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Dimenäs SL, Jönsson B, Lundin M, Lundgren J, Abrahamsson KH. Changing from disease-centred to person-centred - Swedish dental hygienists' views on a theory-based behavioural intervention for improved oral hygiene among adolescents. Int J Dent Hyg 2024. [PMID: 38659277 DOI: 10.1111/idh.12811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 02/22/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVES To explore dental hygienists' (DHs') views on (i) a person-centred, theory-based, behavioural intervention for improving oral hygiene among adolescents and (ii) professional and organizational factors to consider in the implementation of such an intervention in daily dental practice. METHODS Semi-structured interviews were conducted with 13 DHs who had applied the person-centred, theory-based, behavioural intervention directed at adolescents with poor oral hygiene in a field study within the Public Dental Service, Region Västra Götaland, Sweden. The interviews were audio-taped, transcribed verbatim and analysed using qualitative content analysis. RESULTS The main theme 'From individual experts to partners - DHs changing direction from a disease-centred towards a person-centred approach' illustrated a changed professional approach among DHs, from exerting their roles as experts to encouraging partnership in treatment by supporting the adolescents in taking health behavioural decisions and responsibility for their oral health. The DHs considered the changed approach as challenging, but also more enjoyable, compared to conventional information/instruction. Adequate knowledge and skills, personal interest and willingness for a change as well as support from colleagues and clinic management were identified as prerequisites for implementing the person-centred, theory-based, behavioural intervention in daily practice, while the expenditure of time needed in relation to economic demands in care were seen as barriers. CONCLUSIONS The findings elucidate that DHs considered the application of a person-centred, theory-based, behavioural intervention to be challenging but also enjoyable. For such an intervention to be implemented in daily practice, prerequisites and barriers need to be considered on both personal/professional and organizational levels.
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Dimenäs SL, Andersson JS, Jönsson B, Lundgren J, Petzold M, Östberg AL, Abrahamsson KH. Adolescents' self-reported experiences following a person-centred, theory-based educational intervention versus conventional education for improved oral hygiene: Analysis of secondary outcomes of a randomized field study. J Clin Periodontol 2024; 51:63-73. [PMID: 37822115 DOI: 10.1111/jcpe.13883] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/11/2023] [Accepted: 09/12/2023] [Indexed: 10/13/2023]
Abstract
AIM To analyse adolescents' self-reported experiences and behavioural outcomes of a person-centred, theory-based intervention in comparison with conventional information/instruction for improved oral hygiene. MATERIALS AND METHODS Data were derived from a prospective, multi-centred, two-arm, quasi-randomized field study focusing on the effectiveness of educational interventions for improved oral hygiene. Dental hygienists working within the Public Dental Service, Västra Götaland, Sweden, provided treatments, and adolescents with poor oral hygiene conditions were eligible for participation. The person-centred test intervention was based on social cognitive constructs, and motivational interviewing was used as an approach in communication. The control intervention included conventional information/instructions. Clinical examinations were performed, and questionnaires were distributed at baseline and at 6 months. Three-hundred and twelve patients were enrolled, and data from 276 patients, following treatment per protocol, were analysed. RESULTS The test group was more satisfied with the education about gingivitis (very good: 61% vs. 37%) and communication during therapy (very good: 69% vs. 50%) and reported to a larger extent that they were much more careful regarding their oral hygiene after the treatment (30% vs. 15%) and had higher confidence about keeping up healthy gingival conditions, in comparison with the control group (all p < .01). CONCLUSIONS The person-centred, theory-based intervention was superior in terms of adolescents' experiences of education and communication during therapy and self-reported oral hygiene behavioural outcomes at 6 months, in comparison with conventional information/instruction.
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Eriksson MCM, Lindblad U, Daka B, Lundgren J. Validation of a single question to measure internal health locus of control in Swedish primary care. Scand J Psychol 2023; 64:674-678. [PMID: 37102405 DOI: 10.1111/sjop.12923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/22/2023] [Accepted: 04/04/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Behavioral risk factors are highlighted in the prevention of diabetes and cardiovascular disease. Screening for health locus of control could be a feasible way to better identify individuals who could benefit from preventive behavioral change interventions. The aim of the study was to investigate the correlation between a single question measuring internal health locus of control (IHLC) and the Multidimensional Health Locus of Control Scale (MHLC) and to assess how IHLC relates to the General Self-Efficacy scale (GSE) in a primary care setting. METHODS Primary care patients, aged 18 and older, attending three primary care centers in southwest Sweden were consecutively asked to anonymously participate in the study. The patients were given a questionnaire and instructed to return the questionnaire in a sealed box in the waiting room. RESULTS In all, 519 patients were included. The correlation between MHLC Internality and IHLC was weak (r = 0.21, p < 0.001). An increase of one point on the internality scale of the MHLC gave an odds ratio of 1.19 (95% CI 1.11-1.28) for reporting high IHLC, and thus a five-point increase gave a doubled likelihood, OR = 2.40, CI 1.67-3.46. The results for the other scales of the MHLC and GSE were similar. CONCLUSION In this study, we found weak but statistically significant support for the single-question IHLC as a measure of internal health locus of control. Given that the correlation was weak, we recommend using the MHLC when possible.
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Eék N, Sundström C, Kraepelien M, Lundgren J, Kaldo V, Berman AH. High- versus low-intensity internet interventions for alcohol use disorders (AUD): A two-year follow-up of a single-blind randomized controlled trial. Internet Interv 2023; 33:100630. [PMID: 37293578 PMCID: PMC10244691 DOI: 10.1016/j.invent.2023.100630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 05/11/2023] [Accepted: 05/17/2023] [Indexed: 06/10/2023] Open
Abstract
Alcohol Use Disorders (AUD) are widespread and have serious consequences, but are among the most undertreated mental disorders. Internet interventions have been found effective in treating AUD, but we know little about long-term outcomes, two years or more after treatment. This study explored 12- and 24-month outcomes in alcohol consumption following initial 6-month improvements after a therapist-guided high-intensity internet intervention and an unguided low-intensity internet intervention among individuals with alcohol use disorder. Between-group comparisons were analyzed, as well as within-group comparisons with (1) pre-treatment measurements (2) post-treatment measurements. Participants consisted of a general population sample of internet help-seekers in Sweden. A total of 143 adults (47% men) with a score of 14 (women)/16 (men) or more on the Alcohol Use Disorders Identification Test, alcohol consumption of 11 (women)/14 (men) or more standard drinks the preceding week and ≥ 2 DSM-5 alcohol use disorder (AUD) criteria based on a diagnostic interview were included. The high- and low-intensity internet interventions (n = 72 and n = 71 respectively) consisted of modules based on relapse prevention and cognitive-behavioral therapy. The primary outcome was self-reported alcohol consumption in the preceding week measured as (1) number of standard drinks and (2) number of heavy drinking days. Attrition from self-reported questionnaires was 36% at the 12-month follow-up and 53% at the 24-month follow-up. No significant between-group differences occurred in outcomes at either long-term follow-up. Regarding within-group differences, compared to pre-treatment, alcohol consumption was lower in both high- and low-intensity interventions at both long-term follow-ups [within-group standard drinks effect sizes varied between g = 0.38-1.04 and heavy drinking days effect sizes varied between g = 0.65-0.94]. Compared to post-treatment, within-group alcohol consumption in the high intensity intervention increased at both follow-ups; for the low-intensity intervention, within-group consumption decreased at 12-month follow-up, but did not differ compared to post-treatment at 24 months. Both high- and low-intensity internet interventions for AUD were thus associated with overall reductions in alcohol consumption at long term follow-ups, with no significant differences between the two. However, conclusions are hampered by differential and non-differential attrition.
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Terrones-Campos C, Ledergerber B, Forbes N, Smith AG, Petersen J, Helleberg M, Lundgren J, Specht L, Vogelius IR. Prediction of Radiation-induced Lymphopenia following Exposure of the Thoracic Region and Associated Risk of Infections and Mortality. Clin Oncol (R Coll Radiol) 2023; 35:e434-e444. [PMID: 37149425 DOI: 10.1016/j.clon.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/08/2023] [Accepted: 04/11/2023] [Indexed: 05/08/2023]
Abstract
AIMS Large blood volumes are irradiated when the heart is exposed to radiation. The mean heart dose (MHD) may be a good surrogate for circulating lymphocytes exposure. We investigated the association between MHD and radiation-induced lymphopenia and explored the impact of the end-of-radiation-therapy (EoRT) lymphocyte count on clinical outcomes. MATERIALS AND METHODS In total, 915 patients were analysed: 303 patients with breast cancer and 612 with intrathoracic tumours: oesophageal cancer (291), non-small cell lung cancer (265) and small cell lung cancer (56). Heart contours were generated using an interactive deep learning delineation process and an individual dose volume histogram for each heart was obtained. A dose volume histogram for the body was extracted from the clinical systems. We compared different models analysing the effect of heart dosimetry on the EoRT lymphocyte count using multivariable linear regression and assessed goodness of fit. We published interactive nomograms for the best models. The association of the degree of EoRT lymphopenia with clinical outcomes (overall survival, cancer treatment failure and infection) was investigated. RESULTS An increasing low dose bath to the body and MHD were associated with a low EoRT lymphocyte count. The best models for intrathoracic tumours included dosimetric parameters, age, gender, number of fractions, concomitant chemotherapy and pre-treatment lymphocyte count. Models for patients with breast cancer showed no improvement when adding dosimetric variables to the clinical predictors. EoRT lymphopenia grade ≥3 was associated with decreased survival and increased risk of infections among patients with intrathoracic tumours. CONCLUSION Among patients with intrathoracic tumours, radiation exposure to the heart contributes to lymphopenia and low levels of peripheral lymphocytes after radiotherapy are associated with worse clinical outcomes.
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Eriksson MCM, Lundgren J, Hellgren M, Li Y, Björkelund C, Lindblad U, Daka B. Association between low internal health locus of control, psychological distress and insulin resistance. An exploratory study. PLoS One 2023; 18:e0285974. [PMID: 37216359 DOI: 10.1371/journal.pone.0285974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/07/2023] [Indexed: 05/24/2023] Open
Abstract
AIM To assess the hypothesis that low internal health locus of control (IHLC) and psychological distress (PD) are associated with insulin resistance. MATERIALS AND METHODS In 2002-2005, a random population sample of 2,816 men and women aged 30-74 years participated (76%) in two municipalities in southwestern Sweden. This study included 2,439 participants without previously known diabetes or cardiovascular disease. IHLC was measured by a global scale and PD was measured by the 12-item General Health Questionnaire. Insulin resistance was estimated using HOMA-ir. General linear models were used to estimate differences in HOMA-ir between groups with low IHLC, PD, and both low IHLC and PD, respectively. RESULTS Five per cent (n = 138) had both PD and low IHLC, 62 per cent of participants (n = 1509) had neither low IHLC nor PD, 18 per cent (n = 432) had PD, and 15 per cent (n = 360) low IHLC. Participants with both low IHLC and PD had significantly higher HOMA-ir than participants with neither low IHLC nor PD (Δ = 24.8%, 95%CI: 12.0-38.9), also in the fully adjusted model (Δ = 11.8%, 95%CI: 1.5-23.0). Participants with PD had significantly higher HOMA-ir (Δ = 12%, 95%CI: 5.7-18.7), but the significance was lost when BMI was included in the model (Δ = 5.3%, 95%CI:0.0-10.8). Similarly, participants with low IHLC had significantly higher HOMA-ir (Δ = 10.1%, 95%CI: 3.5-17.0) but the significance was lost in the fully adjusted model (Δ = 3.5%, 95%CI: -1.9-9.3). CONCLUSIONS Internal health locus of control (IHLC) and psychological distress (PD) were associated with insulin resistance. Especially individuals with both PD and low IHLC may need special attention.
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Dimenäs SL, Östberg A, Lundin M, Lundgren J, Abrahamsson KH. Adolescents' experiences of a theory-based behavioural intervention for improved oral hygiene: A qualitative interview study. Int J Dent Hyg 2022; 20:609-619. [PMID: 35925040 PMCID: PMC9804348 DOI: 10.1111/idh.12606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/16/2022] [Accepted: 07/31/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Adequate oral hygiene, that is self-performed infection control, is crucial to prevent periodontal disease. Epidemiological studies reveal poor oral hygiene conditions among Swedish adolescents and indicate a need for more effective prevention programs. The aim of the current study was to analyse adolescents' experiences of a person-centred, theory-based, oral health education program for improved oral hygiene. METHODS Data were obtained by interviewing 19 adolescents treated by dental hygienists in accord with the person-centred education program in a preceding clinical field study (ClinicalTrials.gov NCT02906098). Study participants were selected to reflect a variation of male and female adolescents, treated at clinics in areas with various socio-demographic profiles within Region Västra Götaland, Sweden. Interviews were audio-taped, transcribed verbatim and analysed with qualitative content analysis. RESULTS A main theme was identified: 'Adolescents on a guided and challenging journey towards beneficial oral hygiene behavior'. The results elucidate the importance of a person-centred approach in therapy. The adolescents described insight on a personal level about the importance of improved oral hygiene as fundamental for behavioural change. Planning and monitoring of the behaviour, with guidance and support by the dental hygienist, was considered to facilitate change and encouraged further behavioural efforts. However, the adolescents expressed a need of reminders and support to keep up oral hygiene routines over time. CONCLUSIONS The study brings knowledge on factors of importance in educational interventions to increase beneficial health behaviours among adolescents and emphasize areas for further improvements of such interventions.
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Mourad G, Lundgren J, Andersson G, Husberg M, Johansson P. Cost-effectiveness of Internet-delivered cognitive behavioural therapy in patients with cardiovascular disease and depressive symptoms. Eur J Cardiovasc Nurs 2022. [DOI: 10.1093/eurjcn/zvac060.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public hospital(s). Main funding source(s): The Swedish Research Council and the Medical Research of Southeast Sweden
Introduction
Cost-effectiveness evaluations of psychological interventions, such as Internet-delivered cognitive behavioural therapy (iCBT) programs, in patients with cardiovascular disease (CVD) are rare. In a recent study we reported that a 9-week iCBT program (n=72) compared to an online discussion forum (ODF) (n=72) had moderate to large effect on depression in CVD outpatients.
Purpose
To evaluate the cost-effectiveness of this intervention.
Methods
Cost-effectiveness analysis of a RCT, using an incremental cost-effectiveness ratio (ICER). The costs and effects included in the ICER are from baseline to one year post intervention, but also costs for guidance and support to patients in iCBT and ODF groups. Data on healthcare costs were retrieved from healthcare registries, and the EQ-5D-3L was used to calculate the quality-adjusted life years (QALYs). The ICER can be seen as the additional costs needed to gain an additional QALY by the iCBT compared to ODF.
Results
At 12-month follow-up, the QALY was significantly higher in iCBT compared to the ODF group (0.713 vs.0.598, p=.007). The mean difference of 0.115 corresponds with 42 extra days in best imaginable health status in favour of the iCBT group over the course of one year. The ICER for iCBT versus ODF was €18,865 per QALY saved. The cost-effectiveness plane indicated that iCBT is a cheaper and more effective intervention in 24.5% of the cases, and in 75% a costlier and more effective intervention than ODF. Only in about 0.5% of the cases, there was an indication of a costlier, but less effective intervention compared to ODF.
Conclusions
The ICER of €18,865 was lower than the cost-effectiveness threshold range of €23,400-€35,100 as proposed by the NICE guidelines, suggesting that the iCBT treatment of depressive symptoms in patients with CVD is cost-effective.
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Westas M, Mourad G, Andersson G, Lundgren J, Johansson P. Effects of internet-delivered cognitive behavioral therapy for patients with cardiovascular disease and depression on quality of life. A sub-analysis of a randomized controlled trial. Eur J Cardiovasc Nurs 2022. [DOI: 10.1093/eurjcn/zvac060.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish Research Council (2015-02600), ALF grants Region Östergötland (LIO-600321 and LIO-687531)
Background
In patients with cardiovascular disease (CVD), depression can cause poorer Health-Related Quality of Life (HRQoL). However, less is known about whether changes in depression over time are associated with changes in HRQoL. We have recently shown that a 9-week internet-based cognitive behavioral therapy (iCBT) program had a significant positive treatment effect on depression in CVD patients and that this effect was maintained at 12-month follow-up. If long-term improvements in depression corresponded to improvements in HRQoL was however not investigated.
Purpose
To explore if changes in depression after 9 weeks of iCBT are associated with changes in HRQoL at 12 months follow-up.
Methods
This study is a sub-analysis of a randomized controlled trial evaluating the effects of a nine-week iCBT program for depression in CVD patients. Data from patients who had performed iCBT were analyzed (n=72). Patient Health Questionnaire-9 (PHQ-9) was used to measure depression. The 12-Item Short Form Health Survey (SF12) including the Mental Component Score (MCS) and the Physical Component Score (PCS), and the EQ Visual Analogue Scale (EQ-VAS) were used to measure HRQoL. Data was collected at baseline, 9 weeks, 6 months, and 12 months. Linear mixed model was used to explore long-term treatment effects on HRQoL. Pearson correlation was used to explore the association between changes in depression and HRQoL at 12-month follow-up.
Results
There was a significant improved treatment effect of iCBT on HRQoL after 12-months (MCS p<.001, PCS p<.032, and EQ-VAS p<.001). Decreased depression was correlated with improved HRQoL after 12-months. The correlation scores between changes in depression and HRQoL were: MCS p<.001, r=-0.62; PCS p<.001, r=-.34; and EQ-VAS r=-.57, p<.001respectively.
Conclusion
Long term improvement in depression was associated with improvement in HRQoL (Figure 1). Interventions that improve depression in CVD patients are also likely to have sustained positive effect on HRQoL.
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Eriksson-Liebon M, Lundgren J, Rytterstrom P, Johansson P, Mourad G. The experience of internet-delivered cognitive behavioural therapy among patients with non-cardiac chest pain. Eur J Cardiovasc Nurs 2022. [DOI: 10.1093/eurjcn/zvac060.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Kamprad Family Foundation
Region Östergötland
Background
Non-cardiac chest pain (NCCP) is a common health problem at emergency departments. Many patients are discharged with no further explanation regarding the cause of their chest pain. Recurring chest pain, functional limitations and cardiac anxiety affect lives of patients with NCCP and lead to increased healthcare use. Hence, we developed and tested a five-week, nurse-led iCBT program adapted to patients with NCCP in order to improve psychological distress and other patient-reported outcomes. This study was aimed to explore the experiences of patients with NCCP and cardiac anxiety regarding their participation in the iCBT program.
Methods
A qualitative interview study using content analysis to explore the experiences of patients participating in the iCBT program. The data was collected by individual face-to-face interviews with 16 patients after their participation in the iCBT using a semi-structured interview guide.
Results
The study resulted in three categories and eight subcategories, presented in Table 1. "Driving factors for participation in the iCBT program" was the first category and described the impact of pain on patients´ lives and their struggle before participating in the program. The second, "The program facilitates change", described how the program helped them make changes regarding pain, fear and anxiety. The last category, "Learning to live with chest pain", described the program as a tool for gaining the strength and skills to live a normal life despite chest pain.
Conclusions
The life impacted by recurrent chest pain, anxiety and feeling of being disregarded by healthcare was commonly experienced by participants. The invitation to the program was perceived as an opportunity to return to a normal life, without fear or chest pain. By being trustworthy, supportive and encouraging, the program helped participants to challenge their fear, and gain the strength and new insights they needed to live a normal life.
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Dimenäs SL, Jönsson B, Andersson JS, Lundgren J, Petzold M, Abrahamsson I, Abrahamsson KH. A person-centred, theory-based, behavioural intervention programme for improved oral hygiene in adolescents: A randomized clinical field study. J Clin Periodontol 2022; 49:378-387. [PMID: 35132653 PMCID: PMC9306963 DOI: 10.1111/jcpe.13601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/21/2021] [Accepted: 01/31/2022] [Indexed: 11/30/2022]
Abstract
Aim To test the effectiveness of a person‐centred and theory‐based educational intervention to increase adolescents′ adherence to adequate oral hygiene behaviour, that is, self‐performed periodontal infection control. Materials and Methods Data were derived from a prospective, multi‐centred, two‐arm, quasi‐randomized field study in which treatment was performed by dental hygienists (DHs) within the Public Dental Service, Västra Götaland, Sweden. Adolescents with poor oral hygiene conditions were invited to participate. The test intervention was based on cognitive behavioural theory and principles, and the DHs used a collaborative communicative approach, inspired by motivational interviewing. The control intervention consisted of conventional information/instruction. Clinical assessments and oral hygiene behaviours were evaluated at 6 months. Results Three‐hundred and twelve adolescents were enrolled, of whom 274 followed the treatment to 6‐month follow‐up. There were significant improvements in gingival bleeding and plaque scores for both treatment groups at 6 months, with significantly greater improvements in the test group. Adolescents in the test group brushed their teeth and used interdental cleaning aids more frequently compared to participants in the control group at 6 months. Conclusion A person‐centred and theory‐based oral health education programme is more effective than conventional oral health education in improving adolescents' oral hygiene behaviour and periodontal infection control. ClinicalTrials.gov (NCT02906098).
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Helleberg M, Niemann CU, Moestrup KS, Kirk O, Lebech AM, Lundgren J. Response to Aviv et al. J Infect Dis 2021; 224:559-561. [PMID: 33964164 PMCID: PMC8136013 DOI: 10.1093/infdis/jiab249] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/04/2021] [Indexed: 11/25/2022] Open
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Baxter JD, Dunn D, Tostevin A, Marvig RL, Bennedbaek M, Cozzi-Lepri A, Sharma S, Kozal MJ, Gompels M, Pinto AN, Lundgren J. Transmitted HIV-1 drug resistance in a large international cohort using next-generation sequencing: results from the Strategic Timing of Antiretroviral Treatment (START) study. HIV Med 2021; 22:360-371. [PMID: 33369017 PMCID: PMC8049964 DOI: 10.1111/hiv.13038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/11/2020] [Accepted: 11/10/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The aim of this analysis was to characterize transmitted drug resistance (TDR) in Strategic Timing of Antiretroviral Treatment (START) study participants by next-generation sequencing (NGS), a sensitive assay capable of detecting low-frequency variants. METHODS Stored plasma from participants with entry HIV RNA > 1000 copies/mL were analysed by NGS (Illumina MiSeq). TDR was based on the WHO 2009 surveillance definition with the addition of reverse transcriptase (RT) mutations T215N and E138K, and integrase strand transfer inhibitor (INSTI) surveillance mutations (Stanford HIVdb). Drug resistance mutations (DRMs) detected at three thresholds are reported: > 2%, 5% and 20% of the viral population. RESULTS Between 2009 and 2013, START enrolled 4684 antiretroviral therapy (ART)-naïve individuals in 35 countries. Baseline NGS data at study entry were available for 2902 participants. Overall prevalence rates of TDR using a detection threshold of 2%/5%/20% were 9.2%/5.6%/3.2% for nucleoside reverse transcriptase inhibitors (NRTIs), 9.2%/6.6%/4.9% for non-NRTIs, 11.4%/5.5%/2.4% for protease inhibitors (PIs) and 3.5%/1.6%/0.1% for INSTI DRMs and varied by geographic region. Using the 2% detection threshold, individual DRMs with the highest prevalence were: PI M46IL (5.5%), RT K103NS (3.5%), RT G190ASE (3.1%), T215ISCDVEN (2.5%), RT M41L (2.2%), RT K219QENR (1.7%) and PI D30N (1.6%). INSTI DRMs were detected almost exclusively below the 20% detection threshold, most commonly Y143H (0.4%), Q148R (0.4%) and T66I (0.4%). CONCLUSIONS Use of NGS in this study population resulted in the detection of a large proportion of low-level variants which would not have been detected by traditional Sanger sequencing. Global surveillance studies utilizing NGS should provide a more comprehensive assessment of TDR prevalence in different regions of the world.
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Terrones Campos C, Ledergerber B, Vogelius I, Helleberg M, Specht L, Lundgren J. PO-1817: Kinetics and dose-volume effect of radiotherapy on leucocyte and platelet blood cell components. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01835-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Mortensen SB, Hansen AE, Lundgren J, Barfod TS, Ambye L, Dunø M, Schade Larsen C, Andersen DC, Jakobsen MA, Johansen IS. Characteristics of patients with familial Mediterranean fever in Denmark: a retrospective nationwide register-based cohort study. Scand J Rheumatol 2020; 49:489-497. [PMID: 32608308 DOI: 10.1080/03009742.2020.1756400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objectives: To investigate epidemiology, demography, and genetic and clinical characteristics of patients with familial Mediterranean fever (FMF) in Denmark. Method: In this population-based, cross-sectional cohort study, we identified FMF patients from discharge diagnoses using ICD-10 codes in the Danish National Patient Register, and linked data from the Danish Civil Registration System and laboratory databases for results of MEFV gene variant screening. Results: We identified 495 FMF patients (prevalence 1:11 680) with a median age of 29 years and a female ratio of 51%. The median age at diagnosis of FMF was 13 (IQR 7-22) years, with an estimated median diagnostic delay of 3 (IQR 0.7-6.9) years. The predominant ethnicities were Turkish (41.8%), Lebanese (15.8%), Syrian (6.5%), South-West Asian (7.9%), and South-East Asian (3.0%). The MEFV genotype distribution was 18.7% homozygous, 21.2% compound heterozygous, 32.0% heterozygous, 11.0% with complex alleles or unresolved zygosity, and 17.1% with no detected variants. M694V was the most prevalent variant in the overall cohort (32.5%). Homozygous or compound heterozygous MEFV exon 10 variants were associated with younger age at diagnosis (p < 0.001) and reduced number of hospital contacts before diagnosis (p = 0.008). The Charlson Comorbidity Index was ≥ 2 in 8.1% of patients. The prevalence of amyloidosis was 1.0%. Conclusions: FMF in Denmark is rare and patients are mainly of Eastern Mediterranean ethnicity. Diagnostic delay was long but patients with exon 10 MEFV variants were diagnosed at a younger age. Prolonged diagnostic delay is probably caused by lack of FMF awareness in the Danish healthcare system.
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Fägerstad A, Lundgren J, Arnrup K, Carlson E. Barriers and facilitators for adolescent girls to take on adult responsibility for dental care - a qualitative study. Int J Qual Stud Health Well-being 2019; 14:1678971. [PMID: 31608818 PMCID: PMC6807868 DOI: 10.1080/17482631.2019.1678971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2019] [Indexed: 11/03/2022] Open
Abstract
Purpose: This study aims to explore and describe experiences of the dental care system among adolescent dental patients with a recent history of missed dental appointments at public dental clinics (PDCs) in a Swedish county. Methods: Twelve adolescent girls participated in the study. Data were collected by individual, semi-structured, open-ended interviews and analysed with qualitative content analysis. Results: The study findings could be summed into the theme "Triggers for adolescent girls to take on or not take on adult responsibility for dental care". The experience of free dental care could be summarized in five main categories: Pain and discomfort; Attractive and healthy teeth; Feeling safe and secure; Taking on the responsibility; and Free of charge. These five categories consisted of 15 subcategories. Conclusions: The results of this study should increase the knowledge on how to meet and treat adolescent girls in dental care. Knowing what will happen during the dental visit was highlighted by the participants as decisive to whether or not they would attend their dental appointments. Therefore, we should as far as possible ensure that our patients feel safe at their dental visits and by trying to avoid painful treatments.
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Hasse B, Hannan MM, Keller PM, Maurer FP, Sommerstein R, Mertz D, Wagner D, Fernández-Hidalgo N, Nomura J, Manfrin V, Bettex D, Hernandez Conte A, Durante-Mangoni E, Tang THC, Stuart RL, Lundgren J, Gordon S, Jarashow MC, Schreiber PW, Niemann S, Kohl TA, Daley CL, Stewardson AJ, Whitener CJ, Perkins K, Plachouras D, Lamagni T, Chand M, Freiberger T, Zweifel S, Sander P, Schulthess B, Scriven JE, Sax H, van Ingen J, Mestres CA, Diekema D, Brown-Elliott BA, Wallace RJ, Baddour LM, Miro JM, Hoen B, Athan E, Bayer A, Barsic B, Corey GR, Chu VH, Durack DT, Fortes CQ, Fowler V, Hoen B, Krachmer AW, Durante-Magnoni E, Miro JM, Wilson WR. International Society of Cardiovascular Infectious Diseases Guidelines for the Diagnosis, Treatment and Prevention of Disseminated Mycobacterium chimaera Infection Following Cardiac Surgery with Cardiopulmonary Bypass. J Hosp Infect 2019; 104:214-235. [PMID: 31715282 DOI: 10.1016/j.jhin.2019.10.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 10/08/2019] [Indexed: 02/09/2023]
Abstract
Mycobacterial infection-related morbidity and mortality in patients following cardiopulmonary bypass surgery is high and there is a growing need for a consensus-based expert opinion to provide international guidance for diagnosing, preventing and treating in these patients. In this document the International Society for Cardiovascular Infectious Diseases (ISCVID) covers aspects of prevention (field of hospital epidemiology), clinical management (infectious disease specialists, cardiac surgeons, ophthalmologists, others), laboratory diagnostics (microbiologists, molecular diagnostics), device management (perfusionists, cardiac surgeons) and public health aspects.
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Petersen N, Knudsen AD, Mocroft A, Kirkegaard-Klitbo D, Arici E, Lundgren J, Benfield T, Oturai P, Nordestgaard BG, Feldt-Rasmussen B, Nielsen SD, Ryom L. Prevalence of impaired renal function in virologically suppressed people living with HIV compared with controls: the Copenhagen Comorbidity in HIV Infection (COCOMO) study. HIV Med 2019; 20:639-647. [PMID: 31359592 DOI: 10.1111/hiv.12778] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES While renal impairment is reported more frequently in people living with HIV (PLWH) than in the general population, the PLWH samples in previous studies have generally been dominated by those at high renal risk. METHODS Caucasian PLWH who were virologically suppressed on antiretroviral treatment and did not have injecting drug use or hepatitis C were recruited from the Copenhagen Comorbidity in HIV Infection (COCOMO) study. Sex- and age-matched controls were recruited 1:4 from the Copenhagen General Population Study up to November 2016. We defined renal impairment as one measurement of estimated glomerular filtration rate ≤ 60 mL/min/1.73 m2 , and assessed associated factors using adjusted logistic regression models. The impact of HIV-related factors was explored in a subanalysis. RESULTS Among 598 PLWH and 2598 controls, the prevalence of renal impairment was 3.7% [95% confidence interval (CI) 2.3-5.5%] and 1.7% (95% CI 1.2-2.2%; P = 0.0014), respectively. After adjustment, HIV status was independently associated with renal impairment [odds ratio (OR) 3.4; 95% CI 1.8-6.3]. In addition, older age [OR 5.4 (95% CI 3.9-7.5) per 10 years], female sex [OR 5.0 (95% CI 2.6-9.8)] and diabetes [OR 2.9 (95% CI 1.3-6.7)] were strongly associated with renal impairment. The association between HIV status and renal impairment became stronger with older age (P = 0.02 for interaction). Current and nadir CD4 counts, duration of HIV infection and previous AIDS-defining diagnosis were not associated with renal impairment among virologically suppressed PLWH. CONCLUSIONS The prevalence of renal impairment is low among low-risk virologically suppressed Caucasian PLWH, but remains significantly higher than in controls. Renal impairment therefore remains a concern in all PLWH and requires ongoing attention.
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Campos CT, Ledergerber B, Vogelius I, Helleberg M, Specht L, Lundgren J. OC-0278 Radiation-induced lymphopenia: Fractionation effect and association with infections and mortality. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)30698-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Brahm CO, Lundgren J, Carlsson SG, Nilsson P, Hägglin C. Evaluation of the Jönköping dental fear coping model: a patient perspective. Acta Odontol Scand 2019; 77:238-247. [PMID: 30668232 DOI: 10.1080/00016357.2018.1564837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVE This study is a part of a project with the aim to construct and evaluate a structured treatment model (the Jönköping Dental Fear Coping Model, DFCM) for the treatment of dental patients. The aim of the present study was to evaluate the DFCM from a patient perspective. MATERIAL AND METHODS The study was performed at four Public Dental Clinics, with the same 13 dentists and 14 dental hygienists participating in two treatment periods. In Period I, 1351 patients were included and in Period II, 1417. Standard care was used in Period I, and in Period II the professionals had been trained in and worked according to the DFCM. In the evaluation, the outcome measures were self-rated discomfort, pain and tension, and satisfaction with the professionals. RESULTS In comparison with standard care, less tension was reported among patients treated according to the DFCM, (p = .041), which was also found among female patients in a subgroup analysis (p = .028). Additional subgroup analyses revealed that patients expecting dental treatment (as opposed to examination only) reported less discomfort (p = .033), pain (p = .016) and tension (p = .012) in Period II than in Period I. Patients with low to moderate dental fear reported less pain in Period II than in Period I (p = .014). CONCLUSIONS The DFCM has several positive effects on adult patients in routine dental care. In a Swedish context, the differences between standard care and treatment according to the model were small but, in part, statistically significant. However, it is important to evaluate the model in further studies to allow generalization to other settings.
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Kemani MK, Grimby-Ekman A, Lundgren J, Sullivan M, Lundberg M. Factor structure and internal consistency of a Swedish version of the Pain Catastrophizing Scale. Acta Anaesthesiol Scand 2019; 63:259-266. [PMID: 30132784 DOI: 10.1111/aas.13246] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 05/28/2018] [Accepted: 07/27/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pain catastrophizing is highly relevant to assess in the context of long-standing pain. The Pain Catastrophizing Scale (PCS) is a well-established questionnaire used to measure catastrophizing in individuals with long-standing pain. So far, no Swedish translation has been evaluated in regard to validity and reliability. The aims of this study were to translate the PCS questionnaire from English to Swedish, and to investigate its construct validity (face, content, and structural validity) and reliability (internal consistency). METHODS We translated the original English version of the PCS to Swedish and collected item responses from 194 persons suffering from primarily long-standing musculoskeletal pain. We used confirmatory factor analysis to evaluate structural validity, and tested the model fit of a one-factor model, an oblique two-factor model, and an oblique three-factor model. We evaluated the measure's reliability in regard to internal consistency calculated with Cronbach's alpha. RESULTS A three-factor model comprising a four-item rumination factor, a three-item magnification factor, and a six-item helplessness factor provided the best fit to the data. Internal consistency was adequate and Cronbach's α was 0.92 for the entire scale, 0.84 for the rumination subscale; 0.69 for the magnification subscale, and 0.89 for the helplessness subscale. CONCLUSIONS The results indicated adequacy of a three-factor solution and the questionnaire's internal consistency, and provide initial support for the structural validity and internal consistency of a Swedish version of the PCS. Future studies should replicate the study in larger samples and extend the current evaluation in regard to validity and reliability.
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Fägerstad A, Lundgren J, Windahl J, Arnrup K. Dental avoidance among adolescents - a retrospective case -control study based on dental records in the public dental service in a Swedish county. Acta Odontol Scand 2019; 77:1-8. [PMID: 30022701 DOI: 10.1080/00016357.2018.1489978] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: This study aimed to investigate the occurrence of missed dental appointments among 16-19-year-old adolescents in a Swedish county. A second aim was to explore associations between background and concomitant factors and missed appointments and to investigate if these associations differed between areas with different sociodemographic profiles.Materials and methods: A list of booked, and missed, appointments for 10,158 individuals during 2012 was used for assessments. Based on the total sample, 522 cases with, and 522 matched controls without, dental avoidance behavior in 2012 were identified. Data on previous missed and cancelled appointments, oral health status, dental treatment, fear or behavior problems, and medical, and, where available, psychosocial or lifestyle factors were extracted from the dental records using a preset protocol covering the period 2009-2012.Results: In 2012, 13.1% of 23,522 booked appointments were missed, with a higher proportion of missed appointments among boys than girls. Cases with avoidance behavior more often had a record of sociodemographic load and dental fear or behavior management problems. They also had more oral health problems, more invasive dental treatments, and, in the past, more missed and canceled appointments.Conclusion: To enable good oral health and continued regular dental care, we need to pay more attention to adolescents' individual situation and be observant of early signs of avoidance.
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Thudium RF, Lundgren J, Benfield T, Nordestgaard BG, Borges ÁH, Gerstoft J, Nielsen SD, Ronit A. HIV infection is independently associated with a higher concentration of alpha-1 antitrypsin. HIV Med 2018; 19:745-750. [PMID: 30160349 DOI: 10.1111/hiv.12666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Alpha-1 antitrypsin (AAT) deficiency is associated with an increased risk of chronic obstructive pulmonary disease and has been related to CD4 T-cell count decline in people living with HIV (PLWH). We determined whether HIV status is associated with AAT concentrations and assessed associations between AAT concentration, pulmonary function and immunological status. METHODS Alpha-1 antitrypsin was measured and spirometry performed in 1011 PLWH from the Copenhagen Comorbidity in HIV Infection (COCOMO) study and in 11 962 age- and sex-matched uninfected controls. We studied associations between AAT concentration, HIV status, pulmonary function, and current and nadir CD4 T-cell counts using multivariate linear regression analyses. RESULTS The mean age of PLWH was 50.7 [standard deviation (SD) 11.3] years and 98.6% were receiving combination antiretroviral therapy (cART). The mean current CD4 T-cell count was 718 (SD 284) cells/μL. PLWH had a higher median AAT concentration than uninfected controls [1.4 (interquartile range (IQR) 1.3-1.6) versus 1.3 (IQR 1.2-1.4) g/L; P < 0.0001] and HIV infection was independently associated with higher AAT concentration [adjusted β = 0.10 g/L; 95% confidence interval (CI) 0.08; 0.11 g/L; P < 0.001]. Low AAT concentration (< 1.0 g/L) was not more common in PLWH with airflow limitation (defined as forced expiratory volume in 1 second/forced vital capacity (FEV1 /FVC) < 0.7 with FEV1 -predicted < 80%) compared with uninfected controls with airflow limitation, and the effect of AAT on FEV1 %-predicted was comparable to that in uninfected controls (P-interaction = 0.66). AAT concentration was not associated with current or nadir CD4 T-cell count. CONCLUSIONS HIV infection was independently associated with a higher concentration of AAT through unknown mechanisms. However, AAT does not seem to contribute to lower pulmonary function or to low CD4 T-cell counts in PLWH.
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Brahm CO, Lundgren J, Carlsson SG, Nilsson P, Hägglin C. Development and evaluation of the Jönköping Dental Fear Coping Model: a health professional perspective. Acta Odontol Scand 2018; 76:320-330. [PMID: 29560758 DOI: 10.1080/00016357.2018.1453082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The purpose of this study was to design a structured treatment model focusing on all levels of adult's dental fear, the Jönköping Dental Fear Coping Model (DFCM). The aim was to study the DFCM from a dental health professional perspective. MATERIAL AND METHODS The DFCM was studied by means of quantitative and qualitative analyses. Nine dental clinics participated in Period I (pre-intervention/standard care), and 133 dental health professionals (dentists, dental hygienists, dental assistants) and 3088 patients were included. After completion of Period I, four of the clinics were randomized to Period II (intervention), beginning with the professionals undergoing DFCM training. Following that, 51 dental health professionals treated 1417 patients according to the DFCM. The other five clinics served as controls. RESULTS Half or more of the dental health professionals assessed the model as better than standard care, regarding anamnesis and diagnostics, communication and contact, and understanding of patients and dental fear. The dental health professionals reported higher tension in their fearful patients in Period II compared with Period I, possibly due to their increased awareness of dental fear. CONCLUSIONS The qualitative data suggest that dental health professionals find the DFCM beneficial in routine dental care. The model promotes a holistic approach to the treatment of adult patients. However, stress among the professionals was not reduced when measured, neither quantitatively nor qualitatively. It is important to evaluate the model in further studies to make it possible to draw generalizable conclusions.
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Engelbrechtsen L, Lundgren J, Wewer Albrechtsen NJ, Mahendran Y, Iepsen EW, Finocchietto P, Jonsson AE, Madsbad S, Holst JJ, Vestergaard H, Hansen T, Torekov SS. Treatment with liraglutide may improve markers of CVD reflected by reduced levels of apoB. Obes Sci Pract 2017; 3:425-433. [PMID: 29259801 PMCID: PMC5729494 DOI: 10.1002/osp4.133] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/24/2017] [Accepted: 08/28/2017] [Indexed: 01/14/2023] Open
Abstract
Background Dislipidaemia and increased levels of apolipoprotein B (apoB) in individuals with obesity are risk factors for development of cardiovascular disease (CVD). The aim of this study was to investigate the effect of weight loss and weight maintenance with and without liraglutide treatment on plasma lipid profiles and apoB. Methods Fifty‐eight individuals with obesity (body mass index 34.5 ± 3.0 kg/m2 [mean ± SD]) were included in this study. After 8 weeks on a very low‐calorie diet (800 kcal/day), participants were randomized to weight maintenance with meal replacements with or without liraglutide (1.2 mg daily) for 1 year. Plasma samples from before and after weight loss and after 1 year of weight maintenance were subjected to nuclear magnetic resonance‐based lipidomics analysis. Results After an 8‐week low‐calorie diet, study participants lost 12.0 ± 2.9 kg (mean ± SD) of their body weight, which was reflected in their lipid profiles (80 out of 124 lipids changed significantly), including reduced levels of apoB, total cholesterol, free cholesterol, remnant cholesterol, triglycerides, low‐density lipoprotein and very low‐density lipoprotein subclasses. After 1 year of maintained weight loss, the majority of the lipids had returned to pre‐weight loss levels even though weight loss was successfully maintained in both groups. Interestingly, apoB levels remained low in the liraglutide treated group (apoB change: 0.03 ± 0.02 mmol/L, p = 0.4) in contrast to an increase in the control group (apoB change: 0.06 ± 0.07 mmol/L, p = 0.02). Conclusion An 8‐week low‐calorie diet, in individuals with obesity, reduced plasma levels of lipids and the atherogenic marker apoB. After 1 year of weight maintenance, only study participants treated with liraglutide maintained reduced levels of apoB, despite similar body weight maintenance. Treatment with liraglutide may therefore reduce apoB levels and thus reflect lower CVD risk. Including apoB measurements in clinical practice when monitoring patients with dislipidemia or CVD might prove to be useful.
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