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  • 1.
    Albertsson, Daniel
    et al.
    University of Gothenburg, Sweden;Region Kronoberg, Sweden.
    Mellström, Dan
    Sahlgrenska University Hospital, Sweden.
    Petersson, Christer
    Region Kronoberg, Sweden.
    Thulesius, Hans
    Region Kronoberg, Sweden.
    Eggertsen, Robert
    University of Gothenburg, Sweden;Mölnlycke Primary Hlth Care & Res Ctr, Sweden.
    Hip and fragility fracture prediction by 4-item clinical risk score and mobile heel BMD: a women cohort study.2010In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 11, p. 1-11, article id 55Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: One in four Swedish women suffers a hip fracture yielding high morbidity and mortality. We wanted to revalidate a 4-item clinical risk score and evaluate a portable heel bone mineral density (BMD) technique regarding hip and fragility fracture risk among elderly women.

    METHODS: In a population-based prospective cohort study we used clinical risk factors from a baseline questionnaire and heel BMD to predict a two-year hip and fragility fracture outcome for women, in a fracture preventive program. Calcaneal heel BMD was measured by portable dual X-ray laser absorptiometry (DXL) and compared to hip BMD, measured with stationary dual X-ray absorptiometry (DXA) technique.

    RESULTS: Seven women suffered hip fracture and 14 women fragility fracture/s (at hip, radius, humerus and pelvis) among 285 women; 60% having heel BMD <or= -2.5 SD. The 4-item FRAMO (Fracture and Mortality) Index combined the clinical risk factors age >or=80 years, weight <60 kg, prior fragility fracture, and impaired rise-up ability. Women having 2-4 risk factors showed odds ratio (OR) for hip fracture of 5.9 and fragility fracture of 4.4. High risk group hip fracture risk was 2.8% annually compared to 0.5% for the low risk majority (69%). Heel BMD showed hip fracture OR of 3.1 and fragility fracture OR of 2.6 per SD decrease. For 30 DXA assessed participants mean hip BMD at -2.5 SD level corresponded to a lower BMD at the heel. Five of seven hip fractures occurred within a small risk group of 32 women, identified by high FRAMO Index + prior fragility fracture + heel T-score <or=-3.5 SD.

    CONCLUSIONS: In a follow-up study we identified high risk groups for hip and fragility fracture with our plain 4-item risk model. Increased fracture risk was also related to decreasing heel BMD in calcaneal bone, measured with a mobile DXL technique. A combination of high FRAMO Index, prior fragility fracture, and very low BMD restricted the high risk group to 11%, among whom most hip fractures occurred (71%). These practical screening methods could eventually reduce hip fracture incidence by concentrating preventive resources to high fracture risk women.

  • 2.
    Buono, Nicola
    et al.
    National Society of Medical Education in General Practice (SNAMID), Italy.
    Thulesius, Hans
    Region Kronoberg, Sweden.
    Petrazzuoli, Ferdinando
    National Society of Medical Education in General Practice (SNAMID), Italy;Lund university.
    Castelli, Elena
    National Society of Medical Education in General Practice (SNAMID), Italy.
    Cambielli, Marco
    National Society of Medical Education in General Practice (SNAMID), Italy.
    Postherpetic neuralgia, diabetic neuropathy, and trigeminal neuralgia - Chronic peripheral neuropathic pain in 58,480 rural Italian primary care patients2017In: Journal of family medicine and primary care, ISSN 2249-4863, Vol. 6, no 1, p. 110-114Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Chronic peripheral neuropathic pain (CPNP) is a condition due to peripheral nervous system diseases or injury, but its prevalence is unknown in Italian primary care.

    AIM: The aim of this study is to assess the prevalence of CPNP in a rural primary care area in Northern Italy.

    MATERIALS AND METHODS: A multicenter audit study was carried out in a rural area in Northern Italy with 113 participating general practitioners (GPs) seeing 58,480 patients >18 years during 3 months. Patients who for any reason attended GPs' surgeries and had symptoms suggestive of neuropathic pain (NP) were given the NP diagnostic questionnaire "Douleur Neuropathique en 4 Questions" (DN4) and recorded their pain level on a visual analog scale (VAS).

    RESULTS: Chronic NP was established by a DN4 score of ≥4 and a VAS pain score of ≥40 mm for >6 months together with a clinical diagnosis in 448 (254 women and 194 men) out of 58,480 patients giving a prevalence of 0.77%. 179 patients (0.31%) had diabetes neuropathy, 142 (0.24%) had postherpetic pain, 41 (0.07%) had trigeminal neuralgia, 27 (0.05%) had NP postinjury, 27 (0.05%) had NP caused by nerve entrapments, 11 (0.02%) had NP triggered by systemic diseases, and 21 (0.04%) had NP of unknown etiology.

    CONCLUSIONS: The prevalence of CPNP in this population of primary care attenders in a rural area in Northern Italy was 0.77%. Diabetes neuropathy (0.31%) and postherpetic pain (0.24%) were the two most common subgroups of NP, followed by trigeminal neuralgia (0.07%).

  • 3.
    Buono, Nicola
    et al.
    Univ Maastricht, Netherlands.
    Thulesius, Hans
    Univ Maastricht, Netherlands.
    Petrazzuoli, Ferdinando
    Univ Maastricht, Netherlands.
    Van Merode, Tiny
    Univ Maastricht, Netherlands.
    Koskela, Tuomas
    Univ Maastricht, Netherlands.
    Le Reste, Jean-Yves
    Univ Maastricht, Netherlands.
    Prick, Hanny
    Univ Maastricht, Netherlands.
    Soler, Jean Karl
    Univ Maastricht, Netherlands.
    40 years of biannual family medicine research meetings--the European General Practice Research Network (EGPRN).2013In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 31, no 4, p. 185-7Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To document family medicine research in the 25 EGPRN member countries in 2010.

    DESIGN: Semi-structured survey with open-ended questions.

    SETTING: Academic family medicine in 23 European countries, Israel, and Turkey.

    SUBJECTS: 25 EGPRN national representatives.

    MAIN OUTCOME MEASURES: Demographics of the general population and family medicine. Assessments, opinions, and suggestions.

    RESULTS: EGPRN has represented family medicine for almost half a billion people and > 300,000 general practitioners (GPs). Turkey had the largest number of family medicine departments and highest density of GPs, 2.1/1000 people, Belgium had 1.7, Austria 1.6, and France 1.5. Lowest GP density was reported from Israel 0.17, Greece 0.18, and Slovenia 0.4 GPs per 1000 people. Family medicine research networks were reported by 22 of 25 and undergraduate family medicine research education in 20 of the 25 member countries, and in 10 countries students were required to do research projects. Postgraduate family medicine research was reported by 18 of the member countries. Open-ended responses showed that EGPRN meetings promoted stimulating and interesting research questions such as comparative studies of chronic pain management, sleep disorders, elderly care, healthy lifestyle promotion, mental health, clinical competence, and appropriateness of specialist referrals. Many respondents reported a lack of interest in family medicine research related to poor incentives and low family medicine status in general and among medical students in particular. It was suggested that EGPRN exert political lobbying for family medicine research.

    CONCLUSION: Since 1974, EGPRN organizes biannual conferences that unite and promote primary care practice, clinical research and academic family medicine in 25 member countries.

  • 4.
    Burström, Lena
    et al.
    Uppsala University, Sweden.
    Starrin, Bengt
    Karlstad University, Sweden.
    Engström, Marie-Louise
    Uppsala University, Sweden.
    Thulesius, Hans
    Lund University, Sweden;Region Kronoberg, Sweden.
    Waiting management at the emergency department - a grounded theory study.2013In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, p. 1-10, article id 95Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: An emergency department (ED) should offer timely care for acutely ill or injured persons that require the attention of specialized nurses and physicians. This study was aimed at exploring what is actually going on at an ED.

    METHODS: Qualitative data was collected 2009 to 2011 at one Swedish ED (ED1) with 53.000 yearly visits serving a population of 251.000. Constant comparative analysis according to classic grounded theory was applied to both focus group interviews with ED1 staff, participant observation data, and literature data. Quantitative data from ED1 and two other Swedish EDs were later analyzed and compared with the qualitative data.

    RESULTS: The main driver of the ED staff in this study was to reduce non-acceptable waiting. Signs of non-acceptable waiting are physical densification, contact seeking, and the emergence of critical situations. The staff reacts with frustration, shame, and eventually resignation when they cannot reduce non-acceptable waiting. Waiting management resolves the problems and is done either by reducing actual waiting time by increasing throughput of patient flow through structure pushing and shuffling around patients, or by changing the experience of waiting by calming patients and feinting maneuvers to cover up.

    CONCLUSION: To manage non-acceptable waiting is a driving force behind much of the staff behavior at an ED. Waiting management is done either by increasing throughput of patient flow or by changing the waiting experience.

  • 5.
    Eriksson, Jeanette Källstrand
    et al.
    Halmstad University, Sweden.
    Hildingh, Cathrine
    Halmstad University, Sweden.
    Buer, Nina
    Örebro University, Sweden.
    Thulesius, Hans
    Region Kronoberg, Sweden.
    Seniors' self-preservation by maintaining established self and defying deterioration - A grounded theory.2016In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 11, p. 1-9, article id 30265Article in journal (Refereed)
    Abstract [en]

    The purpose of this classic grounded theory study was to understand how seniors who are living independently resolve issues influenced by visual impairment and high fall risk. We interviewed and observed 13 seniors with visual impairment in their homes. We also interviewed six visual instructors with experience from many hundreds of relevant incidents from the same group of seniors. We found that the seniors are resolving their main concern of "remaining themselves as who they used to be" by self-preservation. Within this category, the strategies maintaining the established self and defying deterioration emerged as the most prominent in our data. The theme maintaining the established self is mostly guided by change inertia and includes living the past (retaining past activities, reminiscing, and keeping the home intact) and facading (hiding impairment, leading to avoidance of becoming a burden and to risk juggling). Defying deterioration is a proactive scheme and involves moving (by exercising, adapting activities, using walking aids, driving), adapting (by finding new ways), and networking by sustaining old support networks or finding new networks. Self-preservation is generic human behavior and modifying this theory to other fields may therefore be worthwhile. In addition, health care providers may have use for the theory in fall preventive planning.

  • 6.
    Harris, Michael
    et al.
    University of Bath, UK.
    Frey, Peter
    Universität Bern, Switzerland.
    Esteva, Magdalena
    Majorca Primary Health Care Department, Spain;Instituto de Investigación sanitaria Illes Balears (idISBA), Spain.
    Gašparović Babić, Svjetlana
    University of Rijeka, Croatia.
    Marzo-Castillejo, Mercè
    Institut Català de la Salut, Spain.
    Petek, Davorina
    University of Ljubljana, Slovenia.
    Petek Ster, Marija
    University of Ljubljana, Slovenia.
    Thulesius, Hans
    Lund University, Sweden.
    How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes.2017In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 35, no 1, p. 27-34Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates.

    DESIGN: Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates.

    SETTING: A total of 14 countries.

    SUBJECTS: Consensus groups of PCPs.

    MAIN OUTCOME MEASURES: Probability of initial presentation to a PCP for four clinical vignettes.

    RESULTS: There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r  = -0.16, 95% CI -0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = -0.57, 95% CI -0.83 to -0.12; ovary: r = -0.13, 95% CI -0.57 to 0.38; breast r = 0.14, 95% CI -0.36 to 0.58; bowel: r = 0.20, 95% CI -0.31 to 0.62).

    CONCLUSIONS: There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a "PCP-as-gatekeeper" system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival. KEY POINTS European cancer survival rates vary widely, and health system factors may account for some of these differences. The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP. The degree to which PCPs act as gatekeepers varies considerably from country to country. There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.

  • 7.
    Harris, Michael
    et al.
    University of Bath, UK;University of Bern, Switzerland.
    Vedsted, Peter
    Aarhus University, Denmark.
    Esteva, Magdalena
    Balearic Islands Health Research Institute (IdISBa), Spain.
    Murchie, Peter
    University of Aberdeen, UK.
    Aubin-Auger, Isabelle
    Université Paris Diderot, France.
    Azuri, Joseph
    Tel Aviv University, Israel.
    Brekke, Mette
    University of Oslo, Norway.
    Buczkowski, Krzysztof
    Nicolaus Copernicus University, Poland.
    Buono, Nicola
    National Society of Medical Education in General Practice (SNaMID), Italy.
    Costiug, Emiliana
    Iuliu Hatieganu University of Medicine and Pharmacy, Romania.
    Dinant, Geert-Jan
    Maastricht University, Netherlands.
    Foreva, Gergana
    Medical Center BROD, Plovdiv, Bulgaria.
    Gašparović Babić, Svjetlana
    The Teaching Institute of Public Health of Primorsko-goranska County, Croatia.
    Hoffman, Robert
    Tel Aviv University, Israel.
    Jakob, Eva
    Centro de Saúde Sarria, Spain.
    Koskela, Tuomas H
    University of Tampere, Finland.
    Marzo-Castillejo, Mercè
    Institut Catala De La Salut, Spain.
    Neves, Ana Luísa
    Imperial College London, UK;University of Porto, Porto, Portugal.
    Petek, Davorina
    University of Ljubljana, Slovenia.
    Petek Ster, Marija
    University of Ljubljana, Slovenia.
    Sawicka-Powierza, Jolanta
    Medical University of Bialystok, Poland.
    Schneider, Antonius
    Technische Universität München, Germany.
    Smyrnakis, Emmanouil
    Aristotle University of Thessaloniki, Greece.
    Streit, Sven
    University of Bern, Switzerland.
    Thulesius, Hans
    Lund University, Sweden.
    Weltermann, Birgitta
    University of Bonn, Germany.
    Taylor, Gordon
    University of Bath, UK.
    Identifying important health system factors that influence primary care practitioners' referrals for cancer suspicion: a European cross-sectional survey.2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 9, p. 1-13, article id e022904Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners' (PCPs') referral decisions is lacking.This study analyses health system factors potentially influencing PCPs' referral decision-making when consulting with patients who may have cancer, and how these vary between European countries.

    DESIGN: Based on a content-validity consensus, a list of 45 items relating to a PCP's decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs' referral decision-making.

    SETTING: A primary care study; 25 participating centres in 20 European countries.

    PARTICIPANTS: 1830 PCPs completed the survey. The median response rate for participating centres was 20.7%.

    OUTCOME MEASURES: The factors derived from items related to PCPs' referral decision-making. Mean factor scores were produced for each country, allowing comparisons.

    RESULTS: Factor analysis identified five underlying factors: PCPs' ability to refer; degree of direct patient access to secondary care; PCPs' perceptions of being under pressure; expectations of PCPs' role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses.

    CONCLUSIONS: Five healthcare system factors influencing PCPs' referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.

  • 8.
    Hedin, Katarina
    et al.
    Lund University, Sweden;Region Kronoberg, Sweden.
    Strandberg, Eva Lena
    Lund university, Sweden;Blekinge County Council, Sweden.
    Gröndal, Hedvig
    Uppsala university, Sweden.
    Brorsson, Annika
    Lund university, Sweden;Ctr Primary Hlth Care Res, Malmö, Sweden.
    Thulesius, Hans
    Lund university, Sweden;Region Kronoberg, Sweden.
    André, Malin
    Linköping Univ, Sweden;Uppsala University, Sweden.
    Management of patients with sore throats in relation to guidelines: an interview study in Sweden.2014In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 32, no 4, p. 193-9Article in journal (Refereed)
    Abstract [en]

    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.

  • 9.
    Helgesson, Gert
    et al.
    Karolinska Institutet, Sweden.
    Lindblad, Anna
    Karolinska Institutet, Sweden.
    Thulesius, Hans
    Lund university, Sweden;Region Kronoberg, Sweden.
    Lynöe, Niels
    Karolinska Institutet, Sweden.
    Reasoning about physician-assisted suicide: analysis of comments by physicians and the Swedish general public2009In: Clinical Ethics, ISSN 1477-7509, E-ISSN 1758-101X, Vol. 4, no 1, p. 19-25Article in journal (Refereed)
    Abstract [en]

    Two questionnaires directed to Swedish physicians and a sample of the Swedish population investigated attitudes towards physician-assisted suicide (PAS). The aim of the present work was to analyse qualitative data from these questionnaires in order to explore how respondents reason about PAS. Data were analysed in two steps. First, we categorized different kinds of responses and identified pro and con arguments. Second, we identified general conclusions from the responses. The data reflect the differences in attitudes towards PAS among the public and physicians, with the former mainly in favour of PAS and the latter mainly against. There was, however, considerable agreement about what requirements must be met before PAS could be considered ethical. Many arguments against PAS concerned the professional role of physicians, which indicates that it may not be assisted suicide as such that many PAS opponents disagree with, but rather that it is handled by physicians in the regular health-care system.

  • 10.
    Le Reste, Jean Yves
    et al.
    Univ Bretagne Occidentale, France.
    Nabbe, Patrice
    Univ Bretagne Occidentale, France.
    Rivet, Charles
    Univ Bretagne Occidentale, France.
    Lygidakis, Charilaos
    AIMEF, Bologna, Italy.
    Doerr, Christa
    Allgemein Med Hsch Gottingen, Germany.
    Czachowski, Slawomir
    Nicholas Copernicus Univ, Poland.
    Lingner, Heidrun
    Allgemein Med Hsch Hannover, Germany.
    Argyriadou, Stella
    Greek Assoc Gen Practitioners ELEGEIA, Greece.
    Lazic, Djurdjica
    Univ Zagreb, Croatia.
    Assenova, Radost
    Paisij Hilendarski Univ Plovdiv, Bulgaria.
    Hasaganic, Melida
    Univ Sarajevo, Bosnia-Herzegovina.
    Munoz, Miquel Angel
    IDIAP Jordi Gol, Spain.
    Thulesius, Hans
    Lund University, Sweden.
    Le Floch, Bernard
    Univ Bretagne Occidentale, France.
    Derriennic, Jeremy
    Univ Bretagne Occidentale, France.
    Sowinska, Agnieska
    Nicholas Copernicus Univ, Poland.
    Van Marwijk, Harm
    Vrije Univ Amsterdam Med Ctr, Netherlands.
    Lietard, Claire
    Univ Bretagne Occidentale, France.
    Van Royen, Paul
    Univ Antwerp, Belgium.
    The European General Practice Research Network Presents the Translations of Its Comprehensive Definition of Multimorbidity in Family Medicine in Ten European Languages2015In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 1, article id e0115796Article in journal (Refereed)
    Abstract [en]

    Background Multimorbidity, according to the World Health Organization, exists when there are two or more chronic conditions in one patient. This definition seems inaccurate for the holistic approach to Family Medicine (FM) and long-term care. To avoid this pitfall the European General Practitioners Research Network (EGPRN) designed a comprehensive definition of multimorbidity using a systematic literature review. Objective To translate that English definition into European languages and to validate the semantic, conceptual and cultural homogeneity of the translations for further research. Method Forward translation of the EGPRN's definition of multimorbidity followed by a Delphi consensus procedure assessment, a backward translation and a cultural check with all teamsto ensure the homogeneity of the translations in their national context. Consensus was defined as 70% of the scores being higher than 6. Delphi rounds were repeated in each country until a consensus was reached Results 229 European medical expert FPs participated in the study. Ten consensual translations of the EGPRN comprehensive definition of multimorbidity were achieved. Conclusion A comprehensive definition of multimorbidity is now available in English and ten European languages for further collaborative research in FM and long-term care.

  • 11.
    Liira, Helena
    et al.
    University of Western Australia, Australia;University of Helsinki, Finland.
    Koskela, Tuomas
    University of Tampere, Finland.
    Thulesius, Hans
    Region Kronoberg, Sweden;Lund university, Sweden.
    Pitkälä, Kaisu
    University of Helsinki, Finland.
    Encouraging primary care research: evaluation of a one-year, doctoral clinical epidemiology research course.2016In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 34, no 1, p. 89-96Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Research and PhDs are relatively rare in family medicine and primary care. To promote research, regular one-year research courses for primary care professionals with a focus on clinical epidemiology were started. This study explores the academic outcomes of the first four cohorts of research courses and surveys the participants' perspectives on the research course.

    DESIGN: An electronic survey was sent to the research course participants. All peer-reviewed scientific papers published by these students were retrieved by literature searches in PubMed.

    SETTING: Primary care in Finland.

    SUBJECTS: A total of 46 research course participants who had finished the research courses between 2007 and 2012.

    RESULTS: Of the 46 participants 29 were physicians, eight nurses, three dentists, four physiotherapists, and two nutritionists. By the end of 2014, 28 of the 46 participants (61%) had published 79 papers indexed in PubMed and seven students (15%) had completed a PhD. The participants stated that the course taught them critical thinking, and provided basic research knowledge, inspiration, and fruitful networks for research.

    CONCLUSION: A one-year, multi-professional, clinical epidemiology based research course appeared to be successful in encouraging primary care research as measured by research publications and networking. Activating teaching methods, encouraging focus on own research planning, and support from peers and tutors helped the participants to embark on research projects that resulted in PhDs for 15% of the participants.

    KEY POINTS: Clinical research and PhDs are rare in primary care in Finland, which has consequences for the development of the discipline and for the availability of clinical lecturers at the universities. A clinical epidemiology oriented, one-year research course increased the activity in primary care research. Focus on own research planning and learning the challenges of research with peers appeared to enhance the success of a doctoral research course. A doctoral research course encouraged networking, and the course collaboration sometimes led to paper co-authoring. In the Nordic countries, the primary care health professionals are used to working in multi-professional teams. A multi-professional strategy also seems fruitful in doctoral research education.

  • 12.
    Lindahl, Jeanette
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Elmqvist, Carina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Thulesius, Hans
    Lund University, Sweden;Region Kronoberg, Sweden.
    Edvardsson, David
    La Trobe University, Australia;Umeå University, Sweden.
    Psychometric evaluation of the Swedish language Person-centred Climate Questionnaire - family version2015In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 29, no 4, p. 859-864Article in journal (Refereed)
    Abstract [en]

    Background

    In a holistic view of care, the family is important for the patient as well as for the staff and integration of family members in health care is a growing trend. Yet, family participation in the care is sparsely investigated and valid assessment instruments are needed.

    Setting

    Data were collected from 200 family members participating in an intervention study at an emergency department (ED) in Sweden.

    Method

    The Person-centred Climate Questionnaire – Family (PCQ-F) is a measure for how family members perceive the psychosocial climate. PCQ-F is a self-report instrument that contains 17 items assessing safety, everydayness and hospitality – three subscale dimensions that mirror the Swedish patient version of the questionnaire, the PCQ-P.

    Aim

    The aim of this study was to evaluate the psychometric properties of the Swedish version of the PCQ-F in an ED context.

    Results

    The psychometric properties of the PCQ-F were evaluated using statistical estimates of validity and reliability and showed high content validity and internal consistency. Cronbach's Alpha was >0.7 and item–total correlations were >0.3 and <0.7.

    Conclusion

    In terms of psychometrics, the findings in this study indicate that the PCQ-F can be used with satisfactory validity and reliability to explore to what degree family members perceive ED settings as being person-centred, safe, welcoming and hospitable within an everyday and decorated physical environment. As the PCQ already exists in a valid and reliable patient (PCQ-P) and staff (PCQ-S) version, this new family member version is a significant addition to the literature as it enables further comparative studies of how diverse care settings are perceived by different stakeholders.

  • 13.
    Lindahl, Jeanette
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Thulesius, Hans
    Region Kronoberg.
    Edvardsson, D.
    Elmqvist, Carina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Caring Optimized Physical Environment (COPE) at an emergency department in Sweden2014In: International Emergency Nursing, ISSN 1755-599X, E-ISSN 1878-013X, Vol. 22, no 4, p. 287-288Article in journal (Other academic)
  • 14. Lynoe, N
    et al.
    Löfmark, R
    Thulesius, Hans
    Lund university, Sweden.
    Teaching medical ethics: what is the impact of role models? Some experiences from Swedish medical schools2008In: Journal of Medical Ethics, ISSN 0306-6800, E-ISSN 1473-4257, Vol. 34, no 4, p. 315-6Article in journal (Refereed)
    Abstract [en]

    The goal of the present study was to elucidate what influences medical students' attitudes and interests in medical ethics. At the end of their first, fifth and last terms, 409 medical students from all six medical schools in Sweden participated in an attitude survey. The questions focused on the students' experience of good and poor role models, attitudes towards medical ethics in general and perceived effects of the teaching of medical ethics. Despite a low response rate at some schools, this study indicates that increased interest in medical ethics was related to encountering good physician role models, and decreased interest, to encountering poor role models. Physicians involved in the education of medical students seem to teach medical ethics as role models even when ethics is not on the schedule. The low response rate prevents us from drawing definite conclusions, but the results could be used as hypotheses to be further scrutinised.

  • 15. Lynöe, Niels
    et al.
    Engström, Ingemar
    Löfmark, Rurik
    Sallin, Karl
    Uggla, Charlotta
    Thulesius, Hans
    Region Kronoberg;Lund university.
    Enkätstudie om medicinsk etik i läkarutbildningen: Goda förebilder och tid för reflektion saknas2007In: Läkartidningen, Vol. 9, no 104, p. 676-678Article in journal (Refereed)
    Abstract [sv]

    Cirka tre fjärdedelar av läkarstuderande har varit i kontakt med goda förebilder, och drygt hälften har varit i kontakt med dåliga.

    En tiondel av läkarstuderande har enbart varit i kontakt med dåliga förebilder.

    Mindre än 40 procent har varit med om att läkare/lärare lyft fram etiska problem, och fler har erfarenhet av att läkare/ lärare enbart ger sin egen bedömning utan att ge utrymme för diskussion.

    Det förefaller vara riskabelt att enbart förlita sig på att läkare/lärare fungerar som goda förebilder och att etikdiskussionen är integrerad i den kliniska undervisningen.

    För att utveckla ett etiskt förhållningssätt bör undervisningen i medicinsk etik kompletteras med kunskaper i den etiska grammatiken.

  • 16.
    Melin, Eva O.
    et al.
    Lund University, Sweden;Region Kronoberg, Sweden.
    Svensson, Ralph
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology.
    Gustavsson, Sven-Åke
    Region Kronoberg, Sweden.
    Winberg, Agneta
    Region Kronoberg, Sweden.
    Denward-Olah, Ewa
    Region Kronoberg, Sweden.
    Landin-Olsson, Mona
    Lund University, Sweden;Lund University Hospital, Sweden.
    Thulesius, Hans
    Region Kronoberg, Sweden;Lund University, Sweden.
    Affect school and script analysis versus basic body awareness therapy in the treatment of psychological symptoms in patients with diabetes and high HbA1c concentrations: two study protocols for two randomized controlled trials2016In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 17, article id 221Article in journal (Refereed)
    Abstract [en]

    Background: Depression is linked with alexithymia, anxiety, high HbA1c concentrations, disturbances of cortisol secretion, increased prevalence of diabetes complications and all-cause mortality. The psycho-educational method 'affect school with script analysis' and the mind-body therapy 'basic body awareness treatment' will be trialled in patients with diabetes, high HbA1c concentrations and psychological symptoms. The primary outcome measure is change in symptoms of depression. Secondary outcome measures are changes in HbA1c concentrations, midnight salivary cortisol concentration, symptoms of alexithymia, anxiety, self-image measures, use of antidepressants, incidence of diabetes complications and mortality. Methods: Two studies will be performed. Study I is an open-labeled parallel-group study with a two-arm randomized controlled trial design. Patients are randomized to either affect school with script analysis or to basic body awareness treatment. According to power calculations, 64 persons are required in each intervention arm at the last follow-up session. Patients with type 1 or type 2 diabetes were recruited from one hospital diabetes outpatient clinic in 2009. The trial will be completed in 2016. Study II is a multicentre open-labeled parallel-group three-arm randomized controlled trial. Patients will be randomized to affect school with script analysis, to basic body awareness treatment, or to treatment as usual. Power calculations show that 70 persons are required in each arm at the last follow-up session. Patients with type 2 diabetes will be recruited from primary care. This study will start in 2016 and finish in 2023. For both studies, the inclusion criteria are: HbA1c concentration >= 62.5 mmol/mol; depression, alexithymia, anxiety or a negative self-image; age 18-59 years; and diabetes duration >= 1 year. The exclusion criteria are pregnancy, severe comorbidities, cognitive deficiencies or inadequate Swedish. Depression, anxiety, alexithymia and self-image are assessed using self-report instruments. HbA1c concentration, midnight salivary cortisol concentration, blood pressure, serum lipid concentrations and anthropometrics are measured. Data are collected from computerized medical records and the Swedish national diabetes and causes of death registers. Discussion: Whether the "affect school with script analysis" will reduce psychological symptoms, increase emotional awareness and improve diabetes related factors will be tried, and compared to "basic body awareness treatment" and treatment as usual.

  • 17.
    Melin, Eva O.
    et al.
    Lund University, Sweden;Region Kronoberg, Sweden.
    Svensson, Ralph
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology.
    Thulesius, Hans
    Region Kronoberg, Sweden;Lund University, Sweden.
    Psychoeducation against depression, anxiety, alexithymia and fibromyalgia: a pilot study in primary care for patients on sick leave2018In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 36, no 2, p. 123-133Article in journal (Refereed)
    Abstract [en]

    Objectives: Feasibility testing of a psychoeducational method - The Affect School and Script Analyses (ASSA) - in a Swedish primary care setting. Exploring associations between psychological, and medically unexplained physical symptoms (MUPS). Design: Pilot study. Setting: Three Swedish primary care centers serving 20,000 people. Intervention: 8 weekly 2-hour sessions with a 5-7 participant group led by two instructors - followed by 10 individual hour-long sessions. Subjects: Thirty-six patients, 29 women (81%), on sick-leave due to depression, anxiety, or fibromyalgia. Outcome measures: Feasibility in terms of participation rates and expected improvements of psychological symptoms and MUPS, assessed by self-report instruments pre-, one-week post-, and 18 months post-intervention. Regression coefficients between psychological symptoms and MUPS. Results: The entire 26-hour psychoeducational intervention was completed by 30 patients (83%), and 33 patients (92%) completed the 16-hour Affect School. One-week post-intervention median test score changes were significantly favorable for 27 respondents, with p < .05 after correction for multiple testing for 9 of 11 measures (depression, anxiety, alexithymia, MUPS, general health, self-affirmation, self-love, self-blame, and self-hate); 18 months post intervention the results remained significantly favorable for 15 respondents for 7 of 11 measures (depression, alexithymia, MUPS, general health, self-affirmation, self-love, and self-hate). Conclusions: A psychoeducational method previously untested in primary care for mostly women patients on sick-leave due to depression, anxiety, or fibromyalgia had >80% participation rates, and dear improvements of self-assessed psychological symptoms and MUPS. The ASSA intervention thus showed adequate feasibility in a Swedish primary care setting.

  • 18.
    Melin, Eva O.
    et al.
    Lund University, Sweden;Region Kronoberg, Sweden.
    Svensson, Ralph
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology.
    Thunander, Maria
    Lund University, Sweden;Region Kronoberg, Sweden.
    Hillman, Magnus
    Lund University, Sweden.
    Thulesius, Hans
    Region Kronoberg, Sweden;Lund University, Sweden.
    Landin-Olsson, Mona
    Lund University, Sweden;Skåne University Hospital, Sweden.
    Gender, alexithymia and physical inactivity associated with abdominal obesity in type1 diabetes mellitus: a cross sectional study at a secondary care hospital diabetes clinic2017In: BMC Obesity, E-ISSN 2052-9538, Vol. 4, article id 21Article in journal (Refereed)
    Abstract [en]

    Background: Obesity is linked to cardiovascular diseases and increasingly common in type 1 diabetes mellitus (T1DM) since the introduction of intensified insulin therapy. Our main aim was to explore associations between obesity and depression, anxiety, alexithymia and self-image measures and to control for lifestyle variables in a sample of persons with T1DM. Secondary aims were to explore associations between abdominal and general obesity and cardiovascular complications in T1DM.

    Methods: Cross sectional study of 284 persons with T1DM (age 18–59 years, men 56%), consecutively recruited from one secondary care hospital diabetes clinic in Sweden. Assessments were performed with self-report instruments (Hospital Anxiety and Depression Scale, Toronto Alexithymia Scale-20 items and Structural Analysis of Social Behavior). Anthropometrics and blood samples were collected for this study and supplemented with data from the patients ’ medical records. Abdominal obesity was defined as waist circumference men/women (meters): ≥ 1.02/≥0.88, and general obesity as BMI ≥30 kg/m2 for both genders. Abdominal obesity was chosen in the analyses due to the high association with cardiovascular complications. Different explanatory logistic regression models were elaborated for the associations and calibrated and validated for goodness of fit with the data variables.

    Results: The prevalence of abdominal obesity was 49/284 (17%), men/women: 8%/29% (P < 0.001). Abdominal obesity was associated with women (AOR 4.9), physical inactivity (AOR 3.1), alexithymia (AOR 2.6) and age (per year) (AOR 1.04). One of the three alexithymia sub factors, “difficulty identifying feelings” (AOR 3.1), was associated with abdominal obesity. Gender analyses showed that abdominal obesity in men was associated with “difficulty identifying feelings ” (AOR 7.7), and in women with use of antidepressants (AOR 4.3) and physical inactivity (AOR 3.6). Cardiovascular complications were associated with abdominal obesity (AOR 5.2).

    Conclusions: Alexithymia, particularly the alexithymia subfactor “difficulty identifying feelings”, physical inactivity, and women, as well as cardiovascular complications were associated with abdominal obesity. As abdominal obesity is detrimental in diabetes due to its association with cardiovascular complications, our results suggest two risk factor treatment targets: increased emotional awareness and increased physical activity.

  • 19.
    Melin, Eva O
    et al.
    Lund University, Sweden;Region Kronoberg, Sweden.
    Thulesius, Hans
    Region Kronoberg, Sweden;Lund University, Sweden.
    Hillman, Magnus
    Lund University, Sweden.
    Landin-Olsson, Mona
    Lund University, Sweden;Skåne University Hospital, Sweden.
    Thunander, Maria
    Lund University, Sweden;Region Kronoberg, Sweden;Central Hospital, Växjö, Sweden.
    Abdominal obesity in type 1 diabetes associated with gender, cardiovascular risk factors and complications, and difficulties achieving treatment targets: a cross sectional study at a secondary care diabetes clinic2018In: BMC obesity, E-ISSN 2052-9538, Vol. 5, p. 1-10, article id 15Article in journal (Refereed)
    Abstract [en]

    Background: Abdominal obesity is linked to cardiovascular diseases in type 1 diabetes (T1D). The primary aim was to explore associations between abdominal obesity and cardiovascular complications, metabolic and inflammatory factors. The secondary aim was to explore whether achieved recommended treatment targets differed between the obese and non-obese participants.

    Methods: Cross sectional study of 284 T1D patients (age 18-59 years, men 56%), consecutively recruited from one secondary care specialist diabetes clinic in Sweden. Anthropometrics, blood pressure, serum-lipids and high-sensitivity C-reactive protein (hs-CRP) were collected and supplemented with data from the patients' medical records and from the Swedish National Diabetes Registry. Abdominal obesity was defined as waist circumference men/women (meters): ≥1.02/≥0.88. Hs-CRP was divided into low-, moderate-, and high-risk groups for future cardiovascular events (< 1, 1 to 3, and > 3 to ≤8.9 mg/l). Treatment targets were blood pressure ≤ 130/≤ 80, total cholesterol ≤4.5 mmol/l, LDL: ≤ 2.5 mmol/l, and HbA1c: ≤5 2 mmol/mol (≤ 6.9%). Different explanatory linear, logistic and ordinal regression models were elaborated for the associations, and calibrated and validated for goodness of fit with the data variables.

    Results: The prevalence of abdominal obesity was 49/284 (17%), men/women: 8%/29% (P < 0.001). Women (adjusted odds ratio (AOR) 6.5), cardiovascular complications (AOR 5.7), HbA1c > 70 mmol/mol (> 8.6%) (AOR 2.7), systolic blood pressure (per mm Hg) (AOR 1.05), and triglycerides (per mmol/l) (AOR 1.7), were associated with abdominal obesity. Sub analyses (n = 171), showed that abdominal obesity (AOR 5.3) and triglycerides (per mmol/l) (AOR 2.8) were associated with increasing risk levels of hs-CRP. Treatment targets were obtained for fewer patients with abdominal obesity for HbA1c (8% vs 21%, P = 0.044) and systolic blood pressure (51% vs 68%, P = 0.033). No patients with abdominal obesity reached all treatment targets compared to 8% in patients without abdominal obesity.

    Conclusions: Significant associations between abdominal obesity and gender, cardiovascular disease, and the cardiovascular risk factors low-grade inflammation, systolic blood pressure, high HbA1c, and triglycerides, were found in 284 T1D patients. Fewer patients with abdominal obesity reached the treatment targets for HbA1c and systolic blood pressure compared to the non-obese.

  • 20.
    Melin, Eva O
    et al.
    Kronoberg County Council, Sweden;Lund University, Sweden.
    Thulesius, Hans
    Kronoberg County Council, Sweden;Lund University, Sweden.
    Persson, Bengt A.
    Linnaeus University, Faculty of Health, Social Work and Behavioural Sciences, School of Education, Psychology and Sport Science. Kronoberg County Council, Sweden.
    Affect School for chronic benign pain patients showed improved alexithymia assessments with TAS-20.2010In: BioPsychoSocial Medicine, ISSN 1751-0759, E-ISSN 1751-0759, Vol. 4, no 1, p. 1-10, article id 5Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Alexithymia is a disturbance associated with psychosomatic disorders, pain syndromes, and a variety of psychiatric disorders. The Affect School (AS) based on Tomkins Affect Theory is a therapy focusing on innate affects and their physiological expressions, feelings, emotions and scripts. In this pilot study we tried the AS-intervention method in patients with chronic benign pain.

    METHODS: The AS-intervention, with 8 weekly group sessions and 10 individual sessions, was offered to 59 patients with chronic non-malignant pain at a pain rehabilitation clinic in Sweden 2004-2005. Pre and post intervention assessments were done with the Hospital Anxiety and Depression scale (HAD), the Toronto Alexithymia Scale-20 (TAS-20), the Visual Analogue Scale for pain assessment (VAS-pain), the European Quality of Life health barometer (EQoL) and the Stress and Crisis Inventory-93 (SCI-93). After the group sessions we used Bergdahl's Questionnaire for assessing changes in interpersonal relations, general well-being and evaluation of AS.

    RESULTS: The AS intervention was completed by 54 out of 59 (92%) patients. Significant reductions in total TAS-20 post-test scores (p = 0.0006) as well as TAS-20 DIF and DDF factors (Difficulties Identifying Feelings, and Difficulties Describing Feelings) were seen (p = 0.0001, and p = 0.0008) while the EOT factor (Externally Oriented Thinking) did not change. Improvements of HAD-depression scores (p = 0.04), EQoL (p = 0.02) and self-assessed changes in relations to others (p < 0.001) were also seen. After Bonferroni Correction for Multiple Analyses the TAS-20 test score reduction was still significant as well as Bergdahl's test after group sessions. The HAD, EQoL, SCI-93, and VAS-pain scores were not significantly changed. The AS-intervention was ranked high by the participants.

    CONCLUSIONS: This pilot study involving 59 patients with chronic benign pain indicates that the alexithymia DIF and DDF, as well as depression, social relations and quality of life may be improved by the Affect School therapeutic intervention.

  • 21.
    Melin, Eva O.
    et al.
    Lund University, Sweden;Region Kronoberg, Sweden.
    Thunander, Maria
    Lund University, Sweden;Region Kronoberg, Sweden.
    Landin-Olsson, Mona
    Lund University, Sweden;Lund University Hospital, Sweden.
    Hillman, Magnus
    Lund University, Sweden.
    Thulesius, Hans
    Region Kronoberg, Sweden;Lund University, Sweden.
    Depression differed by midnight cortisol secretion, alexithymia and anxiety between diabetes types: a cross sectional comparison2017In: BMC Psychiatry, ISSN 1471-244X, E-ISSN 1471-244X, Vol. 17, p. 1-10, article id 335Article in journal (Refereed)
    Abstract [en]

    Background: Increased prevalence of depression is found in both type 2 diabetes (T2D) and type 1 diabetes (T1D). Melancholia and atypical depression differ by cortisol secretion and clinical features. The aim was to compare the clinical presentation of T1D and T2D patients in relation to self-reported depression, self-reported anxiety, alexithymia, obesity, and midnight salivary cortisol (MSC). Methods: Comparative cross-sectional design. The participants were consecutively recruited from one hospital diabetes outpatient clinic: 24 T2D patients (31-59 years) and 148 T1D patients (32-59 years). Self-reported depression, anxiety and alexithymia were assessed by Hospital Anxiety and Depression scale and Toronto Alexithymia Scale-20. MSC, HbA1c, anthropometrics and data from medical records were collected. Multiple logistic regression analyses were performed. Results: Comparisons of prevalence between diabetes types showed for T2D/T1D: depression 25%/12% (P = 0.10); high MSC (>= 9.3 nmol/L) 38%/22% (P = 0.13); alexithymia 25%/13% (P = 0.12); anxiety 38%/35% (P = 0.82). The prevalence of high MSC did not differ between depressed and non-depressed T2D patients (17% vs. 44%, P = 0.35), but differed between depressed and non-depressed T1D patients (53% vs. 18%, P = 0.003). The alexithymia prevalence differed between depressed and non-depressed T2D patients (67% vs. 11%, P = 0.018), and between depressed and non-depressed T1D patients (47% vs. 11%, P < 0.001). The anxiety prevalence did not differ between depressed and non-depressed T2D patients (67% vs. 28%, P = 0.15), but differed between depressed and non-depressed T1D patients (76% vs. 30%, P < 0.001). The obesity prevalence (BMI >= 30 kg/m(2)) was 83% for depressed T2D patients and 6% for depressed T1D patients. In the T2D patients, depression was associated with alexithymia (Adjusted odds ratio (AOR) 15.0). In the T1D patients, depression was associated with anxiety (AOR 11.0), foot complications (AOR 8.5), HbA1C > 70 mmol/mol (AOR 6.4), and high MSC (>= 9.3 nmol/L) (AOR 4.8). Conclusions: The depressed T2D patients had traits of atypical depression, without associated high MSC (>= 9.3 nmol/L) and anxiety, but the association with alexithymia was strong. The depressed T1D patients had traits of melancholia with associated high MSC and anxiety. The obesity prevalence was high in depressed T2D patients and low in depressed T1D patients.

  • 22.
    Melin, Eva O.
    et al.
    Lund University, Sweden;Kronoberg County Council, Sweden.
    Thunander, Maria
    Lund University, Sweden;Kronoberg County Council, Sweden.
    Landin-Olsson, Mona
    Lund University, Sweden;Lund University Hospital, Sweden.
    Hillman, Magnus
    Lund University, Sweden.
    Thulesius, Hans
    Kronoberg County Council, Sweden;Lund University, Sweden.
    Depression, smoking, physical inactivity and season independently associated with midnight salivary cortisol in type 1 diabetes2014In: BMC Endocrine Disorders, ISSN 1472-6823, E-ISSN 1472-6823, Vol. 14, p. 1-10, article id 75Article in journal (Refereed)
    Abstract [en]

    Background: Disturbances of the circadian rhythm of cortisol secretion are associated with depression, coronary calcification, and higher all-cause and cardiovascular mortality. The primary aim of this study was to test the associations between midnight salivary cortisol (MSC), depression and HbA1c, and control for behavioural, environmental and intra individual factors with possible impact on cortisol secretion, like smoking, physical inactivity, season, medication, diabetes duration, severe hypoglycemia episodes, age and gender in patients with type 1 diabetes. Secondary aims were to present MSC levels for a reference group of non-depressed type 1 diabetes patients with a healthy life style (physically active and non-smoking), and to explore seasonal variations. Methods: A cross-sectional population based study of 196 patients (54% men and 46% women) aged 18-59 years that participated in a randomized controlled trial targeting depression in type 1 diabetes. Depression was assessed by the Hospital Anxiety and Depression Scale-depression subscale. MSC, HbA1c, serum-lipids, blood pressure, waist circumference and data from medical records and the Swedish National Diabetes Registry were collected. Results: Thirty four patients (17%) had MSC >= 9.3 nmol/L, which was associated with smoking (AOR 5.5), spring season (AOR 4.3), physical inactivity (AOR 3.9), self-reported depression (AOR 3.1), and older age (per year) (AOR 1.08). HbA1c > 70 mmol/mol (>8.6%) (AOR 4.2) and MSC >= 9.3 nmol/L (AOR 4.4) were independently linked to self-reported depression. Season was strongly associated with MSC levels and no other variables studied showed seasonal variations. In a reference group of 137 non-depressed patients with a healthy life style (physically active, non-smoking) the median MSC level was 4.6 nmol/L (range 1.9-23.0). Conclusions: In this study of patients with type 1 diabetes high MSC was linked to smoking, physical inactivity, depression, season and older age. Thus a high cortisol value identified three major targets for treatment in type 1 diabetes.

  • 23.
    Melin, Eva O.
    et al.
    Kronoberg County Council, Sweden;Lund University, Sweden.
    Thunander, Maria
    Lund University, Sweden;Kronoberg County Council, Sweden;Växjö Central Hospital, Sweden.
    Svensson, Ralph
    Kronoberg County Council, Sweden.
    Landin-Olsson, Mona
    Lund University, Sweden.
    Thulesius, Hans
    Kronoberg County Council, Sweden;Lund University, Sweden.
    Depression, obesity, and smoking were independently associated with inadequate glycemic control in patients with type 1 diabetes2013In: European Journal of Endocrinology, ISSN 0804-4643, E-ISSN 1479-683X, Vol. 168, no 6, p. 861-869Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to explore the associations between inadequate glycemic control of diabetes and psychological, anthropometric, and lifestyle variables in a population-based cohort of type 1 diabetes patients. Design: Cross-sectional study. Methods: In this study, 292 patients with type 1 diabetes, aged 18-59 years, participated. Psychological data were assessed by self-report instruments: Hospital Anxiety and Depression Scale and Toronto Alexithymia Scale-20. Anthropometrics, blood analyses, data from medical records, and data from the Swedish National Diabetes Registry were collected. Results: Self-reported depression (adjusted odds ratio (AOR) 4.8), obesity (AOR 4.3), and smoking (AOR 3.0) were independently associated with inadequate glycemic control of diabetes (HbA1c>8.6%). Gender-stratified analyses showed that self-reported depression (AOR 19.8) and obesity (AOR 7.0) in women and smoking in men (AOR 4.2) were associated with HbA1c>8.6%. Alexithymia, antidepressant medication, and physical inactivity were associated with HbA1c>8.6% only in bivariate analyses. Alexithymia, self-rated anxiety, physical inactivity, and absence of abdominal obesity were associated with self-reported depression. Conclusions: Depression was the only psychological factor independently associated with HbA1c>8.6%. The association was of comparable importance as obesity and smoking, well-known risk factors for inadequate glycemic control and diabetes complications. The association between depression and HbA1c>8.6% was particularly strong for women. Alexithymia, which is a relatively stable personality trait, was associated with depression. In the future care of patients with diabetes, psychological aspects should be considered alongside anthropometrics and lifestyle factors in order to achieve the goals for HbA1c.

  • 24.
    Melin, Eva Olga
    et al.
    Lund University, Sweden;Region Kronoberg, Sweden.
    Thulesius, Hans
    Region Kronoberg, Sweden;Lund University, Sweden.
    Hillman, Magnus
    Lund University, Sweden.
    Svensson, Ralph
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology.
    Landin-Olsson, Mona
    Lund University, Sweden.
    Thunander, Maria
    Lund University, Sweden;Region Kronoberg, Sweden.
    Lower HDL, a known marker of cardiovascular risk, was associated with depression in type 1 diabetes2019In: Atherosclerosis, ISSN 0021-9150, E-ISSN 1879-1484, Vol. 287, p. E228-E228Article in journal (Other academic)
  • 25.
    Melin, Eva Olga
    et al.
    Lund University, Sweden;Region Kronoberg, Sweden.
    Thulesius, Hans
    Linnaeus University, Faculty of Health and Life Sciences, Department of Medicine and Optometry. Region Kronoberg, Sweden;Lund University, Sweden.
    Hillman, Magnus
    Lund University, Sweden.
    Svensson, Ralph
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology.
    Landin-Olsson, Mona
    Lund University, Sweden;Skåne University Hospital, Sweden.
    Thunander, Maria
    Lund University, Sweden;Region Kronoberg, Sweden;Central Hospital Växjö, Sweden.
    Lower HDL-cholesterol, a known marker of cardiovascular risk, was associated with depression in type 1 diabetes: a cross sectional study2019In: Lipids in Health and Disease, ISSN 1476-511X, E-ISSN 1476-511X, Vol. 18, p. 1-10, article id 65Article in journal (Refereed)
    Abstract [en]

    Background: Depression, metabolic disturbances and inflammation have been linked to cardiovascular disease and mortality. Low levels of high-density lipoprotein cholesterol (HDL-cholesterol), a known marker of cardiovascular risk, have been observed in patients with major depression in psychiatric populations. Our main aim was to explore associations between depression, antidepressants, and metabolic and inflammatory variables in patients with type 1 diabetes (T1D). A secondary aim was to explore variables associated with HDL-cholesterol. Methods: Cross-sectional design. T1D patients (n = 292, men 55%, age 18-59 years, diabetes duration >= 1 year) were consecutively recruited from one specialist diabetes clinic. Depression was defined as 8 points for Hospital Anxiety and Depression Scale-Depression sub scale. Blood samples, anthropometrics, blood pressure, and data regarding medication and life style were collected from electronic health records. Non-parametric tests, multiple logistic and linear regression analyses were performed. Results: The depression prevalence was 10 and 8% used antidepressants. Median (q(1), q(3)) HDL-cholesterol (mmol/l) was for the depressed 1.3 (1.2, 1.5) and for the non-depressed 1.6 (1.3, 1.8), p = 0.001. HDL-cholesterol levels (per mmol/l) were negatively associated with depression (Adjusted odds ratio (AOR) 0.2, p = 0.007), and the use of antidepressants was positively associated with depression (AOR 8.1, p < 0.001). No other metabolic or inflammatory variables, or life style factors, were associated with depression when adjusted for antidepressants. Abdominal obesity was associated with antidepressants in women (AOR 4.6, p = 0.029). Decreasing HDL-cholesterol levels were associated with increasing triglyceride levels (p < 0.001), increasing high-sensitive C-reactive protein (hs-CRP) levels (p = 0.021), younger age (p < 0.001), male sex (p < 0.001), and depression (p = 0.045). Conclusions: Lower HDL-cholesterol levels, known predictors of cardiovascular disease, were associated with depression in patients with T1D. The use of antidepressants was associated with abdominal obesity in women. Depression, low-grade inflammation measured as hs-CRP, higher triglycerides, male sex, and lower age were independently associated with lower HDL-cholesterol levels.

  • 26.
    Nicholson, Brian D
    et al.
    University of Oxford, UK.
    Goyder, Clare R
    University of Oxford, UK.
    Bankhead, Clare R
    University of Oxford, UK.
    Toftegaard, Berit S
    Aarhus University, Denmark.
    Rose, Peter W
    University of Oxford, UK.
    Thulesius, Hans
    Lund University, Sweden.
    Vedsted, Peter
    Aarhus University, Denmark.
    Perera, Rafael
    University of Oxford, UK.
    Responsibility for follow-up during the diagnostic process in primary care: a secondary analysis of International Cancer Benchmarking Partnership data.2018In: British Journal of General Practice, ISSN 0960-1643, E-ISSN 1478-5242, Vol. 68, no 670, p. e323-e332Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: It is unclear to what extent primary care practitioners (PCPs) should retain responsibility for follow-up to ensure that patients are monitored until their symptoms or signs are explained.

    AIM: To explore the extent to which PCPs retain responsibility for diagnostic follow-up actions across 11 international jurisdictions.

    DESIGN AND SETTING: A secondary analysis of survey data from the International Cancer Benchmarking Partnership.

    METHOD: The authors counted the proportion of 2879 PCPs who retained responsibility for each area of follow-up (appointments, test results, and non-attenders). Proportions were weighted by the sample size of each jurisdiction. Pooled estimates were obtained using a random-effects model, and UK estimates were compared with non-UK ones. Free-text responses were analysed to contextualise quantitative findings using a modified grounded theory approach.

    RESULTS: PCPs varied in their retention of responsibility for follow-up from 19% to 97% across jurisdictions and area of follow-up. Test reconciliation was inadequate in most jurisdictions. Significantly fewer UK PCPs retained responsibility for test result communication (73% versus 85%, P = 0.04) and non-attender follow-up (78% versus 93%, P<0.01) compared with non-UK PCPs. PCPs have developed bespoke, inconsistent solutions to follow-up. In cases of greatest concern, 'double safety netting' is described, where both patient and PCP retain responsibility.

    CONCLUSION: The degree to which PCPs retain responsibility for follow-up is dependent on their level of concern about the patient and their primary care system's properties. Integrated systems to support follow-up are at present underutilised, and research into their development, uptake, and effectiveness seems warranted.

  • 27.
    Nilsson, Lisbeth
    et al.
    Lund University, Sweden.
    Eklund, Mona
    Lund University, Sweden.
    Nyberg, Per
    Lund University, Sweden.
    Thulesius, Hans
    Region Kronoberg, Sweden.
    Driving to learn in a powered wheelchair: the process of learning joystick use in people with profound cognitive disabilities.2011In: American Journal of Occupational Therapy, ISSN 0272-9490, E-ISSN 1943-7676, Vol. 65, no 6, p. 652-660Article in journal (Refereed)
    Abstract [en]

    The Driving to Learn project explored ways to help people with profound cognitive disabilities practice operating a joystick-operated powered wheelchair. The project used a grounded theory approach with constant comparative analysis and was carried out over 12 yr. The participants were 45 children and adults with profound cognitive disabilities. Reference groups included 17 typically developing infants and 64 participants with lesser degrees of cognitive disability. The data sources included video recordings, field notes, open interviews, and a rich mixture of literature. The findings that emerged yielded strategies for facilitating achievements, an 8-phase learning process, an assessment tool, and a grounded theory of deplateauing explaining the properties necessary for participants to exceed expected limitations and plateaus. Eight participants with profound cognitive disabilities reached goal-directed driving or higher. Participants were empowered by attaining increased control over tool use, improving their autonomy and quality of life.

  • 28.
    Petrazzuoli, Ferdinando
    et al.
    SNAMID Natl Soc Med Educ Gen Practice, Italy;Lund University, Sweden.
    Palmqvist, Sebastian
    Lund University, Sweden.
    Thulesius, Hans
    Lund University, Sweden.
    Buono, Nicola
    SNAMID Natl Soc Med Educ Gen Practice, Italy.
    Pirrotta, Enzo
    SNAMID Natl Soc Med Educ Gen Practice, Italy.
    Cuffari, Alfredo
    SNAMID Natl Soc Med Educ Gen Practice, Italy.
    Cambielli, Marco
    SNAMID Natl Soc Med Educ Gen Practice, Italy.
    D'Urso, Maurizio
    SNAMID Natl Soc Med Educ Gen Practice, Italy.
    Farinaro, Carmine
    SNAMID Natl Soc Med Educ Gen Practice, Italy.
    Chiumeo, Francesco
    SNAMID Natl Soc Med Educ Gen Practice, Italy.
    Marsala, Valerio
    SNAMID Natl Soc Med Educ Gen Practice, Italy.
    Wiig, Elisabeth H.
    Boston Univ, USA.
    A Quick Test of Cognitive Speed: norm-referenced criteria for 121 Italian adults aged 45 to 90 years2014In: International psychogeriatrics, ISSN 1041-6102, E-ISSN 1741-203X, Vol. 26, no 9, p. 1493-1500Article in journal (Refereed)
    Abstract [en]

    Background: A Quick Test of Cognitive Speed (AQT) is a brief test that can identify cognitive impairment. AQT has been validated in Arabic, English, Greek, Japanese, Norwegian, Spanish, and Swedish. The aim of this study was to develop Italian criterion-referenced norms for AQT. Methods: AQT consists of three test plates where the patient shall rapidly name (1) the color of 40 blue, red, yellow, or black squares (AQT color), (2) the form of 40 black figures (circles, squares, triangles, or rectangles; AQT form), (3) the color and form of 40 figures (consisting of previous colors and forms; AQT color-form). The AQT test was administered to 121 Italian cognitively healthy primary care patients (age range: 45-90 years). Their mean Mini-Mental State Examination (MMSE) score was 28.8 +/- 0.9 points (range 26-30 points). AQT naming times in seconds were used for developing preliminary criterion cut-off times for different age groups. Results: Age was found to have a significant moderate positive correlation with AQT naming times color (r = 0.65, p < 0.001), form (r = 0.53, p < 0.001), color-form (r = 0.63, p < 0.001) and a moderate negative correlation with MMSE score (r = -0.44, p < 0.001) and AQT naming times differed significantly between younger (45-55 years old), older (56-70 years old), and the oldest (71-90 years old) participants. Years of education correlated positively but weakly with MMSE score (r = 0.27, p = 0.003) and negatively but weakly with AQT color (r = -0.16, p = ns), form (r = -0.24, p = 0.007), and color-form (r = -0.19, p = 0.005). We established preliminary cut-off times for the AQT test based on +1 and +2 standard deviations according to the approach in other languages and settings. Conclusions: This is the first Italian normative AQT study. Future studies of AQT - a test useful for dementia screening in primary care - will eventually refine cut-off times for normality balancing sensitivity and specificity in cognitive diagnostics.

  • 29.
    Petrazzuoli, Ferdinando
    et al.
    Lund University, Sweden..
    Vinker, Shlomo
    Tel Aviv Univ, Israel.
    Koskela, Tuomas H.
    Univ Tampere, Finland.
    Frese, Thomas
    Martin Luther Univ Halle Wittenberg, Germany.
    Buono, Nicola
    SNAMID Natl Soc Med Educ Gen Practice, Italy.
    Soler, Jean Karl
    Mediterranean Inst Primary Care, Malta.
    Ahrensberg, Jette
    Univ Aarhus, Res Unit Gen Practice, Denmark.
    Asenova, Radost
    Med Univ Plovdiv, Bulgaria.
    Boreu, Quinti Foguet
    Univ Autonoma Barcelona, Spain.
    Peker, Gulsen Ceyhun
    Ankara Univ, Turkey.
    Collins, Claire
    Irish Coll Gen Practitioners, Ireland.
    Hanzevacki, Miro
    Hlth Care Ctr Zagreb, Croatia.
    Hoffmann, Kathryn
    Med Univ Vienna, Austria.
    Iftode, Claudia
    Timis Soc Family Med, Romania.
    Kurpas, Donata
    Wroclaw Med Univ, Poland.
    Le Reste, Jean Yves
    Univ Bretagne Occidentale, France.
    Lichtwarck, Bjorn
    Innlandet Hosp Trust, Norway.
    Petek, Davorina
    Univ Ljubljana, Slovenia.
    Pinto, Daniel
    NOVA Med Sch, Portugal.
    Schrans, Diego
    Univ Ghent, Belgium.
    Streit, Sven
    Univ Bern, Switzerland.
    Tang, Eugene Yee Hing
    Newcastle Univ, UK.
    Tatsioni, Athina
    Univ Ioannina, Greece.
    Torzsa, Peter
    Semmelweis Univ, Hungary.
    Unalan, Pemra C.
    Marmara Univ, Turkey.
    van Marwijk, Harm
    Univ Manchester, UK.
    Thulesius, Hans
    Lund University, Sweden.
    Exploring dementia management attitudes in primary care: a key informant survey to primary care physicians in 25 European countries2017In: International psychogeriatrics, ISSN 1041-6102, E-ISSN 1741-203X, Vol. 29, no 9, p. 1413-1423Article in journal (Refereed)
    Abstract [en]

    Background: Strategies for the involvement of primary care in the management of patients with presumed or diagnosed dementia are heterogeneous across Europe. We wanted to explore attitudes of primary care physicians (PCPs) when managing dementia: (i) the most popular cognitive tests, (ii) who had the right to initiate or continue cholinesterase inhibitor or memantine treatment, and (iii) the relationship between the permissiveness of these rules/guidelines and PCP's approach in the dementia investigations and assessment. Methods: Key informant survey. Setting: Primary care practices across 25 European countries. Subjects: Four hundred forty-five PCPs responded to a self-administered questionnaire. Two-step cluster analysis was performed using characteristics of the informants and the responses to the survey. Main outcome measures: Two by two contingency tables with odds ratios and 95% confidence intervals were used to assess the association between categorical variables. A multinomial logistic regression model was used to assess the association of multiple variables (age class, gender, and perceived prescription rules) with the PCPs' attitude of trying to establish a diagnosis of dementia on their own. Results: Discrepancies between rules/guidelines and attitudes to dementia management was found in many countries. There was a strong association between the authorization to prescribe dementia drugs and pursuing dementia diagnostic work-up (odds ratio, 3.45; 95% CI 2.28-5.23). Conclusions: Differing regulations about who does what in dementia management seemed to affect PCP's engagement in dementia investigations and assessment. PCPs who were allowed to prescribe dementia drugs also claimed higher engagement in dementia work-up than PCPs who were not allowed to prescribe.

  • 30.
    Rose, Peter W.
    et al.
    Univ Oxford, UK.
    Hamilton, Willie
    Univ Exeter, UK.
    Aldersey, Kate
    Canc Res UK, UK.
    Barisic, Andriana
    Canc Care Ontario, Canada.
    Dawes, Martin
    Univ British Columbia, Canada.
    Foot, Catherine
    Kings Fund, UK.
    Grunfeld, Eva
    Ontario Inst Canc Res, Canada;Univ Toronto, Canada.
    Hart, Nigel
    Queens Univ Belfast, UK.
    Neal, Richard D.
    Bangor Univ, UK.
    Pirotta, Marie
    Primary Hlth Care Res Evaluat & Dev, Australia.
    Sisler, Jeffrey
    Univ Manitoba, Canada.
    Thulesius, Hans
    Lund University, Sweden.
    Vedsted, Peter
    Aarhus Univ, Denmark.
    Young, Jane
    Univ Sydney, Australia.
    Rubin, Greg
    Univ Durham, UK.
    Development of a survey instrument to investigate the primary care factors related to differences in cancer diagnosis between international jurisdictions2014In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 15, p. 1-8, article id 122Article in journal (Refereed)
    Abstract [en]

    Background: Survival rates following a diagnosis of cancer vary between countries. The International Cancer Benchmarking Partnership (ICBP), a collaboration between six countries with primary care led health services, was set up in 2009 to investigate the causes of these differences. Module 3 of this collaboration hypothesised that an association exists between the readiness of primary care physicians (PCP) to investigate for cancer - the 'threshold' risk level at which they investigate or refer to a specialist for consideration of possible cancer - and survival for that cancer (lung, colorectal and ovarian). We describe the development of an international survey instrument to test this hypothesis. Methods: The work was led by an academic steering group in England. They agreed that an online survey was the most pragmatic way of identifying differences between the jurisdictions. Research questions were identified through clinical experience and expert knowledge of the relevant literature. A survey comprising a set of direct questions and five clinical scenarios was developed to investigate the hypothesis. The survey content was discussed and refined concurrently and repeatedly with international partners. The survey was validated using an iterative process in England. Following validation the survey was adapted to be relevant to the health systems operating in other jurisdictions and translated into Danish, Norwegian and Swedish, and into Canadian and Australian English. Results: This work has produced a survey with face, content and cross cultural validity that will be circulated in all six countries. It could also form a benchmark for similar surveys in countries with similar health care systems. Conclusions: The vignettes could also be used as educational resources. This study is likely to impact on healthcare policy and practice in participating countries.

  • 31.
    Rose, Peter W.
    et al.
    Univ Oxford, UK.
    Rubin, Greg
    Univ Durham, UK.
    Perera-Salazar, Rafael
    Univ Oxford, UK.
    Almberg, Sigrun Saur
    Norwegian Univ Sci & Technol, Norway.
    Barisic, Andriana
    Canc Care Ontario, Canada.
    Dawes, Martin
    Univ British Columbia, Canada.
    Grunfeld, Eva
    Ontario Inst Canc Res, Canada;Univ Toronto, Canada.
    Hart, Nigel
    Queens Univ Belfast, UK.
    Nea, Richard D.
    Bangor Univ, UK.
    Pirotta, Marie
    Primary Hlth Care Res Evaluat & Dev, Australia.
    Sisler, Jeffrey
    Univ Manitoba, Canada.
    Konrad, Gerald
    Univ Manitoba, Canada.
    Toftegaard, Berit Skjodeberg
    Aarhus Univ, Denmark.
    Thulesius, Hans
    Region Kronoberg, Sweden..
    Vedsted, Peter
    Aarhus Univ, Denmark.
    Young, Jane
    Univ Sydney, Australia.
    Hamilton, Willie
    Univ Exeter, UK.
    Explaining variation in cancer survival between 11 jurisdictions in the International Cancer Benchmarking Partnership: a primary care vignette survey2015In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, no 5, p. 1-14, article id e007212Article in journal (Refereed)
    Abstract [en]

    Objectives: The International Cancer Benchmarking Partnership (ICBP) is a collaboration between 6 countries and 12 jurisdictions with similar primary care-led health services. This study investigates primary care physician (PCP) behaviour and systems that may contribute to the timeliness of investigating for cancer and subsequently, international survival differences. Design: A validated survey administered to PCPs via the internet set out in two parts: direct questions on primary care structure and practice relating to cancer diagnosis, and clinical vignettes, assessing management of scenarios relating to the diagnosis of lung, colorectal or ovarian cancer. Participants: 2795 PCPs in 11 jurisdictions: New South Wales and Victoria (Australia), British Columbia, Manitoba, Ontario (Canada), England, Northern Ireland, Wales (UK), Denmark, Norway and Sweden. Primary and secondary outcome measures: Analysis compared the cumulative proportion of PCPs in each jurisdiction opting to investigate or refer at each phase for each vignette with 1-year survival, and conditional 5-year survival rates for the relevant cancer and jurisdiction. Logistic regression was used to explore whether PCP characteristics or system differences in each jurisdiction affected the readiness to investigate. Results: 4 of 5 vignettes showed a statistically significant correlation (p<0.05 or better) between readiness to investigate or refer to secondary care at the first phase of each vignette and cancer survival rates for that jurisdiction. No consistent associations were found between readiness to investigate and selected PCP demographics, practice or health system variables. Conclusions: We demonstrate a correlation between the readiness of PCPs to investigate symptoms indicative of cancer and cancer survival rates, one of the first possible explanations for the variation in cancer survival between ICBP countries. No specific health system features consistently explained these findings. Some jurisdictions may consider lowering thresholds for PCPs to investigate for cancer-either directly, or by specialist referral, to improve outcomes.

  • 32.
    Sanden, Ulrika
    et al.
    Lund University, Sweden.
    Nilsson, Fredrik
    Lund University, Sweden.
    Thulesius, Hans
    Linnaeus University, Faculty of Health and Life Sciences, Department of Medicine and Optometry. Research & Development Kronoberg, Sweden.
    Hägglund, Maria
    Uppsala University, Sweden;Uppsala University Hospital, Sweden.
    Harrysson, Lars
    Lund University, Sweden.
    Cancer, a relational disease exploring the needs of relatives to cancer patients2019In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 14, no 1, article id 1622354Article in journal (Refereed)
    Abstract [en]

    Purpose: In this qualitative interview study we investigated the experiences of family members to cancer patients. Our objective was to explore and to differentiate their needs from the needs of cancer patients. Methods: Five focus groups and six individual narrative interviews with 17 family members to cancer patients in Sweden were conducted and compared with 19 cancer patient interviews. Our analysis was inspired by classic grounded theory. Results: Family members to cancer patients expressed own morbidity connected to high stress levels and difficulties in recognizing own stress due to ongoing comparisons with the cancer patient. Family members were trapped in a momentary terror-like situation where they became their sick relative's safety net. A percieved inability to improve their loved one's well being contributed to a feeling of guilt. The longing for it all to end was encumbered with shame since the end included possible death. Conclusions: By recognizing cancer as a disease striking both body and relationships, family members are given precedence over their own struggles, differentiated from the patient's experiences. We define differences in needs between cancer patients and family members. Family members to cancer patients may be supported in developing balancing strategies towards less stress, increased safety and moments of contentment.

  • 33.
    Sandgren, Anna
    et al.
    Linnaeus University, Faculty of Health, Social Work and Behavioural Sciences, School of Health and Caring Sciences. Region Kronoberg, Sweden.
    Fridlund, Bengt
    Linnaeus University, Faculty of Health, Social Work and Behavioural Sciences, School of Health and Caring Sciences. Jönköping university, Sweden.
    Nyberg, Per
    Lund university, Sweden.
    Strang, Peter
    Stockholms Sjukhems FoUU, Sweden;Karolinska Institutet.
    Petersson, Kerstin
    Region Kronoberg, Sweden.
    Thulesius, Hans
    Region Kronoberg, Sweden.
    Symptoms, care needs and diagnosis in palliative cancer patients in acute care hospitals: A 5-year follow-up survey2010In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 49, no 4, p. 460-466(7)Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Palliative cancer care in acute hospitals is scarcely studied. We therefore described and compared symptoms, care needs and types of cancer sites in 2002 compared to 2007 and analysed the relationships between these factors. METHODS: The study was population-based with a cross-sectional design and was carried out in medical, surgical and oncology wards in two acute care hospitals with no advanced palliative home care service. In 2002, 82 one-day-inventories were done (1 352 patients) compared to 142 one-day-inventories in 2007 (2 972 patients). Symptoms, care needs and cancer site were registered according to a questionnaire. Multiple logistic regression models were used to analyse associations between symptoms, care needs and cancer site. RESULTS: The proportion of palliative cancer patients had decreased during a five year period (14% vs. 11%, p<0.01). The patients were older in 2007 (74 vs. 70 years, p<0.001) and had more symptoms and care needs per patient (2.6 vs. 1.6, p<0.001). The most common symptoms were pain and deterioration and the most common cancer sites were prostate and colorectal cancer in both samples. Associations between symptoms, care needs and cancer site were mostly weak. Deterioration was associated with colorectal cancer, whereas pain was not associated with any specific cancer site. In haematological malignancies there was a high occurrence of infections and a high need of blood transfusions and infusions. Stomach/oesophagus cancers were significantly associated with nausea, nutritional problems and need of infusions while unknown primary malignancies were associated with abdominal surgery and infusions. DISCUSSION: Although we do not know all the causes for hospitalization, this study indicates that more focus should be on the symptoms instead of the specific cancer diagnosis. The findings also indicate that many palliative cancer patients' problems would be suitable for advanced palliative home care instead of acute hospital care.

  • 34.
    Sandgren, Anna
    et al.
    Kronoberg County, Research Center, Sweden.
    Thulesius, Hans
    Kronoberg County, Research Center, Sweden.
    Fridlund, Bengt
    Växjö University, Faculty of Humanities and Social Sciences, School of Health Sciences and Social Work.
    Petersson, Kerstin
    Lund university, Sweden;Kronoberg County, Research Center, Sweden.
    Striving for emotional survival in palliative cancer nursing2006In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 16, no 1, p. 79-96Article in journal (Refereed)
    Abstract [en]

    In this grounded theory study, the authors analyze interviews and participant observation data related to palliative cancer nursing in hospitals. Striving for Emotional Survival emerged as the pattern of behavior through which nurses deal with their main concern, the risk of being emotionally overloaded by their work. It involved three main strategies: Emotional Shielding through Professional Shielding or Cold Shielding; Emotional Processing through Chatting, Confirmation Seeking, Self-Reflecting, or Ruminating; and Emotional Postponing through Storing or Stashing. Emotional Competence is a property of Striving for Emotional Survival that explains more or less adequate ways of dealing with emotional overload. The theory Striving for Emotional Survival can be useful in the nurses' daily work and provides a comprehensive framework for understanding how nurses deal with emotional difficulties. The authors suggest that health care organizations encourage self-care, prioritize time to talk, and offer counseling to nursing staff with emotionally difficult working conditions.

  • 35. Sandgren, Anna
    et al.
    Thulesius, Hans
    Petersson, Kerstin
    Fridlund, Bengt
    Anticipatory Caring2008In: The Grounded Theory Review, ISSN 1556-1542, Vol. 7, no 3Article in journal (Refereed)
    Abstract [en]

    Today, more and more people die in own homes and nursinghomes, which fundamentally affects community nursing. The aimof this study was to develop a grounded theory of palliative homenursing care and we analyzed interviews and data related to thebehavior of community nurses caring for palliative cancerpatients. Doing Good Care emerged as the pattern of behaviorthrough which nurses deal with their main concern, their desireto do good care. The theory Doing Good Care involves threecaring behaviors; anticipatory caringmomentary caring andstagnated caring. In anticipatory caring, which is the optimalcaring behavior, nurses are doing their best or even better thannecessary, in momentary caring nurses are doing bestmomentarily and in stagnated caring nurses are doing good butfrom the perspective of what is expected of them. When nursesfail in doing good, they experience a feeling of letting the patientdown, which can lead to frustration and feelings of powerlessness.Depending on the circumstances, nurses can hover between thethree different caring behaviors. We suggest that healthcareproviders increase the status of palliative care and facilitate fornurses to give anticipatory care by providing adequate resourcesand recognition.

  • 36.
    Sandgren, Anna
    et al.
    Växjö University, Faculty of Humanities and Social Sciences, School of Health Sciences and Social Work. University of Gothenburg;Kronoberg County Research Centre.
    Thulesius, Hans
    Kronoberg County Research Centre.
    Petersson, Kerstin
    Kronoberg County Research Centre.
    Fridlund, Bengt
    Växjö University, Faculty of Humanities and Social Sciences, School of Health Sciences and Social Work. University of Gothenburg.
    "Doing good care" - a study of palliative home nursing care2007In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 2, p. 227-235, article id 4Article in journal (Refereed)
    Abstract [en]

    Today, more and more people die in own homes and nursing homes, which fundamentally affects community nursing. The aim of this study was to develop a classic grounded theory of palliative home nursing care and we analysed interviews and data related to the behavior of community nurses caring for palliative cancer patients. Doing Good Care emerged as the pattern of behavior through which nurses deal with their main concern, their desire to do good. The theory Doing Good Care involves three caring behaviors; Anticipatory caringMomentary caring and Stagnated caring. In Anticipatory caring, which is the optimal caring behavior, nurses are doing their best or even better than necessary, in Momentary caring nurses are doing best momentarily and in Stagnated caring nurses are doing good but from the perspective of what is expected of them. When nurses fail in doing good, they experience a feeling of letting the patient down, which can lead to frustration and feelings of powerlessness. Depending on the circumstances, nurses can hover between the three different caring behaviors. We suggest that healthcare providers increase the status of palliative care and facilitate for nurses to give Anticipatory care by providing adequate resources and recognition.

  • 37.
    Sandgren, Anna
    et al.
    Linnaeus University, Faculty of Health, Social Work and Behavioural Sciences, School of Health and Caring Sciences. Kronoberg County Research Center, Sweden.
    Thulesius, Hans
    Kronoberg County Research Center, Sweden.
    Petersson, Kerstin
    Kronoberg County Research Center, Sweden.
    Fridlund, Bengt
    Linnaeus University, Faculty of Health, Social Work and Behavioural Sciences, School of Health and Caring Sciences. Jönköping University, Sweden.
    Living on hold in palliative cancer care2010In: The Grounded Theory Review, ISSN 1556-1542, E-ISSN 1556-1550, Vol. 9, no 1, p. 79-100Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to develop a classic grounded theory of palliative cancer patients and their relatives in the context of home care. We analyzed interviews and data related to the behaviour of both patients and relatives. “Living on hold” emerged as the pattern of behaviour through which the patients and relatives deal with their main concern, being put on hold. Living on Hold involves three modes: Fighting, Adjusting and Surrendering. Mode being may change during a trajectory depending on many different factors. There are also different triggers that can start a reconciling process leading to a change of mode. This means that patients and relatives can either be in the same mode or in different modes simultaneously. More or less synchronous modes may lead to problems and conflicts within the family, or with the health professionals.

  • 38.
    Sandén, Ulrika
    et al.
    Lund university, Sweden.
    Harrysson, Lars
    Lund university, Sweden.
    Thulesius, Hans
    Lund university, Sweden.
    Momentary Contentment: A Modern Version of an Old Survival Culture2015In: The Grounded Theory Review, ISSN 1556-1542, E-ISSN 1556-1550, Vol. 14, no 2, p. 74-85Article in journal (Refereed)
    Abstract [en]

    This is a classic grounded theory based in longitudinal data from everyday life in an environment in Northern Norway characterized by long distances, a harsh climate and people living close to nature and each other. The place has a history of poverty and isolation. Yet, old survival strategies prevail despite modernisation. The theory reveals a culture of momentary contentment with three dimensions: Doing safety, destiny readiness and middle consciousness. This momentary contentment culture explains how the participants resolve their main concern of enjoying life. Doing safety means that common and individual acts create stability. Destiny readiness illuminates a discourse of acceptance, a way of thinking that, with the aid of linguistic strategies, prepares for life changing events. Middle consciousness shows a way of handling difficulties by dividing and separating different phenomena.

  • 39.
    Sandén, Ulrika
    et al.
    Lund University, Sweden.
    Harrysson, Lars
    Lund University, Sweden.
    Thulesius, Hans
    Lund University, Sweden.
    Nilsson, Fredrik
    Lund University, Sweden.
    Exploring health navigating design: momentary contentment in a cancer context.2017In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 12, no 1, p. 1-12, article id 1374809Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The technocratic and medicalized model of healthcare is rarely optimal for patients. By connecting two different studies we explore the possibilities of increasing quality of life in cancer care.

    METHODS: The first study captures survival strategies in a historically isolated Arctic village in Norway resulting in Momentary contentment theory, which emerged from analysing four years of participant observation and interview data. The second study conceptualizes everyday life of cancer patients based on in-depth interviews with 19 cancer patients; this was conceptualized as Navigating a new life situation. Both studies used classic grounded theory methodology. The connection between the studies is based on a health design approach.

    RESULTS: We found a fit between cancer patients challenging life conditions and harsh everyday life in an Arctic village. Death, treatments and dependence have become natural parts of life where the importance of creating spaces-of-moments and a Sense of Safety is imminent to well-being. While the cancer patients are in a new life situation, the Arctic people show a natural ability to handle uncertainties.

    CONCLUSION: By innovation theories connected to design thinking, Momentary contentment theory modified to fit cancer care would eventually be a way to improve cancer patients' quality of life.

  • 40.
    Sandén, Ulrika
    et al.
    Lund university, Sweden.
    Thulesius, Hans
    Lund university, Sweden;Region Kronoberg, Sweden.
    Harrysson, Lars
    Lund university, Sweden.
    Nuets förnöjsamhet: en grundad teori om livsval och överlevnadsstrategier2015In: Sociologisk forskning, ISSN 0038-0342, Vol. 52, no 3, p. 235-256Article in journal (Refereed)
    Abstract [en]

    ”Contentment in the moment” is a classic grounded theory exploring safety and contentment within a small community in northern Norway. The purpose of the study was to explore the village’s everyday life from a participant’s perspective and to develop an understanding of their living conditions. We found different survival strategies, which have their roots in the village’s history of poverty, isolation and harsh climate. Today these strategies have changed from a matter of life and death to a modern psychosocial foundation of contentment. The study is based on four and a half years of observations, in-depth interviews and informal but focused conversations with people living in Polarfjorden. The data was analysed using the constant comparative method of classic grounded theory. In this article we further relate our work to more general sociological theory, more specifically to Charles Tilly’s work on reason and routines.

  • 41.
    Streit, Sven
    et al.
    University of Bern, Switzerland.
    Gussekloo, Jacobijn
    Leiden University Medical Center, Netherlands.
    Burman, Robert A
    Vennesla Primary Health Care Centre, Norway.
    Collins, Claire
    Irish College of General Practitioners, Ireland.
    Kitanovska, Biljana Gerasimovska
    University Clinical Centre, University St. Cyril and Metodius, Macedonia.
    Gintere, Sandra
    Riga Stradiņs University, Latvia.
    Gómez Bravo, Raquel
    University of Luxembourg, Luxembourg.
    Hoffmann, Kathryn
    Medical University of Vienna, Austria.
    Iftode, Claudia
    Sano Med West Private Clinic , Timisoara , Romania.
    Johansen, Kasper L
    Danish College of General Practitioners , Denmark.
    Kerse, Ngaire
    University of Auckland, New Zealand.
    Koskela, Tuomas H
    University of Tampere, Finland.
    Peštić, Sanda Kreitmayer
    University of Tuzla, Bosnia-Herzegovina.
    Kurpas, Donata
    Wroclaw Medical University, Poland.
    Mallen, Christian D
    Keele University, UK.
    Maisonneuve, Hubert
    University of Geneva, Switzerland.
    Merlo, Christoph
    Institute of Primary and Community Care Lucerne (IHAM), Switzerland.
    Mueller, Yolanda
    Institute of Family Medicine Lausanne (IUMF), Switzerlan.
    Muth, Christiane
    Institute of General Practice Goethe-University, Germany.
    Ornelas, Rafael H
    Hospital Israelita Albert Einstein, Brazil.
    Šter, Marija Petek
    University of Ljubljana, Slovenia.
    Petrazzuoli, Ferdinando
    SNAMID (National Society of Medical Education in General Practice), Italy;Lund University, Sweden.
    Rosemann, Thomas
    University of Zurich, Switzerland.
    Sattler, Martin
    SSLMG - Societé Scientifique Luxembourgois en Medicine generale, Luxembourg.
    Švadlenková, Zuzana
    Ordinace Řepy, s.r.o, Prague, Czech Republic.
    Tatsioni, Athina
    University of Ioannina, Greece.
    Thulesius, Hans
    Lund University, Sweden;Region Kronoberg, Sweden.
    Tkachenko, Victoria
    Institute of Family Medicine at Shupyk National Medical Academy of Postgraduate Education, Ukraine.
    Torzsa, Peter
    Semmelweis University, Hungary.
    Tsopra, Rosy
    LIMICS, INSERM , Paris , France;St James's University Hospital, UK.
    Tuz, Canan
    Kemaliye Town Hospital, Turkey;Erzincan University, Turkey.
    Verschoor, Marjolein
    University of Bern, Switzerland.
    Viegas, Rita P A
    NOVA Medical School, Portugal.
    Vinker, Shlomo
    Tel Aviv University, Israel.
    de Waal, Margot W M
    Leiden University Medical Center, Netherlands.
    Zeller, Andreas
    University of Basel, Switzerland.
    Rodondi, Nicolas
    University of Bern, Switzerland;Bern University Hospital, Switzerland.
    Poortvliet, Rosalinde K E
    Leiden University Medical Center, Netherlands.
    Burden of cardiovascular disease across 29 countries and GPs' decision to treat hypertension in oldest-old.2018In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 36, no 1, p. 89-98Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: We previously found large variations in general practitioner (GP) hypertension treatment probability in oldest-old (>80 years) between countries. We wanted to explore whether differences in country-specific cardiovascular disease (CVD) burden and life expectancy could explain the differences.

    DESIGN: This is a survey study using case-vignettes of oldest-old patients with different comorbidities and blood pressure levels. An ecological multilevel model analysis was performed.

    SETTING: GP respondents from European General Practice Research Network (EGPRN) countries, Brazil and New Zeeland.

    SUBJECTS: This study included 2543 GPs from 29 countries.

    MAIN OUTCOME MEASURES: GP treatment probability to start or not start antihypertensive treatment based on responses to case-vignettes; either low (<50% started treatment) or high (≥50% started treatment). CVD burden is defined as ratio of disability-adjusted life years (DALYs) lost due to ischemic heart disease and/or stroke and total DALYs lost per country; life expectancy at age 60 and prevalence of oldest-old per country.

    RESULTS: Of 1947 GPs (76%) responding to all vignettes, 787 (40%) scored high treatment probability and 1160 (60%) scored low. GPs in high CVD burden countries had higher odds of treatment probability (OR 3.70; 95% confidence interval (CI) 3.00-4.57); in countries with low life expectancy at 60, CVD was associated with high treatment probability (OR 2.18, 95% CI 1.12-4.25); but not in countries with high life expectancy (OR 1.06, 95% CI 0.56-1.98).

    CONCLUSIONS: GPs' choice to treat/not treat hypertension in oldest-old was explained by differences in country-specific health characteristics. GPs in countries with high CVD burden and low life expectancy at age 60 were most likely to treat hypertension in oldest-old. Key Points  • General practitioners (GPs) are in a clinical dilemma when deciding whether (or not) to treat hypertension in the oldest-old (>80 years of age).  • In this study including 1947 GPs from 29 countries, we found that a high country-specific cardiovascular disease (CVD) burden (i.e. myocardial infarction and/or stroke) was associated with a higher GP treatment probability in patients aged >80 years.  • However, the association was modified by country-specific life expectancy at age 60. While there was a positive association for GPs in countries with a low life expectancy at age 60, there was no association in countries with a high life expectancy at age 60.  • These findings help explaining some of the large variation seen in the decision as to whether or not to treat hypertension in the oldest-old.

  • 42.
    Streit, Sven
    et al.
    University of Bern, Switzerland.
    Verschoor, Marjolein
    University of Bern, Switzerland.
    Rodondi, Nicolas
    University of Bern, Switzerland;Bern University Hospital, Switzerland.
    Bonfim, Daiana
    Hospital Israelita Albert Einstein, São Paulo, Brazil.
    Burman, Robert A
    4 Vennesla Primary Health Care Centre, Bergen, Norway.
    Collins, Claire
    Irish College of General Practitioners, Ireland.
    Biljana, Gerasimovska Kitanovska
    University St. Cyril and Metodius, Macedonia.
    Gintere, Sandra
    Riga Stradins University, Latvia.
    Gómez Bravo, Raquel
    University of Luxembourg, Luxembourg.
    Hoffmann, Kathryn
    Medical University of Vienna, Austria.
    Iftode, Claudia
    Sano Med West Private Clinic, Romania.
    Johansen, Kasper L
    Danish College of General Practitioners, Denmark.
    Kerse, Ngaire
    University of Auckland, New Zealand.
    Koskela, Tuomas H
    University of Tampere, Finland.
    Peštić, Sanda Kreitmayer
    University of Tuzla, Bosnia-Herzegovina.
    Kurpas, Donata
    Wroclaw Medical University, Poland.
    Mallen, Christian D
    Keele University, UK.
    Maisoneuve, Hubert
    University of Geneva, Switzerland.
    Merlo, Christoph
    Institute of Primary and Community Care Lucerne (IHAM), Switzerland.
    Mueller, Yolanda
    Institute of Family Medicine Lausanne (IUMF), Switzerland.
    Muth, Christiane
    Goethe-University, Germany.
    Šter, Marija Petek
    University of Ljubljana, Slovenia.
    Petrazzuoli, Ferdinando
    SNAMID, Prata Sannita, Italy;Lund University, Sweden.
    Rosemann, Thomas
    University of Zurich, Switzerland.
    Sattler, Martin
    SSLMG, Societé Scientifique Luxembourgois en Medicine generale, Luxembourg.
    Švadlenková, Zuzana
    Ordinace Řepy, s.r.o., Prague, Czech Republic.
    Tatsioni, Athina
    University of Ioannina, Greece.
    Thulesius, Hans
    Lund University, Sweden;Region Kronoberg, Sweden.
    Tkachenko, Victoria
    Institute of Family Medicine at Shupyk National Medical Academy of Postgraduate Education, Ukraine.
    Torzsa, Peter
    Semmelweis University, Hungary.
    Tsopra, Rosy
    Univ Paris, France.
    Canan, Tuz
    Kemaliye Town Hospital, Turkey;Erzincan University, Turkey.
    Viegas, Rita P A
    NOVA Medical School, Portugal.
    Vinker, Shlomo
    Tel Aviv University, Israel.
    de Waal, Margot W M
    Leiden University Medical Center, Netherlands.
    Zeller, Andreas
    Centre for Primary Health Care, Basel, Switzerland.
    Gussekloo, Jacobijn
    Leiden University Medical Center, Netherlands.
    Poortvliet, Rosalinde K E
    Leiden University Medical Center, Netherlands.
    Variation in GP decisions on antihypertensive treatment in oldest-old and frail individuals across 29 countries.2017In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 17, no 1, p. 1-7, article id 93Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In oldest-old patients (>80), few trials showed efficacy of treating hypertension and they included mostly the healthiest elderly. The resulting lack of knowledge has led to inconsistent guidelines, mainly based on systolic blood pressure (SBP), cardiovascular disease (CVD) but not on frailty despite the high prevalence in oldest-old. This may lead to variation how General Practitioners (GPs) treat hypertension. Our aim was to investigate treatment variation of GPs in oldest-olds across countries and to identify the role of frailty in that decision.

    METHODS: Using a survey, we compared treatment decisions in cases of oldest-old varying in SBP, CVD, and frailty. GPs were asked if they would start antihypertensive treatment in each case. In 2016, we invited GPs in Europe, Brazil, Israel, and New Zealand. We compared the percentage of cases that would be treated per countries. A logistic mixed-effects model was used to derive odds ratio (OR) for frailty with 95% confidence intervals (CI), adjusted for SBP, CVD, and GP characteristics (sex, location and prevalence of oldest-old per GP office, and years of experience). The mixed-effects model was used to account for the multiple assessments per GP.

    RESULTS: The 29 countries yielded 2543 participating GPs: 52% were female, 51% located in a city, 71% reported a high prevalence of oldest-old in their offices, 38% and had >20 years of experience. Across countries, considerable variation was found in the decision to start antihypertensive treatment in the oldest-old ranging from 34 to 88%. In 24/29 (83%) countries, frailty was associated with GPs' decision not to start treatment even after adjustment for SBP, CVD, and GP characteristics (OR 0.53, 95%CI 0.48-0.59; ORs per country 0.11-1.78).

    CONCLUSIONS: Across countries, we found considerable variation in starting antihypertensive medication in oldest-old. The frail oldest-old had an odds ratio of 0.53 of receiving antihypertensive treatment. Future hypertension trials should also include frail patients to acquire evidence on the efficacy of antihypertensive treatment in oldest-old patients with frailty, with the aim to get evidence-based data for clinical decision-making.

  • 43.
    Thulesius, Hans
    Lund university, Sweden;Region Kronoberg, Sweden.
    Work incentives, chronic illnesses and how sickness certificates are written affect sickness absence.2019In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 37, no 1, p. 1-2Article in journal (Refereed)
  • 44.
    Thulesius, Hans
    et al.
    Region Kronoberg.
    Alveblom, Ann-Kathrine
    Håkansson, Anders
    Post-traumatic stress associated with low self-rated well-being in primary care attenders.2004In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 58, no 4, p. 261-6Article in journal (Refereed)
    Abstract [en]

    In this study, we assessed the prevalence of self-rated post-traumatic stress in relation to reported trauma in an unselected primary care population. A total of 1,113 out of 1,378 consecutive attenders (response rate 81%) to 10 health centres completed the self-report instruments Impact of Event Scale (IES), and Post Traumatic Symptom Scale (PTSS-10). A horizontal visual analogue scale (VAS; 0-100 mm) resembling the EuroQoL (quality of life) health barometer was used for evaluating well-being. Trauma was reported by 325 attenders (29.2%) when applying DSM-IV trauma criteria. Prevalence of possible post-traumatic stress disorder (PTSD) was 6.5% (n=72) using cut-off scores of >35 for IES and >5 for PTSS-10. The two most common traumas in the PTSD group were accidents (2.0%, n=22), followed by cancer (1.3%, n=15). When excluding diseases and unspecified death as trauma, the rate of possible PTSD was 3.5% (n=39). Mean VAS-QoL score was 39.6 mm in the PTSD group (n=72), and 64.7 mm in the non-PTSD group with a reported trauma (n=253). In a multiple logistic regression analysis low self-rated well-being showed the strongest association with possible PTSD, followed by sexual assault, female gender, immigrant status and less than 2 years since trauma.

  • 45.
    Thulesius, Hans
    et al.
    Region Kronoberg.
    Barfod, Toke
    Ekström, Helene
    Håkansson, Anders
    Grundad teori« utvecklar läkekonsten. Populär beteendevetenskaplig forskningsmetod kan finna nya samband2004In: Läkartidningen, ISSN 0023-7205, Vol. 101, no 40, p. 3066-3070Article in journal (Refereed)
  • 46.
    Thulesius, Hans
    et al.
    Region Kronoberg;Lund University, Sweden.
    Grahn, Birgitta E
    Region Kronoberg;Lund University, Sweden.
    Reincentivizing--a new theory of work and work absence.2007In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 7, p. 1-8, article id 100Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Work capacity correlates weakly to disease concepts, which in turn are insufficient to explain sick leave behavior. With data mainly from Sweden, a welfare state with high sickness absence rates, our aim was to develop an explanatory theory of how to understand and deal with work absence and sick leave.

    METHODS: We used classic grounded theory for analyzing data from >130 interviews with people working or on sick leave, physicians, social security officers, and literature. Several hundreds of typed and handwritten memos were the basis for writing up the theory.

    RESULTS: In this paper we present a theory of work incentives and how to deal with work absence. We suggest that work disability can be seen as hurt work drivers or people caught in mode traps. Work drivers are specified as work capacities + work incentives, monetary and non-monetary. Also, people can get trapped in certain modes of behavior through changed capacities or incentives, or by inertia. Different modes have different drivers and these can trap the individual from reincentivizing, ie from going back to work or go on working. Hurt drivers and mode traps are recognized by driver assessments done on several different levels. Mode driver calculations are done by the worker. Then follows employer, physician, and social insurance officer assessments. Also, driver assessments are done on the macro level by legislators and other stakeholders. Reincentivizing is done by different repair strategies for hurt work drivers such as body repair, self repair, work-place repair, rehumanizing, controlling sick leave insurance, and strengthening monetary work incentives. Combinations of these driver repair strategies also do release people from mode traps.

    CONCLUSION: Reincentivizing is about recognizing hurt work drivers and mode traps followed by repairing and releasing the same drivers and traps. Reincentivizing aims at explaining what is going on when work absence is dealt with and the theory may add to social psychological research on work and work absence, and possibly inform sick leave policies.

  • 47.
    Thulesius, Hans
    et al.
    Region Kronoberg.
    Håkansson, A
    Screening for posttraumatic stress disorder symptoms among Bosnian refugees.1999In: Journal of Traumatic Stress, ISSN 0894-9867, E-ISSN 1573-6598, Vol. 12, no 1, p. 167-74Article in journal (Refereed)
    Abstract [en]

    To assess the level of posttraumatic stress disorder (PTSD) symptoms among Bosnian war refugees, a consecutive cohort of 206 Bosnian refugees, arriving in Sweden in 1993, was screened for PTSD using a modified version of the self-report instrument PTSS-10. A comparison group of 387 visitors to seven Swedish health centers was recruited. Prevalence of possible PTSD, using two estimates, was 18 to 33% among the Bosnian refugees, and .3 to 1% in the comparison group. The PTSS-10 showed high internal consistency reliability (Cronbach's alpha = .92) and stability (test-retest reliability r = .89). Thus, Bosnian war refugees showed high levels of PTSD symptoms compared to a nonrefugee comparison group.

  • 48.
    Thulesius, Hans
    et al.
    Region Kronoberg.
    Håkansson, Anders
    Department of Community Medicine, Malmö.
    Petersson, Kerstin
    Kronoberg county Research Centre;Lund university.
    Balancing: a basic process in end-of-life cancer care.2003In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 13, no 10, p. 1353-1377Article in journal (Refereed)
    Abstract [en]

    In this grounded theory study, the authors interviewed caregivers and patients in end-of-life cancer care and found Balancing to be a fundamental process explaining the problem-solving strategies of most participants and offering a comprehensive perspective on both health care in general and end-of-life cancer care in particular. Balancing stages were Weighing--sensing needs and wishes signaled by patients, gauging them against caregiver resources in diagnosing and care planning; Shifting--breaking bad news, changing care places, and treatments; and Compensating--controlling symptoms, educating and team-working, prioritizing and "stretching" time, innovating care methods, improvising, and maintaining the homeostasis of hope. The Balancing outcome is characterized by Compromising, or "Walking a fine line," at best an optimized situation, at worst a deceit.

  • 49.
    Thulesius, Hans
    et al.
    Region Kronoberg.
    Håkansson, Anders
    Petersson, Kerstin
    Balancing in palliative care2004In: European Journal of Palliative Care, Vol. 11, no 4, p. 160-162Article in journal (Refereed)
  • 50.
    Thulesius, Hans
    et al.
    Region Kronoberg.
    Lindgren, Anna C
    Olsson, Håkan L
    Håkansson, Anders
    Diagnosis and prognosis of breast and ovarian cancer--a population-based study of 234 women.2004In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 43, no 2, p. 175-81Article in journal (Refereed)
    Abstract [en]

    The diagnosis and prognosis for 135 women with breast cancer and 99 women with ovarian cancer in a well-defined geographical area, and a follow-up of 7-15 years are described, based on patients' records. Diagnosis was initiated in primary care for 53% of women with breast cancer, and for 57% of women with ovarian cancer. Median patient delay was 1 week for breast cancer, and 3.5 weeks for ovarian cancer patients, and median provider delay was 3 weeks for both groups. Crude, relative, and corrected 5-year survival was 73%, 91%, and 82% in breast cancer, and 40%, 49%, and 43% in ovarian cancer. Cox multiple regression analyses showed that stage IIIA and IV, and young age were associated with impaired disease-related survival in breast cancer. In patients with ovarian cancer, stages III and IV at diagnosis, old age, and systemic symptoms dominating at presentation were predictive of reduced disease-related survival while a family history of cancer was predictive of increased survival.

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