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1.	The Ethics of Antibiotic Resistance 2019 In: Bioethics. - 0269-9702 .- 1467-8519. ; 33:7, s. 729-850 Other publication (other academic/artistic)
2.	Munthe, Christian, 1962, et al. (author) The Ethics of Antibiotic Resistance: Towards an Agenda for Feasible and Justified Global Health Policy 2019 In: Bioethics. - : Wiley. - 0269-9702 .- 1467-8519. ; 33:7, s. 731-733 Journal article (other academic/artistic)abstract Guest editorial to special issue on the ethics of antibiotic resistance
3.	Hultén, Anna-Maria, et al. (author) Self-reported sick leave following a brief preventive intervention on work-related stress : A randomised controlled trial in primary health care 2021 In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 11:3 Journal article (peer-reviewed)abstract Objectives To evaluate the effectiveness of a brief intervention about early identification of work-related stress combined with feedback at consultation with a general practitioner (GP) on the number of self-reported sick leave days. Design Randomised controlled trial. Prospective analyses of self-reported sick leave data collected between November 2015 and January 2017. Setting Seven primary healthcare centres in western Sweden. Participants The study included 271 employed, non-sick-listed patients aged 18-64 years seeking care for mental and/or physical health complaints. Of these, 132 patients were allocated to intervention and 139 patients to control. Interventions The intervention group received a brief intervention about work-related stress, including training for GPs, screening of patients' work-related stress, feedback to patients on screening results and discussion of measures at GP consultation. The control group received treatment as usual. Outcome measures The number of self-reported gross sick leave days and the number of self-reported net sick leave days, thereby also considering part-time sick leave. Results At 6 months' follow-up, 220/271 (81%) participants were assessed, while at 12 months' follow-up, 241/271 (89%) participants were assessed. At 6-month follow-up, 59/105 (56%) in the intervention group and 61/115 (53%) in the control group reported no sick leave. At 12-month follow-up, the corresponding numbers were 61/119 (51%) and 57/122 (47%), respectively. There were no statistically significant differences between the intervention group and the control group in the median number of self-reported gross sick leave days and the median number of self-reported net sick leave days. Conclusions The brief intervention showed no effect on the numbers of self-reported sick leave days for patients seeking care at the primary healthcare centres. Other actions and new types of interventions need to be explored to address patients' perceiving of ill health due to work-related stress.
4.	Pepic, I., et al. (author) Early detection of sepsis using artificial intelligence : a scoping review protocol 2021 In: Systematic Reviews. - : Springer Nature. - 2046-4053. ; 10:1 Journal article (peer-reviewed)abstract Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. To decrease the high case fatality rates and morbidity for sepsis and septic shock, there is a need to increase the accuracy of early detection of suspected sepsis in prehospital and emergency department settings. This may be achieved by developing risk prediction decision support systems based on artificial intelligence.Methods: The overall aim of this scoping review is to summarize the literature on existing methods for early detection of sepsis using artificial intelligence. The review will be performed using the framework formulated by Arksey and O’Malley and further developed by Levac and colleagues. To identify primary studies and reviews that are suitable to answer our research questions, a comprehensive literature collection will be compiled by searching several sources. Constrictions regarding time and language will have to be implemented. Therefore, only studies published between 1 January 1990 and 31 December 2020 will be taken into consideration, and foreign language publications will not be considered, i.e., only papers with full text in English will be included. Databases/web search engines that will be used are PubMed, Web of Science Platform, Scopus, IEEE Xplore, Google Scholar, Cochrane Library, and ACM Digital Library. Furthermore, clinical studies that have completed patient recruitment and reported results found in the database ClinicalTrials.gov will be considered. The term artificial intelligence is viewed broadly, and a wide range of machine learning and mathematical models suitable as base for decision support will be evaluated. Two members of the team will test the framework on a sample of included studies to ensure that the coding framework is suitable and can be consistently applied. Analysis of collected data will provide a descriptive summary and thematic analysis. The reported results will convey knowledge about the state of current research and innovation for using artificial intelligence to detect sepsis in early phases of the medical care chain.Ethics and dissemination: The methodology used here is based on the use of publicly available information and does not need ethical approval. It aims at aiding further research towards digital solutions for disease detection and health innovation. Results will be extracted into a review report for submission to a peer-reviewed scientific journal. Results will be shared with relevant local and national authorities and disseminated in additional appropriate formats such as conferences, lectures, and press releases.
5.	Lindén, Thomas, 1962, et al. (author) Recurrent Stroke Prevention: Diuretic and Angiotensin-Converting Enzyme Inhibitors (ACEIs)—The PROGRESS Trial. 2011 In: Hypertension and stroke - pathophysiology and management. - New York : Springer Humana Press. - 9783319291529 ; , s. 143-157 Book chapter (peer-reviewed)
6.	Teede, Helena J, et al. (author) Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. 2023 In: Fertility and sterility. - 1556-5653. ; 120:4, s. 767-793 Journal article (peer-reviewed)abstract What is the recommended assessment and management of those with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference?International evidence-based guidelines address prioritized questions and outcomes and include 254 recommendations and practice points, to promote consistent, evidence-based care and improve the experience and health outcomes in PCOS.The 2018 International PCOS Guideline was independently evaluated as high quality and integrated multidisciplinary and consumer perspectives from six continents; it is now used in 196 countries and is widely cited. It was based on best available, but generally very low to low quality, evidence. It applied robust methodological processes and addressed shared priorities. The guideline transitioned from consensus based to evidence-based diagnostic criteria and enhanced accuracy of diagnosis, whilst promoting consistency of care. However, diagnosis is still delayed, the needs of those with PCOS are not being adequately met, evidence quality was low and evidence-practice gaps persist.The 2023 International Evidence-based Guideline update reengaged the 2018 network across professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Extensive evidence synthesis was completed. Appraisal of Guidelines for Research and Evaluation-II (AGREEII)-compliant processes were followed. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength and diversity and inclusion were considered throughout.This summary should be read in conjunction with the full Guideline for detailed participants and methods. Governance included a six-continent international advisory and management committee, five guideline development groups, and paediatric, consumer, and translation committees. Extensive consumer engagement and guideline experts informed the update scope and priorities. Engaged international society-nominated panels included paediatrics, endocrinology, gynaecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, obesity care, public health and other experts, alongside consumers, project management, evidence synthesis, statisticians and translation experts. Thirty-nine professional and consumer organizations covering 71 countries engaged in the process. Twenty meetings and five face-to-face forums over 12 months addressed 58 prioritized clinical questions involving 52 systematic and 3 narrative reviews. Evidence-based recommendations were developed and approved via consensus across five guideline panels, modified based on international feedback and peer review, independently reviewed for methodological rigour, and approved by the Australian Government National Health and Medical Research Council (NHMRC).The evidence in the assessment and management of PCOS has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report and analyses (∼6000 pages) underpins 77 evidence-based and 54 consensus recommendations, with 123 practice points. Key updates include: i) further refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone (AMH) levels as an alternative to ultrasound in adults only; ii) strengthening recognition of broader features of PCOS including metabolic risk factors, cardiovascular disease, sleep apnea, very high prevalence of psychological features, and high risk status for adverse outcomes during pregnancy; iii) emphasizing the poorly recognized, diverse burden of disease and the need for greater healthcare professional education, evidence-based patient information, improved models of care and shared decision making to improve patient experience, alongside greater research; iv) maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and v) emphasizing evidence-based medical therapy and cheaper and safer fertility management.Overall, recommendations are strengthened and evidence is improved, but remain generally low to moderate quality. Significantly greater research is now needed in this neglected, yet common condition. Regional health system variation was considered and acknowledged, with a further process for guideline and translation resource adaptation provided.The 2023 International Guideline for the Assessment and Management of PCOS provides clinicians and patients with clear advice on best practice, based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation programme supports the Guideline with an integrated evaluation program.This effort was primarily funded by the Australian Government via the National Health Medical Research Council (NHMRC) (APP1171592), supported by a partnership with American Society for Reproductive Medicine, Endocrine Society, European Society for Human Reproduction and Embryology, and the Society for Endocrinology. The Commonwealth Government of Australia also supported Guideline translation through the Medical Research Future Fund (MRFCRI000266). HJT and AM are funded by NHMRC fellowships. JT is funded by a Royal Australasian College of Physicians (RACP) fellowship. Guideline development group members were volunteers. Travel expenses were covered by the sponsoring organizations. Disclosures of interest were strictly managed according to NHMRC policy and are available with the full guideline, technical evidence report, peer review and responses (www.monash.edu/medicine/mchri/pcos). Of named authors HJT, CTT, AD, LM, LR, JBoyle, AM have no conflicts of interest to declare. JL declares grant from Ferring and Merck; consulting fees from Ferring and Titus Health Care; speaker's fees from Ferring; unpaid consultancy for Ferring, Roche Diagnostics and Ansh Labs; and sits on advisory boards for Ferring, Roche Diagnostics, Ansh Labs, and Gedeon Richter. TP declares a grant from Roche; consulting fees from Gedeon Richter and Organon; speaker's fees from Gedeon Richter and Exeltis; travel support from Gedeon Richter and Exeltis; unpaid consultancy for Roche Diagnostics; and sits on advisory boards for Roche Diagnostics. MC declares travels support from Merck; and sits on an advisory board for Merck. JBoivin declares grants from Merck Serono Ltd.; consulting fees from Ferring B.V; speaker's fees from Ferring Arzneimittell GmbH; travel support from Organon; and sits on an advisory board for the Office of Health Economics. RJN has received speaker's fees from Merck and sits on an advisory board for Ferring. AJoham has received speaker's fees from Novo Nordisk and Boehringer Ingelheim. The guideline was peer reviewed by special interest groups across our 39 partner and collaborating organizations, was independently methodologically assessed against AGREEII criteria and was approved by all members of the guideline development groups and by the NHMRC.
7.	Möllerberg, Marie-Louise, et al. (author) The effects of a cancer diagnosis on the health of a patient's partner : a population-based registry study of cancer in Sweden 2016 In: European Journal of Cancer Care. - : Hindawi Limited. - 0961-5423 .- 1365-2354. ; 25:5, s. 744-752 Journal article (peer-reviewed)abstract The aim of this population-based registry study was to explore how cancer influences the health of partners, by examining the onset of new diagnoses for partners, health care use and health care costs among partners living with patients with cancer. The sample consisted of partners of patients with cancer (N = 10 353) and partners of age- and sex-matched controls who did not have cancer (N = 74 592). Diagnoses, health care use and health care costs were studied for a continuous period starting 1 year before the date of cancer diagnosis and continued for 3 years. One year after cancer diagnosis, partners of patients with cancer had significantly more mood disorders, reactions to severe stress and ischaemic heart disease than they exhibited in the year before the diagnosis. Among partners of patients with cancer, the type of cancer was associated with the extent and form of increased health care use and costs; both health care use and costs increased among partners of patients with liver cancer, lung cancer, colon cancer and miscellaneous other cancers. The risk of poorer health varied according to the type of cancer diagnosed, and appeared related to the severity and prognosis of that diagnosis.
8.	von Below, Bernhard, 1952, et al. (author) Student-centred GP ambassadors: Perceptions of experienced clinical tutors in general practice undergraduate training 2015 In: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 33:2, s. 142-149 Journal article (peer-reviewed)abstract Objective. To explore experienced general practitioner (GP) tutor perceptions of a skilled GP tutor of medical students. Design. Interview study based on focus groups. Setting. Twenty GPs experienced in tutoring medical students at primary health care centres in two Swedish regions were interviewed. Method. Four focus-group interviews were analysed using qualitative content analysis. Subjects. Twenty GP tutors, median age 50, specifically selected according to age, gender, and location participated in two focus groups in Gothenburg and Malmo, respectively. Main outcome measures. Meaning units in the texts were extracted, coded and condensed into categories and themes. Results. Three main themes emerged: "Professional as GP and ambassador to general practice", "Committed and student-centred educator", and "Coordinator of the learning environment". Conclusion. Experienced GP tutors describe their skills as a clinical tutor as complex and diversified. A strong professional identity within general practice is vital and GP tutors describe themselves as ambassadors to general practice, essential to the process of recruiting a new generation of general practitioners. Leaders of clinical education and health care planners must understand the complexity in a clinical tutor's assignment and provide adequate support, time, and resources in order to facilitate a sustainable tutorship and a good learning environment, which could also improve the necessary recruitment of future GPs.
9.	Bernhardsson, Susanne, 1958, et al. (author) Clinical practice in line with evidence? A survey among primary care physiotherapists in western Sweden 2015 In: Journal of Evaluation in Clinical Practice. - : Wiley. - 1356-1294 .- 1365-2753. ; 21:6, s. 1169-1177 Journal article (peer-reviewed)abstract Rationale, aims and objectives Evidence-based practice is becoming increasingly important in primary care physiotherapy. Clinical practice needs to reflect current best evidence and be concordant with evidence-based clinical guidelines. There is limited knowledge about therapeutic interventions used in primary care physiotherapy in Sweden. The objectives were to examine preferred treatment interventions reported by publicly employed physiotherapists in primary care for three common musculoskeletal disorders (low back pain, neck pain and subacromial pain), the extent to which these interventions were supported by evidence, and associations with demographic variables. Methods 419 physiotherapists in primary care in western Sweden were surveyed using a validated web-based questionnaire. Results The survey was completed by 271 respondents (65%). Median number of interventions reported was 7 (range 1-16). The most common treatment interventions across the three conditions were advice on posture (reported by 82-94%), advice to stay active (86-92%), and different types of exercise (65-92%). Most of these interventions were supported by evidence. However, interventions with insufficient evidence, such as advice on posture, TENS and aquatic exercise, were also used by 29-96%. Modalities such as laser therapy and ultrasound were sparingly used (< 5%), which is in line with evidence. For neck pain, use of evidence-based interventions was associated with gender and for subacromial pain, with work experience. Conclusions Advice and exercise therapy were the interventions most frequently reported across the three diagnoses, illustrating an active treatment strategy. While most reported interventions are supported by evidence, interventions with unclear or no evidence of effect were also used to a high extent.
10.	Taddei, C, et al. (author) Repositioning of the global epicentre of non-optimal cholesterol 2020 In: Nature. - : Springer Science and Business Media LLC. - 1476-4687 .- 0028-0836. ; 582:7810, s. 73- Journal article (peer-reviewed)abstract High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol—which is a marker of cardiovascular risk—changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million–4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.
11.	Zhou, B, et al. (author) Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants 2017 In: Lancet (London, England). - 1474-547X .- 0140-6736. ; 389:10064, s. 37-55 Journal article (peer-reviewed)
12.	Hultén, Anna-Maria, et al. (author) Work-related stress and future sick leave in a working population seeking care at primary health care centres : a prospective longitudinal study using the WSQ 2022 In: BMC Public Health. - : BioMed Central. - 1471-2458. ; 22:1 Journal article (peer-reviewed)abstract Background: Studying the relationship between work-related stress and sick leave is valuable in identifying and assessing employees at risk of sick leave, but also in developing interventions and taking actions for workers’ health. The overall aim of this study was to analyse the association between work-related stress, measured with the work stress questionnaire (WSQ), and registered sick leave in a working population seeking care at primary health care centres in Sweden. Methods: A prospective longitudinal study was performed with 232 employed patients aged 18–64 years seeking care for mental and/or physical health complaints at seven primary health care centres. Bivariate logistic regression analysis adjusted for educational level, occupational class and marital status was performed using questionnaire data on work-related stress and sociodemographic factors collected between May 2015 until January 2016 together with registered sick leave data from a national database. Results: High stress due to indistinct organization and conflicts was reported by 21% (n = 49), while 45% (n = 105) reported high stress due to individual demands and commitment. Thirty-six percent were on sick leave for 15 days or more during 12 months after baseline. The odds of being on registered sick leave during this period was approximately twice as high for patients perceiving high stress due to indistinct organization and conflicts (OR 2.25, 95% CI 1.18;4.26), high stress due to individual demands and commitment (OR 2.21, 95% CI 1.28;3.82), low influence at work (OR 2.07, 95% CI 1.20;3.57), or high interference between work and leisure time (OR 2.19, 95% CI 1.27;3.80). Perceiving high stress due to both indistinct organization and conflicts as well as individual demands and commitment quadrupled the odds of sick leave, OR 4.15 (95% CI 1.84; 9.38). Conclusions: Work-related stress and sick leave were prevalent among the patients. Perceiving one or more of the work-related stressors and stress increased the odds of registered sick leave between two to four times. Hence, to capture the dynamic interaction between the individual and the work environment, a wide spectrum of factors must be considered. In addition, primary health care could be a suitable arena for preventing sick leave due to work-related stress. Trial registration: ClinicalTrials.gov. Identifier: NCT02480855. Registered 20 May 2015.
13.	Entezarjou, Artin (author) eVisits in the digital era of Swedish primary care 2022 Doctoral thesis (other academic/artistic)abstract Objective: To evaluate asynchronous digital visits (eVisits) with regard to digital communication, clinical decisionmaking,and subsequent care utilization in the digital era of primary care in Sweden.Methods: A mixed-methods approach was adopted across the various papers in the thesis, with all studiesevaluating the eVisit platform Flow in various clinical contexts.- Paper I was a comparative study of digital triage decisions when presented with automated patienthistory reports generated by the platform. Inter-rater reliability of triage decisions by majority vote in apanel of five physicians was compared to triage decisions by a machine learning model trained usingdata labelled by an expert primary care physician.- Paper II was a qualitative focus group study of nurse and physician experiences of digitalcommunication at three primary health care centers using the platform. Themes were generated usingqualitative content analysis as described by Graneheim and Lundman.- Papers III and IV were observational studies comparing office visits in the Skåne Region from Capio,a large private health care provider, to eVisit patients from Capio Go, a national eVisit service. Adultpatients with a chief complaint of sore throat, dysuria, or cough/common cold/influenza were recruited.eVisit patients were recruited prospectively digitally prior to their eVisit, while the office visit controlgroup was recruited retrospectively using letters. Paper III primarily compared antibiotic prescriptionrates per sore throat visit, while paper IV primarily compared subsequent physical health careutilization within two weeks for patients in the Skåne Region.Results: Interrater reliability was low (Cohen κ 0.17) between the panel majority vote and the machine learningmodel. Physicians and nurses experienced digitally filtered primary care, adjusting to a novel medium ofcommunication highlighting challenges in interpreting symptoms through text as well as alterations in practiceworkflow using asynchronous communication. Antibiotics prescription rate within three days was not higher aftereVisits compared to office visits (169/798 (21.2%) vs. 124/312 (39.7%) for sore throat, respectively; P<.001). Nosignificant differences in subsequent physical visits within two weeks (excluding the first 48 h of expected “digi-physical”care) were noted following eVisits compared to office visits (179 (18.0%) vs. 102 (17.6%); P = .854).Conclusions: eVisits do not seem to be associated with over-prescription of antibiotics, or over-utilization ofphysical health care when assessing common infectious symptoms. Given staff experiencing uncertainties ininterpretation of symptoms and triage decisions being inconsistent, eVisits may be best used as one of manymodalities to access primary care, with focus placed on facilitating patient-centered professional judgement bystaff, rather than automation of complex decisions.
14.	Blomstrand, Ann, et al. (author) Forty-four-year longitudinal study of stroke incidence and risk factors - the Prospective Population Study of Women in Gothenburg 2022 In: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 40:1, s. 139-147 Journal article (peer-reviewed)abstract Objective To assess stroke incidence over 44 years and association with risk factors. To study total stroke incidence at 60-82 years of age and risk factors. Design Prospective population study. Setting Gothenburg, Sweden, with similar to 450,000 inhabitants. Subjects A representative sample of a general population of women (1462 in total) in 5 age strata aged 38-60 years in 1968-1969 (the Population Study of Women in Gothenburg, PSWG) were followed up to the ages of 82-104 years in 2012. Further, analysis was also performed for the age interval 60-82 years. Main outcome measures Incidence of total stroke (TS), ischaemic (IS), haemorrhagic (HS), non-specified (NS) and fatal (FS) strokes and association with baseline classic risk factors (such as hypertension, atrial fibrillation, low physical activity, diabetes, high waist-hip-ratio, hyperlipidaemia, smoking), low education, mental stress, pre-eclampsia and oral health as expressed by loss of teeth and bone score. Blood pressure in levels 1-3 according to modern guidelines. Associations with atrial fibrillation, diabetes and myocardial infarction shown in survival analyses. The five cohorts contributed to risk time data concerning associations with TS in the 60-82 age interval from the examination performed when they were 60. Results Three hundred and thirty-seven (23%) women had a first-ever stroke, 64 (19%) fatal. TS was associated with physical inactivity, high triglycerides and low education in multivariable analysis. The main sub-type IS was associated with systolic blood pressure, physical inactivity and low education. Pre-eclampsia showed association with IS only in the univariable analysis. FS was associated with systolic blood pressure and smoking. During 60-82 years of age, having <20 teeth (HR 1.74, CI 1.25-2.42), diabetes (HR 2.28 CI 1.09-4.76), WHR (HR 1.29 per 0.1 units CI 1.01-1.63), systolic blood pressure (HR 1.11 per 10 units CI 1.04-1.18) and smoking (HR 1.57, CI 1.14-2.16), were associated with TS in the combined five cohorts. Conclusions Several classic risk factors showed independent associations with stroke. Vulnerability factors as low education and oral health, reflected by loss of teeth, also showed association with stroke. All these factors are possible to target in primary care preventive interventions.
15.	Heltveit-Olsen, S. R., et al. (author) Experiences and management strategies of Norwegian GPs during the COVID-19 pandemic: a longitudinal interview study 2023 In: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 41:1, s. 2-12 Journal article (peer-reviewed)abstract Objective When the COVID-19 pandemic reached Norway, primary health care had to reorganize to ensure safe patient treatment and maintain infection control. General practitioners (GPs) are key health care providers in the municipalities. Our aim was to explore the experiences and management strategies of Norwegian GPs during the COVID-19 pandemic - over time, and in the context of a sudden organizational change. Design Longitudinal qualitative interview study with two interview rounds. The first round of interviews was conducted from September-December 2020, the second round from January-April 2021. In the first interview round, we performed eight semi-structured interviews with GPs from eight municipalities in Norway. In the second round, five of the GPs were re-interviewed. Consecutive interviews were performed 2-4 months apart. To analyze the data, we used thematic analysis. Results The COVID-19 pandemic required GPs to balance several concerns, such as continuity of care and their own professional efforts. Several GPs experienced challenges in the collaboration with the municipality and in relation to defining their own professional position. Guided by The Norwegian Association of General practitioners, The Norwegian College of General Practice and collegial support, they found viable solutions and ended up with a feeling of having adapted to a new normal. Conclusions Although our study demonstrates that the GPs adapted to the changing conditions, the current municipal health care models are not ideal. There is a need for clarification of responsibilities between GPs and the municipality to facilitate a more coordinated future pandemic response.
16.	Andersson, Susanne, 1957, et al. (author) The association between self-rated health and impaired glucose tolerance in Swedish adults: A cross-sectional study 2013 In: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 31:2, s. 111-118 Journal article (peer-reviewed)abstract Objective. To investigate gender differences in the association between self-rated health (SRH) and impaired glucose tolerance (IGT) in subjects unaware of their glucose tolerance. Design. A cross-sectional population-based study. Setting. The two municipalities of Vara and Skövde in south-western Sweden. Subjects. A total of 2502 participants (1301 women and 1201 men), aged 30–75, were randomly selected from the population. Main outcome measures. IGT was regarded as the outcome measure and SRH as the main risk factor. Results. The prevalence of IGT was significantly higher in women (11.9%) than in men (10.1%), (p = 0.029), as was the prevalence of low SRH (women: 35.4%; men: 22.1%, p = 0.006). Both men and women with low SRH had a poorer risk factor profile than those with high SRH, and a statistically significant crude association between SRH and IGT was found in both men (OR = 2.8, 95% CI 1.8–4.4) and women (OR = 1.5, 95% CI 1.0–2.2, p = 0.033). However, after controlling for several lifestyle factors and biomedical variables, the association was attenuated and remained statistically significant solely in men (OR = 2.3, 95% CI 1.2–4.3). Conclusion. The gender-specific associations found between SRH and IGT suggest that SRH may be a better indicator of IGT in men than in women. Future studies should evaluate the utility of SRH in comparison with objective health measures as a potential aid to health practitioners when deciding whether to screen for IGT and T2DM.
17.	Sturesson Stabel, Linda, et al. (author) Migrant physicians' choice of employment and the medical specialty general practice : a mixed-methods study 2021 In: Human Resources for Health. - : Springer Science and Business Media LLC. - 1478-4491. ; 19:1 Journal article (peer-reviewed)abstract Objective: In many countries, migrant physicians (MP) tend to fill staff shortages in medical specialties perceived as low status. The aim of this study was to explore aspects that influence MPs', with a medical degree from outside EU/EEA, choice of employment and medical specialty in Sweden, and to explore and understand a potential over-representation in general practice (family medicine), a specialty suffering from staff shortages in Sweden.Methods: A mixed-methods approach was applied. This included questionnaire data from 101 MPs training and working as medical specialists in Sweden and semi-structured interview data from four MPs specializing in general practice.Results: Regardless of specialty, the most influential aspects when choosing employment were the ability to combine work with family, to develop one ' s competence, and to have highly competent colleagues. Women scored higher on some aspects related to private life and the surroundings. More than half (55%) of the respondents specialized in general practice, and more women than men. The MPs in general practice scored higher on the aspect 'ability to have the same patients for a longer period' than MPs specializing in other specialties. No significant difference between MP general practitioner respondents and MPs in other medical specialties was found in relation to the item 'Was the specialty your first choice?'. Aspects identified in the interviews that influenced the choice to specialize in general practice related to job opportunities, positive experiences of primary health care, working conditions, and family conditions.Conclusion: Labour market conditions such as high competition, and the time-consuming recertification process, can influence the choice to specialize in general practice as this reduces the time to become a medical specialist. We however did not find any results indicating that MPs' decision to specialize in general practice and to work as general practitioners was any less voluntary than that of MPs who chose other specialties.
18.	Lowden, Arne, et al. (author) Eating and shift work : effects on habits, metabolism and performance 2010 In: Scandinavian Journal of Work, Environment and Health. - 0355-3140 .- 1795-990X. ; 36:2, s. 150-162 Journal article (peer-reviewed)abstract Compared to individuals who work during the day, shift workers are at higher risk of a range of metabolic disorders and diseases (eg, obesity, cardiovascular disease, peptic ulcers, gastrointestinal problems, failure to control blood sugar levels, and metabolic syndrome). At least some of these complaints may be linked to the quality of the diet and irregular timing of eating, however other factors that affect metabolism are likely to play a part, including psychosocial stress, disrupted circadian rhythms, sleep debt, physical inactivity, and insufficient time for rest and revitalization. In this overview, we examine studies on food and nutrition among shift workers [ie, dietary assessment (designs, methods, variables) and the factors that might influence eating habits and metabolic parameters]. The discussion focuses on the quality of existing dietary assessment data, nutritional status parameters (particularly in obesity), the effect of circadian disruptions, and the possible implications for performance at work. We conclude with some dietary guidelines as a basis for managing the nutrition of shift workers.
19.	Liljeroos, Maria, 1965-, et al. (author) Long-term effects of a dyadic psycho-educational intervention on caregiver burden and morbidity in partners of patients with heart failure : a randomized controlled trial 2017 In: Quality of Life Research. - Dordrecht : Springer Netherlands. - 0962-9343 .- 1573-2649. ; 26:2, s. 367-379 Journal article (peer-reviewed)abstract BackgroundPartners of patients with heart failure provide both practical and emotional support. Many partners assume caregiving responsibilities without being aware of the burden related with this role.ObjectiveOur work has established that a psycho-educational intervention has benefits at 3, but not at 12 months for patients with heart failure. Further we had not described the long-term effects in caregivers. This study aimed to determine the 24-months effects of a dyadic psycho-educational intervention on caregiver burden and morbidity in partners of patients with heart failure and study factors associated with a change in caregiver burden.DesignA randomized controlled study design, with a follow-up assessment after 24 months.Setting and participantsPartners to patients with heart failure were recruited from two hospitals in the southeast of Sweden.InterventionA three session nurse-led psycho-educational program was tested and included psychosocial support to maintain the partners’ physical and mental functions, and perceived control. Several instrument were used to measure caregiver burden, perceived control, physical and mental health, depression and morbidity.ResultsOne hundred fifty-five partners were included. There were no significant differences in any index of caregiver burden or morbidity among the partners in the intervention and control groups after 24 months. Overall, the mean total caregiver burden was found to be significantly increased compared to baseline (36 ± 12 vs 38 ± 14, p < 0.05). A younger partner, less comorbidity, higher levels of perceived control, better physical health and less symptoms of depression in patients, and better mental health in the partners were factors associated with absence of increased caregiver burden over time.Discussion and conclusionOur intervention did not significantly decrease caregiver burden or morbidity. Over time, several aspects of burden increased in both groups. To improve outcomes, individualized and targeted interventions might be beneficial.
20.	Ödesjö, Helena, et al. (author) Pay for performance associated with increased volume of medication reviews but not with less inappropriate use of medications among the elderly - an observational study 2017 In: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 35:3, s. 271-278 Journal article (peer-reviewed)abstract Objective: A pay for performance programme was introduced in 2009 by a Swedish county with 1.6 million inhabitants. A process measure with payment linked to coding for medication reviews among the elderly was adopted. We assessed the association with inappropriate medication for five years after baseline. Design and setting: Observational study that compared medication for elderly patients enrolled at primary care units that coded for a high or low volume of medication reviews. Patients: 144,222 individuals at 196 primary care centres, age 75 or older. Main outcome measures: Percentage of patients receiving inappropriate drugs or polypharmacy during five years at primary care units with various levels of reported medication reviews. Results: The proportion of patients with a registered medication review had increased from 3.2% to 44.1% after five years. The high-coding units performed better for most indicators but had already done so at baseline. Primary care units with the lowest payment for coding for medication reviews improved just as well in terms of inappropriate drugs as units with the highest payment - from 13.0 to 8.5%, compared to 11.6 to 7.4% and from 13.6 to 7.2% vs 11.8 to 6.5% for polypharmacy. Conclusions: Payment linked to coding for medication reviews was associated with an increase in the percentage of patients for whom a medication review had been registered. However, the impact of payment on quality improvement is uncertain, given that units with the lowest payment for medication reviews improved equally well as units with the highest payment.
21.	Rosengren, Annika, 1951, et al. (author) COVID-19 in people aged 18–64 in Sweden in the first year of the pandemic: Key factors for severe disease and death 2022 In: Global Epidemiology. - : Elsevier BV. - 2590-1133. ; 4 Journal article (peer-reviewed)abstract Background: Studies on risk factors for severe COVID-19 in people of working age have generally not included non-working persons or established population attributable fractions (PAFs) for occupational and other factors. Objectives: We describe the effect of job-related, sociodemographic, and other exposures on the incidence, relative risks and PAFs of severe COVID-19 in individuals aged 18–64. Methods: We conducted a registry-based study in Swedish citizens aged 18–64 from 1 January 2020 to 1 February 2021 with respect to COVID-19-related hospitalizations and death. Results: Of 6,205,459 persons, 272,043 (7.5%) were registered as infected, 3399 (0.05%) needed intensive care, and 620 (0.01%) died, with an estimated case fatality rate of 0.06% over the last 4-month period when testing was adequate. Non-Nordic origin was associated with a RR for need of intensive care of 3·13, 95%CI 2·91–3·36, and a PAF of 32·2% after adjustment for age, sex, work, region and comorbidities. In a second model with occupation as main exposure, and adjusted for age, sex, region, comorbidities and origin, essential workers had an RR of 1·51, 95%CI, 1·35–1·6, blue-collar workers 1·18, 95%CI 1·06–1·31, school staff 1·21, 95%CI 1·01–1·46, and health and social care workers 1·89, 95%CI 1·67–2·135) compared with people able to work from home, with altogether about 13% of the PAF associated with these occupations. Essential workers and blue-collar workers, but no other job categories had higher risk of death, adjusted RRs of 1·79, 95%CI 1·34–2·38 and 1·37, 95%CI 1·04–1·81, with adjusted PAFs of altogether 9%. Conclusion: Among people of working age in Sweden, overall mortality and case fatality were low. Occupations that require physical presence at work were associated with elevated risk of needing intensive care for COVID-19, with 14% cases attributable to this factor, and 9% of deaths.
22.	Rosengren, Annika, 1951, et al. (author) Severe COVID-19 in people 55 and older during the first year of the pandemic in Sweden 2022 In: Journal of Internal Medicine. - : Wiley. - 0954-6820 .- 1365-2796 .- 0955-7873. ; 292:4, s. 641-653 Journal article (peer-reviewed)abstract Background Exposure to many contacts is the main risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, while risk of serious disease and death is chiefly determined by old age and comorbidities. Relative and population-attributable fractions (PAFs) of multiple medical and social exposures for COVID-19 outcomes have not been evaluated among older adults. Objectives We describe the effect of multiple exposures on the odds of testing positive for the virus and of severe disease (hospital care or death) and PAFs in Swedish citizens aged 55 years and above. Methods We used national registers to follow all citizens aged 55 years and above with respect to (1) testing positive, (2) hospitalization, and (3) death between 31 January 2020 and 1 February 2021. Results Of 3,410,241 persons, 156,017 (4.6%, mean age 68.3 years) tested positive for SARS-CoV-2, while 35,999 (1.1%, mean age 76.7 years) were hospitalized or died (12,384 deaths, 0.4%, mean age 84.0 years). Among the total cohort, the proportion living without home care or long-term care was 98.8% among persons aged 55-64 and 22.1% of those aged 95 and above. After multiple adjustment, home care and long-term care were associated with odds ratios of 7.9 (95% confidence interval [CI] 6.8-9.1) and 22.5 (95% CI 19.6-25.7) for mortality, with PAFs of 21.9% (95% CI 20.9-22.9) and 33.3% (95% CI 32.4-34.3), respectively. Conclusion Among Swedish residents aged 55 years and above, those with home care or long-term care had markedly increased risk for COVID-19 death during the first year of the pandemic, with over 50% of deaths attributable to these factors.
23.	Zhou, B, et al. (author) Contributions of mean and shape of blood pressure distribution to worldwide trends and variations in raised blood pressure: a pooled analysis of 1018 population-based measurement studies with 88.6 million participants 2018 In: International journal of epidemiology. - : Oxford University Press (OUP). - 1464-3685 .- 0300-5771. ; 47:3, s. 872- Journal article (peer-reviewed)
24.	Fagevik Olsén, Monika, 1964, et al. (author) Evaluation of Pressure Generated by Resistors From Different Positive Expiratory Pressure Devices 2015 In: Respiratory Care. - : Daedalus Enterprises. - 0020-1324 .- 1943-3654. ; 60:10, s. 1418-1423 Journal article (peer-reviewed)abstract BACKGROUND: Breathing exercises with positive expiratory pressure (PEP) are used to improve pulmonary function and airway clearance. Different PEP devices are available, but there have been no studies that describe the pressure generated by different resistors. The purpose of this study was to compare pressures generated from the proprietary resistor components of 4 commercial flow-dependent PEP valves with all other parameters kept constant. METHODS: Resistors from 4 flow-regulated PEP devices (Pep/Rmt system, Wellspect HealthCare; Pipe P breathing exerciser, Koo Medical Equipment; Mini-PEP, Philips Respironics [including resistors by Rusch]; and 15-mm endo-adapter, VBM Medizintechnik) were tested randomly by a blinded tester at constant flows of 10 and 18 L/min from an external gas system. All resistors were tested 3 times. RESULTS: Resistors with a similar diameter produced statistically significant different pressures at the same flow. The differences were smaller when the flow was 10 L/min compared with 18 L/min. The differences were also smaller when the diameter of the resistor was increased. The pressures produced by the 4 resistors of the same size were all significantly different when measuring 1.5- and 2.0-mm resistors at a flow of 10 L/min and 2.0-mm resistors at a flow of 18 L/min (P < .001). There were no significant differences between any of the resistors when testing sizes of 4.5 and 5.0 mm at either flow. The Mini-PEP and adapter resistors gave the highest pressures. CONCLUSIONS: Pressures generated by the different proprietary resistor components of 4 commercial PEP devices were not comparable, even though the diameter of the resistors is reported to be the same. The pressures generated were significantly different, particularly when using small-diameter resistors at a high flow. Therefore, the resistors may not be interchangeable. This is important information for clinicians, particularly when considering PEP for patients who do not tolerate higher pressures. (C) 2015 Daedalus Enterprises
25.	Mishra, A, et al. (author) Diminishing benefits of urban living for children and adolescents' growth and development 2023 In: Nature. - : Springer Science and Business Media LLC. - 1476-4687 .- 0028-0836. ; 615:7954, s. 874-883 Journal article (peer-reviewed)abstract Optimal growth and development in childhood and adolescence is crucial for lifelong health and well-being1–6. Here we used data from 2,325 population-based studies, with measurements of height and weight from 71 million participants, to report the height and body-mass index (BMI) of children and adolescents aged 5–19 years on the basis of rural and urban place of residence in 200 countries and territories from 1990 to 2020. In 1990, children and adolescents residing in cities were taller than their rural counterparts in all but a few high-income countries. By 2020, the urban height advantage became smaller in most countries, and in many high-income western countries it reversed into a small urban-based disadvantage. The exception was for boys in most countries in sub-Saharan Africa and in some countries in Oceania, south Asia and the region of central Asia, Middle East and north Africa. In these countries, successive cohorts of boys from rural places either did not gain height or possibly became shorter, and hence fell further behind their urban peers. The difference between the age-standardized mean BMI of children in urban and rural areas was <1.1 kg m–2 in the vast majority of countries. Within this small range, BMI increased slightly more in cities than in rural areas, except in south Asia, sub-Saharan Africa and some countries in central and eastern Europe. Our results show that in much of the world, the growth and developmental advantages of living in cities have diminished in the twenty-first century, whereas in much of sub-Saharan Africa they have amplified.
26.	Westerståhl, Anna, 1948, et al. (author) Gender in medical curricula: course organizer views of a gender-issues perspective in medicine in Sweden. 2003 In: Women & health. - 0363-0242. ; 37:4, s. 35-47 Journal article (peer-reviewed)abstract While there is growing awareness of the importance of gender issues in medicine, with new knowledge and new perspectives intensely debated, reports on the implementation of gender issues into medical curricula are scarce. In 1996, the Medical Faculty of Göteborg University, Sweden, determined that a gender-issues perspective be included in medical education. In 1999, course organizers from preclinical and clinical departments of the faculty were interviewed to determine whether they felt that a gender-issues perspective had contributed to their scientific field and, if so, how they implemented it in their teaching. The interviews revealed varied opinions on the relevance of this perspective in medicine. These variations followed gender division rather than that of preclinicians/clinicians. Thus, female gender was overwhelming for inspiring and introducing a gender-issues perspective both scientifically and practically. Positivism is firmly established in medicine and this must be taken into consideration when introducing a more culturally- and socially-based understanding of sex/gender issues. Female gender is important in this process, but successful implementation requires thorough faculty support and participation of male colleagues and students.
27.	Bernhardsson, Susanne, 1958, et al. (author) Does a tailored guideline implementation strategy have an impact on clinical physiotherapy practice? A nonrandomized controlled study 2019 In: J Eval Clin Pract. - : Wiley. - 1356-1294. ; 25:4, s. 575-584 Journal article (peer-reviewed)abstract Rationale, aims, and objectives Clinical practice guidelines are a common strategy for implementing research findings into practice and facilitating evidence-based practice in health care settings. There is a paucity of knowledge about the impact of different guideline implementation strategies on clinical practice in a physiotherapy context. The study aimed to assess the impact of a guideline implementation intervention on clinical physiotherapy practice. Methods A tailored, multicomponent guideline implementation was compared with usual practice. Clinical practice was evaluated in physiotherapy treatment methods used for 3 common musculoskeletal disorders. Data were collected with a validated web-based questionnaire. Results Postimplementation data were collected from 168 physiotherapists in the intervention group and 88 in the control group. The most frequently reported treatment methods for low back pain were advice on posture (reported by 95% in the intervention group vs 90% in the control group), advice to stay active (93% vs 90%), and stabilization exercise (88% vs 80%). Differences between groups were not significant. Reported use of body awareness training (23% vs 6%, P = .023) and spinal manipulation (9% vs 23%, P = .044) differed between the groups. The most frequently used treatment methods for neck pain were advice on posture (95% vs 92%), advice to stay active (89% vs 87%), and ROM exercise (85% vs 71%) (no significant differences between groups). Reported use of body awareness training (24% vs 7%, P = .023) differed between the groups. The most frequently used treatment methods for subacromial pain were range of motion exercises (reported by 93% in both groups), advice on posture (90% vs 87%), home exercise (77% vs 74%), and stabilization exercise (69% vs 66%) (no significant difference between groups). Conclusions Treatment methods used were largely in line with evidence already before the guideline implementation, which may explain why the guideline implementation had only little impact on clinical practice.
28.	Skoglund, Ingmarie, 1955, et al. (author) A randomized controlled trial comparing two ways of providing evidence-based drug information to GPs 2013 In: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 31:2, s. 67-72 Journal article (peer-reviewed)abstract Objective. To investigate whether tailored evidence-based drug information (EBDI) to general practitioners (GPs) can change the proportion of ACE inhibitor prescriptions more effectively than EBDI provided as usual three and six months after the intervention.Design. Randomized controlled trial.Setting. GPs in southern Sweden working at primary health care centres (PHCCs) in seven drug and therapeutic committee areas.Intervention. EBDI tailored to motivational interviewing (MI) technique and focused on the benefit aspect was compared with EBDI provided as usual.Subjects. There were 408 GPs in the intervention group and 583 GPs in the control group.Main outcome measures. Change in proportion of ACE inhibitor prescriptions relative to the sum of ACE inhibitors and angiotensin receptor blockers, three and six months after the intervention.Results. The GPs' average proportions of prescribed ACE inhibitors increased in both groups. No statistically significant differences in the change of proportions were found between intervention and control groups. Information was provided to 29% of GPs in both groups.Conclusion. This study could not prove that specially tailored EBDI using MI implements guidelines more effectively than EBDI provided as usual.
29.	Wennergren, Mattias, 1993, et al. (author) Swedish Child Health Services Register: a quality register for child health services and children's well-being. 2023 In: BMJ paediatrics open. - : BMJ. - 2399-9772. ; 7:1 Journal article (peer-reviewed)abstract Swedish child health services (CHS) is a free-of-charge healthcare system that reaches almost all children under the age of 6. The aim for the CHS is to improve children's physical, psychological and social health by promoting health and development, preventing illness and detecting emerging problems early in the child's life. The services are defined in a national programme divided into three parts: universal interventions, targeted interventions and indicated interventions.The Swedish Child Health Services Register (BHVQ) is a national Quality Register developed in 2013. The register extracts data from the child's health record and automatically presents current data in real time. At present, the register includes 21 variables.We aim to describe data available in the BHVQ and the completeness of data in BHVQ across variables.Child-specific data were exported from the register, and data for children born in the regions were retrieved from Statistics Sweden to calculate coverage.The register includes over 110000 children born between 2011 and 2022 from 221 child healthcare centres in eight of Sweden's 21 regions. In seven of the eight regions, 100% of centres report data.The completeness of data differs between participating regions and birth cohorts. The average coverage for children born in 2021 is 71%.The BHVQ is a valuable resource for evaluating Child Health Services nationally, with high coverage for the youngest children. As a result of continuous improvement of the services, the possibility to follow the development of children's health in Sweden is possible through the register. When fully expanded, the register will be a natural and essential part of developing preventive services, improving healthcare for children below 6years of age and a tool for developing evidence-based child health interventions.
30.	Steineck, I., et al. (author) Insulin pump therapy, multiple daily injections, and cardiovascular mortality in 18 168 people with type 1 diabetes: observational study 2015 In: Bmj-British Medical Journal. - : BMJ. - 1756-1833. ; 350 Journal article (peer-reviewed)abstract OBJECTIVE To investigate the long term effects of continuous subcutaneous insulin infusion (insulin pump therapy) on cardiovascular diseases and mortality in people with type 1 diabetes. Design Observational study. 18 168 people with type 1 diabetes, 2441 using insulin pump therapy and 15 727 using multiple daily insulin injections. Cox regression analysis was used to estimate hazard ratios for the outcomes, with stratification of propensity scores including clinical characteristics, risk factors for cardiovascular disease, treatments, and previous diseases. Follow-up was for a mean of 6.8 years until December 2012, with 114 135 person years. With multiple daily injections as reference, the adjusted hazard ratios for insulin pump treatment were significantly lower: 0.55 (95% confidence interval 0.36 to 0.83) for fatal coronary heart disease, 0.58 (0.40 to 0.85) for fatal cardiovascular disease (coronary heart disease or stroke), and 0.73 (0.58 to 0.92) for all cause mortality. Hazard ratios were lower, but not significantly so, for fatal or non-fatal coronary heart disease and fatal or non-fatal cardiovascular disease. Unadjusted absolute differences were 3.0 events of fatal coronary heart disease per 1000 person years; corresponding figures were 3.3 for fatal cardiovascular disease and 5.7 for all cause mortality. When lower body mass index and previous cardiovascular diseases were excluded, results of subgroup analyses were similar to the results from complete data. A sensitivity analysis of unmeasured confounders in all individuals showed that an unmeasured confounders with hazard ratio of 1.3 would have to be present in > 80% of the individuals treated with multiple daily injections versus not presence in those treated with pump therapy to invalidate the significantly lower hazard ratios for fatal cardiovascular disease. Data on patient education and frequency of blood glucose monitoring were missing, which might have influenced the observed association. Among people with type 1 diabetes use of insulin pump therapy is associated with lower cardiovascular mortality than treatment with multiple daily insulin injections.
31.	Lytsy, Per, 1968- (author) Power of the Pill : Views about Cardiovascular Risk and the Risk-reducing Effect of Statins 2010 Doctoral thesis (other academic/artistic)abstract Medical treatments with statins are prescribed to patients with increased risk of cardiovascular events. The benefits from statin treatment are well documented in clinical trials, but long-term adherence in patients is low, indicating that patients have an uncertainty about the necessity and benefits of treatment. The aims of this thesis were to investigate how patients and doctors view different aspects of statin treatment. Further aims were to investigate if the cardiovascular risk level in patients affects their views about different aspects of statin treatment. Yet further aims were to compare health behaviours and views about risk factors in patients using statins to a non-treated population. Data was obtained from patients (n = 829), doctors (n = 330) and a population sample (n = 720) using postal questionnaires. Views about the effect of statin treatment were assessed in different ways for patients and doctors. Patients based their assessments on their own situation, and doctors’ treatment decisions and assessments of anticipated effect of treatment were based on two hypothetical patient cases. The results indicate that patients greatly overestimate the general effect of statins, compared to efficacy results reported from clinical trials. Patients’ previous coronary heart disease or high overall risk were factors not associated with their views and expectations of treatment effect. Statin users with an internally perceived health control and patients satisfied with their doctor’s treatment explanation reported higher beliefs in treatment necessity and benefits. Statin users reported having better health behaviours and generally rated risk factors as more important than the non-treated population. Doctors had suboptimal understanding of the number of patients expected to benefit following five years of statin treatment and had a varying understanding of statins’ ability to prolong life. Overall the results illustrate that patients and doctors have different perspectives and views of the benefits from statin treatment which puts emphasis on how statin treatment is discussed in the clinical setting.
32.	Gerdle, Björn, et al. (author) The importance of emotional distress, cognitive behavioural factors and pain for life impact at baseline and for outcomes after rehabilitation - a SQRP study of more than 20,000 chronic pain patients 2019 In: Scandinavian Journal of Pain. - : Walter de Gruyter GmbH. - 1877-8860 .- 1877-8879. ; 19:4, s. 693-711 Journal article (peer-reviewed)abstract Background and aims Although literature concerning chronic pain patients indicates that cognitive behavioural variables, specifically acceptance and fear of movement/(re)injury, are related to life impact, the relative roles of these factors in relation to pain characteristics (e.g. intensity and spreading) and emotional distress are unclear. Moreover, how these variables affect rehabilitation outcomes in different subgroups is insufficiently understood. This study has two aims: (1) to investigate how pain, cognitive behavioural, and emotional distress variables intercorrelate and whether these variables can regress aspects of life impact and (2) to analyse whether these variables can be used to identify clinically meaningful subgroups at baseline and which subgroups benefit most from multimodal rehabilitation programs (MMRP) immediately after and at 12-month follow-up. Methods Pain aspects, background variables, psychological distress, cognitive behavioural variables, and two life impact variables were obtained from the Swedish Quality Registry for Pain Rehabilitation (SQRP) for chronic pain patients. These data were analysed mainly using advanced multivariate methods. Results The study includes 22,406 chronic pain patients. Many variables, including acceptance variables, showed important contributions to the variation in clinical presentations and in life impacts. Based on the statistically important variables considering the clinical presentation, three clusters/subgroups of patients were identified at baseline; from the worst clinical situation to the relatively good situation. These clusters showed significant differences in outcomes after participating in MMRP; the subgroup with the worst situation at baseline showed the most significant improvements. Conclusions Pain intensity/severity, emotional distress, acceptance, and life impacts were important for the clinical presentation and were used to identify three clusters with marked differences at baseline (i.e. before MMRP). Life impacts showed complex relationships with acceptance, pain intensity/severity, and emotional distress. The most significant improvements after MMRP were seen in the subgroup with the lowest level of functioning before treatment, indicating that patients with complex problems should be offered MMRP. Implications This study emphasizes the need to adopt a biopsychosocial perspective when assessing patients with chronic pain. Patients with chronic pain referred to specialist clinics are not homogenous in their clinical presentation. Instead we identified three distinct subgroups of patients. The outcomes of MMRP appears to be related to the clinical presentation. Thus, patients with the most severe clinical presentation show the most prominent improvements. However, even though this group of patients improve they still after MMRP show a complex situation and there is thus a need for optimizing the content of MMRP for these patients. The subgroup of patients with a relatively good situation with respect to pain, psychological distress, coping and life impact only showed minor improvements after MMRP. Hence, there is a need to develop other complex interventions for them.
33.	Deribe, Leul, et al. (author) Stress and coping strategies among parents of children with cancer at Tikur Anbessa Specialized Hospital paediatric oncology unit, Ethiopia: a phenomenological study 2023 In: BMJ. British Medical Journal. - : BMJ. - 0959-8146. ; 13:e065090, s. 1-13 Journal article (peer-reviewed)abstract Objective This study explores sources of stress, conditions that help reduce stress levels and coping strategies among parents of children with cancer receiving chemotherapy at Tikur Anbessa Specialized Hospital (TASH) in Ethiopia. Design A qualitative phenomenological approach was used. Setting Parents of children receiving chemotherapy at the TASH paediatric oncology unit. Participants Fifteen semistructured in-depth interviews were conducted with nine mothers and six fathers of children with cancer from November 2020 to January 2021. Results Sources of stress related to child’s health condition as the severity of the child’s illness, fear of treatment side effects and loss of body parts were identified. Parents mentioned experiencing stress arising from limited access to health facilities, long waiting times, prolonged hospital stays, lack of chemotherapy drugs, and limited or inadequate information about their child’s disease condition and treatment. Other sources of stress were insufficient social support, stigmatisation of cancer and financial problems. Conditions decreasing parents’ stress included positive changes in the child’s health, receiving cancer treatment and access to drugs. Receiving counselling from healthcare providers, getting social support and knowing someone who had a positive treatment outcome also helped reduce stress. Coping strategies used by parents were religious practices including prayer, crying, accepting the child’s condition, denial and communication with health providers. Conclusion The main causes of stress identified by parents of children with cancer in Ethiopia were the severity of their child’s illness, expectations of poor treatment outcomes, unavailability of cancer treatment services and lack of social/financial support. Measures that should be considered to reduce parents’ stress include providing psycho-oncological care for parents and improving the counselling available to parents concerning the nature of the child’s illness, its treatment, diagnostic procedures and treatment side effects. It may also be helpful to establish and strengthen family support groups and parent-to-parent communication, improve the availability of chemotherapy drugs and offer more education on coping strategies.
34.	Vilhelmsson, Andreas, et al. (author) Nudging healthcare professionals to improve treatment of COVID-19: a narrative review 2021 In: Bmj Open Quality. - : BMJ. - 2399-6641. ; 10:4 Journal article (peer-reviewed)
35.	Spreco, Armin, et al. (author) Nowcasting (Short-Term Forecasting) of COVID-19 Hospitalizations Using Syndromic Healthcare Data, Sweden, 2020 2022 In: Emerging Infectious Diseases. - : Centers for Disease Control and Prevention (CDC). - 1080-6040 .- 1080-6059. ; 28:3, s. 564-571 Journal article (peer-reviewed)abstract We report on local nowcasting (short-term forecasting) of coronavirus disease (COVID-19) hospitalizations based on syndromic (symptom) data recorded in regular healthcare routines in Östergötland County (population ≈465,000), Sweden, early in the pandemic, when broad laboratory testing was unavailable. Daily nowcasts were supplied to the local healthcare management based on analyses of the time lag between telenursing calls with the chief complaints (cough by adult or fever by adult) and COVID-19 hospitalization. The complaint cough by adult showed satisfactory performance (Pearson correlation coefficient r>0.80; mean absolute percentage error <20%) in nowcasting the incidence of daily COVID-19 hospitalizations 14 days in advance until the incidence decreased to <1.5/100,000 population, whereas the corresponding performance for fever by adult was unsatisfactory. Our results support local nowcasting of hospitalizations on the basis of symptom data recorded in routine healthcare during the initial stage of a pandemic. © 2022 Centers for Disease Control and Prevention (CDC). All rights reserved.
36.	Hedna, Khedidja, 1978, et al. (author) Clinical relevance of alerts from a decision support system, PHARAO, for drug safety assessment in the older adults 2019 In: BMC Geriatrics. - : Springer Science and Business Media LLC. - 1471-2318. ; 19:1, s. 164- Journal article (peer-reviewed)abstract BackgroundPHARAO is a decision support system developed to evaluate the risk for a set of either common or serious side-effects resulting from a combination of pharmacodynamic effects from a patient's medications. The objective of this study was to investigate the validity of the risk scores for the common side-effects generated by PHARAO in older patients.MethodsSide-effects included were sedation, constipation, orthostatic symptoms, anticholinergic and serotonergic effects. The alerts generated by PHARAO were tested in 745 persons 65years old. Dispensed prescriptions retrieved from the Swedish prescribed drug register were used to generate the pharmacological risk scores of patients' medications. Symptoms possibly related to side-effects were extracted from medical records data.ResultsThe PHARAO system generated 776 alerts, most often for the risk of anticholinergic symptoms. The total specificity estimates of the PHARAO system were 0.95, 0.89 and 0.78 for high, intermediate and low risk alerts, respectively. The corresponding sensitivity estimates were between 0.12 and 0.37. The negative predictive value was 0.90 and the positive predictive value ranged between 0.20-0.25.ConclusionsThe PHARAO system had a high specificity and negative predictive value to detect symptoms possibly associated with the of patients' medications, while the sensitivity and positive predictive value were low. The PHARAO system has the potential to minimise the risk of over-alerts in combination with a drug-drug interaction alert system, but should be used in connection with a medical evaluation of the patient.
37.	Lendaro, Eva, 1989, et al. (author) Phantom motor execution as a treatment for phantom limb pain: Protocol of an international, double-blind, randomised controlled clinical trial 2018 In: BMJ Open. - : BMJ. - 2044-6055 .- 2044-6055. ; 8:7 Journal article (peer-reviewed)abstract Introduction Phantom limb pain (PLP) is a chronic condition that can greatly diminish quality of life. Control over the phantom limb and exercise of such control have been hypothesised to reverse maladaptive brain changes correlated to PLP. Preliminary investigations have shown that decoding motor volition using myoelectric pattern recognition, while providing real-time feedback via virtual and augmented reality (VR-AR), facilitates phantom motor execution (PME) and reduces PLP. Here we present the study protocol for an international (seven countries), multicentre (nine clinics), double-blind, randomised controlled clinical trial to assess the effectiveness of PME in alleviating PLP. Methods and analysis Sixty-seven subjects suffering from PLP in upper or lower limbs are randomly assigned to PME or phantom motor imagery (PMI) interventions. Subjects allocated to either treatment receive 15 interventions and are exposed to the same VR-AR environments using the same device. The only difference between interventions is whether phantom movements are actually performed (PME) or just imagined (PMI). Complete evaluations are conducted at baseline and at intervention completion, as well as 1, 3 and 6 months later using an intention-to-treat (ITT) approach. Changes in PLP measured using the Pain Rating Index between the first and last session are the primary measure of efficacy. Secondary outcomes include: Frequency, duration, quality of pain, intrusion of pain in activities of daily living and sleep, disability associated to pain, pain self-efficacy, frequency of depressed mood, presence of catastrophising thinking, health-related quality of life and clinically significant change as patient's own impression. Follow-up interviews are conducted up to 6 months after the treatment. Ethics and dissemination The study is performed in agreement with the Declaration of Helsinki and under approval by the governing ethical committees of each participating clinic. The results will be published according to the Consolidated Standards of Reporting Trials guidelines in a peer-reviewed journal.
38.	Higueras-Fresnillo, Sara, et al. (author) Low prevalence of ideal cardiovascular health in the general Swedish population: Results from the Swedish CArdioPulmonary bioImage Study (SCAPIS) 2023 In: Scandinavian Journal of Public Health. - : SAGE Publications. - 1403-4948 .- 1651-1905. ; 51:4, s. 527-530 Journal article (peer-reviewed)abstract The aim of the current study was to examine the prevalence of ideal cardiovascular health (iCVH) in the general Swedish middle-aged population. To address this aim, we utilised data from the Swedish CArdioPulmonary bioImage Study (SCAPIS) which is a large Swedish population-based study (N=30,154) that combined comprehensive state-of-the-art imaging technology with clinical examinations and included all iCVH components. A total iCVH score was calculated as the number of iCVH metrics at an ideal level for the seven components and classified as: ideal (> 5 ideal components), intermediate (3-4 ideal components) and poor (<= 2 ideal components). Our results showed that only 18.2% of the population reached ideal status (i.e. > 5 components at the ideal level), whereas 51.9% were classified as intermediate status and 29.9% as poor status of iCVH. Women had a higher prevalence of iCVH status (23.9% vs. 12.0%) and a lower prevalence of poor iCVH status (23.5% vs. 36.8%). Our data may serve as benchmarks for future national and international comparisons and motivate efforts to promote cardiovascular health in the general population, given the strong link between iCVH with all-cause and cardiovascular disease mortality and morbidity.
39.	Westman, Anders, 1946- (author) Musculoskeletal pain in primary health care : a biopsychosocial perspective for assessment and treatment 2010 Doctoral thesis (other academic/artistic)abstract Long-term musculoskeletal pain is a large public health problem with serious consequences for both the individual and society. Psychosocial factors have been shown to be good predictors of long-term disability and play an important role in the transition from acute to chronic pain. Early identification and intervention of those that run the risk of developing long-term disability would offer a great opportunity for reducing costs and personal suffering. The overall aim of this thesis was to assess a biopsychosocial approach to the assessment and management of musculoskeletal pain patients in primary health care. To this end, biopsychosocial assessment and treatment methods were tested in two different populations of primary care patients suffering pain. Results indicated that improvements in quality of life and work capacity one year after early multimodal rehabilitation were basically maintained after five years. The most salient prognostic factors determining return to work were educational level and the individual’s perceived health (Study I). Psychosocial factors as measured by the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) were related to disability and perceived health three years after treatment for non-acute pain problems (Study II). The experimental group in the controlled multimodal pain rehabilitation programme had lower health care utilization and a reduced risk of using large amounts of medication after three years compared with the participants in the control group. However, there were no significant differences between the groups on variables such as work capacity, function, catastrophizing and pain (Study III). Distinct profiles of catastrophizing, fear-avoidance beliefs, and distress were extracted and meaningfully related to future sick leave and dysfunction (Study IV). Our findings provide support for the biopsychosocial model and highlight the importance of psychosocial factors in long-term outcome. The results underscore the need for early identification of patients at risk. Further, multimodal treatment that covers not only biological but also psychosocial factors seems to be a key to successful treatment, and ideally this intervention should be matched to the patients' needs.
40.	Ahlander, Britt-Marie, 1954- (author) Magnetic Resonance Imaging of the Heart : Image quality, measurement accuracy and patient experience 2016 Doctoral thesis (other academic/artistic)abstract Background: Non-invasive diagnostic imaging of atherosclerotic coronary artery disease (CAD) is frequently carried out with cardiovascular magnetic resonance imaging (CMR) or myocardial perfusion single photon emission computed tomography (MPS). CMR is the gold standard for the evaluation of scar after myocardial infarction and MPS the clinical gold standard for ischemia. Magnetic Resonance Imaging (MRI) is at times difficult for patients and may induce anxiety while patient experience of MPS is largely unknown.Aims: To evaluate image quality in CMR with respect to the sequences employed, the influence of atrial fibrillation, myocardial perfusion and the impact of patient information. Further, to study patient experience in relation to MRI with the goal of improving the care of these patients.Method: Four study designs have been used. In paper I, experimental cross-over, paper (II) experimental controlled clinical trial, paper (III) psychometric crosssectional study and paper (IV) prospective intervention study. A total of 475 patients ≥ 18 years with primarily cardiac problems (I-IV) except for those referred for MRI of the spine (III) were included in the four studies.Result: In patients (n=20) with atrial fibrillation, a single shot steady state free precession (SS-SSFP) sequence showed significantly better image quality than the standard segmented inversion recovery fast gradient echo (IR-FGRE) sequence (I). In first-pass perfusion imaging the gradient echo-echo planar imaging sequence (GREEPI) (n=30) had lower signal-to-noise and contrast–to-noise ratios than the steady state free precession sequence (SSFP) (n=30) but displayed a higher correlation with the MPS results, evaluated both qualitatively and quantitatively (II). The MRIAnxiety Questionnaire (MRI-AQ) was validated on patients, referred for MRI of either the spine (n=193) or the heart (n=54). The final instrument had 15 items divided in two factors regarding Anxiety and Relaxation. The instrument was found to have satisfactory psychometric properties (III). Patients who prior CMR viewed an information video scored significantly (lower) better in the factor Relaxation, than those who received standard information. Patients who underwent MPS scored lower on both factors, Anxiety and Relaxation. The extra video information had no effect on CMR image quality (IV).Conclusion: Single shot imaging in atrial fibrillation produced images with less artefact than a segmented sequence. In first-pass perfusion imaging, the sequence GRE-EPI was superior to SSFP. A questionnaire depicting anxiety during MRI showed that video information prior to imaging helped patients relax but did not result in an improvement in image quality.
41.	Bixby, H., et al. (author) Rising rural body-mass index is the main driver of the global obesity epidemic in adults 2019 In: Nature. - : Springer Science and Business Media LLC. - 0028-0836 .- 1476-4687. ; 569:7755, s. 260-4 Journal article (peer-reviewed)abstract Body-mass index (BMI) has increased steadily in most countries in parallel with a rise in the proportion of the population who live in cities(.)(1,2) This has led to a widely reported view that urbanization is one of the most important drivers of the global rise in obesity(3-6). Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017. We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017-and more than 80% in some low- and middle-income regions-was due to increases in BMI in rural areas. This large contribution stems from the fact that, with the exception of women in sub-Saharan Africa, BMI is increasing at the same rate or faster in rural areas than in cities in low- and middle-income regions. These trends have in turn resulted in a closing-and in some countries reversal-of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women. There is an urgent need for an integrated approach to rural nutrition that enhances financial and physical access to healthy foods, to avoid replacing the rural undernutrition disadvantage in poor countries with a more general malnutrition disadvantage that entails excessive consumption of low-quality calories.
42.	Giang, K. W., et al. (author) Strategies for achieving efficiency in the general practitioner's everyday life 2022 In: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 40:2, s. 261-270 Journal article (peer-reviewed)abstract Objective To describe concrete, effective strategies used by experienced GPs to achieve time efficiency, increase patient satisfaction and maintain high medical quality during patient meetings. Design Qualitative observation yielded field notes for qualitative content analysis according to Graneheim and Lundman. Follow-up telephone interviews were conducted to get feedback from patients. Setting A normal working day with patient meetings in a primary health care center in Sweden. Subjects Five GPs known for being experienced and well-functioning clinicians were strategically chosen to participate in an observational study during patient meetings. Afterwards a random selection of 25 patients (five from each GP) were asked to rate their experience of their meeting. Results Observation and analysis of GPs' work before, during, and after patient meetings revealed several concrete strategies, which we classified into two main categories: Behavioral and Communicative, comprising nine and seven subcategories, respectively. Conclusion Most important behavioral skills for time efficiency were a GP's ability to handle interruptions, and effective administration. Medical quality during patient meetings was most supported by GP continuity and relationship, an exploratory patient-centered approach, a focus on one task at a time, and the ability to acknowledge and learn from medical uncertainty. Patients were most satisfied with GPs who had good communicative skills, good GP continuity and relationship.
43.	Hellgren, Mikko, 1972-, et al. (author) Hypertension management in primary health care : a survey in eight regions of Sweden 2023 In: Scandinavian Journal of Primary Health Care. - : Taylor & Francis. - 0281-3432 .- 1502-7724. ; 41:3, s. 343-350 Journal article (peer-reviewed)abstract Purpose: To explore hypertension management in primary healthcare (PHC).Design: Structured interviews of randomly selected PHC centres (PHCCs) from December 2019 to January 2021.Setting: Seventy-six PHCCs in eight regions of Sweden.Main outcome measures: Staffing and organization of hypertension care. Methods of measuring blood pressure (BP), laboratory tests, registration of co-morbidities and lifestyle advice at diagnosis and follow-up.Results: The management of hypertension varied among PHCCs. At diagnosis, most PHCCs (75%) used the sitting position at measurements, and only 13% routinely measured standing BP. One in three (33%) PHCCs never used home BP measurements and 25% only used manual measurements. The frequencies of laboratory analyses at diagnosis were similar in the PHCCs. At follow-up, fewer analyses were performed and the tests of lipids and microalbuminuria decreased from 95% to 45% (p < 0.001) and 61% to 43% (p = 0.001), respectively. Only one out of 76 PHCCs did not measure kidney function at routine follow-ups. Lifestyle, physical activity, food habits, smoking and alcohol use were assessed in & GE;96% of patients at diagnosis. At follow-up, however, there were fewer assessments. Half of the PHCCs reported dedicated teams for hypertension, 82% of which were managed by nurses. There was a great inequality in the number of patients per tenured GP in the PHCCs (median 2500; range 1300-11300) patients.Conclusions: The management of hypertension varies in many respects between PHCCs in Sweden. This might lead to inequity in the care of patients with hypertension.
44.	Pourhamidi, Kaveh, et al. (author) Evaluation of clinical tools and their diagnostic use in distal symmetric polyneuropathy 2014 In: Primary care diabetes. - : Elsevier. - 1878-0210 .- 1751-9918. ; 8:1, s. 77-84 Journal article (peer-reviewed)abstract AIMS: To compare the diagnostic usefulness of tuning fork, monofilament, biothesiometer and skin biopsies in peripheral neuropathy in individuals with varying glucose metabolism.METHODS: Normoglycaemic, impaired glucose tolerance (IGT) and type 2 diabetes (T2DM) individuals were recruited. Nerve conduction studies (NCS) and thermal threshold tests were performed. Vibrotactile sense was tested with a biothesiometer and a 128-Hz tuning fork. Touch/pressure perception was examined with a 10-g monofilament. Skin biopsies were performed and intraepidermal nerve fibres were quantified. Distal symmetric polyneuropathy (DSPN) was defined as neuropathy disability score ≥2 and abnormal NCS. Thermal threshold tests were used to define small nerve fibre neuropathy (sDSPN) in cases where NCS (large nerve fibres) were normal.RESULTS: The prevalence of DSPN and sDSPN in the whole group (n=119) was 18% and 23%, respectively. For the biothesiometer, a cut-off of ≥24.5V had a sensitivity of 82% and specificity of 70% (AUC=0.81, 95% CI 0.71-0.91) when evaluating DSPN. An intraepidermal nerve fibre density cut-off of ≤3.39fibres/mm showed a sensitivity of 74% and specificity of 70% in the detection of sDSPN, whereas the sensitivity of the tuning fork and the biothesiometer were relatively low, 46% and 67%, respectively. When combining skin biopsies with the tuning fork, 10 more sDSPN cases were identified. Adding skin biopsy to the combination of the tuning fork and biothesiometer increased the sensitivity of finding sDSPN cases, but not DSPN, from 81% to 93%.CONCLUSION: Using a biothesiometer in clinical routine might be a sensitive method to detect large nerve fibre dysfunction in the lower extremity, whereas skin biopsies in combination with methods measuring vibrotactile sense could increase the diagnostic sensitivity of detecting peripheral neuropathy at an early stage.
45.	Hedin, Katarina, et al. (author) Management of patients with sore throats in relation to guidelines : an interview study in Sweden. 2014 In: Scandinavian Journal of Primary Health Care. - : Taylor & Francis. - 0281-3432 .- 1502-7724. ; 32:4, s. 193-9 Journal article (peer-reviewed)abstract OBJECTIVE: To explore how a group of Swedish general practitioners (GPs) manage patients with a sore throat in relation to current guidelines as expressed in interviews.DESIGN: Qualitative content analysis was used to analyse semi-structured interviews.SETTING: Swedish primary care.SUBJECTS: A strategic sample of 25 GPs.MAIN OUTCOME MEASURES: Perceived management of sore throat patients.RESULTS: It was found that nine of the interviewed GPs were adherent to current guidelines for sore throat and 16 were non-adherent. The two groups differed in terms of guideline knowledge, which was shared within the team for adherent GPs while idiosyncratic knowledge dominated for the non-adherent GPs. Adherent GPs had no or low concerns for bacterial infections and differential diagnosis whilst non-adherent GPs believed that in patients with a sore throat any bacterial infection should be identified and treated with antibiotics. Patient history and examination was mainly targeted by adherent GPs whilst for non-adherent GPs it was often redundant. Non-adherent GPs reported problems getting patients to abstain from antibiotics, whilst no such problems were reported in adherent GPs.CONCLUSION: This interview study of sore throat management in a strategically sampled group of Swedish GPs showed that while two-thirds were non-adherent and had a liberal attitude to antibiotics one-third were guideline adherent with a restricted view on antibiotics. Non-adherent GPs revealed significant knowledge gaps. Adherent GPs had discussed guidelines within the primary care team while non-adherent GPs had not. Guideline implementation thus seemed to be promoted by knowledge shared in team discussions.
46.	Rawshani, Nina, et al. (author) Could ten questions asked by the dispatch center predict the outcome for patients with chest discomfort? 2016 In: International Journal of Cardiology. - : Elsevier BV. - 0167-5273 .- 1874-1754. ; 209, s. 223-225 Journal article (peer-reviewed)abstract BACKGROUND AND AIMS: From 2009 to 2010, approximately 14,000 consecutive persons who called for the EMS due to chest discomfort were registered. From the seventh month, dispatchers ask 2285 patient ten pre-specified questions. We evaluate which of these questions was independently able to predict an acute coronary syndrome (ACS), life-threatening condition (LTC) and death.METHODS: The questions asked mainly dealt with previous history and type of symptoms, each with yes/no answers. The dispatcher took a decision on priority; 1) immediately with sirens/blue light; 2) EMS on the scene within 30min; 3) normal waiting time.We examined the relationship between the answers to these questions and subsequent dispatch priority, as well as outcome, in terms of ACS, LTC and all-cause mortality.RESULTS: 2285 patients (mean age 67years, 49% women) took part, of which 12% had a final diagnosis of ACS and 15% had a LTC. There was a significant relationship between all the ten questions and the priority given by dispatchers. Localisation of the discomfort to the center of the chest, more intensive pain, history of angina or myocardial infarction as well as experience of cold sweat were the most important predictors when evaluating the probability of ACS and LTC. Not breathing normally and having diabetes were related to 30-day mortality.CONCLUSIONS: Among individuals, who call for the EMS due to chest discomfort, the intensity and the localisation of the pain, as well as a history of ischemic heart disease, appeared to be the most strongly associated with outcome.
47.	Peilot, Birgitta, 1947, et al. (author) Time to gain trust and change-Experiences of attachment and mindfulness-based cognitive therapy among patients with chronic pain and psychiatric co-morbidity 2014 In: International Journal of Qualitative Studies on Health and Well-Being. - : Informa UK Limited. - 1748-2623 .- 1748-2631. ; 9:24420 Journal article (peer-reviewed)abstract The treatment of patients with chronic pain disorders is complex. In the rehabilitation of these patients, coping with chronic pain is seen as important. The aim of this study was to explore the meaning of attachment and mindfulness-based cognitive therapy (CT) among patients with chronic pain and psychiatric co-morbidity. A phenomenological approach within a lifeworld perspective was used. In total, 10 patients were interviewed after completion of 7-to 13-month therapy. The findings reveal that the therapy and the process of interaction with the therapist were meaningful for the patients' well-being and for a better management of pain. During the therapy, the patients were able to initiate a movement of change. Thus, CT with focus on attachment and mindfulness seems to be of value for these patients. The therapy used in this study was adjusted to the patients' special needs, and a trained psychotherapist with a special knowledge of patients with chronic pain might be required.
48.	Rothlind, Erica, et al. (author) The informal curriculum of family medicine - what does it entail and how is it taught to residents? A systematic review 2020 In: BMC Family Practice. - : Springer Science and Business Media LLC. - 1471-2296. ; 21:1 Research review (peer-reviewed)abstract BackgroundThe informal curriculum is a seemingly well-explored concept in the realm of medical education. However, it is a concept with multiple definitions and the term the hidden curriculum is often used interchangeably. In short, they both refer to the implicit learning taking place outside the formal curriculum, encompassing both a trickling down effect of organizational values and attitudes passed on by a mentor or colleague. While the informal curriculum is a recurrent theme in medical education literature; it is seldom discussed in Family Medicine. As the informal curriculum is likely to be highly influential in the forming of future family practitioners, our aim was to explore the area further, with respect to the following: which elements of the informal curriculum are applicable in a Family Medicine context and what educational interventions for Family Medicine residents, visualizing the various educational elements of it, have been performed?MethodsWe conducted a systematic review comprising iterative literature searches and a narrative synthesis of the results.ResultsTwenty articles, published between 2000 and 2019, were included in the analysis which resulted in three partly interrelated themes comprising the informal curriculum in Family Medicine: gaining cultural competence, achieving medical professionalism and dealing with uncertainty. The themes on cultural competence and uncertainty seemed to be more contextual than professionalism, the latter being discussed in relation to the informal curriculum across other medical disciplines as well. Formalized training for Family Medicine residents in aspects of the informal curriculum appeared to be lacking, and in general, the quality of the few interventional studies found was low.ConclusionsImportant aspects of being a family practitioner, such as cultural competence and dealing with uncertainty, are learned through a context-dependent informal curriculum. In order to ensure a more uniform base for all residents and to reduce the impact of the individual supervisor's preferences, complementary formalized training would be beneficial. However, to date there are too few studies published to conclude how to best teach the informal curriculum.
49.	Danielsson, M., et al. (author) Prevalence, duration of exposure and predicting factors for snus use among young Finnish men: a cross-sectional study 2021 In: Bmj Open. - : BMJ. - 2044-6055. ; 11:9 Journal article (peer-reviewed)abstract Objective The health hazards of tobacco products depend on the level of exposure, but little is known about the characteristics of snus use. The aim of this study was to investigate the duration of daily exposure to snus among occasional and daily users and its associated predictive factors among young Finnish men. Design Cross-sectional questionnaire study. Setting Three out of 16 Finnish Defence Forces units. Participants 1280 young Finnish male conscripts starting their military service in 2016 chosen by simple random sampling. Primary and secondary measures The prevalence, duration of use and the amount of daily usage of snus and cigarettes were investigated. The attitudes towards perceived harmfulness of snus and the predictive factors affecting the total time of snus consumption were examined. Results Almost a fifth (19.5%) of the conscripts reported daily snus use, and a further 16% reported occasional use. Daily snus use was associated with an earlier starting age, longer duration of use and higher daily exposure time compared with occasional use. On average, daily snus users consumed 10 portions and occasional users three portions per day (p<0.001). The daily total exposure time for daily users was 372 min (95% CI 344 to 401) and for occasional users 139 min (95% CI 106 to 171). Respondents with an upper secondary education had significantly less daily total exposure than those with basic comprehensive education (p=0.036). Perceptions of snus as a harmful substance resulted in a significantly lower duration of exposure. Conclusion Snus use was very common among young Finnish men. High snus exposure duration was associated with an earlier starting age, a longer history of use and a careless attitude to its health hazards. A higher education level was a protective factor for total exposure time. Studies of the long-term health effects and dependency profile of snus use are needed.
50.	Joelsson, Monica, et al. (author) Patients with chronic pain may need extra support when prescribed physical activity in primary care: a qualitative study 2017 In: Scandinavian Journal of Primary Health Care. - : Informa UK Limited. - 0281-3432 .- 1502-7724. ; 35:1, s. 64-74 Journal article (peer-reviewed)abstract Background: Physical activity plays an important role in the prevention and treatment of chronic musculoskeletal pain, but chronic pain may implicate a poor rehabilitation outcome. The concept of physical activity on prescription (PAP) is a therapeutic option for various diseases, but there is a lack of knowledge about how patients with chronic musculoskeletal pain experience receiving the prescription. Objectives: The objective of this study was to describe the experiences of and thoughts about receiving a prescription for physical activity of people with chronic musculoskeletal pain. Design: Interviews analysed using qualitative content analysis with an inductive approach. Setting: Three primary healthcare centres in a mixed rural and suburban area in the vicinity of a large city in western Sweden. Results: Four categories were identified with the overarching theme "Physical activity in chronic pain requires extra support". There were several barriers for increasing activity level and these patients suffered from the additional burden of pain. The categories were: "Important to identify needs", "Barriers and facilitators for physical activity", "Perceptions of PAP vary" and "Effects found of receiving PAP". Conclusions: Despite the many positive experiences of receiving PAP, patients described confusion about the role and execution of PAP. Chronic pain is an additional barrier for increasing activity level, and it is crucial to consider these patients' circumstances. This study suggests that patients with chronic musculoskeletal pain have a greater need for information and extra support to overcome existing barriers, before or when physical activity is prescribed.

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