Swedish asthma guidelines recommend treating asthma with the lowest effective dose possible. These recommendations are both hard to follow and seldom considered enough in asthma care today. As an example, combination therapy with inhaled corticosteroids (ICS) and long acting beta agonists (LABA) should only be considered if asthma control is not achieved with low to medium dose ICS daily. However, the Swedish National Board of Health and Welfare estimates that 120 000 asthma patients are overmedicated with combination therapy. Guidelines are clear in instructions of when and how to step up asthma treatment, while instructions for stepping down are not that obvious. In this article, we present an asthma treatment algorithm for step 1-3 in adults for use in clinical practice (Fig. 1), where stepping down asthma treatment is considered as an alternative. Included are also instructions of how to step down asthma treatment (Fig. 2). We conclude that stepping down is possible to do in a safe way in certain patient groups while maintaining asthma control. If possible risks are taken into consideration, stepping down asthma treatment can be done in every clinical setting.
Skador vid operation för karpaltunnelsyndrom är ovanliga men inte sällan allvarligt invalidiserande.
Operationen måste göras på rätt indikation och med rätt och varsam teknik.
[Low dosage CT better than conventional radiography in the diagnosis of rhinosinusitis--a comment from the Medical Products Agency and Strama]
How are we to understand a child's development--both the potentiating and inhibiting factors? The past two decades have witnessed intensive research both on mental trauma and its possible effects on the child's developing brain, and on the importance of risk factors and protective factors in children's development and health. Research in these two fields has been conducted concurrently and has yielded new, important, and in many cases complementary, information. To promote the general availability and clinical applicability of these advances in our knowledge, it is necessary to modify our conceptual approach, basing it on the child's perspective instead.
Millenniemål 4 lyder: »Barnadödligheten under de fem första levnadsåren ska minska med två tredjedelar till 2015 jämfört med år 1990«.
Barnadödligheten minskar i stora delar av världen, men inte i tillräckligt snabb takt för att uppnå målet. Den skiljer sig också kraftigt mellan länder och mellan olika grupper inom länderna.
Sex dödsorsaker står för mer än 90 procent av alla dödsfall före 5 års ålder: neonatal mortalitet, lunginflammation, diarré, malaria, mässling och HIV/aids. Undernäring beräknas vara delorsak till cirka en tredjedel av dessa dödsfall.
Vi har kunskap och metoder att med kostnadseffektiva lösningar reducera barnadödligheten med två tredjedelar. Fortsatt internationellt samarbete, utökade resurser samt lokal, nationell politisk vilja krävs för att lyckas.
Markers of renal function (glomerular filtration rate; GFR) are frequently used. In most cases GFR is estimated based on plasma creatinine, but cystatin C, creatinine clearance (with urine collection), iohexol clearance and 51Cr-EDTA clearance are also used. A questionnaire was sent to representatives for clinical chemistry laboratories in Sweden to collect information regarding the use of these markers during the years 2006 2009. The aim was to compare the use in different parts of Sweden and how it has changed over time. The overall use of markers of renal function, including creatinine, continues to increase on a national level, with the exception for endogenous creatinine clearance and 51Cr-EDTA clearance. Creatinine, the most frequently used marker, continues to grow in numbers. 5,6 million creatinine analyses and about two hundred thousand cystatin C analyses were performed during year 2009. There were considerable variations between counties in the use of the studied markers.
Increasing drug expenditures have resulted in various models to increase cost consciousness among prescribing doctors. In the County of Stockholm, Sweden, a model for quality assessment of prescribing was introduced in 2006. In all, 139 of 154 primary healthcare centres (PHCs) signed a contract linking extra payment to the adherence to the Drug and Therapeutics Committee guidelines if they analysed their prescribing behaviour in an annual quality report. During the first year, the adherence to guidelines increased from 80 to 83%, substantially higher than the 0-2% annual increase that had been observed previous years. The increase was similar for those PHCs not participating in the program. Qualitative analyses of all written quality reports indicate that the incentive scheme has resulted in an increased interest in quality assessment of drug prescribing. In total, 20 million SEK was spent on incentives, with estimated savings of 100 million SEK on drug expenditures.
Home visitations to newly become parents have a long tradition in Sweden. The aim is to give the parents an opportunity to talk about their new situation, to give information on child care and nurse- examine the infant. In recent years, the proportion of families receiving home visits has decreased.The purpose of this study was to explore the attitudes of the child health care nurses to home visitations, the frequency in which they were made and to study the organizational conditions for making these visits.The study consisted of a survey of the frequency in which visits were performed and a questionnaire to all CHC nurses in Sweden exploring their attitudes to home visitations.The questionnaire was sent to 2355 nurses and 1834 responded (78.3%). According to the nurses there were three main reasons for not doing home visitations: the parents declined, lack of time and large districts. There were no differences either in terms of various organizational arrangements or the individual nurse’s work-experience. Remarkably the reasons for not doing home visitation do not correlate with the statements made by them indicating how important they declared these visits to be. Indications are that nurse’s attitudes to home visits as a primary child health care practice is a critical factor that should be studied further. Likewise further exploration is needed on parental attitudes to home visitation. Above all, the nurses need more support and training in such matters, which each respective county child health unit should take more responsibility for.
Breast cancer is the most common form of cancer among women in Sweden. Several decades ago it was recognized that the Human epidermal growth factor receptor 2 (HER2) is involved in a critical growth system for breast cancer cells. Overexpression of HER2 (immunohistochemistry [IHC] 2+/3+, in situ hybridization [ISH] positive) is present in 15 percent of all breast cancers. HER2-low breast cancer has been discovered as a separate entity; the most commonly used definition so far is IHC 1+/2+ and ISH negative, but general consensus is still lacking. Clinical studies with the HER2 antibody drug conjugate trastuzumab deruxtecan (Enhertu) have shown impressive antitumor activity among women with advanced HER2-low breast cancer and this is expected to become part of routine treatment in the near future. Research is needed to establish refined ways to define HER2-low breast cancer, and a possible role lies in new imaging methods such as HER2 positron emission tomography (PET) with a [68Ga]Ga-ABY-025 tracer.
Core needle biopsies for lymphoma diagnosis seriously affect diagnostics, treatment development and research Core needle biopsies (CNBs) are widely used in clinical diagnostic labs to aid in the diagnosis of malignant lymphomas and in latter years their use is increasing. CNBs provide a rapid method for obtaining tumour material and may be beneficial when the affected lymph nodes are located deep in the abdominal cavity or mediastinum and surgical excisional biopsies may be difficult to perform. However, according to the Swedish Haematopathology Quality and Standardization Committee, CNBs are insufficient for lymphoma diagnostic purposes and the guidelines state that material from surgical excisional biopsies are mandatory in order to obtain a robust histopathological evaluation of the lymph node architecture, cellular composition and growth pattern. Surgical excision biopsies also ensure that adequate material is available if additional molecular analyses should be required and also to facilitate future research.
Kirurgi på rätt indikation och vid rätt tidpunkt är ett omistligt komplement till medicinsk behandling vid inflammatorisk tarmsjukdom, som förebygger sjukdomskomplikationer, förbättrar patienternas livskvalitet och ibland är livräddande. Kirurgi för ulcerös kolit görs oftast som ett tvåstegsförfarande: först kolektomi plus ileostomi med rektum lämnad intakt och i senare skede, med optimerad patient, tarmrekonstruktion anpassad efter patientens individuella livssituation. Kirurgi vid Crohns sjukdom korrigerar komplikationer (stenoser och fistlar) och sparar tarm genom begränsade resektioner och strikturplastiker. Laparoskopisk kirurgi verkar ha viktiga fördelar vid primära tarmresektioner. Modern medicinsk behandling har förändrat indikationerna men ännu inte minskat behovet av kirurgi. Pågående antiinflammatorisk och immunmodulerande behandling är viktig att beakta i samband med kirurgi. Ett nära samspel mellan gastroenterolog och kolorektalkirurg är nödvändigt för att uppnå bästa möjliga långtidsprognos för de individer som lever med IBD.
Insulin dependent diabetes mellitus (type 1-diabetes) results from a selective destruction of the insulin producing beta cells and a limited capacity of the remaining cells to regenerate in a compensatory manner. Increased knowledge of the factors involved in the regulation of beta-cell growth may lead to new ways of forming beta cells that in combination with selective immunosuppression could be used for treatment of type 1 diabetes. Physiological and pathophysiological conditions that induce beta-cell growth, different factors that have been implicated to regulate these processes and future perspectives concerning treatment of type 1 diabetes by expanding the beta-cell mass is discussed in this review article.
De betydande sociala och medicinska riskerna vid missbruk av katinon (tuggning av kat) och metkatinon (intravenös injektion av illegala synteser) har i stort sett inte uppmärksammats i svensk narkotikadebatt.
Tullens beslag av kat visar hur det traditionella bruket importeras med immigration från framför allt Östafrika.
Syntesrecept på metkatinon, som kan hämtas från Internet, ger produkter som orsakat manganförgiftning med svåra, irreversibla motoriska handikapp hos hundratals unga framför allt i Baltikum, Ryssland, Ukraina och Georgien. Denna »epidemi« fortgår.
Kunskap om förekomst, kliniska symtom och spridningsrisker vid dessa missbruksformer är angelägen såväl ur ett nationellt som ett internationellt biståndsperspektiv.
Disasters and other adverse life events may cause severe and chronic posttraumatic stress (PTS) in survivors. Knowledge varies within and across countries in Europe regarding psychosocial interventions after such events. Between 2007 and 2011, The European Network for Traumatic Stress (TENTS) established a network of expertise with the aim to examine the effectiveness of interventions on PTS after trauma, and develop and disseminate a teaching package throughout Europe. The systematic review by TENTS found a scarcity of research on acute interventions, and a lack of efficacy for preventive interventions, whereas trauma-focused psychotherapy is effective for severe acute and chronic PTS. Pharmacotherapy can alleviate chronic PTS although its effects are small. Sweden has a developed network for early psychosocial interventions after major events. As in most of Europe, however, there is a need for greater access to evidence-based psychotherapy.
Oxidativ stress (fria radikaler) tros vara orsaken till åldrande och flera sjukdomar, däri bland arterioskleros, men det har saknats en pålitlig metodik för att påvisa aktiviteten av fria radikaler in vivo. Här presenteras isoprostaner som nya och tillförlitliga markörer för mätning av oxidativ stress in vivo genom indirekt mätning av radikalreaktioner. Isoprostaner kan ses i ökad mängd vid flera sjukdomstillstånd som är associerade med oxidativ stress och inflammation, till exempel kardiovaskulära sjukdomar, sjukdomar som är associerade med en ökad kardiovaskulär risk samt lungsjukdomar. Mätning av isoprostaner kan vidare ge ökad kunskap om fria radikalers fysiologiska roll och antioxidanternas roll vid sjukdomar samt vara ett verktyg vid utveckling av nya läkemedel mot oxidativ stress.