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1.  Variability of platelet aggregation in patients with clopidogrel treatment and hip fracture: A retrospective case-control study on 112 patients 
World Journal of Orthopedics  2015;6(5):439-445.
AIM: To identify the rate of non-responders to clopidogrel treatment in hip fracture patients and study how non-responders differ from controls.
METHODS: In a retrospective case-control study we included 28 cases of acute proximal femoral fracture with clopidogrel treatment 2011 to 2013. Eighty-four controls from the same time period were included. Data collected included response to clopidogrel measured with multiple electrode aggregometry (MEA), intraoperative bleeding, erythrocyte transfusion, time to surgery and the incidence of adverse events up to 3 mo after surgery.
RESULTS: Eight (29%) of the 28 cases were non-responders. The median intraoperative bleeding was 300 mL (range, 0-1500), and was lower for non-responders (50 mL) but did not reach statistical significance. Erythrocyte transfusions did not differ between responders, non-responders and controls. Forty-five (40%) of 112 patients had adverse events postoperatively but the rate did not differ between patients with and without clopidogrel treatment.
CONCLUSION: Almost one-third of patients with clopidogrel treatment and an acute proximal femoral fracture are non-responders to antiplatelet therapy and can be operated without delay.
PMCID: PMC4458495  PMID: 26085986
Proximal femoral fracture; Clopidogrel; Variability; Bleeding; Adverse events
2.  Education Attainment is Associated With Patient-reported Outcomes: Findings From the Swedish Hip Arthroplasty Register 
Age, sex, and medical comorbidities may be associated with differences in patient-reported outcome scores after THA. Highest level of education may be a surrogate for socioeconomic status, but the degree to which this is associated with patient-reported outcomes after THA is not known.
We investigated the national Swedish Hip Arthroplasty Register for the association of education attainment on patient-reported outcomes 1 year after THA; specifically, we evaluated level of education attainment against health-related quality of life (HRQoL), pain reduction, and satisfaction with treatment 1 year after THA.
All THAs for osteoarthritis performed from 2005 through 2007 with complete patient-reported outcome measures (representing 49% of the THAs performed for this diagnosis) were selected from the Swedish Hip Arthroplasty Register. These cases were merged with national databases containing education attainment, marital status, and comorbidities (n = 11,464; mean age of patients, 64 years). The patient-reported outcome measure protocol included the HRQoL measure EuroQol five-dimension scale (EQ-5D), a VAS for pain, the Charnley classification survey, and a VAS addressing THA satisfaction. Linear regression analyses determined the association of preoperative patient factors with patient-reported outcomes.
High education attainment was associated with higher HRQoL (EQ-5D index ßhigh = 0.03 ± 0.01; EQ VAS ßhigh = 2.6 ± 0.5) after THA, whereas those with low and medium education were at risk for lower HRQoL. High education was associated with less pain after treatment (ßhigh = −3.3 ± 0.05). Individuals with low or medium education were at risk for less satisfaction with THA (p < 0.001).
Our results suggest clinicians should support patients with low and medium education to a greater extent. Identification of patients who will benefit most from THA and educating those at risk for poorer outcomes, like patients with low and medium education, ultimately may improve patient satisfaction, HRQoL, pain, and the cost utility of THA.
Level of Evidence
Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-014-3504-2) contains supplementary material, which is available to authorized users.
PMCID: PMC4016468  PMID: 24549772
3.  Validation of reoperations due to infection in the Swedish Hip Arthroplasty Register 
Complete or almost complete recording of reoperations is essential to enable a correct interpretation of data in arthroplasty registers. The completeness of recordings due to infection is unknown in the Swedish Hip Arthroplasty Register (SHAR). We therefore used a combination of data from the Swedish Prescribed Drug Register (SPDR) and studies of medical records to validate the data of reoperations due to infection in the SHAR.
All patients registered for a primary Total Hip Replacement (THR) in the SHAR between July 1, 2005 and December 31, 2008 were selected for the study (45,531 patients with 49,219 THRs) and were matched with the SPDR. All patients with a minimum of 4 weeks of continuous outpatient antibiotic treatment within 2 years after their primary THR (1,989 patients, with 2,219 THRs) were selected for a medical records review to find the THRs reoperated due to infection.
599 (1.3%) of the THRs had been reoperated within 2 years after the index operation and in 47.4% of these the prosthesis had been revised or extracted. 400 of the THRs were registered for a reoperation in the SHAR resulting in a completeness of 67%.
The completeness of registration due to early infection after THR questions whether the SHAR reoperation data can be used in order to evaluate changes in postoperative infection rates.
PMCID: PMC4247680  PMID: 25410189
Arthroplasty Register; Validity; Completeness; Hip replacement; Reoperation; Infection
4.  Women in Charnley class C fail to improve in mobility to a higher degree after total hip replacement 
Acta Orthopaedica  2014;85(4):335-341.
The Charnley comorbidity classification organizes patients into 3 classes: (A) 1 hip involved, (B) 2 hips involved, and (C) other severe comorbidities. Although this simple classification is a known predictor of health-related quality of life (HRQoL) after total hip replacement (THR), interactions between Charnley class, sex, and age have not been investigated and there is uncertainty regarding whether A and B should be grouped together.
We selected a nationwide cohort of patients from the Swedish Hip Arthroplasty Register operated with THR due to primary osteoarthritis between 2008 and 2010. For estimation of HRQoL, we used the generic health outcome questionnaire EQ-5D of the EuroQol group. This consists of 2 parts: the EQ-5D index and the EQ VAS estimates. We modeled the EQ-5D index and the EQ VAS against the self-administered Charnley classification. Confounding was controlled for using preoperative HRQoL values, pain, and previous contralateral hip surgery.
We found that women in class C had a poorer EQ-5D outcome than men. This effect was mostly due to the fact that women failed to improve in the mobility dimension; only 40% improved, while about 50% of men improved. Age did not interact with Charnley class. We also found that the classification performed best without splitting or aggregating classes.
Our results suggests that the self-administered Charnley classification should be used in its full capacity and that it may be interesting to devote special attention to women in Charnley class C.
PMCID: PMC4105762  PMID: 24954483
5.  Different patient-reported outcomes in immigrants and patients born in Sweden 
Acta Orthopaedica  2014;85(3):221-228.
Background and purpose
Some patients have persistent symptoms after total hip arthroplsty (THA). We investigated whether the proportions of inferior clinical results after total hip arthroplasty—according to the 5 dimensions in the EQ-5D form, and pain and satisfaction according to a visual analog scale (VAS)—are the same in immigrants to Sweden as observed in those born in Sweden.
Records of total hip arthroplasties performed between 1992 and 2007 were retrieved from the Swedish Hip Arthroplasty Register (SHAR) and cross-matched with data from the National Board of Health and Welfare and also Statistics, Sweden. 18,791 operations (1,451 in immigrants, 7.7%) were eligible for analysis. Logistic and linear regression models including age, sex, diagnosis, type of fixation, comorbidity, surgical approach, marital status, and education level were analyzed. Outcomes were the 5 dimensions in EQ-5D, EQ-VAS, VAS pain, and VAS satisfaction. Preoperative data and data from 1 year postoperatively were studied.
Preoperatively (and after inclusion of covariates in the regression models), all immigrant groups had more negative interference concerning self-care. Immigrants from the Nordic countries outside Sweden and Europe tended to have more problems with their usual activities and patients from Europe and outside Europe more often reported problems with anxiety/depression. Patients born abroad showed an overall tendency to report more pain on the VAS than patients born in Sweden.
After the operation, the immigrant groups reported more problems in all the EQ-5D dimensions. After adjustment for covariates including the preoperative baseline value, most of these differences remained except for pain/discomfort and—concerning immigrants from the Nordic countries—also anxiety/depression. After the operation, pain according to VAS had decreased substantially in all groups. The immigrant groups indicated more pain than those born in Sweden, both before and after adjustment for covariates.
The frequency of patients who reported moderate to severe problems, both before and 1 year after the operation, differed for most of the dimensions in EQ-5D between patients born in Sweden and those born outside Sweden.
PMCID: PMC4062786  PMID: 24803309
6.  Projections of total hip replacement in Sweden from 2013 to 2030 
Acta Orthopaedica  2014;85(3):238-243.
Background and purpose
The continuously increasing demand for joint replacement surgery in the past decades imposes higher constraints on the budgets of hospitals and healthcare providers. We undertook an analysis of historical trends in total hip replacement performed in Sweden between 1968 and 2012 in order to provide projections of future demand.
Data and methods
We obtained data on total hip replacements registered every year and on the evolution of the Swedish population between 1968 and 2012. We assumed the existence of a maximum incidence. So we adopted a regression framework that assumes the existence of an upper limit of total hip replacement incidence.
We found that the incidence of total hip replacement will continue to increase until a projected upper incidence level of about 400 total hip replacements per 105 Swedish residents aged 40 years and older will be reached around the year 2107. In 2020, the estimated incidence of total hip replacement will be 341 (95% prediction interval (PI): 302–375) and in 2030 it will be 358 (PI: 317–396). Using official forecasted population growth data, about 18,000 operations would be expected to be performed in 2020 and 20,000 would be expected to be performed in 2030.
Growing incidence, population growth, and increasing life expectancy will probably result in increased demand for hip replacement surgery. Our findings could serve as a basis for decision making.
PMCID: PMC4062789  PMID: 24758323
7.  Age- and health-related quality of life after total hip replacement 
Acta Orthopaedica  2014;85(3):244-249.
While age is a common confounder, its impact on health-related quality of life (HRQoL) after total hip replacement is uncertain. This could be due to improper statistical modeling of age in previous studies, such as treating age as a linear variable or by using age categories. We hypothesized that there is a non-linear association between age and HRQoL.
We selected a nationwide cohort from the Swedish Hip Arthroplasty Register of patients operated with total hip replacements due to primary osteoarthritis between 2008 and 2010. For estimating HRQoL, we used the generic health outcome questionnaire EQ-5D of the EuroQol group that consits or 2 parts: the EQ-5D index and the EQ VAS estimates.
Using linear regression, we modeled the EQ-5D index and the EQ VAS against age 1 year after surgery. Instead of using a straight line for age, we applied a method called restricted cubic splines that allows the line to bend in a controlled manner. Confounding was controlled by adjusting for preoperative HRQoL, sex, previous contralateral hip surgery, pain, and Charnley classification.
Complete data on 27,245 patients were available for analysis. Both the EQ-5D index and EQ VAS showed a non-linear relationship with age. They were fairly unaffected by age until the patients were in their late sixties, after which age had a negative effect.
There is a non-linear relationship between age and HRQoL, with improvement decreasing in the elderly.
PMCID: PMC4062790  PMID: 24786908
8.  Factors influencing health-related quality of life after total hip replacement - a comparison of data from the Swedish and Danish hip arthroplasty registers 
There is an increasing focus on measuring patient-reported outcomes (PROs) as part of routine medical practice, particularly in fields such as joint replacement surgery where pain relief and improvement in health-related quality of life (HRQoL) are primary outcomes. Between-country comparisons of PROs may present difficulties due to cultural differences and differences in the provision of health care. However, in order to understand how these differences affect PROs, common predictors for poor and good outcomes need to be investigated. This cross-sectional study investigates factors influencing health-related quality of life (HRQoL) one year after total hip replacement (THR) surgery in Sweden and in Denmark.
Data was retrieved from the Swedish (n = 14 560 patients) and Danish (n = 632 patients) Hip Arthroplasty Registers according to preset selection criteria. Using linear regression models, we examined how sex, age, comorbidity and country of surgery were associated with different aspects of HRQoL as measured by the EQ-5D index and EQ VAS.
Danish patients had an overall higher EQ-5D index and EQ VAS than Swedish patients (p < 0.001). After regression analysis, the estimated coefficients for sex, age, or the Charlson score did not differ between countries for either the EQ-5D index (p = 0.83) or EQ VAS (p = 0.41) one year after THR.
We conclude that there are clear similarities in how basic predictors influence patient-reported outcomes (PROs) in patients with THR in Sweden and Denmark and these known predictors of good or poor HRQoL outcomes are not specific for each country.
PMCID: PMC4228371  PMID: 24192304
Total hip replacement; EQ-5D; Predictors; Comorbidity; Patient-reported outcome; Patient-reported outcome measures; Register study
9.  No influence of immigrant background on the outcome of total hip arthroplasty 
Acta Orthopaedica  2013;84(1):18-24.
Background and purpose
Total Hip Replacement (THA) is one of the most successful and cost-effective operations. Despite its benefits, marked ethnic differences in the utilization of THA are well documented. However, very little has been published on the influence of ethnicity on outcome. We investigate whether the outcome—in terms of reoperation within 2 years or revision up to 14 years after the primary operation—varies depending on ethnic background.
Records of total hip arthroplasties performed between 1992 and 2007 were retrieved from the Swedish Hip Arthropalsty Registry and integrated with data on ethnicity of patients from 2 demographical databases (i.e. Patient Register and Statistics Sweden). The first operated side in patients with THA recorded in the Swedish Hip Arthroplasty Register (SHAR) between 1992 and 2007 were generally included. We excluded patients with 1 Swedish and 1 non-Swedish parent and patients born abroad with 2 Swedish parents. After these exclusions 151,838 patients were left for analysis. There were 11,539 Swedish patients born outside Sweden. We used a Cox regression model including age, sex, diagnosis, type of fixation, whether or not there was comorbidity according to Elixhauser or not, marital status and educational level.
The mean age was lowest in the group of patient coming from outside Europe including the former Soviet Union (61 years), and highest in the Swedish population (70 years). Before adjustment, for covariates, patients born in Europe outside the Nordic countries showed a lower risk to undergo early reoperation (HR = 0.73, 95% CI: 0.56–0.97), which increased after adjustment to (HR = 0.76, 95% CI: 0.58–1.01). Before adjustment, patients born in the Nordic countries outside Sweden and those born outside Europe (including the former Soviet Union) showed a higher risk to undergo revision than patients born in Sweden (HR = 1.14, 95% CI: 1.02–1.27; HR = 1.49, 95% CI: 1.2–1.9), but this difference disappeared after adjustment for covariates.
We did not find any certain differences in reoperation within 2 years, or revision within 14 years, between patients born in Sweden and immigrants. Further studies are needed to determine whether our observations are biased by the attitude of health providers regarding performance of these procedures, or by a reluctance of certain patient groups to seek medical attention should any complications requiring reoperation or revision occur.
PMCID: PMC3584597  PMID: 23343377
10.  Molecular Epidemiology of Mycobacterium tuberculosis in Western Sweden 
Journal of Clinical Microbiology  2004;42(7):3046-3051.
The genetic diversity of Mycobacterium tuberculosis isolates among patients from Sweden was determined by a combination of two PCR-based techniques (spoligotyping and variable number of tandem repeats analysis). It resulted in a clustering of 23.6% of the isolates and a rate of recent transmission of 14.1%. The clustered isolates mainly belonged to the Haarlem family (23.2%), followed by the Beijing (9.8%), Latin American and Mediterranean (LAM; 8%), and East African-Indian (EAI; 6.2%) families. A comparison of the spoligotypes with those in the international spoligotyping database showed that 62.5% of the clustered isolates and 36.6% of all isolates typed were grouped into six major shared types. A comparison of the spoligotypes with those in databases for Scandinavian countries showed that 33% of the isolates belonged to an ill-defined T family, followed by the EAI (22%), Haarlem (20%), LAM (11%), Central Asian (5%), X (5%), and Beijing (4%) families. Both the highest number of cases and the proportion of clustered cases were observed in patients ages 15 to 39 years. Nearly 10% of the isolates were resistant to one or more drugs (essentially limited to isoniazid monoresistance). However, none of the strains were multidrug resistant. Data on the geographic origins of the patients showed that more than two-thirds of the clustered patients with tuberculosis were foreign-born individuals or refugees. These results are explained on the basis of both the historical links within specific countries and recently imported cases of tuberculosis into Sweden.
PMCID: PMC446260  PMID: 15243058
11.  Snapshot of Moving and Expanding Clones of Mycobacterium tuberculosis and Their Global Distribution Assessed by Spoligotyping in an International Study†  
Journal of Clinical Microbiology  2003;41(5):1963-1970.
The present update on the global distribution of Mycobacterium tuberculosis complex spoligotypes provides both the octal and binary descriptions of the spoligotypes for M. tuberculosis complex, including Mycobacterium bovis, from >90 countries (13,008 patterns grouped into 813 shared types containing 11,708 isolates and 1,300 orphan patterns). A number of potential indices were developed to summarize the information on the biogeographical specificity of a given shared type, as well as its geographical spreading (matching code and spreading index, respectively). To facilitate the analysis of hundreds of spoligotypes each made up of a binary succession of 43 bits of information, a number of major and minor visual rules were also defined. A total of six major rules (A to F) with the precise description of the extra missing spacers (minor rules) were used to define 36 major clades (or families) of M. tuberculosis. Some major clades identified were the East African-Indian (EAI) clade, the Beijing clade, the Haarlem clade, the Latin American and Mediterranean (LAM) clade, the Central Asian (CAS) clade, a European clade of IS6110 low banders (X; highly prevalent in the United States and United Kingdom), and a widespread yet poorly defined clade (T). When the visual rules defined above were used for an automated labeling of the 813 shared types to define nine superfamilies of strains (Mycobacterium africanum, Beijing, M. bovis, EAI, CAS, T, Haarlem, X, and LAM), 96.9% of the shared types received a label, showing the potential for automated labeling of M. tuberculosis families in well-defined phylogeographical families. Intercontinental matches of shared types among eight continents and subcontinents (Africa, North America, Central America, South America, Europe, the Middle East and Central Asia, and the Far East) are analyzed and discussed.
PMCID: PMC154710  PMID: 12734235
12.  Global Distribution of Mycobacterium tuberculosis Spoligotypes 
Emerging Infectious Diseases  2002;8(11):1347-1349.
We present a short summary of recent observations on the global distribution of the major clades of the Mycobacterium tuberculosis complex, the causative agent of tuberculosis. This global distribution was defined by data-mining of an international spoligotyping database, SpolDB3. This database contains 11,708 patterns from as many clinical isolates originating from more than 90 countries. The 11,708 spoligotypes were clustered into 813 shared types. A total of 1,300 orphan patterns (clinical isolates showing a unique spoligotype) were also detected.
PMCID: PMC2738532  PMID: 12453368
Mycobacterium tuberculosis; spoligotyping

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