Adherence to treatment in Swedish HIV-infected patients.

OBJECTIVES: The objectives were to assess the prevalence of adherence to antiretroviral treatment in Swedish human immunodeficiency virus (HIV)-infected patients and to evaluate factors associated with adherence. METHODS: All HIV-treated patients, who attended one of 30 (of a total of 32) Swedish infectious diseases clinics, during 7 months, were asked to complete an anonymous questionnaire containing the 9-item Morisky Medication Adherence Scale (MMAS) and questions about other factors potentially affecting adherence. The summary score of MMAS ranges from 1 to 13, where 13 indicates perfect adherence; patients scoring 11 or above (corresponding to 95% adherence level) were classified as 'adherent'. RESULTS AND DISCUSSION: In total 946 patients participated (response rate 97.5%). The proportion of patients who reported not missing a dose during the day prior to the completion of the questionnaire was 97% and the proportion classified as 'adherent' was 63%. 'Adherent' patients were more likely to have a good relationship with their health care professionals (P < 0.05) and not have problems with drugs or alcohol (P < 0.01). Being older (P < 0.01) and having a shorter time on current treatment (P < 0.01) and on treatment in total (P < 0.05) were factors also associated with good adherence. CONCLUSION: Factors modifiable for interventions by health care professionals are patient-provider relationship, drug or alcohol problems and patients with long treatment periods.

The prevalence of violence investigated in a pregnant population in Sweden.

All women registered for antenatal care within a Swedish municipality during a 6-month period were assessed regarding acts of violence. The Abuse Assessment Screen was used on two occasions during pregnancy, and once between 4 and 20 weeks after delivery. The efficacy of repeated interviews was investigated, and characteristics of abused and non-abused women were compared. The participation rate was 93% (1038 women). Physical abuse by a close acquaintance or relative during or shortly after pregnancy was reported by 1.3%, and by 2.8% when the year preceding pregnancy was included. The lifetime prevalence of emotional, physical or sexual abuse was 19.4%. Repeated questioning increased the detection of abuse. Women abused during pregnancy reported more preceding ill-health and more elective abortions than non-abused women. Intervention against sexual violence has been on the political agenda in Sweden for several decades. Even so, physical abuse is a risk factor comparable in frequency to obstetric complications such as gestational diabetes and pre-eclampsia. Routines need to be established to make questioning about violence an integral part of the standardized screening for risk factors during pregnancy.

Factors associated with pregnancy termination in Ukrainian women.

OBJECTIVES: To study differences in social and demographic characteristics between women undergoing an induced abortion and antenatal care attendants in the Ukraine. DESIGN: Hospital-based unmatched case control study. METHODS: From a survey including 1,694 women of fertile age, who attended five women's clinics in the Donetsk region, Ukraine, we studied those who came for termination of pregnancy (n = 919) and for antenatal care (n = 478). The data were obtained through an anonymous self-questionnaire. From the 192-item questionnaire questions dealing with social and demographic characteristics, previous pregnancy experience, and attitude towards abortion were analyzed. Multiple logistic regression was used to analyze the risk of pregnancy termination. RESULTS: Termination of pregnancy was associated with being single (OR = 11.8). Both previous childbirth and previous induced abortion were other determinants as well as being younger than 19 years old (OR = 3.8), having a positive attitude towards abortion (OR = 2.7), and sharing apartment with parents (OR = 1.9). A higher risk for an induced abortion was found among women with a history of previous induced abortion(s). Neither income nor educational level was identified as a risk factor for pregnancy termination. CONCLUSION: This study demonstrated major social and demographic differences between women attending for abortion and antenatal care patients, and highlights some of the factors influencing the decision to terminate a pregnancy.

Combined oral contraceptives do not increase the risk of back and pelvic pain during pregnancy or after delivery.

OBJECTIVES: To elucidate whether the duration of previous use of combined oral contraceptives (COC) is associated with disabling back or pelvic pain during pregnancy and pain persisting eight months after delivery. METHODS: Questionnaires were distributed to a group of women at 36 weeks of pregnancy and eight months after their delivery. There were no exclusion criteria. Disabling pain was defined as moderate or severe pain restricting physical activity. Multiple logistic regression analysis of disabling pain during pregnancy and persistent pain after delivery comprised the duration of COC use adjusted for age, pain in a previous pregnancy and a history of back pain when not pregnant. RESULTS: The study comprised 161 women. Pain during pregnancy was classified as disabling in 57 of the women (35%), pain in a previous pregnancy being a risk factor, odds ratio (OR) 5.0 (95% CI 2.1; 12.1), whereas no association was found with the duration of COC use. Persistent pain eight months after delivery was reported by 41 women (26%), risk factors being a history of back pain when not pregnant; OR 7.5 (2.8; 19.5), disabling pain in the recent pregnancy; OR 5.0 (1.9; 13.4), and short use of COC; 0-<1 year; OR 4.2 (1.3; 12.9), 1-<5 years; OR 4.6 (1.5; 14.4) (reference=>10 years). CONCLUSION: The results indicate that non- or short term users of COC have an increased risk of persistent pain after delivery compared to long term users. No association was found between the duration of COC use and back or pelvic pain during pregnancy.

Symphyseal distention in relation to serum relaxin levels and pelvic pain in pregnancy.

OBJECTIVE: To elucidate whether there is an association between symphyseal distention, circulating relaxin levels and pelvic pain in pregnancy. METHODS: Serum relaxin and symphyseal width were assessed in 19 consecutive referral cases with severe pelvic pain at 35 weeks of pregnancy and in a cohort of 49 women at 12 and 35 weeks of pregnancy. The referral cases were received over a period of two years and four months and the cohort was recruited over a period of two months. Relaxin was measured with an ELISA test and symphyseal width assessed using ultrasonography. All women with pelvic pain were clinically assessed. The women were divided into three groups; Group A (n= 38), cohort cases with no or mild pain; Group B (n= 11), cohort cases with disabling pain; and Group C (n= 19), referral cases. RESULTS: At 35 weeks of pregnancy, mean symphyseal width was 4.5 mm (s.d. 1.0 mm) in Group A, 5.7 mm (s.d. 2.6 mm) in Group B, and 7.4 mm (s.d. 3.5 mm) in Group C. The difference between Groups A and B is statistically significant (p=0.044) as is that between Groups A and C (p<0.0001). Serum relaxin levels were not associated with symphyseal distention or disabling pain. CONCLUSION: Severe pelvic pain during pregnancy was strongly associated with an increased symphyseal distention. However, the severity of pain did not predict the degree of symphyseal distention in the individual case, indicating that other mechanisms are also involved. Serum relaxin levels were not associated with the degree of symphyseal distention or with pelvic pain in pregnancy.

Pregnancy-related back and pelvic pain and changes in bone density.

OBJECTIVE: To elucidate whether there is an association between pregnancy-related back and pelvic pain and changes in bone density. METHODS: In this prospective cohort study, bone density was measured in the distal and ultra-distal forearm at 12 and 35 weeks of pregnancy and at 5 months post partum. The location and degree of any back or pelvic pain was registered. The patients were classified into four subgroups on the basis of presence or absence of disabling pain in late pregnancy and presence or absence of pain at 5 months' follow-up. Forty-nine women participated. RESULTS: Bone density decreases during pregnancy and lactation. Trabecular bone is mainly lost during pregnancy and cortical bone during lactation. No association between back or pelvic pain during pregnancy and bone loss was found. Between 35 weeks of pregnancy and 5 months post partum, bone loss in all the women was estimated as 1.1% of cortical bone (p < 0.001) and 0.6% of trabecular bone (n.s.). During the same period five women with mild pain during pregnancy and pain at follow-up lost 3.9% of cortical bone (p=0.043) and 5.3% of trabecular bone (p=0.043). Although this bone loss was significant compared to the other subgroups, the small study size does not permit general conclusions to be drawn from this finding. CONCLUSION: The results indicate that bone density decreases during pregnancy and lactation. The decrease in bone density was not associated with back or pelvic pain during pregnancy. It remains unclear whether bone loss is associated with back and pelvic pain during lactation.

Adolescent depression: social network and family climate--a case-control study.

In a study of a total high-school population, 2300 students aged 16-17 years were screened for depression (BDI, CES-DC). Those with a self-evaluation indicating depression, together with controls matched for sex, age, and class were interviewed (DICA-R-A). The 177 pairs, where both individuals were interviewed and the control had no lifetime diagnosis of depression, were analysed in the form of paired differences for psychosocial factors and compared within diagnostic groups. The psychosocial factors were measured with the ISSI subscales and six attitude questions about family climate (KSP). Adolescents with an episode of major depression during part of the last year did not differ from their controls. Those with long-lasting depressive symptoms, i.e. dysthymia with or without episodes of major depression, had a more limited social interaction and were not satisfied with it. They also evaluated their family climate and attachment network as being more inadequate than did their controls. Depressed adolescents with comorbid conduct disorder had a more negative evaluation of availability and adequacy of both social interaction and attachment network than their controls. This group had a very negative view of their family climate. Since this is a case-control study conclusions cannot be drawn about cause and effect.

The Misgav Ladach method for cesarean section compared to the Pfannenstiel method.

OBJECTIVE: The aim of the study was to evaluate the outcome of two different methods of cesarean section (CS). DESIGN: The study was designed as a prospective, randomized, controlled trial. SETTING: All CS were performed at the University Hospital in Uppsala, Sweden. POPULATION: Fifty women admitted to hospital for a first elective CS were consecutively included in the study. They were randomly allocated to two groups. METHODS: One group was operated on by the Misgav Ladach method for CS and the other group by the Pfannenstiel method. All operations were performed by the same surgeon. MAIN OUTCOME MEASURES: Duration of operation, amount of bleeding, analgesics required, scar appearance and length of hospitalization. RESULTS: Operating time was significantly different between the two methods, with an average of 12.5 minutes with the Misgav Ladach method and 26 minutes with the Pfannenstiel method (p<0.001). The amount of blood loss differed significantly, with 448 ml and 608 ml respectively (p=0.017). Significantly less analgesic injections and tablets (p=0.004) were needed after the Misgav Ladach method. CONCLUSION: The Misgav Ladach method of CS has advantages over the Pfannenstiel method by being significantly quicker to perform, with a reduced amount of bleeding and diminished postoperative pain. The women were satisfied with the appearance of their scars. In this study no negative effects of the new operation technique were discovered.

Sonographic assessment of symphyseal joint distention during pregnancy and post partum with special reference to pelvic pain.

OBJECTIVE: To elucidate whether there is a relationship between pregnancy-related pelvic pain and degree of symphyseal laxity. METHODS: Forty-nine women were interviewed and examined and ultrasonographic measurement of symphyseal width and vertical shift was conducted at 12 and 35 weeks of pregnancy and at 5 months post partum. The patients were retrospectively classified into four groups on the basis of presence and degree of pain in late pregnancy and presence or absence of pain at follow up. RESULTS: The prevalence of pelvic pain of any degree during pregnancy was 49%, of pronounced pain 16.3% and of severe pain 6.1%. Nineteen percent had any remaining pain at 5 months post partum. The median symphyseal width at 12 and 35 weeks of pregnancy and at 5 months post partum was 3.5 mm, 4.6 mm and 2.8 mm, the median vertical shift 0.0 mm, 0.8 and 0.9 mm respectively. Those with disabling pain during pregnancy and no pain at follow up had greater symphyseal width (6.3 mm) and vertical shift (1.8 mm) at 35 weeks of pregnancy than controls; 4.5 mm (p<0.01) and 0.5 mm (p<0.01) respectively. Those with disabling pain during pregnancy and persistent pain at follow up did not differ significantly from controls in symphyseal width or shift. The most severe cases were in this group. CONCLUSION: There is a minor pregnancy-induced physiological increase in laxity of the symphyseal soft tissue. There is no evidence that the degree of symphyseal distention determines the severity of pelvic pain in pregnancy or after childbirth.

Maternal smoking and feto-infant mortality: biological pathways and public health significance.

Smoking during pregnancy has in many countries replaced poverty as the most important preventable risk factor for an unsuccessful pregnancy outcome. Maternal smoking induces fetal hypoxia and morphological changes in the placenta, which increase the risks of intrauterine growth retardation and placental abruption, which may cause late fetal death and possibly also neonatal mortality. Smoking influences post-neonatal mortality through increased risk of sudden infant death syndrome (SIDS), but why maternal smoking increases the risk of SIDS is essentially unknown. In reducing the overall smoking prevalence in society, general preventive measures have been successful. Such measures, which aim at preventing young girls from starting to smoke are in the long run the most effective way to reduce smoking during pregnancy.

Effects on birthweights of maternal education, socio-economic status, and work-related characteristics.

Birthweights of 3,451 infants of women registered for antenatal care in Uppsala County, Sweden, were analyzed using three different maternal socio-economic indicators; education, socio-economic status and work environment exposure characteristics. Other explanatory variables were maternal age, parity, height, smoking habits, and length of gestation. Mean birthweights increase with longer education and higher socio-economic status. No general pattern was seen for work environment characteristics. When smoking habits are controlled for, social differences in birthweight decrease to non-significant values. A regression model with a socio-economic indicator alone explains only a minor part, less than 1%, of the variation in birthweight. When smoking is included, adding a socio-economic indicator does not significantly improve the model. Practically all social differences in birthweight are related to the differences in maternal age, parity, height, and smoking habits. If a socio-economic indicator is to be included in the analysis of birthweights (for other reasons like international comparisons), we recommend education.

Pregnancy outcome and infant mortality in diabetic patients in Sweden.

Between 1983 and 1986, 914 single births to women with diabetes mellitus before pregnancy and a randomly selected control sample of 4000 births were identified by using the Swedish Medical Birth Registry. Twenty-four percent of diabetic women were delivered preterm, as compared with 6% in the control group. The rates of late fetal death were a 1.3% among infants born to women with diabetes and 0.4% in the control group. Infant mortality was 0.9% and 0.5% among infants to mothers with and without diabetes mellitus, respectively. The increased rates of late fetal and infant deaths in the diabetes group were largely explained by higher mortality in the more prevalent preterm deliveries. Fourteen of 20 late fetal and infant deaths occurred among preterm infants in diabetic pregnancies, while in the control group, 17 of 33 late fetal and infant deaths occurred among preterm infants. Elimination of the increased rates of late fetal death and congenital malformation in diabetic pregnancy is required to meet the goals of the St Vincent Declaration. A nation-wide registry of diabetic pregnancy outcomes is feasible and necessary for further quality assurance of diabetic pregnancies.

Smoking habits and birthweights in two successive births in Sweden.

A population-based longitudinal study of mothers and their first and second infant (both live and single) was conducted to investigate the change in smoking habits from one pregnancy to the next and the effect on infants' birthweights. Of the 57,732 women, 6% quit and 3% started to smoke, 61% were non-smokers and 18% were smokers during both pregnancies. Smoking information on 12% was missing. Compared with women who never smoked, the mean birthweight difference was higher among women who quit smoking and lower among women who started to smoke. Among women who quit smoking, the second birthweight was the same as among women who never smoked. The first infants of women who quit smoking were heavier than those of women who maintained smoking (3392 g vs. 3287 g). Every fourth smoker stopped smoking. Women who quit smoking differed from those who continued to smoke in terms of distribution of age and level of education. Moderate smokers quit smoking more often than heavy smokers.

Social differences in late fetal death and infant mortality in Sweden 1985-86.

Social differences in late fetal death and infant mortality were examined in a population-based prospective study. All singletons born to Nordic citizens in Sweden 1985-86 were included, 185,156 births in all. The overall rates of late fetal death and infant mortality were 3.5 and 5.3 per 1000 respectively. Socio-economic status of the household (SES) and mothers' education were used as social indicators. Logistic regression analyses showed significant odds ratios between 1.3 and 1.8 for late fetal death for blue-collar workers and women with less than 12 years education. The analyses of neonatal mortality showed a U-shaped relationship: both unskilled blue-collar workers and high level white-collar workers had significant odds ratios (OR) as compared with intermediate level white-collar workers (OR = 1.5). Similar results were obtained when using the mothers' education as indicator of social status: 9 years education or less or 15 years or more were associated with significant higher mortality rates than 12 years education (OR = 1.6). An inverse relationship between social status and post-neonatal mortality was seen in the crude analysis. Mothers' education revealed more social differences than SES (crude OR = 2.0 and 1.5 respectively in the least privileged group). However, when adjusting for the effects of maternal age, parity and smoking, no significant odds ratios for the social variables were obtained.

Effects of small doses of bisoprolol on blood pressure and lipoprotein concentrations in hypertensive patients.

The effects of bisoprolol 2.5 and 5 mg per day on blood pressure, and lipoprotein and apolipoprotein concentrations were compared in 18 newly detected hypertensives in a double-blind, crossover study. All treatment results were related to the values at the end of a four-week placebo run-in period. Each of the two following treatment periods lasted for 3 months. The systolic and diastolic pressures in the supine position were reduced by 19.5/11.7 mm Hg and 14.6/10.4 mm Hg by 2.5 and 5 mg bisoprolol per day, respectively, with no significant difference in effect. Supine heart rate was reduced by 4.7 and 8.2 beats.min-1, respectively, (P = 0.0517 for different effects). The cholesterol concentration in low-density (LDL) and high-density (HDL) lipoproteins was reduced during both regimens, by about 0.3 and 0.1 mmol.l-1, respectively, difference not significant. Triglyceride concentrations were not significantly affected during either regimen. We conclude that, in this study population, treatment with bisoprolol 2.5 mg per day was equally effective as 5.0 mg per day in reducing blood pressure. The effects on lipoprotein concentrations were small and included an unexpected reduction in LDL-cholesterol concentration. A low dose of a highly selective beta-adrenoceptor blocker like bisoprolol appears to retain the blood pressure reducing capacity and has lost most of the unfavourable effects on lipoproteins characteristic of higher doses.

Social differences in Swedish infant mortality by cause of death, 1983 to 1986.

OBJECTIVE: We sought to investigate social differences in Swedish infant mortality by cause of death. METHODS: All live single births in Sweden between 1983 and 1986 to mothers 15 to 44 years old with Nordic citizenship were studied. The causes of death were classified into six major groups. Mother's education was used as a social indicator. Logistic regression analysis was used with identical models for all groups of causes of death. RESULTS: There were 355,601 births and 2012 infant deaths. Only for sudden infant death syndrome were significant social differences found, with crude odds ratios of 2.6 for mothers with less than 10 years of education and of 1.9 for mothers with 10 to 11 years, compared with 1.0 for mothers with 15 years or more. After adjusting for age, parity, and smoking habits, these ratios were no longer significant. CONCLUSIONS: The social differences obtained could be explained by the fact that mothers with less education smoke more, are younger, and have higher parity than those with more education.

Predictors of mortality for the oldest old. A 4-year follow-up of community-based elderly in Sweden.

The aim of this study is to investigate predictors for mortality in two age groups, 75-84 years old and 85 years and older. Interviews were carried out on 161 community-based persons aged 75-84 and 260 persons aged 85 and over. Predictors for mortality 4 years later were analyzed using logistic regression. Different models to predict mortality were found for the two age groups. Gender and IADL (Instrumental Activities of Daily Living) were found to be significant for the older group while ADL (Primary Activities of Daily Living), mobility and life satisfaction were significant for the younger group. Eliminating variables based on the nurse's evaluations did not change the model for the 85+ age group; in the 75-84 age group the nurse's assessment of ADL was replaced by a self-reported IADL index. Results confirm the heterogeneity of the elderly population and the importance of ADL and subjective measures for predicting mortality.

Screening for Chlamydia trachomatis infection in women and aspects of the laboratory diagnostics.

Nine hundred and thirty-three women who attended consecutively a gynecological clinic for various symptoms, for abortion, or for contraceptives, were screened for genital Chlamydia trachomatis infection. A total of 95 (10.2%) women were found infected. Of women below 25 years of age, 13.4% were infected, as compared with 4.9% over 25. Women with symptoms of genital infection were not over-represented in the infected population. Enzyme immunoassays (EIA) verified with a direct fluorescence antigen test were evaluated and compared with culture controls. Reactive samples detected using EIA were regarded as true positive if they were also positive according to the verification test. The sensitivity of the verified EIA test was 91%, the specificity 100%, the positive predictive value 100% and the negative predictive value was 99%. The sensitivity of the culture was 90%. Low age is the most predictable risk factor for genital Chlamydia trachomatis infection. Compared with cultures, EIA verified with a direct fluorescence antigen test is a rapid and effective method for clinical use.

PIP: 933 women who attended a gynecologic clinic for the treatment of various symptoms, to receive contraceptives, or to undergo abortion were screened for genital Chlamydia trachomatis infection. A total of 95 *10.2%) women were found to be infected. Of the women under age 25, 13.4% were infected, as compared with 4.9% over the age of 25. Women with genital infection symptoms were not overrepresented in the infected population. Enzyme immunoassays (EIA) verified with a direct fluorescence antigen test were evaluated and compared with culture controls. Reactive samples detected using EIA were regarded as being true positive if they were also positive according to the verification test. The sensitivity of the verified EIA test was 91%, the specificity 100%., the positive predictive valued 100%, and the negative predictive value 99%. The sensitivity of the culture was 90%. Low age is the most predictable risk factor for genital Chlamydia trachomatis infection. Compared with cultures. EIA verified with a direct fluorescence antigen test is a rapid and effective method for clinical use.

Plasma levels of levonorgestrel and free levonorgestrel index in women using NORPLANT implants or two covered rods (NORPLANT-2).

Plasma levels of levonorgestrel, sex hormone binding globulin (SHBG) and estradiol were studied during four years in 283 healthy women using either NORPLANT implants or two covered rods (NORPLANT-2). The women were randomized to use either type of implant. Both implant systems have previously been shown to have similar release rates of levonorgestrel. In both groups plasma levels of levonorgestrel decreased throughout the study, and there were no statistically significant differences between the two groups in mean plasma levels of levonorgestrel. During the study 8 women became pregnant. All pregnancies but one occurred after 35 months of implant use and only in women using the covered rods. No significant differences were seen between the women who became pregnant and the rest of the group using two covered rods with respect to plasma levels of levonorgestrel. SHBG capacity tended to be somewhat higher in women using the two covered rods. As levonorgestrel is to a great extent bound to SHBG, and in that form not biologically active, a "free levonorgestrel index" was calculated as a ratio between levonorgestrel and SHBG. This index was significantly lower in users of two covered rods than in users of NORPLANT implants at 1, 12 and 48 months of use. Women who became pregnant had significantly lower "free levonorgestrel index" than had the rest of the group. It is postulated that the difference in "free levonorgestrel index" between users of the two implant systems reflect differences in release rate, the covered rods having a lower release rate of levonorgestrel than NORPLANT throughout the observation period. It is concluded that "free levonorgestrel index" is a better parameter than levonorgestrel plasma levels to describe implant function, and to discriminate women who are at risk of pregnancy.

PIP: The plasma levels of levonorgestrel, sex hormone binding globulin (SHBG), and estradiol were compared over a 4-year period in 283 users of 2 types of Norplant systems--implants and covered rods. Plasma levels of norgestrel decreased throughout the study period in both groups, and there were no significant differences in mean plasma levels of levonorgestrel. 7 of the 8 pregnancies recorded during the study occurred after 35 months of implant use, and all involved women in the covered rods group. No significant differences were found between the women who became pregnant and the rest of the study subjects in terms of plasma levels of levonorgestrel. SHBG capacity was slightly higher in women using the 2 covered rods. The free levonorgestrel index, calculated as a ratio between levonorgestrel and SHBG, was significantly lower in users of 2 covered rods than in users of implant capsules at 1, 12, and 48 months of use. In addition, women who became pregnant had a significantly lower free levonorgestrel index. These findings suggest that the 2 covered rods had a lower release rate of levonorgestrel than Norplant implants, despite almost identical plasma levels. Thus, the free levonorgestrel index is considered a better parameter than levonorgestrel plasma concentrations to describe implant function and to predict the risk of pregnancy.