“Direct-to-consumer (DTC) telemedicine” is increasing worldwide and changing the map of primary health care (PHC). Virtual care has increased in the last decade and with the ongoing COVID-19 ...pandemic, patients’ use of online care has increased even further. In Sweden, online consultations are a part of government-supported health care today, and there are several digital care providers on the Swedish market, which makes it possible to get in touch with a doctor within a few minutes. The fast expansion of this market has raised questions about the quality of primary care provided only in an online setting without any physical appointments. Antibiotic prescribing is a common treatment in PHC. This study aimed to compare antibiotic prescribing between digital PHC providers (internet-PHC) and traditional physical PHC providers (physical-PHC) and to determine whether prescriptions for specific diagnoses differed between internet-PHC and physical-PHC appointments, adjusted for the effects of attained age at the time of appointment, gender, and time relative to the COVID-19 pandemic. Antibiotic prescribing data based on Anatomical Therapeutic Chemical (ATC) codes were obtained for Region Sörmland residents from January 2020 until March 2021 from the Regional Administrative Office. In total, 160,238 appointments for 68,332 Sörmland residents were included (124,398 physical-PHC and 35,840 internet-PHC appointments). Prescriptions issued by internet-PHC or physical-PHC physicians were considered. Information on the appointment date, staff category serving the patient, ICD-10 (International Statistical Classification of Diseases, Tenth Revision) diagnosis codes, ATC codes of prescribed medicines, and patient-attained age and gender were used. A total of 160,238 health care appointments were registered, of which 18,433 led to an infection diagnosis. There were large differences in gender and attained age distributions among physical-PHC and internet-PHC appointments. Physical-PHC appointments peaked among patients aged 60-80 years while internet-PHC appointments peaked at 20-30 years of age for both genders. Antibiotics with the ATC codes J01A-J01X were prescribed in 9.3% (11,609/124,398) of physical-PHC appointments as compared with 6.1% (2201/35,840) of internet-PHC appointments. In addition, 61.3% (6412/10,454) of physical-PHC infection appointments resulted in antibiotic prescriptions, as compared with only 25.8% (2057/7979) of internet-PHC appointments. Analyses of the prescribed antibiotics showed that internet-PHC followed regional recommendations for all diagnoses. Physical-PHC also followed the recommendations but used a wider spectrum of antibiotics. The odds ratio of receiving an antibiotic prescription (after adjustments for attained age at the time of appointment, patient gender, and whether the prescription was issued before or during the COVID-19 pandemic) during an internet-PHC appointment was 0.23-0.39 as compared with a physical-PHC appointment. Internet-PHC appointments resulted in a significantly lower number of antibiotics prescriptions than physical-PHC appointments, adjusted for the large differences in the characteristics of patients who consult internet-PHC and physical-PHC. Internet-PHC prescribers showed appropriate prescribing according to guidelines.
Abstract
Objective
To study cumulative incidence and predictors of myocardial infarction (MI) in two random general population samples consisting of middle-aged Swedish men born 30 years apart.
...Method
Results from the “
Study of Men Born In 1913”
and the
“Study of Men Born In 1943”
, two longitudinal cohort studies performed in the same geographic area and using the same methodology were compared. Both cohorts were followed prospectively from 50 to 70 years of age. MI was defined as first myocardial infarction, fatal or non-fatal.
Results
Men born in 1943 had a 34% lower cumulative risk of first MI HR 0.66 (0.50–0.88),
p
= 0.0051 during follow-up as compared to men born in 1913. Interaction analysis showed that hypertension had a significantly higher impact on risk of MI in cohort 1943 than in cohort 1913 HR 2.33 (95% CI 1.41–3.83) and HR 1.10 (0.74–1.62),
p
= 0.0009 respectively. The population attributable risk for hypertension was 2.5-fold higher in the cohort of men born in 1943 as compared to men born in 1913, and diabetes mellitus and sedentary lifestyle attributed more to MI risk in cohort 1943 than in cohort 1913. On the contrary, smoking and total cholesterol have less attributable risk to MI in cohort 1943 than in cohort 1913.
Conclusion
Despite declining incident MI and improved cardiovascular prevention in general, hypertension remains an increasingly important attributable risk factor to MI together with diabetes mellitus and sedentary lifestyle over time.
Objective:
To analyse treatment effects of eccentric vs. concentric graded exercise in chronic tennis elbow.
Design:
Randomized controlled trial.
Setting:
Primary care in Uppsala County, Sweden.
...Subjects:
A total of 120 subjects with tennis elbow lasting more than three months were recruited from primary care and by advertisement.
Intervention:
Eccentric (n = 60) or concentric exercise (n = 60), by lowering or lifting a weight, at home daily, for three months with gradually increasing load.
Main measures:
Pain during muscle contraction and muscle elongation, as well as strength, was assessed at baseline and after one, two, three, six, and 12 months. Function and quality of life was assessed at baseline and after three, six and 12 months.
Results:
The eccentric exercise group had faster regression of pain, with an average of 10% higher responder rate at all levels of pain reduction, both during muscle contraction and elongation, (p < 0.0001 and p = 0.006, respectively). Significant differences were found in Cox’s analysis from two months onwards (HR 0.78, 95% confidence interval (CI) 0.63–0.96, p < 0.02). This represents an absolute pain reduction of 10% in the eccentric vs. the concentric group and a number-needed-to-treat of 10. The eccentric group also had a greater increase of muscle strength than the concentric (p < 0.02). The differences persisted throughout the follow-up period. There were no significant differences between the groups regarding function or quality of life measures.
Conclusion:
Eccentric graded exercise reduced pain and increased muscle strength in chronic tennis elbow more effectively than concentric graded exercise.
Background. The purpose of this study was to analyse whether the parallel life situation between stroke patients and their informal caregivers (dyads) shown in cross-sectional studies prevails also ...in a longitudinal perspective.
Methods. A total of 377 Swedish stroke patients, aged ≥65 years, and their 268 informal caregivers were followed from hospital admission and one year on. Analyses were based on patient interviews, functional ability (MMSE) score, Nottingham Health Profile (NHP) score, Hospital Anxiety and Depression (HAD) score, self-rated health score, and the Gothenburg Quality of Life (GQL) activity score. Similar information was obtained by postal questionnaires from informal caregivers, also including information on the nature and amount of assistance provided and on Caregiver Burden (CB) score.
Results. Before index admission informal caregivers provided care on average 5 h per week and after discharge 11 h per week (P < 0.0001). Support volume was associated with patient sex (more for men), low patient's functional ability, low received municipal social service support, closeness of patient-caregiver relation, and short distance to patient's home. Significant positive associations within the dyads were found for HAD anxiety score (P < 0.0001), total NHP score (P < 0.0001), and GQL activity score (P < 0.0001) after adjustment for patient's age, sex, functional ability, and patient-caregiver relationship. CB score increased with amount of informal caregiver support, patient's age, and with low functional ability and low amount of municipal social service support. All these associations were constant across time.
Conclusions. There was an association within the dyads regarding anxiety score, NHP score, and activity score. CB score was generally high.
Neuropeptide Y is associated with stress in animal and human laboratory studies. However, data from clinical studies are scarce and no clinical longitudinal studies have been published. The aim of ...this clinical study was to assess the possible association between changes in the levels of pain, depression, and stress measures, on the one hand, and plasma neuropeptide Y levels, on the other.
Forty-four women with the fibromyalgia syndrome were exposed to a Cognitive Behavioral Therapy intervention. Levels of the plasma neuropeptide Y as well as pain, depression, and stress measures were obtained at the start and at the end of the intervention, and after a further six month follow-up. Based on these data, a before-and-after analysis was performed.
Almost all measures of pain, depression, and stress improved during the study; specifically, variables measuring life control (coping), depression, and stress-related time urgency improved significantly. Moreover, during the same time period, the mean plasma neuropeptide Y level was reduced from 93.2 ± 38.8 fmol/mL before the Cognitive Behavioral Therapy to 75.6 ± 42.9 fmol/mL (p<0.001) at the end of the study.
After exposure to a Cognitive Behavioral Therapy intervention, levels of most of the pain, depression, and stress measures improved, half of them significantly, as did the levels of neuropeptide Y. This circumstance indicates a possible functional relationship between pain-depression-stress and neuropeptide Y.
There is consensus on the importance of early detection and treatment of high blood pressure. Dental care is one of few medical services to which a considerable proportion of the general population ...comes for regular check-ups. We tested the effects of blood pressure screening in dental care centres with subsequent work-up of subjects screening positive in primary health care (PHCC).
Altogether 1,149 subjects 40-65 years old or 20-39 years old with body mass index >25, and with no previously known hypertension, who came for a dental examination had their blood pressure measured with an Omron M4® automatic blood pressure reading device. Subjects with systolic blood pressure readings above 160 mmHg or diastolic above 90 mmHg were referred to their PHCC for a check up. Outcome data were obtained by scrutiny of PHCC and hospital patient records for hypertension diagnoses during the three years following screening.
237 (20.6%) subjects screened positive. Of these, 230 (97.1%) came to their PHCC within the 3-year follow-up period, as compared with 695 (76.2%) of those who screened negative (p < 0.0001). Of those who screened positive, 76 (32.1%) received a diagnosis of hypertension, as compared with 26 (2.9%) of those who screened negative. Sensitivity was 79.1%, specificity 84.8% and positive predictive value 30.1%. The number of subjects needed to screen to find one case of hypertension was 18.
Co-operation between dental and primary care for blood pressure screening and work-up appears to be an effective way of detecting previously unknown hypertension.
Abstract
Background. Chronic tennis elbow (lateral epicondylosis) is a common disorder. Like other chronic soft-tissue pain conditions it is often difficult to treat successfully. The effects of ...exercise have been discussed, but no convincing evidence has been put forward so far, and a simple protocol for exercise is lacking.
Aims of the study. This study is a randomized, controlled, clinical trial of the effect of exercise versus expectation (wait-list) on pain, muscle strength, function, and quality of life in patients with long-standing lateral epicondylosis.
Methods. Eighty-one subjects with tennis elbow lasting for more than 3 months were randomly allocated to an exercise group (n = 40) or a reference group (n = 41). The exercise group performed daily exercise, with weekly load increase, for 3 months. The reference group was wait-listed, but otherwise followed in the same way. Outcome measures were pain during maximum voluntary muscle contraction (Cozen's test) and pain during maximum muscle elongation with a load (modified Empty-can-test); muscle strength was measured with a Chatillon MSE 100 hand-held dynamometer, and the Disability of the Arm, Shoulder and Hand (DASH) and the Gothenburg Quality of Life questionnaires.
Results. The exercise group had greater and faster regression of pain, both during muscle contraction and muscle elongation, than the reference group (p = 0.0005 and p = 0.0016, respectively). There was a non-significant muscle strength difference between the groups, but no differences regarding DASH scores or quality of life measures.
Conclusions. Exercise appears to be superior to expectation in reducing pain in chronic lateral epicondylosis.
•A 20 % reduction in mortality risk is find while using warfarin for non-malignant diagnoses.•The number needed to treat to prevent one death was four if warfarin was used in near proximity to the ...colorectal cancer diagnosis.•Considering warfarin use at any time, approximately ten patients must be treated.•Among the case subjects, approximately 10 % seem to have been protected by warfarin use during the study period.
Several studies have analyzed the effect of anticoagulants on cancer survival, with varying results. This study aimed to assess the effect of warfarin on survival in patients with colorectal cancer (CRC) in relation to timing of warfarin initiation.
Data on 10,051 individuals aged ≥45 years in the Västra Götaland Region of Sweden, and diagnosed with CRC between 2000 and 2009, were obtained from the Swedish National Cancer Register. Those who received warfarin treatment (n= 1,216) during the study period were labeled cases and those who did not (n= 8,873) were labeled controls. For statistical analysis, National Cancer Register data were merged with mortality data from the Swedish National Cause of Death register and data from the regional warfarin treatment register.
Hazard rates for CRC-specific mortality were lower in cases than in controls. When warfarin was used for any reason at any time, cases had a significantly lower CRC-specific mortality than controls among both women (hazard ratio HR 0.71; 95 % confidence interval CI 0.59–0.85; p= 0.0002) and men (HR 0.61; 95 % CI 0.52–0.72; p < 0001). Warfarin treatment after CRC diagnosis reduced CRC-specific mortality by 80 %; however, when warfarin was given before or ≥5 years after diagnosis, CRC-specific mortality did not significantly decrease. The number needed to treat to avoid one death was four.
Use of warfarin early after diagnosis in patients with CRC was associated with improved survival.
Low aerobic capacity has been associated with increased mortality in short-term studies. The aim of this study was to evaluate the predictive power of aerobic capacity for mortality in middle-aged ...men during 45-years of follow-up.
The study design was a population-based prospective cohort study.
A representative sample from Gothenburg of men born in 1913 was followed from 50-99 years of age, with periodic medical examinations and data from the National Hospital Discharge and Cause of Death registers. At 54 years of age, 792 men performed an ergometer exercise test, with 656 (83%) performing the maximum exercise test.
In Cox regression analysis, low predicted peak oxygen uptake (Formula: see text), smoking, high serum cholesterol and high mean arterial blood pressure at rest were significantly associated with mortality. In multivariable analysis, an association was found between predicted Formula: see text tertiles and mortality, independent of established risk factors. Hazard ratios were 0.79 (95% confidence interval (CI) 0.71-0.89; p < 0.0001) for predicted Formula: see text, 1.01 (1.002-1.02; p < 0.01) for mean arterial blood pressure, 1.13 (1.04-1.22; p < 0.005) for cholesterol, and 1.58 (1.34-1.85; p < 0.0001) for smoking. The variable impact (Wald's χ(2)) of predicted Formula: see text tertiles (15.3) on mortality was secondary only to smoking (31.4). The risk associated with low predicted Formula: see text was evident throughout four decades of follow-up.
In this representative population sample of middle-aged men, low aerobic capacity was associated with increased mortality rates, independent of traditional risk factors, including smoking, blood pressure and serum cholesterol, during more than 40 years of follow-up.
Chronic obstructive pulmonary disease (COPD) develops in small airways. Severity of small airway pathology relates to progression and mortality. The present study evaluated the prediction of COPD of ...a validated test for small airway disease, i.e. a slope of the alveolar plateau of the single breath nitrogen test (N
2
-slope). The N
2
-slope, spirometry, age, smoking habits, and anthropometric variables at baseline were obtained in a population-based sample (n = 592). The cohort was followed for first COPD events (first hospital admission of COPD or related conditions or death from COPD) during 38 years. During follow-up, 52 subjects (8.8%) had a first COPD event, of which 18 (3.0%) died with a first COPD diagnosis. In the proportional hazard regression analysis adjusted for age and smoking habits, the cumulative COPD event incidence increased from 5% among those with high forced expired volume in one second (FEV
1
) to 25% among those with low FEV
1
, while increasing from 4% among those with the lowest N
2
-slope to 26% among those with the highest. However, combining the N
2
-slope and FEV
1
resulted in considerable synergy in the prediction of first COPD event and even more so when taking account of smoking habits. The cumulative COPD event incidence rate was 75% among heavy smokers with the highest N
2
-slope and lowest FEV
1
, and less than 1% among never smokers with the lowest N
2
-slope and highest FEV
1
. Thus, combining the results of the single breath N
2
-slope and FEV
1
considerably improved the prediction of COPD events as compared to either test alone.
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