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Affaitati G, Costantini R, Fiordaliso M, Giamberardino MA, Tana C. Pain from Internal Organs and Headache: The Challenge of Comorbidity. Diagnostics (Basel) 2024; 14:1750. [PMID: 39202238 PMCID: PMC11354044 DOI: 10.3390/diagnostics14161750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 07/24/2024] [Accepted: 08/08/2024] [Indexed: 09/03/2024] Open
Abstract
Headache and visceral pain are common clinical painful conditions, which often co-exist in the same patients. Numbers relative to their co-occurrence suggest possible common pathophysiological mechanisms. The aim of the present narrative review is to describe the most frequent headache and visceral pain associations and to discuss the possible underlying mechanisms of the associations and their diagnostic and therapeutic implications based on the most recent evidence from the international literature. The conditions addressed are as follows: visceral pain from the cardiovascular, gastrointestinal, and urogenital areas and primary headache conditions such as migraine and tension-type headache. The most frequent comorbidities involve the following: cardiac ischemic pain and migraine (possible shared mechanism of endothelial dysfunction, oxidative stress, and genetic and hormonal factors), functional gastrointestinal disorders, particularly IBS and both migraine and tension-type headache, primary or secondary dysmenorrhea and migraine, and painful bladder syndrome and headache (possible shared mechanisms of peripheral and central sensitization processes). The data also show that the various visceral pain-headache associations are characterized by more than a simple sum of symptoms from each condition but often involve complex interactions with the frequent enhancement of symptoms from both, which is crucial for diagnostic and treatment purposes.
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Affiliation(s)
- Giannapia Affaitati
- Department of Innovative Technologies in Medicine and Dentistry, Center for Advanced Studies and Technology (CAST), G. D’Annunzio University of Chieti, 66100 Chieti, Italy;
| | | | - Michele Fiordaliso
- Department of Medicine and Ageing Sciences, G D’Annunzio University of Chieti, 66100 Chieti, Italy;
| | - Maria Adele Giamberardino
- Headache Center, Geriatrics Clinic, Department of Medicine and Science of Aging, Center for Advanced Studies and Technology (CAST), G. D’Annunzio University of Chieti, 66100 Chieti, Italy;
| | - Claudio Tana
- Headache Center, Geriatrics Clinic, SS Annunziata Hospital, 66100 Chieti, Italy
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Guldan M, Unlu S, Abdel-Rahman SM, Ozbek L, Gaipov A, Covic A, Soler MJ, Covic A, Kanbay M. Understanding the Role of Sex Hormones in Cardiovascular Kidney Metabolic Syndrome: Toward Personalized Therapeutic Approaches. J Clin Med 2024; 13:4354. [PMID: 39124622 PMCID: PMC11312746 DOI: 10.3390/jcm13154354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 07/18/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Cardiovascular kidney metabolic (CKM) syndrome represents a complex interplay of cardiovascular disease (CVD), chronic kidney disease (CKD), and metabolic comorbidities, posing a significant public health challenge. Gender exerts a critical influence on CKM syndrome, affecting the disease severity and onset through intricate interactions involving sex hormones and key physiological pathways such as the renin-angiotensin system, oxidative stress, inflammation, vascular disease and insulin resistance. It is widely known that beyond the contribution of traditional risk factors, men and women exhibit significant differences in CKM syndrome and its components, with distinct patterns observed in premenopausal women and postmenopausal women compared to men. Despite women generally experiencing a lower incidence of CVD, their outcomes following cardiovascular events are often worse compared to men. The disparities also extend to the treatment approaches for kidney failure, with a higher prevalence of dialysis among men despite women exhibiting higher rates of CKD. The impact of endogenous sex hormones, the correlations between CKM and its components, as well as the long-term effects of treatment modalities using sex hormones, including hormone replacement therapies and gender-affirming therapies, have drawn attention to this topic. Current research on CKM syndrome is hindered by the scarcity of large-scale studies and insufficient integration of gender-specific considerations into treatment strategies. The underlying mechanisms driving the gender disparities in the pathogenesis of CKM syndrome, including the roles of estrogen, progesterone and testosterone derivatives, remain poorly understood, thus limiting their application in personalized therapeutic interventions. This review synthesizes existing knowledge to clarify the intricate relationship between sex hormones, gender disparities, and the progression of CVD within CKM syndrome. By addressing these knowledge gaps, this study aims to guide future research efforts and promote tailored approaches for effectively managing CKD syndrome.
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Affiliation(s)
- Mustafa Guldan
- Department of Medicine, Koç University School of Medicine, 34450 Istanbul, Turkey; (M.G.); (S.U.); (S.M.A.-R.); (L.O.)
| | - Selen Unlu
- Department of Medicine, Koç University School of Medicine, 34450 Istanbul, Turkey; (M.G.); (S.U.); (S.M.A.-R.); (L.O.)
| | - Sama Mahmoud Abdel-Rahman
- Department of Medicine, Koç University School of Medicine, 34450 Istanbul, Turkey; (M.G.); (S.U.); (S.M.A.-R.); (L.O.)
| | - Laşin Ozbek
- Department of Medicine, Koç University School of Medicine, 34450 Istanbul, Turkey; (M.G.); (S.U.); (S.M.A.-R.); (L.O.)
| | - Abduzhappar Gaipov
- Department of Medicine, School of Medicine, Nazarbayev University, Astana 010000, Kazakhstan;
| | - Andreea Covic
- Department of Nephrology, Grigore T. Popa University of Medicine, 700115 Iasi, Romania;
| | - Maria José Soler
- Nephrology Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research, 08035 Barcelona, Spain;
- Centro de Referencia en Enfermedad, Glomerular Compleja del Sistema Nacional de Salud de España (CSUR), RICORS2040 (Kidney Disease), 08003 Barcelona, Spain
- GEENDIAB (Grupo Español de Estudio de la Nefropatía Diabética), 39008 Santander, Spain
| | - Adrian Covic
- Department of Nephrology, Grigore T. Popa University of Medicine, 700115 Iasi, Romania;
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koç University School of Medicine, 34450 Istanbul, Turkey;
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Hondros CAB, Khan I, Solvik M, Hanseth S, Pedersen EKR, Hovland S, Larsen TH, Lønnebakken MT. Compositional plaque progression in women and men with non-obstructive coronary artery disease. IJC HEART & VASCULATURE 2024; 51:101352. [PMID: 38356931 PMCID: PMC10865024 DOI: 10.1016/j.ijcha.2024.101352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/22/2024] [Accepted: 01/27/2024] [Indexed: 02/16/2024]
Abstract
Background In coronary artery disease (CAD), plaque progression and plaque composition are associated with cardiovascular risk. Whether compositional plaque progression in non-obstructive CAD differs between women and men is less studied. Methods We included 31 patients (42% women) with chronic non-obstructive CAD from the Norwegian Registry of Invasive Cardiology, undergoing serial coronary computed tomography angiography (CCTA) on clinical indication (median inter-scan interval 1.8 [1.5-2.2] years). We performed quantitative and qualitative plaque analysis of all coronary artery segments. Results Women were older compared to men (65 ± 8 years vs. 55 ± 12 years, p = 0.019), while there was no difference in the prevalence of hypertension, diabetes, smoking or statin treatment between groups. At baseline, women had a higher total plaque burden, more calcified plaques, and less fibro-fatty and necrotic core plaques compared to men (all p < 0.05). During follow-up, men showed faster progression of fibro-fatty plaques (4.0 ± 5.4 % per year vs. -0.6 ± 3.1 % per year, p = 0.019) and a greater reduction of fibrous plaques (-7.3 ± 6.1 % per year vs. 2.1 ± 7.2 % per year, p = 0.003) compared to women even after age adjustment. At follow-up, total plaque burden remained higher in women compared to men (24.9 ± 3.3 % vs. 21.1 ± 2.6 %, p = 0.001), while men had an increase in fibro-fatty (21.2 ± 9.3 % vs. 28.6 ± 9.8 %, p = 0.004) and necrotic core plaques (5.6 ± 3.6 % vs. 10.8 ± 7.2 %, p = 0.006), and a decrease in fibrous plaques (69.0 ± 11.9 % vs. 54.7 ± 13.7 %, p < 0.001). Women's plaque composition remained unaltered. Conclusion In non-obstructive CAD, serial CCTA demonstrated a higher total plaque burden and a stable plaque composition in women, while men had a faster progression of unstable low-attenuating fibro-fatty plaques.Clinical trial registration: ClinicalTrials.gov: Identifier NCT04009421.
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Affiliation(s)
- Caroline Annette Berge Hondros
- Department of Heart Disease, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway
- Department of Clinical Science, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
| | - Ingela Khan
- Department of Clinical Science, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
| | - Margrete Solvik
- Department of Heart Disease, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway
| | - Silja Hanseth
- Department of Clinical Science, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
- Department of Medicine, Haraldsplass Deaconess Hospital, Ulriksdal 8, 5009 Bergen, Norway
| | - Eva Kristine Ringdal Pedersen
- Department of Heart Disease, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway
- Department of Clinical Science, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
| | - Siren Hovland
- Department of Heart Disease, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway
- Norwegian Registry of Invasive Cardiology, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway
| | - Terje Hjalmar Larsen
- Department of Heart Disease, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway
- Department of Biomedicine, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
| | - Mai Tone Lønnebakken
- Department of Heart Disease, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway
- Department of Clinical Science, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
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Chen JJ, Jain J, Merker JB, Webber TK, Huffman JC, Seligowski AV. The impact of PTSD on associations between sex hormones and cardiovascular disease symptoms. Eur J Psychotraumatol 2024; 15:2320993. [PMID: 38445477 PMCID: PMC10919301 DOI: 10.1080/20008066.2024.2320993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/12/2024] [Indexed: 03/07/2024] Open
Abstract
Background: Women have twice the lifetime prevalence of posttraumatic stress disorder (PTSD) relative to men, and PTSD is a known risk factor for cardiovascular disease (CVD). Two sex hormones - estradiol and progesterone - have been found to impact both PTSD and CVD symptomatology, but the way in which sex hormones influence cardiovascular physiology among individuals with PTSD is not well understood.Objective: This study sought to clarify the association between sex hormones, PTSD, and CVD among trauma-exposed women.Method: Sixty-six trauma-exposed women (M age = 31.45, SD = 8.92) completed a clinical interview for PTSD and self-reported CVD symptoms; estradiol and progesterone were assayed from blood samples. The association between each sex hormone and CVD symptoms was analyzed, controlling for age, systolic blood pressure (BP), and diastolic BP.Results: Neither estradiol nor the PTSD-by-estradiol interaction was significantly associated with CVD symptoms. Higher progesterone and, relatedly, progesterone-to-estradiol ratio (PE ratio) were each significantly associated with greater CVD symptom severity, but only for individuals with lower relative PTSD severity.Conclusions: The findings indicate that PTSD moderates the relationship between progesterone and CVD symptoms, and further research is warranted to reconcile findings in existing literature regarding the direction of and mechanisms behind this relationship.
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Affiliation(s)
| | - Jahnvi Jain
- UT Health McGovern Medical School, Houston, TX, USA
| | - Julia B. Merker
- Department of Psychological & Brain Sciences, University of Delaware, Newark, DE, USA
| | | | - Jeffery C. Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Antonia V. Seligowski
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA
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Calderón-Parra J, Domínguez F, González-Rico C, Arnaiz de las Revillas F, Goenaga MÁ, Alvarez I, Muñoz P, Alonso D, Rodríguez-García R, Miró JM, De Alarcón A, Antorrena I, Goikoetxea-Agirre J, Moral-Escudero E, Ojeda-Burgos G, Ramos-Martínez A. Epidemiology and Risk Factors of Mycotic Aneurysm in Patients With Infective Endocarditis and the Impact of its Rupture in Outcomes. Analysis of a National Prospective Cohort. Open Forum Infect Dis 2024; 11:ofae121. [PMID: 38500574 PMCID: PMC10946656 DOI: 10.1093/ofid/ofae121] [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: 07/14/2023] [Accepted: 03/12/2024] [Indexed: 03/20/2024] Open
Abstract
Background Several aspects of the occurrence and management of mycotic aneurysm (MA) in patients with infective endocarditis (IE) have not been studied. Objectives To determine the incidence and factors associated with MA presence and rupture and to assess the evolution of those initially unruptured MA. Methods Prospective multicenter cohort including all patients with definite IE between January 2008 and December 2020. Results Of 4548 IE cases, 85 (1.9%) developed MA. Forty-six (54.1%) had intracranial MA and 39 (45.9%) extracranial MA. Rupture of MA occurred in 39 patients (45.9%). Patients with ruptured MA had higher 1-year mortality (hazard ratio, 2.33; 95% confidence interval, 1.49-3.67). Of the 55 patients with initially unruptured MA, 9 (16.4%) presented rupture after a median of 3 days (interquartile range, 1-7) after diagnosis, being more frequent in intracranial MA (32% vs 3.3%, P = .004). Of patients with initially unruptured MA, there was a trend toward better outcomes among those who received early specific intervention, including lower follow-up rupture (7.1% vs 25.0%, P = .170), higher rate of aneurysm resolution in control imaging (66.7% vs 31.3%, P = .087), lower MA-related mortality (7.1% vs 16.7%, P = .232), and lower MA-related sequalae (0% vs 27.8%, P = .045). Conclusions MA occurred in 2% of the patients with IE. Half of the Mas occurred in an intracranial location. Their rupture is frequent and associated with poor prognosis. A significant proportion of initially unruptured aneurysms result from rupture during the first several days, being more common in intracranial aneurysms. Early specific treatment could potentially lead to better outcomes.
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Affiliation(s)
- Jorge Calderón-Parra
- Infectious Diseases Unit, Department of Internal Medicine, Puerta de Hierro University Hospital, Majadahonda, Spain
- Research Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), Majadahonda, Spain
| | - Fernando Domínguez
- Research Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), Majadahonda, Spain
- Department of Cardiology, Puerta de Hierro University Hospital, Majadahonda, Spain
| | - Claudia González-Rico
- Department of Infectious Diseases, University Hospital Marqués de Valdecilla, CIBER Infectious Diseases (CIBERINFEC, CB21/13/00068). Cantabria University, Santander, Spain
| | - Francisco Arnaiz de las Revillas
- Department of Infectious Diseases, University Hospital Marqués de Valdecilla, CIBER Infectious Diseases (CIBERINFEC, CB21/13/00068). Cantabria University, Santander, Spain
| | | | - I Alvarez
- Department of Infectious Diseases, OSI Donostialdea, San Sebastian, Spain
| | - Patricia Muñoz
- Department of Microbiology and Infectious Diseases, University Hospital Gregorio Marañón, CIBER Respiratory Diseases (CIBERES, CB06/06/0058), Complutense University, Madrid, Spain
| | - David Alonso
- Department of Microbiology and Infectious Diseases, University Hospital Gregorio Marañón, CIBER Respiratory Diseases (CIBERES, CB06/06/0058), Complutense University, Madrid, Spain
| | | | - José María Miró
- Department of Infectious Diseases, Clinic Hospital—IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Arístides De Alarcón
- Infectious Diseases, Microbiology, and Parasitology Unit, University Hospital Virgen del Rocio, Seville University, Seville, Spain
| | - Isabel Antorrena
- Cardiology Department, University Hospital La Paz- IDIPAZ, Madrid, Spain
| | | | | | | | - Antonio Ramos-Martínez
- Infectious Diseases Unit, Department of Internal Medicine, Puerta de Hierro University Hospital, Majadahonda, Spain
- Research Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), Majadahonda, Spain
- Faculty of Medicine, Autónoma University of Madrid, Madrid, Spain
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van den Houdt SCM, Mommersteeg PMC, Widdershoven J, Kupper N. Sex and Gender Differences in Psychosocial Risk Profiles Among Patients with Coronary Heart Disease - the THORESCI-Gender Study. Int J Behav Med 2024; 31:130-144. [PMID: 37170007 PMCID: PMC10803502 DOI: 10.1007/s12529-023-10170-5] [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] [Accepted: 03/04/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Psychosocial factors tend to cluster and exhibit differences associated with sex assigned at birth. Gender disparities, though, remain uncharted so far. The current study aimed to first explore the clustering of eight established psychosocial risk factors among patients with coronary heart disease (CHD), followed by examining how sex and gender differences characterize these psychosocial risk profiles, while adjusting for the effect of age. METHOD In total, 532 patients with CHD (Mage = 68.2 ± 8.9; 84% male) completed the comprehensive psychosocial screener and questionnaires to gauge gender identity, traits, and sociocultural norm scores. A three-step latent profile analysis (LPA) was performed to identify latent profiles and their correlates. RESULTS LPA revealed six psychosocial risk profiles: (1) somewhat distressed overall (32%); (2) low distress (27%); (3) anger, hostility, and Type D (15%); (4) emotional distress and trauma (11%); (5) anxiety (9%); and (6) high overall distress (7%). Masculine traits and older age increased the odds to belong to the low distress profile (#2), while feminine traits and a feminine gender norm score increased the chance to belong to profiles with moderate to high distress. The effects of gender identity and feminine traits were sex dependent. CONCLUSION The current study's findings explain heterogeneity among patients with CHD by considering the joint occurrence of psychosocial risk factors, and the role of sex, age, and gender within those profiles. Being more sensitive to the roles that sex, gender, and an integrated set of risk factors play may ultimately improve treatment and adherence.
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Affiliation(s)
- Sophie C M van den Houdt
- Center of Research On Psychological Disorders and Somatic Diseases (CoRPS), Department of Medical & Clinical Psychology, Tilburg University, PO Box 90153, 5000 LE, Tilburg, the Netherlands
| | - Paula M C Mommersteeg
- Center of Research On Psychological Disorders and Somatic Diseases (CoRPS), Department of Medical & Clinical Psychology, Tilburg University, PO Box 90153, 5000 LE, Tilburg, the Netherlands
| | - Jos Widdershoven
- Center of Research On Psychological Disorders and Somatic Diseases (CoRPS), Department of Medical & Clinical Psychology, Tilburg University, PO Box 90153, 5000 LE, Tilburg, the Netherlands
- Department of Cardiology, Elisabeth-TweeSteden Hospital, Doctor Deelenlaan 5, 5042 AD, Tilburg, the Netherlands
| | - Nina Kupper
- Center of Research On Psychological Disorders and Somatic Diseases (CoRPS), Department of Medical & Clinical Psychology, Tilburg University, PO Box 90153, 5000 LE, Tilburg, the Netherlands.
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Wuopio J, Lin YT, Orho-Melander M, Engström G, Ärnlöv J. The association between sodium intake and coronary and carotid atherosclerosis in the general Swedish population. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead024. [PMID: 37006408 PMCID: PMC10063371 DOI: 10.1093/ehjopen/oead024] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 02/11/2023] [Accepted: 03/08/2023] [Indexed: 04/04/2023]
Abstract
Aims A high intake of salt raises blood pressure and the risk of cardiovascular disease. Previous studies have reported on the association between salt intake and carotid stenosis, but the association with coronary atherosclerosis has not been reported. Therefore, this project aimed at studying the association between salt intake and both carotid and coronary atherosclerosis in a contemporary community-based cohort. Methods and results Estimated 24-h sodium excretion (est24hNa) was calculated by the Kawasaki formula for participants of two sites (Uppsala and Malmö) of the Swedish Cardiopulmonary bioImage Study, who underwent a coronary computed tomography (n = 9623) and measurement of coronary artery calcium score (CACS, n = 10 289). Carotid ultrasound was used to detect carotid plaques (n = 10 700). Ordered logistic regression was used to calculate odds ratios (OR) per 1000 mg increase in est24hNa. We also investigated potential J-formed associations using quintiles of est24hNa. Increased est24hNa was associated with increased occurrence of carotid plaques [OR: 1.09, P < 0.001, confidence interval (CI): 1.06-1.12], higher CACS (OR: 1.16, P < 0.001, CI: 1.12-1.19), and coronary artery stenosis (OR: 1.17, P < 0.001, CI: 1.13-1.20) in minimal adjusted models. Associations were abolished when adjusting for blood pressure. When adjusting for established cardiovascular risk factors (not including blood pressure), associations remained for carotid plaques but not for coronary atherosclerosis. There was no evidence of J-formed associations. Conclusion Higher est24hNa was associated with both coronary and carotid atherosclerosis in minimal adjusted models. The association seemed mainly mediated by blood pressure but to some degree also influenced by other established cardiovascular risk factors.
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Affiliation(s)
- Jonas Wuopio
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Family Medicine and Primary Care, Karolinska Institute, Alfred Nobels Allé 23, 141 52, Huddinge, Sweden
- Center for Clinical Research Dalarna, Nissers väg 3, 791 82 Falun, Uppsala University, Sweden
| | - Yi-Ting Lin
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Family Medicine and Primary Care, Karolinska Institute, Alfred Nobels Allé 23, 141 52, Huddinge, Sweden
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No 100, Tzou 1 Road Kaohsiung, Sanmin District, Kaoshiung City, 807, Taiwan
| | - Marju Orho-Melander
- Department of Clinical Sciences, Lund University, Clinical Research Centre, Box 50332, 202 13 Malmö, Sweden
| | - Gunnar Engström
- Department of Clinical Sciences, Lund University, Clinical Research Centre, Box 50332, 202 13 Malmö, Sweden
| | - Johan Ärnlöv
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Family Medicine and Primary Care, Karolinska Institute, Alfred Nobels Allé 23, 141 52, Huddinge, Sweden
- Center for Clinical Research Dalarna, Nissers väg 3, 791 82 Falun, Uppsala University, Sweden
- School of Health and Social Studies, Dalarna University, 79188 Falun, Sweden
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