomarker clearance to blood in traumatic brain injury (TBI) is not fully understood. The aim of this study was to analyze the effect that a disrupted blood–brain barrier (BBB) had on biomarker clearance. Seventeen severe TBI patients admitted to Karolinska University Hospital were prospectively included. Cerebrospinal fluid (CSF) and blood concentrations of S100 calcium binding protein B (S100B) and neuron-specific enolase (NSE) were analyzed every 6–12 h for ∼1 week. Blood and CSF albumin were analyzed every 12–24 h, and BBB integrity was assessed using the CSF:blood albumin quotient (QA). We found that time-dependent changes in the CSF and blood levels of the two biomarkers were similar, but that the correlation between the biomarkers and QA was lower for NSE (ρ = 0.444) than for S100B (ρ = 0.668). Because data were longitudinal, we also conducted cross correlation analyses, which indicated a directional flow and lag-time of biomarkers from CSF to blood. For S100B, this lag-time could be ascribed to BBB integrity, whereas for NSE it could not. Upon inferential modelling, using generalized least square estimation (S100B) or linear mixed models (NSE), QA (p = 0.045), time from trauma (p < 0.001), time from trauma2 (p = 0.023), and CSF biomarker levels (p = 0.008) were independent predictors of S100B in blood. In contrast, for NSE, only time from trauma was significant (p < 0.001). These findings are novel and important, but must be carefully interpreted because of different characteristics between the two proteins. Nonetheless, we present the first data that indicate that S100B and NSE are cleared differently from the central nervous system, and that both the disrupted BBB and additional alternative pathways, such as the recently described glymphatic system, may play a role. This is of importance both for clinicians aiming to utilize these biomarkers and for the pathophysiological understanding of brain protein clearance, but warrants further examination.
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Affiliation(s)
- Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Address correspondence to: Caroline Lindblad, MD, Karolinska Universitetssjukhuset Solna J5:20, Tema Neuro, forskargrupp Svensson, SE-17176 Stockholm, Sweden
| | - David W. Nelson
- Department of Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, and University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, and Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, and Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Per Hamid Ghatan
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Henrik von Horn
- Department of Division of Clinical Chemistry, and Karolinska Institutet, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mårten Risling
- Department of Neuroscience, and Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska Institutet, Stockholm, Sweden
| | - Denes V. Agoston
- Department of Neuroscience, and Karolinska Institutet, Stockholm, Sweden
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska Institutet, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Department of Theme Neuro, Karolinska Institutet, Stockholm, Sweden
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Steingrimsson S, Bilonic G, Ekelund AC, Larson T, Stadig I, Svensson M, Vukovic IS, Wartenberg C, Wrede O, Bernhardsson S. Electroencephalography-based neurofeedback as treatment for post-traumatic stress disorder: A systematic review and meta-analysis. Eur Psychiatry 2020; 63:e7. [PMID: 32093790 PMCID: PMC8057448 DOI: 10.1192/j.eurpsy.2019.7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background. Post-traumatic stress disorder (PTSD) is debilitating for patients and society. There are a number of treatment methods albeit not all patients respond to these and an interesting method using electroencephalography-based neurofeedback (EEG-NF) has become more prominent in recent years. This systematic review aimed to assess whether EEG-NF, compared with sham NF, other treatment, or no treatment, is effective for PTSD. Primary outcomes were self-harm, PTSD symptoms, level of functioning and health-related quality of life. Methods. Systematic literature searches for randomized controlled trials (RCTs) were conducted in six databases. Random effects meta-analysis was performed. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation. Results. Four RCTs were included (123 participants). Suicidal thoughts were significantly reduced after EEG-NF compared with a waiting list in a small study. PTSD symptoms were assessed in all studies with different instruments. Results were consistently in favor of EEG-NF with large effect sizes (standardized mean difference −2.30 (95% confidence interval: −4.37 to −0.24). One study reported significantly improved level of executive functioning and one study a reduction in use of psychotropic medication. Complications were scarcely reported. Certainty of evidence was assessed as very low for the four assessed outcomes. Conclusions. Based on four RCTs, with several study limitations and imprecision, it is uncertain whether EEG-NF reduces suicidal thoughts, PTSD symptoms, medication use, or improves function. Although all studies showed promising results, further studies are needed to increase the certainty of evidence.
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Affiliation(s)
- Steinn Steingrimsson
- Region Västra Götaland, Psykiatri Affektiva, Department of Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden.,University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Gorana Bilonic
- Region Västra Götaland, Psykiatri Affektiva, Department of Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ann-Catrin Ekelund
- Region Västra Götaland, Medical Library, Skaraborg Hospital, Lidköping, Sweden
| | - Tomas Larson
- Region Västra Götaland, Psykiatri Affektiva, Department of Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden.,University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Ida Stadig
- Region Västra Götaland, Medical Library, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Iris Sarajlic Vukovic
- Region Västra Götaland, Psykiatri Affektiva, Department of Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Olof Wrede
- Region Västra Götaland, Crisis and Trauma Unit, Gothenburg, Sweden
| | - Susanne Bernhardsson
- University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.,Region Västra Götaland, HTA-Centrum, Gothenburg, Sweden.,Research and Development Primary Health Care, Gothenburg, Sweden
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Djerf H, Millinger J, Falkenberg M, Jivegård L, Svensson M, Nordanstig J. Absence of Long-Term Benefit of Revascularization in Patients With Intermittent Claudication: Five-Year Results From the IRONIC Randomized Controlled Trial. Circ Cardiovasc Interv 2020; 13:e008450. [PMID: 31937137 DOI: 10.1161/circinterventions.119.008450] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The long-term benefit of revascularization for intermittent claudication is poorly understood. The aim of this study was to investigate the long-term effectiveness and cost-effectiveness compared with a noninvasive approach. METHODS The IRONIC trial (Invasive Revascularization or Not in Intermittent Claudication) randomized patients with mild-to-severe intermittent claudication to either revascularization + best medical therapy + structured exercise therapy (the revascularization group) or best medical therapy + structured exercise therapy (the nonrevascularization group). The health-related quality of life short form 36 questionnaire was primary outcome and disease-specific health-related quality of life (vascular quality of life questionnaire) and treadmill walking distances were secondary end points. Health-related quality of life has previously been reported superior in the revascularization group at 1- and 2-year follow-up. In this study, the 5-year results were determined. The cost-effectiveness of the treatment options was analyzed from a payer/healthcare standpoint. RESULTS Altogether, 158 patients were randomized in a 1:1 ratio. Regarding the primary end point, no intergroup differences were observed for the short form 36 sum or domain scores from baseline to 5 years, except for the short form 36 role emotional domain score, with greater improvement in the nonrevascularization group (n=116, P=0.007). No intergroup differences were observed in the vascular quality of life questionnaire total and domain scores (n=116, NS) or in treadmill walking distances (n=91, NS). A revascularization strategy resulted in almost twice the cost per patient compared with a noninvasive treatment approach ($13 098 versus $6965, P=0.02). CONCLUSIONS After 5 years of follow-up, a revascularization strategy had lost its early benefit and did not result in any long-term improvement in health-related quality of life or walking capacity compared to a noninvasive treatment strategy. Revascularization was not a cost-effective treatment option from a payer/healthcare point of view. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01219842.
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Affiliation(s)
- Henrik Djerf
- Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Radiology, Institute of Clinical Science (H.D., M.F.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Johan Millinger
- Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine (J.M., L.J., J.N.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Mårten Falkenberg
- Department of Radiology, Institute of Clinical Science (H.D., M.F.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Lennart Jivegård
- HTA Centrum (Health Technology Assessment Center) Västra Götaland (L.J.), Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine (J.M., L.J., J.N.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Mikael Svensson
- Department of Public Health and Community Medicine (M.S.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Joakim Nordanstig
- Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine (J.M., L.J., J.N.), Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
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Djerf H, Falkenberg M, Jivegård L, Lindgren H, Svensson M, Nordanstig J. Cost-Effectiveness of Revascularisation in Patients with Intermittent Claudication on Best Medical Treatment and Unsupervised Training in a Randomised Controlled Trial. Eur J Vasc Endovasc Surg 2019. [DOI: 10.1016/j.ejvs.2019.06.807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Beckman L, von Kobyletzki L, Svensson M. Economic costs of antidepressant use: a population-based study in Sweden. J Ment Health Policy Econ 2019; 22:125-130. [PMID: 32058977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 09/23/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Prescription of antidepressant drugs (ADs) has increased in recent decades, with rising costs for patients as well as for the health care system. There is sparse evidence of which factors explain the high economic costs and financial burden for the general population. AIMS OF THE STUDY The aim was to assess individual-level determinants of out-of-pocket and total health care costs of AD use in the Swedish general population. METHODS We randomly sampled 400,000 individuals aged 18+ from Statistics Sweden's population register from 2010 to 2013. Two-part regression models were used for our two primary outcome variables: (i) total health care costs for AD use per year and individual, and (ii) total out-of-pocket costs of AD use per year and individual. RESULTS Women, the unemployed, unmarried people and residents of big cities have both higher use of ADs and higher associated total health care and out-of-pocket costs. Today, ADs are relatively inexpensive and average cost differences among all groups are therefore minor. The elderly have higher use of ADs, but are more commonly low-volume users and do not have higher total health care or out-of-pocket costs. DISCUSSION AND LIMITATIONS Groups with relatively low socioeconomic status are at risk of higher costs for antidepressant use. However, given the Swedish system of drug subsidies, differences in financial burden for individuals are minor. The limitations of this study included that we lacked data on diagnosis and could therefore not categorize the reasons for AD consumption. Furthermore, our results may not be generalized to other countries with a lower AD prevalence then Sweden's, since our estimates are dependent on the point prevalence of antidepressant use in the population. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE Groups with higher AD consumption and economic costs may suffer from more severe depression owing to more risk factors and less social support in their surroundings, and may be in greater need of additional treatment and support than other groups. IMPLICATIONS FOR HEALTH POLICIES AND FURTHER RESEARCH Our results offer insight at an aggregate level, and more information on the underlying causes of higher costs is needed to discern the policy implications.
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Affiliation(s)
- Linda Beckman
- Department of Public Health, Karlstad University, Universitetsgatan 2, 65188, Karlstad. Sweden, E-mail:
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71
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Johansson N, Jakobsson N, Svensson M. Effects of primary care cost-sharing among young adults: varying impact across income groups and gender. Eur J Health Econ 2019; 20:1271-1280. [PMID: 31401700 PMCID: PMC6803576 DOI: 10.1007/s10198-019-01095-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 07/31/2019] [Indexed: 06/10/2023]
Abstract
We estimate the price sensitivity in health care among adolescents and young adults, and assess how it varies across income groups and gender, using a regression discontinuity design. We use the age differential cost-sharing in Swedish primary care as our identification strategy. At the 20th birthday, the copayment increases from €0 to approx. €10 per primary care physician visit and close to this threshold the copayment faced by each person is distributed almost as good as if randomized. The analysis is performed using high-quality health care and economic register data of 73,000 individuals aged 18-22. Our results show that the copayment decreases the average number of visits by 7%. Among women visits are reduced by 9%, for low-income individuals by 11%, and for low-income women by 14%. In conclusion, modest copayments have significant utilization effects, and even in a policy context with relatively low income inequalities, the effect is substantially larger in low-income groups and among women.
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Affiliation(s)
- Naimi Johansson
- Health Metrics, Sahlgrenska Academy at University of Gothenburg, PO Box 463, 405 30, Gothenburg, Sweden.
| | - Niklas Jakobsson
- Department of Economics, Karlstad University, Universitetsgatan 2, 651 88, Karlstad, Sweden
- Norwegian Social Research (NOVA), Oslo, Norway
| | - Mikael Svensson
- Health Metrics, Sahlgrenska Academy at University of Gothenburg, PO Box 463, 405 30, Gothenburg, Sweden
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72
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Kebede TT, Svensson M, Addissie A, Trollfors B, Andersson R. Cost-effectiveness of childhood pneumococcal vaccination program in Ethiopia: results from a quasi-experimental evaluation. BMC Public Health 2019; 19:1078. [PMID: 31399030 PMCID: PMC6688319 DOI: 10.1186/s12889-019-7423-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 07/31/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Ethiopia was among the 15 countries that, together accounted for 64% of the world's severe episodes of pneumonia among children below the age of 5 in 2011. To reduce this burden, the 10-valent pneumococcal conjugate vaccine (PCV 10) was introduced into the general childhood national immunization program in Ethiopia in 2011. However, there is little evidence on its cost-effectiveness, and the aim of this study was to estimate the cost-effectiveness of the introduction of PCV 10 vaccination in the Ethiopian setting. METHODS The cost-effectiveness analysis was carried out based on a quasi-experimental evaluation of implementing PCV 10 at the Butajira rural health program site in Ethiopia. The intervention and the control groups consisted 876 and 1010 children, respectively. Using data from program site's surveillance system database as a framework, health outcome and vaccination data were collected from medical records, immunization registration books and reports. Disability- Adjusted Life Year (DALY) was a main health outcome metric complimented by incidence of acute lower respiratory infection/1000-person years. Vaccination and treatment costs were collected by document review and cross-sectional household survey. RESULTS In the intervention cohort, 626 of 876 (71.5%) children received PCV 10 vaccination. Until the first year of life, the incidence of acute lower respiratory infection was higher in the intervention group. After the first year of life, the incidence rate was 35.2 per 1000-person years in the intervention group compared to 60.4 per 1000-person years in the control group. The incremental cost-effectiveness ratio (ICER) per averted DALY for the intervention group during the total follow-up period was (2013 US$) 394.3 (undiscounted) and 413.8 (discounted). The ICER per averted DALY excluding the first year of life was (2013 US$) 225 (undiscounted) and 292.7 (discounted). CONCLUSION Compared to the WHO's suggested cost-effectiveness threshold value, the results indicate that the general childhood PCV 10 vaccination was a cost-effective intervention in the Butajira rural health program site.
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Affiliation(s)
- Tayue Tateke Kebede
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Mikael Svensson
- Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Adamu Addissie
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Birger Trollfors
- Department of Paediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rune Andersson
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Thelin E, Al Nimer F, Frostell A, Zetterberg H, Blennow K, Nyström H, Svensson M, Bellander BM, Piehl F, Nelson DW. A Serum Protein Biomarker Panel Improves Outcome Prediction in Human Traumatic Brain Injury. J Neurotrauma 2019; 36:2850-2862. [PMID: 31072225 PMCID: PMC6761606 DOI: 10.1089/neu.2019.6375] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Brain-enriched protein biomarkers of tissue fate are being introduced clinically to aid in traumatic brain injury (TBI) management. The aim of this study was to determine how concentrations of six different protein biomarkers, measured in samples collected during the first weeks after TBI, relate to injury severity and outcome. We included neurocritical care TBI patients that were prospectively enrolled from 2007 to 2013, all having one to three blood samples drawn during the first 2 weeks. The biomarkers analyzed were S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1), tau, and neurofilament-light (NF-L). Glasgow Outcome Score (GOS) was assessed at 12 months. In total, 172 patients were included. All serum markers were associated with injury severity as classified on computed tomography scans at admission. Almost all biomarkers outperformed other known outcome predictors with higher levels the first 5 days, correlating with unfavorable outcomes, and UCH-L1 (0.260, pseduo-R2) displaying the best discrimination in univariate analyses. After adjusting for acknowledged TBI outcome predictors, GFAP and NF-L added most independent information to predict favorable/unfavorable GOS, improving the model from 0.38 to 0.51 pseudo-R2. A correlation matrix indicated substantial covariance, with the strongest correlation between UCH-L1, GFAP, and tau (r = 0.827-0.880). Additionally, the principal component analysis exhibited clustering of UCH-L1 and tau, as well as GFAP, S100B, and NSE, which was separate from NF-L. In summary, a panel of several different protein biomarkers, all associated with injury severity, with different cellular origin and temporal trajectories, improve outcome prediction models.
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Affiliation(s)
- Eric Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Faiez Al Nimer
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Arvid Frostell
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom.,UK Dementia Research Institute, UCL, London, United Kingdom
| | - Kaj Blennow
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Harriet Nyström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - David W Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
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Fletcher-Sandersjöö A, Lindblad C, Thelin EP, Bartek J, Sallisalmi M, Elmi-Terander A, Svensson M, Bellander BM, Broman LM. Serial S100B Sampling Detects Intracranial Lesion Development in Patients on Extracorporeal Membrane Oxygenation. Front Neurol 2019; 10:512. [PMID: 31156541 PMCID: PMC6532588 DOI: 10.3389/fneur.2019.00512] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/30/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction: Intracranial lesion development is a recognized complication in adults treated with extracorporeal membrane oxygenation (ECMO) and is associated with increased mortality. As neurological assessment during ECMO treatment remains challenging, protein biomarkers of cerebral injury could provide an opportunity to detect intracranial lesion development at an early stage. The aim of this study was to determine if serially sampled S100B could be used to detect intracranial lesion development during ECMO treatment. Methods: We conducted an observational cohort study of all patients treated with ECMO at ECMO Center Karolinska (Karolinska University Hospital, Stockholm, Sweden) between January and August 2018, excluding patients who did not undergo a computerized tomography scan (CT) during treatment. S100B was prospectively collected at hospital admission and then once daily. The primary end-point was any type of CT verified intracranial lesion. Receiver operating characteristics (ROC) curves and Cox proportional hazards models were employed. Results: Twenty-nine patients were included, of which 15 (52%) developed an intracranial lesion and exhibited higher levels of S100B overall. S100B had a robust association with intracranial lesion development, especially during the first 200 hours following admission. The best area-under-curve (AUC) to predict intracranial lesion development was 40 and 140 hours following ECMO initiation, were a S100B level of 0.69μg/L had an AUC of 0.81 (0.628-0.997). S100B levels were markedly increased following the development of intracranial hemorrhage. Conclusions: Serial serum S100B samples in ECMO patients were both significantly elevated and had an increasing trajectory in patients developing intracranial lesions. Larger prospective trials are warranted to validate these findings and to ascertain their clinical utility.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marko Sallisalmi
- ECMO Center Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Center Karolinska, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Bornhöft L, Thorn J, Svensson M, Nordeman L, Eggertsen R, Larsson MEH. More cost-effective management of patients with musculoskeletal disorders in primary care after direct triaging to physiotherapists for initial assessment compared to initial general practitioner assessment. BMC Musculoskelet Disord 2019; 20:186. [PMID: 31043169 PMCID: PMC6495522 DOI: 10.1186/s12891-019-2553-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 04/03/2019] [Indexed: 01/21/2023] Open
Abstract
Background A model for triaging patients in primary care to provide immediate contact with the most appropriate profession to treat the condition in question has been developed and implemented in parts of Sweden. Direct triaging of patients with musculoskeletal disorders (MSD) to physiotherapists at primary healthcare centres has been proposed as an alternative to initial assessment by general practitioners (GPs) and has been shown to have many positive effects. The aim of this study was to evaluate the cost-effectiveness from the societal perspective of this new care-pathway through primary care regarding triaging patients with MSD to initial assessment by physiotherapists compared to standard practice with initial GP assessment. Methods Nurse-assessed patients with MSD (N = 55) were randomised to initial assessment and treatment with either physiotherapists or GPs and were followed for 1 year regarding health-related quality of life, utilization of healthcare resources and absence from work for MSD. Quality-adjusted life-years (QALYs) were calculated based on EQ5D measured at 5 time-points. Costs for healthcare resources and production loss were compiled. Incremental cost-effectiveness ratios (ICERS) were calculated. Multiple imputation was used to compensate for missing values and bootstrapping to handle uncertainty. A cost-effectiveness plane and a cost-effectiveness acceptability curve were construed to describe the results. Results The group who were allocated to initial assessment by physiotherapists had slightly larger gains in QALYs at lower total costs. At a willingness-to-pay threshold of 20,000 €, the likelihood that the intervention was cost-effective from a societal perspective including production loss due to MSD was 85% increasing to 93% at higher thresholds. When only healthcare costs were considered, triaging to physiotherapists was still less costly in relation to health improvements than standard praxis. Conclusion From the societal perspective, this small study indicated that triaging directly to physiotherapists in primary care has a high likelihood of being cost-effective. However, further larger randomised trials will be necessary to corroborate these findings. Trial registration ClinicalTrials.gov NCT02218749. Registered August 18, 2014.
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Affiliation(s)
- Lena Bornhöft
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Närhälsan Torslanda Rehabilitation Centre, Gothenburg, Sweden.
| | - Jörgen Thorn
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lena Nordeman
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Sweden
| | - Robert Eggertsen
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Maria E H Larsson
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Sweden
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Sankavaram SR, Hakim R, Covacu R, Frostell A, Neumann S, Svensson M, Brundin L. Adult Neural Progenitor Cells Transplanted into Spinal Cord Injury Differentiate into Oligodendrocytes, Enhance Myelination, and Contribute to Recovery. Stem Cell Reports 2019; 12:950-966. [PMID: 31031190 PMCID: PMC6524946 DOI: 10.1016/j.stemcr.2019.03.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 12/17/2022] Open
Abstract
Long-term survival and integration of neural progenitor cells (NPCs) transplanted following spinal cord injury (SCI) have been observed. However, questions concerning the differentiation choice, the mechanism of action, and the contribution of NPCs to functional recovery remains unanswered. Therefore, we investigated the differentiation of NPCs, global transcriptomal changes in transplanted NPCs, the effect of NPCs on neuroinflammation, and the causality between NPC transplantation and functional recovery. We found that NPCs transplanted following SCI differentiate mainly into oligodendrocytes and enhance myelination, upregulate genes related to synaptic signaling and mitochondrial activity, and downregulate genes related to cytokine production and immune system response. NPCs suppress the expression of pro-inflammatory cytokines/chemokines; moreover, NPC ablation confirm that NPCs were responsible for enhanced recovery in hindlimb locomotor function. Understanding the reaction of transplanted NPCs is important for exploiting their full potential. Existence of causality implies that NPCs are useful in the treatment of SCI. NPCs differentiate mainly into oligodendrocytes and enhance myelination NPCs suppress expression of pro-inflammatory cytokines/chemokines Causality exists between transplantation of NPCs and functional recovery NPCs upregulate genes related to synaptic signaling, oligodendrocytes/myelination
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Affiliation(s)
- Sreenivasa Raghavan Sankavaram
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden; Center of Molecular Medicine, Karolinska Institutet, 17177 Stockholm, Sweden; Departments of Neurology and Neurosurgery, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Ramil Hakim
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden; Center of Molecular Medicine, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Ruxandra Covacu
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden; Center of Molecular Medicine, Karolinska Institutet, 17177 Stockholm, Sweden; Departments of Neurology and Neurosurgery, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Arvid Frostell
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Susanne Neumann
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden; Center of Molecular Medicine, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden; Departments of Neurology and Neurosurgery, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Lou Brundin
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden; Center of Molecular Medicine, Karolinska Institutet, 17177 Stockholm, Sweden; Departments of Neurology and Neurosurgery, Karolinska University Hospital, 17176 Stockholm, Sweden.
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Hakim R, Covacu R, Zachariadis V, Frostell A, Sankavaram SR, Brundin L, Svensson M. Mesenchymal stem cells transplanted into spinal cord injury adopt immune cell-like characteristics. Stem Cell Res Ther 2019; 10:115. [PMID: 30944028 PMCID: PMC6448247 DOI: 10.1186/s13287-019-1218-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/27/2019] [Accepted: 03/20/2019] [Indexed: 02/06/2023] Open
Abstract
Background Mesenchymal stem cells (MSCs) and their cellular response to various stimuli have been characterized in great detail in culture conditions. In contrast, the cellular response of MSCs in an in vivo setting is still uncharted territory. In this study, we investigated the cellular response of MSCs following transplantation into spinal cord injury (SCI). Methods Mouse bone marrow-derived MSCs were transplanted 24 h following severe contusion SCI in mice. As controls, MSCs transplanted to the uninjured spinal cord and non-transplanted MSCs were used. At 7 days post transplantation, the MSCs were isolated from the SCI, and their global transcriptional changes, survival, differentiation, proliferation, apoptosis, and phenotypes were investigated using RNA sequencing, immunohistochemistry, and flow cytometry. Results MSCs transplanted into SCI downregulated genes related to cell-cycle regulation/progression, DNA metabolic/biosynthetic process, and DNA repair and upregulated genes related to immune system response, cytokine production/response, response to stress/stimuli, signal transduction and signaling pathways, apoptosis, and phagocytosis/endocytosis. MSCs maintained their surface expression of Sca1 and CD29 but upregulated expression of CD45 following transplantation. Transplanted MSCs maintained their surface expression of MHC-I but upregulated surface expression of MHC-II. Transplanted MSCs survived and proliferated to a low extent, did not express Caspase-3, and did not differentiate into neurons or astrocytes. Conclusion MSCs transplanted into SCI upregulate expression of CD45 and MHC-II and expression of genes related to cytokine production, phagocytosis/endocytosis, and immune cells/response and thereby adopt immune cell-like characteristics within the recipient. Electronic supplementary material The online version of this article (10.1186/s13287-019-1218-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ramil Hakim
- Department of Neurology, Karolinska University Hospital, 17176, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, 17176, Stockholm, Sweden.,BioClinicum, Karolinska University Hospital, Solnavägen 30, Solna, 171 64, Stockholm, Sweden
| | - Ruxandra Covacu
- Department of Neurology, Karolinska University Hospital, 17176, Stockholm, Sweden.,Center for Molecular Medicine, Karolinska Institutet, 17176, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, 17176, Stockholm, Sweden
| | - Vasilios Zachariadis
- Department of Oncology and Pathology, Karolinska Institutet, 17176, Stockholm, Sweden
| | - Arvid Frostell
- Department of Clinical Neuroscience, Karolinska Institutet, 17176, Stockholm, Sweden.,BioClinicum, Karolinska University Hospital, Solnavägen 30, Solna, 171 64, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Sreenivasa Raghavan Sankavaram
- Center for Molecular Medicine, Karolinska Institutet, 17176, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, 17176, Stockholm, Sweden
| | - Lou Brundin
- Department of Neurology, Karolinska University Hospital, 17176, Stockholm, Sweden. .,Department of Clinical Neuroscience, Karolinska Institutet, 17176, Stockholm, Sweden. .,BioClinicum, Karolinska University Hospital, Solnavägen 30, Solna, 171 64, Stockholm, Sweden.
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, 17176, Stockholm, Sweden.,BioClinicum, Karolinska University Hospital, Solnavägen 30, Solna, 171 64, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, 17176, Stockholm, Sweden
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Abstract
Marine n-3 polyunsaturated fatty acids (PUFAs) may improve cardiovascular, renal, and mental health. No previous trial has investigated the effects of marine n-3 PUFA supplementation on quality of life (QoL) indices after renal transplant. METHODS In this trial, 132 renal transplant recipients were randomized to receive daily either 2.6 g of marine n-3 PUFAs or an equivalent dose of olive oil (controls) on top of standard care for 44 weeks. We used a Short Form 36 (SF-36) questionnaire at baseline (8 weeks post transplant) and at the end of the study (1 year after transplant) to assess QoL. Results were expressed as net change (Δ) in SF-36 individual and composite mental and physical scores during follow-up. RESULTS We found no improvement of Δ SF-36 individual or composite scores after marine n-3 PUFA supplementation compared with controls. In per-protocol analysis, patients who received marine n-3 PUFAs had a Δ emotional role function (mean, 17% [SD, 50%] vs mean, 3% [SD, 37%]; P = .11). In addition, plasma marine n-3 PUFA levels showed a weak but statistically significant correlation with Δ composite mental function score (r = .18; P = .04). CONCLUSION Marine n-3 PUFA supplementation did not improve QoL after renal transplant.
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Affiliation(s)
- W Aasebø
- Department of Renal Medicine, Akershus University Hospital, Lørenskog, Norway.
| | - M Svensson
- Department of Renal Medicine, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - T Jenssen
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway; Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - I A Eide
- Department of Renal Medicine, Akershus University Hospital, Lørenskog, Norway; Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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Hakim R, Covacu R, Zachariadis V, Frostell A, Sankavaram S, Svensson M, Brundin L. Syngeneic, in contrast to allogeneic, mesenchymal stem cells have superior therapeutic potential following spinal cord injury. J Neuroimmunol 2019; 328:5-19. [PMID: 30551037 DOI: 10.1016/j.jneuroim.2018.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/06/2018] [Accepted: 11/07/2018] [Indexed: 01/11/2023]
Abstract
We evaluated the importance of histocompatibility of transplanted MSCs in terms of therapeutic potential. Mouse syngeneic MSCs or allogeneic MSCs were transplanted following SCI in mouse. In this study we found that syngeneic, but not allogeneic, MSCs alternatively activated macrophages resulting in a down-regulation of pro-inflammation. Syngeneic MSCs also had a general suppressive effect on the immune response as compared to allogeneic MSCs. Additionally, syngeneic, but not allogeneic, MSCs significantly enhanced the recovery of hind limb function. In this study we show that the histocompatibility of transplanted MSCs is of importance for their therapeutic potential.
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Affiliation(s)
- Ramil Hakim
- Center for Molecular Medicine, Karolinska Institutet, Solna 17176, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Solna 17176, Stockholm, Sweden.
| | - Ruxandra Covacu
- Center for Molecular Medicine, Karolinska Institutet, Solna 17176, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Solna 17176, Stockholm, Sweden.
| | - Vasilios Zachariadis
- Department of Oncology and Pathology, Karolinska Institutet, Solna 17176, Stockholm, Sweden.
| | - Arvid Frostell
- Department of Clinical Neuroscience, Karolinska Institutet, Solna 17176, Stockholm, Sweden.
| | - Sreenivasa Sankavaram
- Center for Molecular Medicine, Karolinska Institutet, Solna 17176, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Solna 17176, Stockholm, Sweden.
| | - Mikael Svensson
- Department of Neurology and Neurosurgery, Karolinska University Hospital, BioClinicum, Solnavägen 30, Solna, Stockholm 17176, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Solna 17176, Stockholm, Sweden.
| | - Lou Brundin
- Department of Neurology and Neurosurgery, Karolinska University Hospital, BioClinicum, Solnavägen 30, Solna, Stockholm 17176, Sweden; Center for Molecular Medicine, Karolinska Institutet, Solna 17176, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Solna 17176, Stockholm, Sweden.
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80
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Zachrisson K, Elverfors S, Jensen G, Hellström M, Svensson M, Herlitz H, Falkenberg M. Long-term outcome of stenting for atherosclerotic renal artery stenosis and the effect of angiographic restenosis. Acta Radiol 2018; 59:1438-1445. [PMID: 29660989 DOI: 10.1177/0284185118764209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Symptomatic renal artery stenosis (RAS) is mainly treated with pharmacological blood pressure control, sometimes with percutaneous transluminal renal angioplasty (PTRA). It is unclear if PTRA benefits these patients over time. PURPOSE To determine long-term renal function, morbidity, and mortality in patients with symptomatic RAS treated with PTRA, and whether long-term outcomes are associated with angiographic restenosis. MATERIAL AND METHODS Retrospective single-center, long-term follow-up of 57 patients with atherosclerotic RAS treated with PTRA with stent during 1995-2004 and investigated for restenosis with angiography after one year. Outcomes were retrieved from medical records and from mandatory healthcare registries. Mortality rates were related to expected survival in an age- and gender-matched population, using a life-table database. Surviving patients were assessed with blood pressures, laboratory tests, duplex ultrasonography, and radioisotope renography. RESULTS Median follow-up was 11 years 7 months. Major indications for PTRA were therapy-resistant hypertension and declining renal function. Angiographic restenosis at one year was found in 21 of 57 patients (37%). Thirty-six patients (60%) died during follow-up. Main cause of death was cardiovascular events (54%). Mortality was significantly increased, and morbidity and healthcare utilization were high. Hypertension control during follow-up was stable with persistent need for anti-hypertensive medication, and renal function remained moderately reduced with no long-term difference between patients with vs. without restenosis. CONCLUSION Long-term prognosis after PTRA for atherosclerotic RAS is dismal, with high mortality and morbidity and reduced renal function, despite maintained hypertension control. Restenosis does not appear to affect late outcome.
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Affiliation(s)
- Karin Zachrisson
- Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sven Elverfors
- Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gert Jensen
- Department of Molecular and Clinical Medicine/Nephrology, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Hellström
- Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- Health Metrics Unit, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Herlitz
- Department of Molecular and Clinical Medicine/Nephrology, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mårten Falkenberg
- Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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81
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Holst A, Ginter A, Björkelund C, Hange D, Petersson EL, Svenningsson I, Westman J, André M, Wikberg C, Wallin L, Möller C, Svensson M. Cost-effectiveness of a care manager collaborative care programme for patients with depression in primary care: economic evaluation of a pragmatic randomised controlled study. BMJ Open 2018; 8:e024741. [PMID: 30420353 PMCID: PMC6252772 DOI: 10.1136/bmjopen-2018-024741] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the cost-effectiveness of a care manager (CM) programme compared with care as usual (CAU) for treatment of depression at primary care centres (PCCs) from a healthcare as well as societal perspective. DESIGN Cost-effectiveness analysis. SETTING 23 PCCs in two Swedish regions. PARTICIPANTS Patients with depression (n=342). MAIN OUTCOME MEASURES A cost-effectiveness analysis was applied on a cluster randomised trial at PCC level where patients with depression had 3 months of contact with a CM (11 intervention PCCs, n=163) or CAU (12 control PCCs, n=179), with follow-up 3 and 6 months. Effectiveness measures were based on the number of depression-free days (DFDs) calculated from the Montgomery-Åsberg Depression Rating Scale-Self and quality-adjusted life years (QALYs). Results were expressed as the incremental cost-effectiveness ratio: ∆Cost/∆QALY and ∆Cost/∆DFD. Sampling uncertainty was assessed based on non-parametric bootstrapping. RESULTS Health benefits were higher in intervention group compared with CAU group: QALYs (0.357 vs 0.333, p<0.001) and DFD reduction of depressive symptom score (79.43 vs 60.14, p<0.001). The mean costs per patient for the 6-month period were €368 (healthcare perspective) and €6217 (societal perspective) for the intervention patients and €246 (healthcare perspective) and €7371 (societal perspective) for the control patients (n.s.). The cost per QALY gained was €6773 (healthcare perspective) and from a societal perspective the CM programme was dominant. DISCUSSION The CM programme was associated with a gain in QALYs as well as in DFD, while also being cost saving compared with CAU from a societal perspective. This result is of high relevance for decision-makers on a national level, but it must be observed that a CM programme for depression implies increased costs at the primary care level. TRIAL REGISTRATION NUMBER NCT02378272; Results.
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Affiliation(s)
- Anna Holst
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annika Ginter
- Department of Public Health and Community Medicine/Health Metrics, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Björkelund
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Dominique Hange
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva-Lisa Petersson
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
| | - Irene Svenningsson
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
| | - Jeanette Westman
- Division of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Malin André
- Department of Public Health and Caring Sciences-Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Carl Wikberg
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Wallin
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Department of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christina Möller
- Primary Health Care Head Office, Närhälsan, Region Västra Götaland, Hisings Backa, Sweden
| | - Mikael Svensson
- Department of Public Health and Community Medicine/Health Metrics, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Djerf H, Falkenberg M, Jivegård L, Lindgren H, Svensson M, Nordanstig J. Cost-effectiveness of revascularization in patients with intermittent claudication. Br J Surg 2018; 105:1742-1748. [PMID: 30357819 DOI: 10.1002/bjs.10992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 07/06/2018] [Accepted: 08/06/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Revascularization is a treatment option for patients with intermittent claudication. However, there is a lack of evidence to support its long-term benefits and cost-effectiveness. The aim of this study was to compare the cost-effectiveness of revascularization and best medical therapy (BMT) with that of BMT alone. METHODS Data were used from the IRONIC (Invasive Revascularization Or Not in Intermittent Claudication) RCT where consecutive patients with mild-to-severe intermittent claudication owing to aortoiliac or femoropopliteal disease were allocated to either BMT alone (including a structured, non-supervised exercise programme) or to revascularization together with BMT. Inpatient and outpatient costs were obtained prospectively over 24 months of follow-up. Mean improvement in quality-adjusted life-years (QALYs) was calculated based on responses to the EuroQol Five Dimensions EQ-5D-3 L™ questionnaire. Cost-effectiveness was assessed as the cost per QALY gained. RESULTS A total of 158 patients were randomized, 79 to each group. The mean cost per patient in the BMT group was €1901, whereas it was €8280 in the group treated with revascularization in addition to BMT, with a cost difference of €6379 (95 per cent c.i. €4229 to 8728) per patient. Revascularization in addition to BMT resulted in a mean gain in QALYs of 0·16 (95 per cent c.i. 0·06 to 0·24) per patient, giving an incremental cost-effectiveness ratio of €42 881 per QALY. CONCLUSION The costs associated with revascularization together with BMT in patients with intermittent claudication were about four times higher than those of BMT alone. The incremental cost-effectiveness ratio of revascularization was within the accepted threshold for public willingness to pay according to the Swedish National Guidelines, but exceeded that of the UK National Institute for Health and Care Excellence guidelines.
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Affiliation(s)
- H Djerf
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Radiology, Institute of Clinical Science, Gothenburg, Sweden
| | - M Falkenberg
- Department of Radiology, Institute of Clinical Science, Gothenburg, Sweden
| | - L Jivegård
- Health Technology Assessment Centre, Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department for Molecular and Clinical Medicine, Institute of Medicine, Gothenburg, Sweden
| | - H Lindgren
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
| | - M Svensson
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - J Nordanstig
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department for Molecular and Clinical Medicine, Institute of Medicine, Gothenburg, Sweden
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83
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Zampa F, Fish J, Hilgert M, Lövby T, Svensson M, Vaughan J, Mattei A. The 2016 ENFSI Fingerprint Working Group testing programme. Forensic Sci Int 2018; 292:148-162. [PMID: 30312945 DOI: 10.1016/j.forsciint.2018.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 09/16/2018] [Accepted: 09/24/2018] [Indexed: 11/18/2022]
Abstract
In 2016, the Fingerprint Working Group (EFP-WG) of the European Network of Forensic Science Institutes (ENFSI), officially established an advisory group with the task of organising proficiency tests (PTs), as well as collaborative exercises (CEs) as a way of raising standards within the fingerprint profession. This article will provide an overview of the Visualisation collaborative exercise and the Comparison proficiency test, which were carried out in 2016. Both the exercise and the test were organised and co-funded by the Prevention of and Fight against Crime Programme of the European Union [1-3], Direct Grant "Towards the Vision for European Forensic Science 2020 (TVEFS-2020)" HOME/2013/ISEC/MO/ENFSI/4000005962, work package T3 "Proficiency Tests and Collaborative Exercises for the Fingerprint Domain". The characteristics of the testing programme are summarised, followed by an overview of the knowledge that has been gained, including lessons learnt.
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Affiliation(s)
- F Zampa
- Reparto Carabinieri Investigazioni Scientifiche (R.I.S.), Parma, Italy.
| | - J Fish
- National Crime Agency (NCA), London, United Kingdom
| | - M Hilgert
- Bunderskriminalamt (BKA), Wiesbaden, Germany
| | - T Lövby
- National Forensic Centre (NFC), Linkoping, Sweden
| | - M Svensson
- National Forensic Centre (NFC), Linkoping, Sweden
| | | | - A Mattei
- Reparto Carabinieri Investigazioni Scientifiche (R.I.S.), Messina, Italy
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84
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Hua AY, Westin O, Hamrin Senorski E, Svantesson E, Grassi A, Zaffagnini S, Samuelsson K, Svensson M. Mapping functions in health-related quality of life: mapping from the Achilles Tendon Rupture Score to the EQ-5D. Knee Surg Sports Traumatol Arthrosc 2018; 26:3083-3088. [PMID: 29691617 PMCID: PMC6154025 DOI: 10.1007/s00167-018-4954-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/16/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE Health state utility values are derived from preference-based measurements and are useful in calculating quality-adjusted life years (QALYs), which is a metric commonly used in cost-effectiveness studies. The purpose of this study was to convert the Achilles Tendon Rupture Score (ATRS) to the preference-based European Quality of Life-5 Dimension Questionnaire (EQ-5D) by estimating the relationship between the two scores using mapping. METHODS Data were collected from a randomised controlled trial, where 100 patients were treated either surgically or non-surgically for Achilles tendon rupture. Forty-three and forty-four patients in surgical group and non-surgical group completed the ATRS and the EQ-5D alongside each other during follow-up at three time points. Different models of the relationship between the ATRS and the EQ-5D were developed and analysed based on direct mapping and cross-validation. The model with the lowest mean absolute error was observed as the one with the best fit. RESULTS Among the competing models, mapping based on using a combination of the ATRS items four, five, and six associated with limitation due to pain, during activities of daily living and when walking on uneven ground, produced the best predictor of the EQ-5D score. CONCLUSIONS The present study provides a mapping algorithm to enable the derivation of utility values directly from the ATRS. This approach makes it feasible for researchers, as well as medical practitioners, to obtain preference-based values in clinical studies or settings where only the ATRS is being administered. The algorithm allows for the calculation of QALYs for use in cost-effectiveness analyses, making it valuable in the study of acute Achilles tendon ruptures. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Ay-Yen Hua
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Olof Westin
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eleonor Svantesson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Alberto Grassi
- II Orthopaedic Clinic, IRCCS Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Stefano Zaffagnini
- II Orthopaedic Clinic, IRCCS Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Mikael Svensson
- Health Metrics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Ryen L, Bonander C, Svensson M. From loss of life to loss of years: a different view on the burden of injury fatalities in Sweden 1972-2014. Eur J Public Health 2018; 28:853-858. [PMID: 29846567 DOI: 10.1093/eurpub/cky083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Worldwide, about 5.8 million people die each year due to injuries. In Sweden, the corresponding number amounts to 3000. There are large differences among injury types regarding the age-profile of the fatalities and as most of them occur in older age groups, counting the absolute number of injury fatalities does not fully reflect the size of the burden of injury. Methods Using age- and sex-specific life expectancy tables in combination with data on external causes of injury, the number of injury fatalities in Sweden for the time period 1972-2014 is converted to a sum of potential years of life lost (PYLL). We then fit cause and group-specific spline regression models to the data to estimate temporal trends in both fatality counts and PYLL. Results There has been a steady reduction in the number of injury fatalities and in the sum of PYLL from the early 1970s to around the year 2000. Since then, there has been an increase in the number of injury fatalities and in the sum of PYLL. The upward trend is mainly explained by an increasing number of deaths due to poisonings and suicide, specifically among younger men. Conclusions The increases in suicide and poisoning mortality offset the reductions in downward trending causes of injury mortality during the last decades. The share of PYLL is larger than the share of fatalities for both suicides and poisonings implying that an aging population does not cause the increase.
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Affiliation(s)
- Linda Ryen
- Swedish Civil Contingencies Agency, Karlstad, Sweden.,Health Metrics, The Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Carl Bonander
- Department of Environmental and Life Sciences, Karlstad University, Sweden
| | - Mikael Svensson
- Health Metrics, The Sahlgrenska Academy, University of Gothenburg, Sweden.,Department of Economics, Williams College, US
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Veličković VM, Borisenko O, Svensson M, Spelman T, Siebert U. Congenital heart defect repair with ADAPT tissue engineered pericardium scaffold: An early-stage health economic model. PLoS One 2018; 13:e0204643. [PMID: 30261033 PMCID: PMC6160133 DOI: 10.1371/journal.pone.0204643] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 09/12/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the cost effectiveness of tissue engineered bovine tissue pericardium scaffold (CardioCel) for the repair of congenital heart defects in comparison with surgery using xenogeneic, autologous, and synthetic patches over a 40-year time horizon from the perspective of the UK National Health Service. METHODS A six-state Markov state-transition model to model natural history of disease and difference in the interventional effect of surgeries depending on patch type implanted. Patches differed regarding their probability of re-operation due to patch calcification, based on a systematic literature review. Transition probabilities were based on the published literature, other clinical inputs were based on UK registry data, and cost data were based on UK sources and the published literature. Incremental cost-effectiveness ratio (ICER) was determined as incremental costs per quality adjusted life years (QALY) gained. We used a 40-year analytic time-horizon and adopted the payer perspective. Comprehensive sensitivity analyses were performed. RESULTS According to the model predictions, CardioCel was associated with reduced incidence of re-operation, increased QALY, and costs savings compared to all other patches. Cost savings were greatest compared to synthetic patches. Estimated cost savings associated with CardioCel were greatest within atrioventricular septal defect repair and lowest for ventricular septal defect repair. Based on our model, CardioCel relative risk for re-operations is 0.938, 0.956and 0.902 relative to xenogeneic, autologous, and synthetic patches, respectively. CONCLUSION CardioCel was estimated to increase health benefits and save cost when used during surgery for congenital heart defects instead of other patches.
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Affiliation(s)
- Vladica M. Veličković
- Synergus AB, Health Economics and Evidence Synthesis Department, Stockholm, Sweden
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Reseaech and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Oleg Borisenko
- Synergus AB, Health Economics and Evidence Synthesis Department, Stockholm, Sweden
| | - Mikael Svensson
- Health Metrics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tim Spelman
- Synergus AB, Health Economics and Evidence Synthesis Department, Stockholm, Sweden
- Centre for Population Health, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Reseaech and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
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87
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Mattsson P, Frostell A, Björck G, Persson JKE, Hakim R, Zedenius J, Svensson M. Recovery of Voice After Reconstruction of the Recurrent Laryngeal Nerve and Adjuvant Nimodipine. World J Surg 2018; 42:632-638. [PMID: 29282507 PMCID: PMC5801379 DOI: 10.1007/s00268-017-4235-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Transection injury to the recurrent laryngeal nerve (RLN) has been associated with permanent vocal fold palsy, and treatment has been limited to voice therapy or local treatment of vocal folds. Microsurgical repair has been reported to induce a better function. The calcium channel antagonist nimodipine improves functional recovery after experimental nerve injury and also after cranial nerve injury in patients. This study aims to present voice outcome in patients who underwent repair of the RLN and received nimodipine during regeneration. Methods From 2002–2016, 19 patients were admitted to our center with complete unilateral injury to the RLN and underwent microsurgical repair of the RLN. After nerve repair, patients received nimodipine for 2–3 months. Laryngoscopy was performed repeatedly up to 14 months postoperatively. The Voice Handicap Index (VHI) was administered, and patients’ maximum phonation time (MPT) was recorded during the follow-up. Results All patients recovered well after surgery, and nimodipine was well tolerated with no dropouts. None of the patients suffered from atrophy of the vocal fold, and some patients even showed a small ab/adduction of the vocal fold on the repaired side with laryngoscopy. During long-term follow-up (>3 years), VHI and MPT normalized, indicating a nearly complete recovery from unilateral RLN injury. Conclusions In this cohort study, we report the results of the first 19 consecutive cases at our center subjected to reconstruction of the RLN and adjuvant nimodipine treatment. The outcome of the current strategy is encouraging and should be considered after iatrogenic RLN transection injuries.
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Affiliation(s)
- P Mattsson
- Division of Clinical CNS Research, Section of Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet R2:02, Karolinska University Hospital, 171 76, Stockholm, Sweden. .,Department of Breast, Endocrine and Sarcoma Tumors, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - A Frostell
- Division of Clinical CNS Research, Section of Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet R2:02, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - G Björck
- Department of ENT Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - J K E Persson
- Division of Clinical CNS Research, Section of Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet R2:02, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - R Hakim
- Division of Clinical CNS Research, Section of Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet R2:02, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - J Zedenius
- Department of Breast, Endocrine and Sarcoma Tumors, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - M Svensson
- Division of Clinical CNS Research, Section of Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet R2:02, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, 171 76, Stockholm, Sweden
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Abstract
Economic evaluations are an important input to decision-making and priority-setting in the health care sector. Measuring preferences for health improvements, as the demand-side value (willingness to pay) of gaining a quality-adjusted life year (QALY), is one relevant component in the interpretation of the results from health economic evaluations. Our article addresses whether willingness to pay for a QALY (WTP-Q) is sensitive to the size of the health differences and the probability for improvement. We use data from a contingent valuation survey based on 1400 respondents conducted in the spring of 2014. The results show that the expectation of sensitivity to scope, or higher WTP to the larger expected quality of life improvement, is not supported. We find WTP-Q values that conform reasonably well to previous studies in Sweden.
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Affiliation(s)
- Björn Sund
- Swedish Civil Contingencies Agency (MSB), 651 81, Karlstad, Sweden.
- Department of Economics, Karlstad University, Karlstad, Sweden.
| | - Mikael Svensson
- Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Holst A, Björkelund C, Metsini A, Madsen JH, Hange D, Petersson ELL, Eriksson MCM, Kivi M, Andersson PÅÅ, Svensson M. Cost-effectiveness analysis of internet-mediated cognitive behavioural therapy for depression in the primary care setting: results based on a controlled trial. BMJ Open 2018; 8:e019716. [PMID: 29903785 PMCID: PMC6009451 DOI: 10.1136/bmjopen-2017-019716] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To perform a cost-effectiveness analysis of a randomised controlled trial of internet-mediated cognitive behavioural therapy (ICBT) compared with treatment as usual (TaU) for patients with mild to moderate depression in the Swedish primary care setting. In particular, the objective was to assess from a healthcare and societal perspective the incremental cost-effectiveness ratio (ICER) of ICBT versus TaU at 12 months follow-up. DESIGN A cost-effectiveness analysis alongside a pragmatic effectiveness trial. SETTING Sixteen primary care centres (PCCs) in south-west Sweden. PARTICIPANTS Ninety patients diagnosed with mild to moderate depression at the PCCs. MAIN OUTCOME MEASURE ICERs calculated as (CostICBT-CostTaU)/(Health outcomeICBT-Health outcomeTaU)=ΔCost/ΔHealth outcomes, the health outcomes being changes in the Beck Depression Inventory-II (BDI-II) score and quality-adjusted life-years (QALYs). RESULTS The total cost per patient for ICBT was 4044 Swedish kronor (SEK) (€426) (healthcare perspective) and SEK47 679 (€5028) (societal perspective). The total cost per patient for TaU was SEK4434 (€468) and SEK50 343 (€5308). In both groups, the largest cost was associated with productivity loss. The differences in cost per patient were not statistically significant. The mean reduction in BDI-II score was 13.4 and 13.8 units in the ICBT and TaU groups, respectively. The mean QALYs per patient was 0.74 and 0.79 in the ICBT and TaU groups, respectively. The differences in BDI-II score reduction and mean QALYs were not statistically significant. The uncertainty of the study estimates when assessed by bootstrapping indicated that no firm conclusion could be drawn as to whether ICBT treatment compared with TaU was the most cost-effective use of resources. CONCLUSIONS ICBT was regarded to be as cost-effective as TaU as costs, health outcomes and cost-effectiveness were similar for ICBT and TaU, both from a healthcare and societal perspective. TRIAL REGISTRATION NUMBER ID NR 30511.
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Affiliation(s)
- Anna Holst
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Björkelund
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | | | | | - Dominique Hange
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Eva-Lisa L Petersson
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden
| | - Maria CM Eriksson
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Marie Kivi
- Department of Psychology, University of Gothenburg, Gothenburg, Sweden
| | - Per-Åke Å Andersson
- Department of Economics, School of Business, Economics and Law at University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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90
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Frostell A, Mattsson P, Svensson M. Guiding Device for Precision Grafting of Peripheral Nerves in Complete Thoracic Spinal Cord Injury: Design and Sizing for Clinical Trial. Front Neurol 2018; 9:356. [PMID: 29872421 PMCID: PMC5972322 DOI: 10.3389/fneur.2018.00356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/01/2018] [Indexed: 01/08/2023] Open
Abstract
Background In an effort to translate preclinical success in achieving spinal cord regeneration through peripheral nerve grafts, this study details the design and sizing of a guiding device for precision grafting of peripheral nerves for use in a clinical trial in complete (AIS-A) thoracic spinal cord injury (SCI). The device’s design and sizing are compared to a simulation of human spinal cord sizes based on the best available data. Methods Spinal cord segmental sizes were generated by computer simulation based on data from a meta-analysis recently published by our group. Thoracic segments T2–T12 were plotted, and seven elliptical shapes were positioned across the center of the distribution of sizes. Geometrical measures of error-of-fit were calculated. CAD modeling was used to create cranial and caudal interfaces for the human spinal cord, aiming to guide descending white matter tracts to gray matter at the caudal end of the device and ascending white matter tracts to gray matter at the cranial end of the device. The interfaces were compared qualitatively to the simulated spinal cord sizes and gray-to-white matter delineations. Results The mean error-of-fit comparing simulated spinal cord segments T2–T12 to the best elliptical shape was 0.41 and 0.36 mm, and the 95th percentile was found at 1.3 and 0.98 mm for transverse and anteroposterior diameter, respectively. A guiding device design was reached for capturing the majority of corticospinal axons at the cranial end of the device and guiding them obliquely to gray matter at the caudal end of the device. Based on qualitative comparison, the vast majority of spinal cord sizes generated indicate an excellent fit to the device’s interfaces. Conclusion A set of SCI guiding devices of seven sizes can cover the variability of human thoracic spinal cord segments T2–T12 with an acceptable error-of-fit for the elliptical shape as well as guiding channels. The computational framework developed can be used with other medical technologies involving the human spinal cord where exact sizes and positioning are of importance.
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Affiliation(s)
- Arvid Frostell
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Per Mattsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Breast, Endocrine and Sarcoma Tumors, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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91
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Johansson N, Jakobsson N, Svensson M. Regional variation in health care utilization in Sweden - the importance of demand-side factors. BMC Health Serv Res 2018; 18:403. [PMID: 29866201 PMCID: PMC5987462 DOI: 10.1186/s12913-018-3210-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Differences in health care utilization across geographical areas are well documented within several countries. If the variation across areas cannot be explained by differences in medical need, it can be a sign of inefficiency or misallocation of public health care resources. METHODS In this observational, longitudinal panel study we use regional level data covering the 21 Swedish regions (county councils) over 13 years and a random effects model to assess to what degree regional variation in outpatient physician visits is explained by observed demand factors such as health, demography and socio-economic factors. RESULTS The results show that regional mortality, as a proxy for population health, and demography do not explain regional variation in visits to primary care physicians, but explain about 50% of regional variation in visits to outpatient specialists. Adjusting for socio-economic and basic supply-side factors explains 33% of the regional variation in primary physician visits, but adds nothing to explaining the variation in specialist visits. CONCLUSION 50-67% of regional variation remains unexplained by a large number of observable regional characteristics, indicating that omitted and possibly unobserved factors contribute substantially to the regional variation. We conclude that variations in health care utilization across regions is not very well explained by underlying medical need and demand, measured by mortality, demographic and socio-economic factors.
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Affiliation(s)
- Naimi Johansson
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, PO Box 463, SE-405 30 Gothenburg, Sweden
| | - Niklas Jakobsson
- Department of Economics, Karlstad University, SE-651 88 Karlstad, Sweden
- Norwegian Social Research (NOVA), Oslo, Norway
| | - Mikael Svensson
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, PO Box 463, SE-405 30 Gothenburg, Sweden
- Department of Economics, Williams College, Williamstown, MA USA
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92
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Svensson M, Barregård L, Axelsson G, Andersson E. A cost-effectiveness analysis of lowering residential radon levels in Sweden—Results from a modelling study. Health Policy 2018; 122:687-692. [DOI: 10.1016/j.healthpol.2018.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 03/09/2018] [Accepted: 03/10/2018] [Indexed: 10/17/2022]
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93
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Rubenson Wahlin R, Nelson DW, Bellander BM, Svensson M, Helmy A, Thelin EP. Prehospital Intubation and Outcome in Traumatic Brain Injury-Assessing Intervention Efficacy in a Modern Trauma Cohort. Front Neurol 2018; 9:194. [PMID: 29692755 PMCID: PMC5903008 DOI: 10.3389/fneur.2018.00194] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 03/13/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Prehospital intubation in traumatic brain injury (TBI) focuses on limiting the effects of secondary insults such as hypoxia, but no indisputable evidence has been presented that it is beneficial for outcome. The aim of this study was to explore the characteristics of patients who undergo prehospital intubation and, in turn, if these parameters affect outcome. MATERIAL AND METHODS Patients ≥15 years admitted to the Department of Neurosurgery, Stockholm, Sweden with TBI from 2008 through 2014 were included. Data were extracted from prehospital and hospital charts, including prospectively collected Glasgow Outcome Score (GOS) after 12 months. Univariate and multivariable logistic regression models were employed to examine parameters independently correlated to prehospital intubation and outcome. RESULTS A total of 458 patients were included (n = 178 unconscious, among them, n = 61 intubated). Multivariable analyses indicated that high energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation, and distance to the hospital were independently correlated with intubation, and among them, only pupil responsiveness was independently associated with outcome. Prehospital intubation did not add independent information in a step-up model versus GOS (p = 0.154). Prehospital reports revealed that hypoxia was not the primary cause of prehospital intubation, and that the procedure did not improve oxygen saturation during transport, while an increasing distance from the hospital increased the intubation frequency. CONCLUSION In this modern trauma cohort, prehospital intubation was not independently associated with outcome; however, hypoxia was not a common reason for prehospital intubation. Prospective trials to assess efficacy of prehospital airway intubation will be difficult due to logistical and ethical considerations.
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Affiliation(s)
- Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - David W. Nelson
- Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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94
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Lindblad C, Thelin EP, Nekludov M, Frostell A, Nelson DW, Svensson M, Bellander BM. Assessment of Platelet Function in Traumatic Brain Injury-A Retrospective Observational Study in the Neuro-Critical Care Setting. Front Neurol 2018; 9:15. [PMID: 29434566 PMCID: PMC5790800 DOI: 10.3389/fneur.2018.00015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 01/09/2018] [Indexed: 11/13/2022] Open
Abstract
Background Despite seemingly functional coagulation, hemorrhagic lesion progression is a common and devastating condition following traumatic brain injury (TBI), stressing the need for new diagnostic techniques. Multiple electrode aggregometry (MEA) measures platelet function and could aid in coagulopathy assessment following TBI. The aims of this study were to evaluate MEA temporal dynamics, influence of concomitant therapy, and its capabilities to predict lesion progression and clinical outcome in a TBI cohort. Material and methods Adult TBI patients in a neurointensive care unit that underwent MEA sampling were retrospectively included. MEA was sampled if the patient was treated with antiplatelet therapy, bled heavily during surgery, or had abnormal baseline coagulation values. We assessed platelet activation pathways involving the arachidonic acid receptor (ASPI), P2Y12 receptor, and thrombin receptor (TRAP). ASPI was the primary focus of analysis. If several samples were obtained, they were included. Retrospective data were extracted from hospital charts. Outcome variables were radiologic hemorrhagic progression and Glasgow Outcome Scale assessed prospectively at 12 months posttrauma. MEA levels were compared between patients on antiplatelet therapy. Linear mixed effect models and uni-/multivariable regression models were used to study longitudinal dynamics, hemorrhagic progression and outcome, respectively. Results In total, 178 patients were included (48% unfavorable outcome). ASPI levels increased from initially low values in a time-dependent fashion (p < 0.001). Patients on cyclooxygenase inhibitors demonstrated low ASPI levels (p < 0.001), while platelet transfusion increased them (p < 0.001). The first ASPI (p = 0.039) and TRAP (p = 0.009) were significant predictors of outcome, but not lesion progression, in univariate analyses. In multivariable analysis, MEA values were not independently correlated with outcome. Conclusion A general longitudinal trend of MEA is identified in this TBI cohort, even in patients without known antiplatelet therapies. Values appear also affected by platelet inhibitory treatment and by platelet transfusions. While significant in univariate models to predict outcome, MEA values did not independently correlate to outcome or lesion progression in multivariable analyses. Further prospective studies to monitor coagulation in TBI patients are warranted, in particular the interpretation of pathological MEA values in patients without antiplatelet therapies.
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Affiliation(s)
- Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Michael Nekludov
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Arvid Frostell
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David W Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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95
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Acosta S, Seternes A, Venermo M, Vikatmaa L, Sörelius K, Wanhainen A, Svensson M, Djavani K, Björck M. Open Abdomen Therapy with Vacuum and Mesh Mediated Fascial Traction After Aortic Repair: an International Multicentre Study. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2017.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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96
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Westin O, Svensson M, Nilsson Helander K, Samuelsson K, Grävare Silbernagel K, Olsson N, Karlsson J, Hansson Olofsson E. Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2018; 26:3074-3082. [PMID: 29696317 PMCID: PMC6154020 DOI: 10.1007/s00167-018-4953-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/16/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE An Achilles tendon rupture is a common injury that typically affects people in the middle of their working lives. The injury has a negative impact in terms of both morbidity for the individual and the risk of substantial sick leave. The aim of this study was to investigate the cost-effectiveness of surgical compared with non-surgical management in patients with an acute Achilles tendon rupture. METHODS One hundred patients (86 men, 14 women; mean age, 40 years) with an acute Achilles tendon rupture were randomised (1:1) to either surgical treatment or non-surgical treatment, both with an accelerated rehabilitation protocol (surgical n = 49, non-surgical n = 51). One of the surgical patients was excluded due to a partial re-rupture and five surgical patients were lost to the 1-year economic follow-up. One patient was excluded due to incorrect inclusion and one was lost to the 1-year follow-up in the non-surgical group. The cost was divided into direct and indirect costs. The direct cost is the actual cost of health care, whereas the indirect cost is the production loss related to the impact of the patient's injury in terms of lost ability to work. The health benefits were assessed using quality-adjusted life years (QALYs). Sampling uncertainty was assessed by means of non-parametric boot-strapping. RESULTS Pre-injury, the groups were comparable in terms of demographic data and health-related quality of life (HRQoL). The mean cost of surgical management was €7332 compared with €6008 for non-surgical management (p = 0.024). The mean number of QALYs during the 1-year time period was 0.89 and 0.86 in the surgical and non-surgical groups respectively. The (incremental) cost-effectiveness ratio was €45,855. Based on bootstrapping, the cost-effectiveness acceptability curve shows that the surgical treatment is 57% likely to be cost-effective at a threshold value of €50,000 per QALY. CONCLUSIONS Surgical treatment was more expensive compared with non-surgical management. The cost-effectiveness results give a weak support (57% likelihood) for the surgical treatment to be cost-effective at a willingness to pay per QALY threshold of €50,000. This is support for surgical treatment; however, additionally cost-effectiveness studies alongside RCTs are important to clarify which treatment option is preferred from a cost-effectiveness perspective. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Olof Westin
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Mikael Svensson
- Health Metrics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Karin Grävare Silbernagel
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
| | - Nicklas Olsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jón Karlsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Elisabeth Hansson Olofsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg, Sweden
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97
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von Vogelsang AC, Thelin EP, Hakim R, Svensson M. Health-Related Quality of Life Dynamics 2 Years Following Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study Using EQ-5D. Neurosurgery 2017; 81:650-658. [PMID: 28368438 DOI: 10.1093/neuros/nyx059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 01/25/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Previous studies have shown that aneurysmal subarachnoid hemorrhage (aSAH) affects health-related quality of life (HRQoL) to a large extent. However, longitudinal studies on HRQoL after aSAH are scarce, and there is limited knowledge whether different HRQoL dimension scores change over time, and if so, if the scoring differs from results from the general population. OBJECTIVE To evaluate HRQoL dynamics over time, 2 years following aSAH, and compare the results with general population. METHODS In a prospective cohort design, 88 consecutive aSAH patients (85% of eligible) were followed up with the generic HRQoL instrument EQ-5D at 3 time points: 6 months, 1 year, and 2 years after the onset. Data were collected in 2006 to 2009, and the results were compared with a general population sample from the Stockholm Public Health Survey 2006, matched by age and sex. RESULTS Overall HRQoL in the aSAH sample was stationary over time. Improved function was only found in the usual activities dimension (P = .026). HRQoL was most affected in participants reporting comorbidity. Compared with the general population, women in the aSAH sample reported significantly more problems in 4 out of 5 dimensions (mobility, self-care, usual activities, and anxiety/depression). Men in the aSAH sample reported significantly more problems in the usual activities dimension in comparison to the general population. CONCLUSION HRQoL is stationary during the first 2 years following aSAH, and is significantly worse when compared to the general population. Rehabilitation efforts should be initiated shortly after hospitalization.
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Affiliation(s)
- Ann-Christin von Vogelsang
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Ramil Hakim
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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98
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Persson L, Svensson M. Classmate characteristics, class composition and children's perceived classroom climate. Z Gesundh Wiss 2017; 25:473-480. [PMID: 28959519 PMCID: PMC5596030 DOI: 10.1007/s10389-017-0809-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 05/02/2017] [Indexed: 11/27/2022]
Abstract
AIM A beneficial classroom climate is vital for school achievements, health, well-being, and school satisfaction. However, there is little knowledge as to how the classmate characteristics and class composition are related to the level of a perceived messy and disorderly classroom climate and whether the estimated relationships vary between different groups of children. The aim of the study was to explore the relationship between classmate characteristics as well as class composition and children's perceived classroom climate. METHOD Data from a cross-sectional survey administrated in 71 classes including 1,247 children in a mid-sized Swedish city were used. The analyses were conducted using multilevel models. RESULTS A class with a higher proportion of girls was associated with a lower likelihood of perceiving the classroom climate as messy and disorderly. Moreover, a higher proportion of immigrant children in a class was associated with a perception of a messier and disorderly classroom climate among non-immigrant children, but not among immigrant children themselves. CONCLUSION Classmate characteristics and class composition deserve more research attention and can be important considerations when aiming to improve the classroom climate and children's well-being in general.
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Affiliation(s)
- Louise Persson
- Centre for Research on Child and Adolescent Mental Health, Karlstad University, SE-651 88 Karlstad, Sweden.,Public Health Sciences, Karlstad University, Karlstad, Sweden
| | - Mikael Svensson
- Department of Health Metrics, Gothenburg University, Gothenburg, Sweden
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99
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Abstract
Background The aim of this study was to report our single centre experience with the Medina Embolic Device (MED). Methods We performed a retrospective analysis of prospectively collected data to identify all patients treated with the MED. A total of 14 aneurysms (non-consecutive), in 13 patients, were treated including one ruptured and one partially thrombosed aneurysm. Fundus diameter was ≥5 mm in all cases. We evaluated the angiographic appearances, the clinical status, complications, and the need for adjunctive devices or repeat treatments. Results Aneurysm location was cavernous internal carotid artery (ICA; n = 1), supraclinoid ICA ( n = 1), terminal ICA ( n = 2), anterior communicating artery (AComA; n = 4), A2-3 ( n = 1), M1-2 junction ( n = 1), posterior communicating artery (PComA; n = 1), superior cerebellar artery (SCA; n = 1), and basilar tip ( n = 2). The average aneurysm fundus size was 8.6 mm (range 7-10 mm) and average neck size 3.75 mm (range 1.9-6.9 mm). Immediate angiographic results were modified Raymond-Roy occlusion classification (mRRC) I n = 2, mRRC II n = 1, mRRC IIIa n = 2, mRRC IIIb n = 2, the remaining 7 aneurysms showed complete opacification. At follow-up angiography (mean 5 months) mRRC I n = 5, mRRC II n = 5, mRRC IIIa n = 3, and persistent filling was seen in 1 aneurysm. Overall, four patients had repeat treatment and one is pending further treatment. Of the aneurysms treated with more than one MED, 75% showed complete occlusion at 6-month follow up whereas only one aneurysm treated with a single device showed complete occlusion. Overall, three patients had temporary complications and there were no deaths. Conclusions The MED is an intra-saccular flow-diverting device with satisfactory angiographic results and an acceptable safety profile. Use of a single MED cannot be recommended and further longer term studies are needed prior to widespread clinical use.
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Affiliation(s)
- P Bhogal
- 1 Department of Neuroradiology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,2 Neuroradiology Clinic, 40666 Klinikum Stuttgart , Stuttgart, Germany
| | - P A Brouwer
- 1 Department of Neuroradiology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - L Yeo
- 1 Department of Neuroradiology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,3 Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - M Svensson
- 4 Department of Neurosurgery , 59562 Karolinska University Hospital and Karolinska Institutet, Stockholm , Sweden
| | - M Söderman
- 1 Department of Neuroradiology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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100
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Mattei A, Fish J, Hilgert M, Lövby T, Svensson M, Vaughan J, Zampa F. The 2015 ENFSI Fingerprint Working Group testing programme. Forensic Sci Int 2017; 280:55-63. [PMID: 28946033 DOI: 10.1016/j.forsciint.2017.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 08/31/2017] [Accepted: 09/04/2017] [Indexed: 10/18/2022]
Abstract
As early as 2004, the Fingerprint Working Group (EFP-WG) of the European Network of Forensic Science Institutes (ENFSI) has organised proficiency tests (PT's), as well as collaborative exercises (CE's), as a way of raising standards within the fingerprint profession. This article provides an overview of the three collaborative exercises carried out in 2015. The characteristics of the testing programme are summarised, followed by an overview of the knowledge that has been gained, including depicting what lessons have been learnt.
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Affiliation(s)
- A Mattei
- Reparto Carabinieri Investigazioni Scientifiche (R.I.S.), Messina, Italy
| | - J Fish
- National Crime Agency (NCA), London, United Kingdom
| | - M Hilgert
- Bunderskriminalamt (BKA), Wiesbaden, Germany
| | - T Lövby
- National Forensic Centre (NFC), Linkoping, Sweden
| | - M Svensson
- National Forensic Centre (NFC), Linkoping, Sweden
| | | | - F Zampa
- Reparto Carabinieri Investigazioni Scientifiche (R.I.S.), Parma, Italy.
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