Anders Nordlund

Increasing Stroke Incidence in Sweden Between 1989 and 2000 Among Persons Aged 30 to 65 Years: Evidence From the Swedish Hospital Discharge Register

Background and Purpose— Stroke mortality is decreasing in Sweden, as is the case in other Western European countries. However, both decreases and increases have been reported in Sweden for persons younger than age 65 years. The aim of this study was to compare the incidence of stroke in Sweden between the periods 1989 and 1991 and 1998 and 2000 in persons aged 30 to 65 years. Methods— All first-ever stroke patients aged 30 to 65 years in the Swedish Hospital Discharge Register between 1989 and 2000 were included. Results— The age-standardized, 3-year average incidence increased by 19%, from 98.9 to 118.0 per 100 000 among men, and by 33%, from 48.4 to 64.4 among women, between 1989 and 1991 and 1998 and 2000. The largest increase was seen among those younger than 60 years. On a county level, the change in age-standardized stroke incidence varied from small decreases (−3%) to large increases (82%). Conclusion— Stroke incidence increased in Sweden for both men and women between 1989 and 2000. The increase was larger among women. This calls for action when it comes to studying risk factors and planning for prevention and health promotion and indicates the need for gender-specific studies.

Pre-existing disease: the most important factor for health related quality of life long-term after critical illness: a prospective, longitudinal, multicentre trial

IntroductionThe aim of the present multicenter study was to assess long term (36 months) health related quality of life in patients after critical illness, compare ICU survivors health related quality of life to that of the general population and examine the impact of pre-existing disease and factors related to ICU care on health related quality of life.MethodsProspective, longitudinal, multicentre trial in three combined medical and surgical intensive care units of one university and two general hospitals in Sweden. By mailed questionnaires, health related quality of life was assessed at 6, 12, 24 and 36 months after the stay in ICU by EQ-5D and SF-36, and information of pre-existing disease was collected at the 6 months measure. ICU related factors were obtained from the local ICU database. Comorbidity and health related quality of life (EQ-5D; SF-36) was examined in the reference group. Among the 5306 patients admitted, 1663 were considered eligible (>24 hrs in the intensive care unit, and age ≥ 18 yrs, and alive 6 months after discharge). At the 6 month measure 980 (59%) patients answered the questionnaire. Of these 739 (75%) also answered at 12 month, 595 (61%) at 24 month, and 478 (47%) answered at the 36 month measure. As reference group, a random sample (n = 6093) of people from the uptake area of the hospitals were used in which concurrent disease was assessed and adjusted for.ResultsOnly small improvements were recorded in health related quality of life up to 36 months after ICU admission. The majority of the reduction in health related quality of life after care in the ICU was related to the health related quality of life effects of pre-existing diseases. No significant effect on the long-term health related quality of life by any of the ICU-related factors was discernible.ConclusionsA large proportion of the reduction in the health related quality of life after being in the ICU is attributable to pre-existing disease. The importance of the effect of pre-existing disease is further supported by the small, long term increment in the health related quality of life after treatment in the ICU. The reliability of the conclusions is supported by the size of the study populations and the long follow-up period.

Prevalence of sleep disturbances and long-term reduced health-related quality of life after critical care: a prospective multicenter cohort study

IntroductionThe aim of the present prospective multicenter cohort study was to examine the prevalence of sleep disturbance and its relation to the patients reported health-related quality of life after intensive care. We also assessed the possible underlying causes of sleep disturbance, including factors related to the critical illness.MethodsBetween August 2000 and November 2003 we included 1,625 consecutive patients older than 17 years of age admitted for more than 24 hours to combined medical and surgical intensive care units (ICUs) at three hospitals in Sweden. Conventional intensive care variables were prospectively recorded in the unit database. Six months and 12 months after discharge from hospital, sleep disturbances and the health-related quality of life were evaluated using the Basic Nordic Sleep Questionnaire and the Medical Outcomes Study 36-item Short-form Health Survey, respectively. As a nonvalidated single-item assessment, the quality of sleep prior to the ICU period was measured. As a reference group, a random sample (n = 10,000) of the main intake area of the hospitals was used.ResultsThe prevalence of self-reported quality of sleep did not change from the pre-ICU period to the post-ICU period. Intensive care patients reported significantly more sleep disturbances than the reference group (P < 0.01). At both 6 and 12 months, the main factor that affected sleep in the former hospitalised patients with an ICU stay was concurrent disease. No effects were related to the ICU period, such as the Acute Physiology and Chronic Health Evaluation score, the length of stay or the treatment diagnosis. There were minor correlations between the rate and extent of sleep disturbance and the health-related quality of life.ConclusionThere is little change in the long-term quality of sleep patterns among hospitalised patients with an ICU stay. This applies both to the comparison before and after critical care as well as between 6 and 12 months after the ICU stay. Furthermore, sleep disturbances for this group are common. Concurrent disease was found to be most important as an underlying cause, which emphasises that it is essential to include assessment of concurrent disease in sleep-related research in this group of patients.

Role of preexisting disease in patients' perceptions of health-related quality of life after intensive care.

Objectives:To find out how patients perceive their health-related quality of life after they have been treated in an intensive care unit and whether preexisting disease influenced their perception. Design:Follow-up, quantitative, dual-site study. Setting:Combined medical and surgical intensive care units of one university and one general hospital in Sweden. Patients:Among the 1,938 patients admitted, 562 were considered eligible (>24 hrs in the intensive care unit, and age >18 yrs). The effect of preexisting disease was assessed by use of a large reference group, a random sample (n = 10,000) of the main intake area of the hospitals. Interventions:None. Measurements and Main Results:During 2000–2002, data were collected from the intensive care unit register and from a questionnaire mailed to the patients 6 months after their discharge from hospital. Subjects in the reference group were sent postal questionnaires during 1999. Of the patients in the intensive care unit group, 74% had preexisting diseases compared with 51% in the reference group. Six months after discharge, health-related quality of life was significantly lower among patients than in the reference group. When comparisons were restricted to the previously healthy people in both groups, the observed differences were about halved, and when we compared the patients in the intensive care unit who had preexisting diseases with subjects in the reference group who had similar diseases, we found little difference in perceived health-related quality of life. In some dimensions of health-related quality of life, we found no differences between patients in the intensive care unit and the subjects in the reference population. Conclusions:Preexisting diseases significantly affect the extent of the decline of health-related quality of life after critical care, and this effect may have been underestimated in the past. As most patients who are admitted to an intensive care unit have at least one preexisting disease, it is important to account for these effects when examining outcome.

Early impairment in consciousness predicts mortality after hemispheric ischemic stroke.

ObjectiveEarly predictors of poor outcome after acute ischemic stroke may be useful in selecting patients for potentially beneficial but high-risk interventions. DesignCohort study of patients given placebo in a randomized clinical trial. SettingMulticenter trial at 139 U.S. and 14 Canadian hospitals. PatientsA cohort of 564 placebo-treated patients with major anterior circulation ischemic stroke enrolled in the Clomethiazole in Acute Stroke Study-Ischemic Stroke (CLASS-I) trial. Patients did not have significant impairment in consciousness at baseline and were enrolled within 12 hrs of symptom onset. InterventionsProspective data collection of a number of clinical variables including use of a 6-point level of consciousness scale (1 = awake, 6 = no reaction to pain) to measure patients’ level of consciousness at enrollment and 12 additional times during the first 24 hrs after enrollment. The ability of level of consciousness score and additional clinical data to predict 30-day mortality was assessed. Measurements and Main ResultsAt 1 month, 114 of 564 patients (20%) had died. In univariate analysis, factors significantly associated with mortality included older age, white race, higher National Institutes of Health Stroke Scale score, higher serum glucose, atrial fibrillation, and any impairment in level of consciousness (p < .05). After controlling for these factors, increasing level of consciousness score at 3 hrs after enrollment and at all but one subsequent time point was significantly associated with increased mortality (odds ratio, 1.8 per point; 95% confidence interval, 1.2–2.6; p = .003 at 3-hr time point). Maximum level of consciousness score during the initial 24 hrs of monitoring also predicted mortality (odds ratio, 1.9 per point; 95% confidence interval, 1.4–2.5; p < .001). ConclusionThe development of a decreased level of consciousness within the initial hours after stroke onset, as evaluated by a simple six-point scale, is a powerful independent predictor of mortality after major anterior circulation ischemic stroke.

EQ-5D in a general population survey--a description of the most commonly reported EQ-5D health states using the SF-36.

The importance of studying health-related quality of life in the general population has increasingly been emphasized. From a public health perspective, this benefits the identification of population inequalities in health status. One of the currently most popular instruments is the EQ-5D. Evaluations of the EQ-5D generally focus on the overall preference-based index. As this index has a built-in value, exploration of the information from the underlying health states is also important. In this study, the ten most commonly reported EQ-5D health states are described using the SF-36. Data collected in 1999 by questionnaires mailed to a random sample aged 20–74 in south-eastern Sweden were used (n = 9489). Almost 43% reported the best possible EQ-5D health state and 78% were accounted for by three EQ-5D health states. The EQ-5D health state classification was largely reflected by the SF-36, with the EQ-5D items mobility, usual activities, pain/discomfort and anxiety/depression tapping most clearly on the SF-36 scales physical functioning, role limitations due to physical health problems, bodily pain, and mental health, respectively. However, within the same level of EQ-5D (i.e., moderate problems) there was a rather large variation of SF-36 scale scores, particularly regarding the EQ-5D item pain/discomfort and the SF-36 scale BP.

Self reported musculoskeletal symptoms in the neck/shoulders and/or arms and general health (SF-36): eight year follow up of a case-control study

Aims: To explore and compare the prevalence after eight years of self reported musculoskeletal symptoms and general health (SF-36) for groups with initially different degrees of severity of symptoms in the neck/shoulders and/or arms. Methods: A case-control study was performed in 1989 comprising 129 clinically examined cases and 655 survey controls. The study population was followed up in 1997 with a postal survey. The controls, none of which were clinically examined at baseline (1989), were divided into groups according to degree of severity of self reported symptoms in the neck/shoulders and/or arms at baseline: no symptoms, light symptoms, and severe symptoms. Cases were clinically diagnosed with a musculoskeletal disorder of the neck/shoulders and/or arms at baseline. Results: At the 1997 follow up, there was a trend of increasing prevalence of musculoskeletal symptoms, as well as decreasing health status as rated in the SF-36 over the three severity groups among controls. Only small differences were seen between the cases and the controls reporting severe musculoskeletal symptoms or the neck/shoulders and/or arms. Conclusion: The degree of questionnaire based self reported musculoskeletal symptoms of the neck/shoulders and/or arms clearly indicate different degrees of future health problems (both in terms of self reported musculoskeletal problems and health in general as captured by the SF-36). Therefore, there is a need for improved intervention and health promotion strategies. Such effort should be implemented before musculoskeletal symptoms have developed to clinical cases, particularly in the realm of the workplace.

Psychometric evaluation and further validation of the Hagedoorn et al. modified EVLN measure

The aim of the present study was to evaluate and further validate a modified Exit, Voice, Loyalty and Neglect (EVLN) instrument (Hagedoorn, Van Yperen, Van de Vliert & Buunk, 1999), in a Swedish sample (n= 792). To test the underlying scaling assumptions, the convergent and divergent validity, a multitrait/multi-item analysis was conducted and factor analyses were used to evaluate the factor structure. The concurrent validity was tested by using the modified EVLN instrument as predictor and three different forms of justice as criteria in the analysis. The criterion-related validity was tested and an association between exit behavioral response and actual exit behavior was found (predictive validity). The results showed that the instrument may be considered to be a valid measure with the exception of the aggressive voice scale.

Physical effects of trauma and the psychological consequences of preexisting diseases account for a significant portion of the health-related quality of life patterns of former trauma patients.

Background: Health-related quality of life (HRQoL) is known to be significantly affected in former trauma patients. However, the underlying factors that lead to this outcome are largely unknown. In former intensive care unit (ICU) patients, it has been recognized that preexisting disease is the most important factor for the long-term HRQoL. The aim of this study was to investigate HRQoL up to 2 years after trauma and to examine the contribution of the trauma-specific, ICU-related, sociodemographic factors together with the effects of preexisting disease, and further to make a comparison with a large general population. Methods: A prospective 2-year multicenter study in Sweden of 108 injured patients. By mailed questionnaires, HRQoL was assessed at 6 months, 12 months, and 24 months after the stay in ICU by Short Form (SF)-36, and information of preexisting disease was collected from the national hospital database. ICU-related factors were obtained from the local ICU database. Comorbidity and HRQoL (SF-36) was also examined in the reference group, a random sample of 10,000 inhabitants in the uptake area of the hospitals. Results: For the trauma patients, there was a marked and early decrease in the physical dimensions of the SF-36 (role limitations due to physical problems and bodily pain). This decrease improved rapidly and was almost normalized after 24 months. In parallel, there were extensive decreases in the psychologic dimensions (vitality, social functioning, role limitations due to emotional problems, and mental health) of the SF-36 when comparisons were made with the general reference population. Conclusions: The new and important finding in this study is that the trauma population seems to have a trauma-specific HRQoL outcome pattern. First, there is a large and significant decrease in the physical dimensions of the SF-36, which is due to musculoskeletal effects and pain secondary to the trauma. This normalizes within 2 years, whereas the overall decrease in HRQoL remains and most importantly it is seen mainly in the psychologic dimensions and it is due to preexisting diseases.

Health, quality of life, social network and use of health care: A comparison between those granted and those not granted disability pensions

Purpose. The aim was to compare self-rated health, health-related quality of life (HRQoL), social networks and health care utilisation of those granted disability pension (DP) and those not granted disability pension (nDP). Method. Demographic data and medical diagnoses were obtained from the records of the social insurance office. Data concerning self-reported health, HRQoL social networks, and use of health care were collected by a postal questionnaire. The nDP group included all those not granted full DPs between 1999 and 2000 (n = 99). The DP group were a random sample of those granted full DPs, during the same period (n = 197). Results. The nDP group had more often multiple diagnoses, and lower self-reported health and HRQoL compared to those granted DP. In particular, their average scores were lower on the SF-36 scales social functioning, role limitations due to physical problems and mental health. The nDP group also had significantly smaller social networks. Conclusions. Contrary to expectations, those not granted a disability pension do not seem to have better health, but rather to suffer from more sickness than those who were granted a disability pension.