Does problem-based learning improve patient empowerment and cardiac risk factors in patients with coronary heart disease in a Swedish primary care setting? A long-term prospective, randomised, parallel single randomised trial (COR-PRIM).

OBJECTIVES: To investigate long-term effects of a 1-year problem-based learning (PBL) on self-management and cardiac risk factors in patients with coronary heart disease (CHD). DESIGN: A prospective, randomised, parallel single centre trial. SETTINGS: Primary care settings in Sweden. PARTICIPANTS: 157 patients with stable CHD completed the study. Subjects with reading and writing impairments, mental illness or expected survival less than 1 year were excluded. INTERVENTION: Participants were randomised and assigned to receive either PBL (intervention) or home-sent patient information (control group). In this study, participants were followed up at baseline, 1, 3 and 5 years. PRIMARY AND SECONDARY OUTCOMES: Primary outcome was patient empowerment (Swedish Coronary Empowerment Scale, SWE-CES) and secondary outcomes General Self-Efficacy Scale (GSES), self-rated health status (EQ-VAS), high-density lipoprotein cholesterol (HDL-C), body mass index (BMI), weight and smoking. Outcomes were adjusted for sociodemographic factors. RESULTS: The PBL intervention group resulted in a significant improved change in SWE-CES over the 5-year period (mean (M), 39.39; 95% CI 37.88 to 40.89) compared with the baseline (M 36.54; 95% CI 35.40 to 37.66). PBL intervention group increased HDL-C level (M 1.39; 95% CI 1.28 to 1.50) compared with baseline (M 1.24; 95% CI 1.15 to 1.33) and for EQ-VAS (M 77.33; 95% CI 73.21 to 81.45) compared with baseline (M 68.13; 95% CI 63.66 to 72.59) while these outcomes remained unchanged in the control group. There were no significant differences in BMI, weight or scores on GSES, neither between nor within groups over time. The overall proportion of smokers was significantly higher in the control group than in the experimental group. CONCLUSION: One-year PBL intervention had positive effect on patient empowerment, health status and HDL-C at a 5-year follow-up compared with the control group. PBL education aiming to improve patient empowerment in cardiac rehabilitation should account for sociodemographic factors. TRIAL REGISTRATION NUMBER: NCT01462799.

Maternal characteristics and pregnancy outcomes in the NICE birth cohort: an assessment of self-selection bias.

BACKGROUND: Prospective birth cohorts are essential for identifying associations between exposures and outcomes. However, voluntary participation introduces a potential bias due to self selection since the persons that chose to participate may differ in background characteristics and behaviors. OBJECTIVES: To investigate potential bias due to self-selection in the Nutritional impact on Immunological maturation during Childhood in relation to the Environment (NICE) birth cohort in northern Sweden. METHODS: Women in the NICE birth cohort (N = 621) were compared to nonparticipating pregnant women in Norrbotten County in northern Sweden who were eligible for participation (N = 4976) regarding maternal characteristics and lifestyle. Maternal characteristics and pregnancy outcomes were compared between the groups and associations between exposures (smoking, folic acid, BMI, parity, education) and pregnancy outcomes (birth weight and gestational age) were analyzed by linear regression analyses, examining any interaction with the group. RESULTS: NICE participants were more highly educated, older and more likely to cohabit than the non-participants. They more often took folic acid and multivitamin supplements and less often smoked during early pregnancy. Pregnancy outcomes (mode of delivery, gestational age at delivery, birth weight and APGAR score) did, however, not differ significantly between participants and non-participants. Smoking, BMI, education and parity affected gestational age and birth weight, but the associations were of similar magnitude in participants and non-participants, with no significant effect on the group. CONCLUSION: Self-selection to the NICE study was evident in some factors related to lifestyle and socioeconomic characteristics but did not appear to skew pregnancy outcomes or alter well-known effects of certain lifestyle parameters on pregnancy outcomes.

Characteristics of patients with acute myocardial infarction contacting primary healthcare before hospitalisation: a cross-sectional study.

BACKGROUND: The characteristics of patients with on-going myocardial infarction (MI) contacting the primary healthcare (PHC) centre before hospitalisation are not well known. Prompt diagnosis is crucial in patients with MI, but many patients delay seeking medical care. The aims of this study was to 1) describe background characteristics, symptoms, actions and delay times in patients contacting the PHC before hospitalisation when falling ill with an acute MI, 2) compare those patients with acute MI patients not contacting the PHC, and 3) explore factors associated with a PHC contact in acute MI patients. METHODS: This was a cross-sectional multicentre study, enrolling consecutive patients with MI within 24 hours of admission to hospital from Nov 2012 until Feb 2014. RESULTS: A total of 688 patients with MI, 519 men and 169 women, were included; the mean age was 66±11 years. One in five people contacted PHC instead of the recommended emergency medical services (EMS), and 94% of these patients experienced cardinal symptoms of an acute MI; i.e., chest pain, and/or radiating pain in the arms, and/or cold sweat. Median delay time from symptom-onset-to-decision-to-seek-care was 2:15 hours in PHC patients and 0:40 hours in non-PHC patients (p<0.01). The probability of utilising the PHC before hospitalisation was associated with fluctuating symptoms (OR 1.74), pain intensity (OR 0.90) symptoms during off-hours (OR 0.42), study hospital (OR 3.49 and 2.52, respectively, for two of the county hospitals) and a final STEMI diagnosis (OR 0.58). CONCLUSIONS: Ambulance services are still underutilized in acute MI patients. A substantial part of the patients contacts their primary healthcare centre before they are diagnosed with MI, although experiencing cardinal symptoms such as chest pain. There is need for better knowledge in the population about symptoms of MI and adequate pathways to qualified care. Knowledge and awareness amongst primary healthcare professionals on the occurrence of MI patients is imperative.

Neurofilament light chain protein as a marker of neuronal injury: review of its use in HIV-1 infection and reference values for HIV-negative controls.

INTRODUCTION: Several CSF biomarkers of neuronal injury have been studied in people living with HIV. At this time, the most useful is the light subunit of the neurofilament protein (NFL). This major structural component of myelinated axons is essential to maintain axonal caliber and to facilitate effective nerve conduction. CSF concentrations of NFL provide a sensitive marker of CNS injury in a number of neurological diseases, including HIV-related neuronal injury. Areas Covered: In this review, the authors describe CSF NFL concentrations across the spectrum of HIV-infection, from its early acute phase to severe immunosuppression, with and without neurological conditions, and with and without antiretroviral treatment (n = 516). Furthermore, in order to provide more precise estimates of age-related upper limits of CSF NFL concentrations, the authors present data from a large number (n = 359) of HIV-negative controls. Expert Commentary: Recently a new ultrasensitive diagnostic assay for quantification of NFL in plasma has been developed, providing a convenient way to assess neuronal damage without having to perform a lumbar puncture. This review also considers our current knowledge of plasma NFL in HIV CNS infection.

Clinical decision support for stroke prevention in atrial fibrillation (CDS-AF): Rationale and design of a cluster randomized trial in the primary care setting.

BACKGROUND: Atrial fibrillation (AF) is associated with substantial morbidity, in particular stroke. Despite good evidence for the reduction of stroke risk with anticoagulant therapy, there remains a significant undertreatment. The main aim of the current study is to investigate whether a clinical decision support tool for stroke prevention (CDS) integrated in the electronic health record can improve adherence to guidelines for stroke prevention in patients with AF. METHODS: We will conduct a cluster randomized trial where 43 primary care clinics in the county of Östergötland, Sweden (population 444,347), will be randomized to be part of the CDS intervention or serve as controls. The CDS will alert responsible physicians of patients with AF and increased risk for thromboembolism according to the CHA2DS2VASc (Congestive heart failure, Hypertension, Age ≥ 74 years, Diabetes mellitus, previous Stroke/TIA/thromboembolism, Vascular disease, Age 65-74 years, Sex category (i.e. female sex)) algorithm without anticoagulant therapy. The primary end point will be adherence to guidelines after 1 year. CONCLUSION: The present study will investigate whether a clinical decision support system integrated in an electronic health record can increase adherence to guidelines regarding anticoagulant therapy in patients with AF.

Cost consequences of point-of-care troponin T testing in a Swedish primary health care setting.

OBJECTIVE: To evaluate the safety and cost-effectiveness of point-of-care troponin T testing (POCT-TnT) for the management of patients with chest pain in primary care. DESIGN: Prospective observational study with follow-up. SETTING: Three primary health care (PHC) centres using POCT-TnT and four PHC centres not using POCT-TnT in south-east Sweden. PATIENTS: All patients ≥ 35 years of age, contacting one of the PHC centres for chest pain, dyspnoea on exertion, unexplained weakness and/or fatigue, with no other probable cause than cardiac, were included. Symptoms must have commenced or worsened during the previous seven days. MAIN OUTCOME MEASURES: Emergency referral rates, diagnoses of acute myocardial infarction (AMI) or unstable angina (UA), and costs were collected for 30 days after the patient sought care at the PHC centre. RESULTS: A total of 196 patients with chest pain were included: 128 in PHC centres with POCT-TnT and 68 in PHC centres without POCT-TnT. Fewer patients from the PHC centres with POCT-TnT (n = 32, 25%) were emergently referred to hospital than from centres without POCT-TnT (n = 29, 43%; p = 0.011). Eight patients (6.2%) from PHC centres with POCT-TnT were diagnosed with AMI or UA compared with six patients (8.8%) from centres without POCT-TnT (p = 0.565). Two patients with AMI or UA were classified as missed cases from PHC centres with POCT-TnT and there were no missed cases from PHC centres without POCT-TnT. SKr290 000 was saved per missed case of AMI or UA. CONCLUSION: The use of POCT-TnT in primary care may be cost saving but at the expense of missed cases.

Health-related quality of life and restless legs syndrome among women in Sweden.

AIM: Restless legs syndrome (RLS) is a common neurological movement disorder with a female preponderance, an increasing prevalence with age and comorbidity. Previous studies on the relationship between health-related quality of life (HRQOL) and RLS are still sparse but knowledge is increasing. The aim of this study was to evaluate the unique impact of RLS on HRQOL in a population-based sample. METHODS: A random sample of 5000 women aged 25-64 years was selected from the general Swedish population. The women were sent diagnostic questions on RLS together with the Short Form 12 (SF-12) questionnaire for assessment of physical and mental HRQOL. The unique burden of RLS on HRQOL was analyzed by excluding RLS-positive women from four self-reported diagnostic groups (diabetes, depression, heart problems, muscle and joint pain) and by excluding subjects with these diagnoses from the group of RLS-positive women. RESULTS: Compared with mental SF-12 scores for the RLS-negative women in our population, mental HRQOL of the RLS sample in our study was lower in every age group but not significantly lower in the age group 35-44 years. Physical SF-12 scores for RLS-positive women were also below scores for RLS-negative women in every age group but significance was only found in women between 45 and 54 years. A unique burden of RLS on HRQOL remained after statistical adjustment for comorbidities. CONCLUSION: RLS-positive women had an impaired mental HRQOL compared to RLS-negative women in the studied population. The physical aspects of HRQOL were less affected among RLS-positive women. The impaired well-being among women with RLS further strengthens the importance of identifying women with this condition and evaluating their need for medication or other actions in order to improve their quality of life.

Validity and reliability of the muscle function scale, aimed to assess the lateral flexors of the neck in infants.

Infants with congenital muscular torticollis (CMT) often have an imbalance in muscle function in the lateral flexors of the neck, and the need for a valid and reliable assessment tool to determine muscle function in these muscles is essential. The lateral uprighting response is used to examine and to strengthen the sternocleidomastoid muscle. A Muscle Function Scale (MFS) has been refined and used for several years in a clinic for infants with CMT. The MFS describes an infant's muscle function in the lateral flexors of the neck through ordered categorical scores. The aim of this study was to find out if the muscle function scale (MFS) is valid and reliable. A panel of experts examined validity, and the kappa statistic and intraclass correlation coefficient were calculated for interrater and intrarater reliability. The MFS is found to be a valid tool to measure the muscle function of the lateral flexors of the neck in infants with CMT. The interrater and intrarater reliability is high for both novice and experienced physiotherapists (kappa>0.9; ICC>0.9).

The accuracy of general practitioners' clinical assessment of chest pain patients.

OBJECTIVE: To study general practitioners' (GP) assessment of the probability of ischaemic heart disease (IHD) and GP action in daily practice regarding chest pain patients. METHODS: All chest pain patients aged 20-79 years, attending three primary health-care centres in south-east Sweden and assessed by the GP to have high, low or very low probability of IHD, were included consecutively over a two year period. The "GP action in daily practice" was classed as "active decisions" (investigation or treatment) or "wait and see". "IHD" or "not IHD" was settled according to the results of acute hospital investigation or exercise testing/myocardial perfusion scintigraphy. RESULTS: 516 patients were included, 93 high, 145 low and 278 very low probability cases. The outcome was "IHD" in 47%, 9% and 1% respectively. The sensitivity and specificity of the "GP assessment of the probability of IHD" were 72% and 89%. The sensitivity and specificity of the "GP action in daily practice" were 88% and 72%, respectively. The negative predictive value was 98%. CONCLUSION: GP assessment, after clinical evaluation, that the probability of IHD was low did not safely rule out IHD. GP action in daily practice however, indicates that general practice is an appropriate level of care for chest pain patients.