Annual Report CPF · KCP 2015 by Center for Primary Health Care Research

ANNUAL REPORT

2015

CENTER FOR PRIMARY HEALTHCARE RESEARCH COMPETENCE CENTER FOR PRIMARY HEALTHCARE IN SKÃ&#x2026;NE

Contents

Summary 4 Advancing Positions

Management and Mission

COMPETENCE CENTER FOR 11 PRIMARY HEALTHCARE IN SKÅNE Summary 12 The Financial Perspective

Primary Healthcare Training Unit

Driven by Fairness!

Child Healthcare Knowledge Center

Mustering Strength

It’s Here and Now, Not Later!

CENTER FOR PRIMARY HEALTHCARE RESEARCH 28 Summary 30 (AKC) – The Link between Academia and Primary Healthcare

New Approach Necessary

Unique Appointment

Patrik is on the Side of the Elderly

The Research Leaders

Research Projects

A Humble Guy with a Great Interest in Epidemiology

Courses in Research Methodology

More Atrial Fibrillation Patients Than Expected Got

the Right Care PhD Thesis Defenses 2015

Marking Time…

Enrolled PhD Students

Experimental Research Laboratory

Research Databases

Geographical Data and Area Studies

Analytical Support

International Collaboration

The Financial Perspective

Published Scientific Articles 2015

Summary: 2015 All research, competence development, and ST/AT coordination in Region Skåne’s primary healthcare are merged in two producing and competitively neutral operational divisions, the Center for Primary Healthcare Research (CPF) and the Competence Center for Primary Healthcare in Skåne (KCP), which serve as a cohesive platform for research, education, and development in primary healthcare in both the private and public sectors.

VISION

STAFF

115

64, KCP & 51, CPF

CENTER FOR PRIMARY HEALTHCARE RESEARCH (CPF) To pursue groundbreaking clinical research in order to achieve primary healthcare of the highest quality and thereby a healthier population.

IN-SERVICE TRAINING

2 100 STUDENT ENROLLMENTS

SCIENTIFIC ARTICLES

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110

VISION COMPETENCE CENTER FOR PRiMARY HEALTHCARE IN SKÅNE (KCP) Equal health, equal treatment, and a highly competent staff.

DIVISION

BOARD

MANAGER

OPERATIONS MANAGER

CENTER FOR

COMPETENCE CENTER FOR

PRIMARY HEALTHCARE

PRIMARY

RESEARCH

HEALTHCARE IN SKÅNE

CPF

OPERATIONS AND OFFICE

UNIT HEAD

LABORATORY

AKC KNOWLEDGE CENTER FOR CHILD HEALTHCARE SERVICES

KNOWLEDGE CENTER FOR WOMEN’S HEALTHCARE SERVICES

KNOWLEDGE CENTER, MIGRATION AND HEALTH

LOCAL COOPERATION AMBASSADORS

PRIMARY HEALTHCARE TRAINING UNIT

27, 2 million sek

EXTERNAL FUNDING FOR RESEARCH

13 000 TRAINING AND EDUCATION/ NETWORKS/SEMINARS

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Advancing Positions During the year, we have continued to leave our mark on primary healthcare and in other contexts by means of clinically relevant research projects, educational programs, new activities, and innovation, as well as major international collaborations.

2015 has been a remarkably productive and exciting year during which CPF and KCP have been able to sustain an exceptionally high standard thanks to frequent communication with, and proximity to, primary healthcare facilities. The finely coordinated centers with the year’s two additions, the Knowledge Center for Migration and Health and the Center for Women’s Healthcare Services, now make us the largest R&D facility for primary healthcare in the nation – with impressive breadth and depth. One of our strengths is that most of our staff are clinically active and thus primary healthcare can benefit from their competence while the researchers can find inspiration in the rich clinical soil where the best research ideas are born. Another factor in our success is our scientific production. During the year, we published 110 scientific articles in international journals of very high class. Since 2008, this amounts to 800 such articles, making us one of the most active research units in the world. This year we also congratulate two new professors: District Nurse Ulf Jakobsson, who was appointed Professor of Health Care Science at the Faculty of Medicine, Lund

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A Productive Year with First-Rate Operations!

University, with a focus on elderly care, healthcare science, and chronic disease. The second appointment was awarded to Family Physician and Assistant Professor Patrik Midlöv, whose focus is on the elderly and drugs. During 2015, seven of our 47 doctoral students defended their theses. We also made great investments in continuing education, clinical training, and also in providing assistance for trainee and resident physicians. The whole child healthcare system in the Skåne Region was also prepared for the introduction of a new national child healthcare program. For its work on Equal Parenting – in the Best Interest of the Child, the Knowledge Center was also awarded the Skåne Region’s Great Equal Rights Prize. Local Cooperation Ambassadors (AKOs) were also active. They developed 56 new healthcare guidelines, produced video library films, and laid the foundation for so-called webinars so that our colleagues will soon be able to follow lectures live via the web. Enjoy Reading Our Annual Report! Jan Sundquist Director, Professor, and Family Physician

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Management and Mission The Center for Primary Healthcare Research (CPF) and the Competence Center for Primary Healthcare in Skåne (KCP) are important resources for knowledge development and clinical processes in both public and private primary healthcare. Therefore, competition neutrality is of the utmost importance. The role of operations manager for CPF falls under the remit of CPF’s board while the job of operations manager of KCP falls under the Primary Healthcare Division Management Sund in the Skåne Region. CPF and KCP have a joint management team to create an environment with an emphasis on collaboration and synergies that make for optimal use of resources. Invaluable synergies for research and knowledge development are developed in the work of the joint management team.

We do not favor a public optional healthcare unit over a private one, nor vice versa, says Director Jan Sundquist.

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The participants are the research leaders, Professor Kristina Sundquist and Professor Patrik Midlöv, the team leaders of AKC and AKO, Emelie Stenman and Sten Tyrberg, respectively, the unit heads of the Primary Healthcare Training Unit, Eva Pulverer Marat, of Migration and Health, Jenny Malmsten, and of the Knowledge Center for Child Healthcare Services (BHV), Marie Köhler.

The Work of the Board The CPF is based on collaboration between the Skåne Region and Lund University. The board members lead the work regarding strategic and comprehensive planning, which, among other things, means that it makes decisions about the direction of the research that the CPF intends to conduct. In addition, the Board draws up an operational plan and is responsible for the required follow-up of the CPF’s operations and management of funds. – Our Board has been a good “sounding board” and thus has brought about a creative attitude, says Jan Sundquist. – I cannot adequately stress the great significance and engagement of Professor Emeritus Lars Hjalmar Lindholm. Furthermore, he has brought us closer to the National School of Research in Family Medicine, as well as to his international networks.

CPF’s BOARD (from the left in photo) w Professor Birgit Rasmussen, Lund University w Professor Emeritus Lars Hjalmar Lindholm, Umeå University (Chairman) w Stefan Bremberg, MD, PhD, Medical Expert, Capio w Professor Jan Sundquist, Director of the CPF (Rapporteur) w Professor Bodil Ohlsson, Lund University w Professor Jerzy Leppert, Uppsala University w Professor and Vice Dean Lars B. Dahlin, Lund University

CPF and KCP’s MANAGEMENT TEAM w Jan Sundquist, Professor, Director w Kristina Sundquist, Professor and Research Leader w Patrik Midlöv, Professor and Research Leader w Eva Pulverer Marat, Unit Head w Marie Köhler, Unit Head w Jenny Malmsten, Unit Head w Sten Tyrberg, Team Leader (AKO) w Emelie Stenman, Team Leader (AKC)

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Competence Center for Primary Healthcare in Skåne

The Competence Center for Primary Healthcare in Skåne (KCP) provides in-service training, AT (trainee physician) and ST (resident physician) training, family medicine consultancy activities, continuing education, the Knowledge Center for Child Healthcare, Women’s Healthcare Services, and Migration and Health Services. The common platform entails great advantages of coordination at KCP, as well as between KCP and CPF. The Competence Center’s units and teams: w Primary Healthcare Training Unit w Local Cooperation Ambassadors, Skåne, AKO w Knowledge Center for Child Healthcare Services w Knowledge Center for Women’s Healthcare Services: NEW w Knowledge Center, Migration and Health Services: NEW annualreport2015

NEW AKO HEALTHCARE GUIDELINES

COWORKERS

64 IN-SERVICE TRAINING Number of student enrollments

2 100

TRAINING Total number of participants in seminars, on training days and in continued education courses

10 966

700 INTRODUCTION OF A NEW NATIONAL CHILD HEALTHCARE PROGRAM The number of coworkers and nanagers in the Child Healthcare Services in the SkÃ¥ne Region who underwent continued education

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700

During 2 0 primary 15 we have taken healthca major ed re child hea lthcare se and child healt ucational measur hcare. Fo prepared es in both rvice syst r f e program. or the introducti m in the Skåne example, the ent R o i Children And during the y n of a new natio egion has been re n a e a a t l child VIDEO LIBRARY as many Risk Mission h r, the network of contac healthcare as been e as 600 co ts for the xpanded Skåne Re ntact per FILMS so g ledge Cen ion’s Great Equa sons. It was also g that there are n l r t The number of times the Best er for Child Welf Rights Prize was atifying that th ow are for it Interest o e awarded f the Chi s work on four of our own new to the Kn ld. E ow q ual Pare There ha nting – video library films were ve also be in e Cooperati on Amba n major activitie shown ssadors (A video libr s on the p a K we have ry films that ha Os): for example art of the Local worked h , the prod v e a lread a the oppor tunity t rd on starting a y been viewed 113 uction of four o call att 8 w continued ention to ebinar. I also wa times and e d u c a t n io t elaborate d, as well n programs for f he expansive loca t to take amily ph l and reg as to the ysicians ional work on e t Primary le c t r o n ic knowle hat have been Healthca dge suppo groups de r rt. voted to e’s educational u st medicine nits star ructured t e ( k d so nowledg -called several ctioning groups. A FQ groups) so th e and quality en new collegial at there nother im ing progr hanceme a n a healthca m for trainee ph portant undertak re now 18 such fu t in re assign ment tha ysicians starting ing is the pilot t nra t t was ca rried out heir first prima inThe fine r y i c n o ll Helsingbo in the joi aboration betw rg. een resea ntly prod rch and has also b uced cont c e also laun en a good step fo inued education ontinued educati rw c c o areas: M hed two entirely ards. Last, but atalogue for CPF n not least new Know igration KCP , and Hea le lth and W dge Centers in i we have now mportant Jan Sund omen’s H quist, Op ealth. erations Manager

1 138

600 THE FINANCIAL PERSPECTIVE NETWORK Number of new contact persons for assignments in the Network for Children in Distress

OPERATIONS REVENUE w Local Cooperation Ambassadors

w 3 880 409

w Primary Healthcare Traininig Unit

w 14 359 104

w Knowledge Center, Child Healthcare

w 18 877 500

w Expert Group for Maternal Healthcare/ Knowledge Center for Women’s Healthcare Services

w 2 642 000

TOTAL: 39 759 013 annualreport2015

Primary Healthcare Training Unit The Primary Healthcare Training Unit is co-located with the CPF. The Training Unit is responsible for AT/ST training, continued education issues, and AKOs. Eva Pulverer-Marat heads the unit.

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Trainee Physicians

Resident Physicians

During the year, 118 trainee physicians, ATs, served in primary healthcare in Skåne. Five AT directors of studies were engaged in continuous work to ensure the quality of the training sites. Regular training seminars were also arranged locally for trainee physicians during their placement in primary healthcare. In September 2015, a pilot training course was implemented to teach practical skills to trainee physicians starting their primary healthcare placement. It was implemented in collaboration with Practicum Clinical Skills Centers. The training comprised 1½ days and included practical elements of minor surgery, orthopedics, and ophthalmology and was highly appreciated. On two half-days during the year, KCP arranged a seminar for some 90 trainee physicians in Skåne, the purpose being to increase the interest of the trainees in choosing family medicine as a specialty.

During the last three years, the number of resident physicians, STs, has increased in Skåne. There are now 340 resident physicians distributed relatively proportionately between private and public units. When granting an ST training subsidy, the study director carries out a quality control of the healthcare center. In addition, in order to promote a good training environment, an ST agreement is signed by the study director, operations manager, and the resident physician. The study directors work in four different areas in Skåne. Each area holds its own ST meetings for resident physicians. The meetings are held once a month and include lectures and meetings in collegial groups devoted to knowledge and quality enhancement in medicine (so-called FQ groups). The purpose of these collegial groups including 8–10 participants is to provide a structured development of quality and continued education. Each group has a group leader and, during 2015, a new effort was made to train resident physicians for this role. A total of three FQ courses were conducted. Today there are 18 functioning FQ groups that meet regularly. Other activities during the year were ST Day, supervisor meetings, awarding of diplomas, and start-up meetings. ST Days are

planned by the resident physicians and the theme in 2015 was leadership issues. The study directors of ST Training planned and arranged such courses as, for example, consultation courses, supervisor courses, and courses in family medicine work procedures. The study directors also attended the meetings of the World Organization of Family Doctors (WONCA) in Istanbul, which led to contacts with the exchange program Vasco da Gama for resident physicians.

Continued Education The unit has arranged, coordinated and evaluated training courses for coworkers in primary healthcare under both public and private management. The need for continuous professional development is huge in primary healthcare, the disease panorama is extensive, and the professional categories are numerous. Our training courses are adapted to the needs of the healthcare centers and are planned in cooperation with coworkers in professionally specific reference groups. During 2015 an enquiry targeting all coworkers was conductedwith questions concerning the range of training courses, internet searchability and where on the internet one can look for training courses. It was found that out of the 896 responses, 68% were very satisfied, satisfied, or neither/nor with the training courses on offer. Thus, 32% experienced finding/seeking information about such courses very difficult or difficult. Four professional reference groups for training met 2â&#x20AC;&#x201C;3 times during

the year and made plans for suitable courses according to the needs of the coworkers and the operations. The professional categories included in the reference groups were curator, psychologist, occupational therapist, physiotherapist, medical secretary, nurse, dietician, and district nurse. Examples of training courses for nurses during the year were those dealing with how to approach the patient in connection with telenursing, triage, and Skin & Leg Ulcers Day. ADHD and Self-Inflicted Injury were the major training courses for curators and psychologists. Secretaries were offered a course in Healthcare English and two whole days were devoted to various other subjects. Other examples of training courses were Memory Assessment, aimed at occupational therapists, and Vertigo, for physiotherapists. Recurrent for all coworkers were Motivational Interviewing (MI) training courses, which were arranged several times during the year. Videolibrary film production, as well as the development of webinars, took place in close collaboration with Local Cooperation Ambassadors (AKO) activities.

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BRIEF FACTS

PRIMARY HEALTHCARE’S TRAINING UNIT: NUMBER OF COWORKERS 2.0 administrators 1.5 supervisors 0.80 unit head 12 ST study directors 5 AT study directors 3 diabetes coordinators

NUMBER OF ST ACTIVITIES 27 training sessions/courses 29 ST meetings NUMBER OF AT ACTIVITIES 65 training/educational activities CONTINUED EDUCATION, OTHER COWORKERS 36 activities 1 313 participants Mean value of evaluations, 4.5 (scale 1–5) VFU, WORKPLACE TRAINING 2 100 student enrollments

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Workplace training (VFU) VFU is a link between primary healthcare’s operations and Skåne’s three seats of learning. The mission includes the VFU coordinator and all student categories except medical students. The VFU coordinator took part in evaluations, worked for quality development, and gave support to the managers and personnel in matters concerning workplace training and competence maintenance. This makes great demands on our organization in terms of offering workplace training of the highest quality since it takes up to 30–50% of the time in the majority of healthcare training courses. During 2015, VFU sites were coordinated for a total of approx. 2100 students in all primary healthcare activities – both public and private. Number of enrollments: w Nurses, basic training/education, 1500 w District nurse, 130 w Midwives, 80 w Pediatric nurses, 30 w Various specialist nurses, 10 w Biomedical analysts, 5 w Occupational therapists, 10 w Physiotherapists, 250 w Medical secretaries, 80 w Psychologists in supervised practice training, 5

Collaboration between the training unit and CPF was further developed. Some examples are a joint newsletter, continued education days, and continued education catalogues. Furthermore, the units collaborate on the resident physicians’ research and scientific work.

Diabetes Coordinators During 2015, three diabetes coordinators were employed 50% each. Their mission was to follow up the quality of diabetes care, spread evidence-based knowledge, stimulate competence development, and work to achieve equality in diabetes care. Their mission also includes starting up and leading network activities, as well as initiating and following up on certification of the reception facilities of the optional healthcare units in Skåne.

plans and ideas

w w w w w w w

Interprofessional Casework

A project called Interprofessional Supervision was started in 2015. The goal was to enable students, using thematized outpatient problems, to become familiar with their own professional roles, as well as those of others, and with where the boundaries between them lie. The project is scheduled for further development during 2016 in collaboration with two healthcare centers.

3–4 supervisor training courses Development of webinar activities Introduction of the project “Interprofessional Learning” Complementary service sites Arrangement of “Practical Skills” for trainee physicians Evaluation of the video library Promote certification of diabetes reception units

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Driven by Fairness – It is fun and also an important task to support young colleagues on their way to becoming specialists and see to it that their training is of good quality and that they wish to stay on once they are qualified specialists. Meet Per Jonsson, one of three study directors for Lund’s resident physicians in family medicine.

For almost four years now, Per Jonsson has been study director for Lund’s resident physicians in family medicine. There he plays a central role in the work of seeing to it that the training locomotive keeps puffing ahead – the newly graduated physicians should jump on and then step off after their transformation into specialists in family medicine. – I think it’s both important and fun to work with educational issues. Our specialty is growing and developing rapidly and more and more patients will be treated in primary care. It is therefore important that the training should meet high standards and that the resident physicians are satisfied: partly, so that they will desire to remain as newly graduated specialists and, partly, to ensure the patients’ healthcare, says Per, who serves as family physician at the Måsen Healthcare Center in Lund when he is not engaged in his work as a study director. The number of resident physicians has increased remarkably in the region during the last few years. Just in Lund, there are about 120, and Per has over 50 under his umbrella.

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It Is Good That We Are a Team That Can Share a Joint Structure

Together with two other study directors in Lund, he is working on the development of a structure for determining what the training should look like. A total of 12 study directors work in the Skåne region in connection with the Knowledge Center in Malmö. They meet once a month. – I am driven a little by the principle of fairness – that is, that the training and other conditions are good, not only at individual healthcare centers, but at all healthcare centers in the whole region. Therefore, it is good that we are a team that can bring about a joint structure and joint frameworks, says Per Jonsson.

Knowledge and Quality Enhancement (FQ) Groups This is indeed an important task for Per and his coworkers. Drawing up ST contracts and shouldering the responsibility for longrange planning together with resident physicians and supervisors are two examples. Yearly follow-up conversations with resident physicians, support to the resident physician group and supervisors, and frequent contacts with the operations managers and the units

I t H R S

It Is Important That the Training Is of High Quality and That the Resident Physicians Are Satisfied

where complementary training takes place are other examples. Another important task is to arrange training days and seminars for both resident physicians and supervisors. â&#x20AC;&#x201C; I am most proud of getting our FQ groups started. During a whole day, every month, all resident physicians in Lund meet. There they improve their knowledge of subjects they have chosen themselves and, in smaller groups, they also discuss their future professional and qualitative development, as well as continued education. I assist in the planning and administration.

Certified Specialists Resident physicians are also obliged to carry out a scientific project in the resident training program. The project work is to comprise 10 weeks of full-time studies. The Center for Primary Healthcare Research offers the resident physicians a special 8-day basic course in research methodology with access to a supervisor in the area of scientific competence. â&#x20AC;&#x201C; This collaboration works well. Particularly appreciated is the fact that the courses are scheduled four times per year, says Per Jonsson.

Surer Verbal Consultations Our most immediate aim is to arrange a course dealing with conversations with the patient in the spirit of the Kalmynos method for the fifth year in a row. During the course, the resident physicians are able to practice on their verbal consultation ability. The course is highly appreciated and, according to Per, lays a good foundation for a successful meeting with the patient. â&#x20AC;&#x201C; The doctor who has mastered the professional verbal conversation method will be surer and more effective in meetings with the patient. Everybody can get better, and this should, in fact, be a recurrent element in the work of those of us who are qualified family physicians, concludes Per Jansson.

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Local cooperation ambassadors, AKOs Local cooperation ambassadors (AKO) Skåne are a team at the Competence Center for Primary Healthcare in Skåne commissioned by the Optional Healthcare Unit in Skåne to engage in, from the perspective of primary healthcare, the continued education of family physicians, better handling of referrals, coordination, and healthcare guidelines with respect to specialized healthcare.

Mission 20

The operation is competitively neutral – that is to say, it applies to all optional healthcare and Region Skåne’s specialized medical services in both the private and public sectors regardless of the operational form. Some examples of AKO assignments: w Specialty-based AKO commissions w Local continued education commissions w Regional continued education commissions w Video library and webinar w Development of guidelines w Participation in various healthcare processes and standardized procedures w Handling and examination of referrals w Participation in various collaborative, expert, and competence groups The general medical consultants are experienced specialists in family medicine. They serve as a link between local hospitals and local organ specialties and thus do not automatically follow in the footsteps of the Skåne Region’s three administrations, but build on functioning referral and contact pathways. Local cooperation ambassadors (AKOs) work in the area of professional medical matters where collaboration on commissions and boundaries are discussed.

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Continued Education AKOs have continued to arrange local continued education courses and, in 2015, they concentrated on more regionally oriented continued education. All of the courses, are open to all family physicians in Skåne, as well as to resident physicians in family medicine. The new regional continued education courses for family physicians have been grouped under the name Family Medicine Plus, together with other family medicine courses offered by the KCP. A single continued education catalogue has been created by KCP and CPF.

Video Library The films in our video film library are either self-produced or selected after being examined for quality. The aim is that they should give rise to discussions concerning various subjects of interest and help to create routines. In collaboration with the Skåne University hospital team, four films were produced in 2015: Alarming Cancer Symptoms, The Red Eye, Rheumatoid Arthritis, and The Ocular Microscope.

We wish to: Bring about well-functioning patient care routines and referral systems through cooperation with specialized healthcare facilities. Create and implement various forms of adequate and attractive continued education and healthcare guidelines for family physicians.

Digital Contact Page and Healthcare Guidelines Much work has been devoted to making AKO’s new contact page at Healthcare Provider Skåne as informative and readily accessible as possible. There, the family physician can easily find, for instance, healthcare guidelines and continued education courses available to family physicians. The contact page also contains news and questions and answers. In collaboration with specialized Healthcare, our general medical consultants have worked out short versions of, for instance, all current Region Skåne healthcare programs and standardized care procedures for cancer.

Working Parties The local collaboration between general medical consultants and contact physicians in specialized healthcare is the basis for the local cooperation ambassadors’ (AKOs’) efforts to achieve new or better collaboration and local and regional continued education, and to produce new AKO healthcare guidelines. There has also been a number of different working parties at the local, regional, and national levels: for example, the Diagnostic Center, RCC South’s and Region Skåne’s various standardized care procedures and programs for cancer patients: Care at the Right Level of Care, Skåne University Hospital Medication Days, quality indicators and healthcare programs.

Webinar During the year we have also planned for a new undertaking, a webinar – the possibility of seeing our lectures live via the web. The viewers will also be able to ask questions via a chat function during the lecture.

05 brief facts

LOCAL COOPERATION AMBASSADORS (AKO)

NUMBER OF COWORKERS 10 part-time workers in AKO’s central operations. 51 general medical consultants in 17 different areas distributed locally for Skåne’s hospitals. 37 continued education courses with a total of 1043 participants, including 5 regional courses in Family Medicine Plus. 3 693 unique visitors to AKO’s new contact page, www.skane.se/ako

56 new AKO healthcare guidelines during 2015, of which 15 were newly reproduced short versions of regional healthcare programs or national standardized care procedures. 866 web subscribers to the news about Family Medicine – Primary Healthcare on the Caregiver Skåne pages. 1 138 showings of the four new selfproduced video library films during 2015. Planning of the new undertaking: the webinar

PLANS AND IDEAS

w Joint Skåne referral review w Local and regional continued education w New video library films and start-up of webinar w More locally coordinated family physicians responsible for continued education

w More new AKO guidelines

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Child Healthcare Knowledge Center Our mission involves supporting the activities in the child welfare services: above all, in the form of continued education for coworkers, giving advice, and work on guidelines and healthcare chains. During the year, the continued education has been focused on the introduction of the new child healthcare program which involves a strengthening of the crossprofessional work of teams in the Child Health Services and preventive measures with regard to psychosocial health.

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Continued Education A great effort has been made concerning all aspects of the work of the Knowledge Center for Child Healthcare Services (BHV) in the Skåne Region to prepare for a new national child healthcare service program as from January, 2016. Seven hundred coworkers plus unit heads at the BHV received continued education. The new program strengthens the cross-professional teamwork at the child healthcare centers (BVCs) and highlights prevention and the work on psychosocial health. During the year, a network of 600 contact persons engaged in different activities in the health and medical care services was also created for the “Children in Distress” mission.

More Missions…

brief facts Projects The two projects, Equal Parenting – in the Best Interest of the Child and Domestic Violence – with a focus on the child, have addressed themselves to the coworkers at the maternal and child healthcare services. The aim is to raise the level of knowledge and preparedness to converse with expecting and recent parents concerning equality and domestic violence. For its work on Equal Parenting, the unit was awarded Region Skåne’s Great Equal Rights Prize 2015. A third project is focused on promoting healthy lifestyle habits.

Children in Distress This involves assistance in the form of an action program and continued developmental efforts regarding the implications of the obligation of coworkers in the health and medical care services to file reports when children are in, or suspected of being, in distress.

Children’s Needs in Focus Knowledge-based assistance is required for primary care and medical activities on behalf of children and adolescents to ensure that health examinations of those placed in community care are carried out with highlevel quality. Several continued education activities to reinforce the competence of the physicians was offered.

Children Who Are Next of Kin Children with parents/guardians afflicted with ill health, substance abuse, chronic disease, or who have deceased, have the legal right to information from the health and medical care services and, if necessary, support.

New Knowledge Center for Women’s Healthcare During 2015, the Expert Group for Maternal Healthcare was assigned to this unit, which has worked on the development of guidelines for maternal healthcare. After a political decision issued by the Local Healthcare Commission, planning was started for the new Knowledge Center for Women’s Healthcare. The Knowledge Center is to operate cross-regionally with academic knowledge support and continued education, as well as analysis, follow-up, and monitoring of the external environment in concerning sexual and reproductive health, as well as public health issues in maternal healthcare and screening for cervical cancer.

KNOWLEDGE CENTER FOR CHILD HEALTH CARE SERVICES COWORKERS 8 individuals working full-time and 17 part-time. CONTINUED EDUCATION 700 coworkers plus managers underwent con23 tinued education in Region Skåne to prepare for the introduction of a new national child healthcare program. NETWORK 600 contact persons engaged in various activities for the benefit of Children in Distress AWARD WINNER! The unit was awarded the Skåne Region’s Great Equal Rights Prize for its work on the project, Equal Parenting – in the Best Interest of the Child. Planing of a new knowledge center för women’s health. annualreport2015

Mustering Strength! All of our assignments, projects, courses, tips, advice, and support have a distinct focus, i.e., the best interest of the child comes first. These are the words of Marie Köhler, child health consultant and unit head of the Knowledge Center for Child Healthcare Services.

Close to 1000 individuals in various professions are working in Skåne with the goal of offering good and equal child healthcare to some 95,000 children. However, in spite of good intentions, studies show that this is sometimes difficult to live up to. Among other things, differences are seen in the number of visits to doctors, methods, and

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referral criteria, and it turns out that the health-promoting work must take a back seat and that children with greater requirements don’t always get the help they need. A new national child healthcare program that is now being introduced throughout the country is to come to grips with the above need. The Knowledge Center for

ENTHUSIASM Marie Köhler (left) and Kathy FalkensteinHagander

Child Healthcare Services has a major role to play in the work to ensure a good transmission to the new program. During the year, close to 700 individuals working with child healthcare in the region have received continued education and guidance concerning the program. – This is the first time in the modern era that we have had a joint program for child healthcare. Working together, we shall see to it that every child 0–5 years of age is given the best healthcare available throughout the nation. This is the right of every child. Those are the words of Marie Köhler, Child Health Consultant and unit head, and an enthusiastic advocate for society making early investments to ensure that more children should be better off while, at the same time, fewer children should risk ending up in the risk zone. According to the directives in the new program, child healthcare should operate in a more targeted manner, for instance, with more visits to homes, more follow-up health examinations, and more extensive assessments before referral to another caregiver. The teamwork and collaboration with other agencies, e.g., the social services, child psychiatry, kindergartens, and dental care, are also emphasized. The concept of a basic program is being eliminated. Instead, a three-part model is being introduced that clarifies Child Welfare’s wide-ranging activities. – The program is well anchored in the relevant professions and builds on the latest evidence-based information, says Child Health Consultant Kathy FalkensteinHagander, one of the major players in the continued education drive. It comprises everything from the joint kick-off to secure a common foundation to build on to more far-reaching residential courses for particular professional groups. The efforts are focused on children who are 0–1 year old. – There have been fantastic enthusiasm and also very stimulating discussions and knowledge exchanges, says Kathy.

Other major tasks have been to compile information on the efforts made in the child health services and to increase our knowledge about children at risk, inter alia, strategies to prevent harm, detect the risks early on, and simply take care of the children. Other efforts are to promote the small child’s linguistic and cultural development and to care for infants with cranial asymmetry. A pilot project has also been carried out in 10 operations to formulate a methods material that can serve as an aid for care personnel involved in finding an answer to the question concerning how equal parenting can be put into practice. This work was rewarded last fall with the Skåne Region’s Great Equal Rights Prize. – We are happy that these questions, which are so important for public health and equality, have attracted attention, says Marie Köhler.

Engagement in the National Program Has Been Great.

Pay Attention to Children at Risk All children who are placed in community care are to be offered a medical examination before the placement. In this work, Marie and her coworkers have supported the health and medical care services with their knowledge. How healthcare personnel converse with and inform small children with parents or guardians who are, for instance, mentally ill, addicts, or have a chronic illness constitutes an additional responsibility that is felt to be particularly urgent. We know that if anybody in the family is unwell, everybody is affected, not least the smallest children. The children need to be recognized and given support, says Marie. – Many children and young people have a stressful life situation. Not least is support important for the many newly arrived refugee families who have had dreadful experiences and currently have a weak social network in Sweden. There is a golden opportunity to go into action early and thereby do important preventive work, concludes Marie Köhler.

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It Is Here and Now, Not Later! Skåne is a multicultural region and when many refugees arrived during a short time in the fall, the Skåne Region’s health and medical care services had to face many challenges. An entirely new Knowledge Center for Migration and Health has been created to support the healthcare centers in matters of competence – in both the short and long term.

The new Knowledge Center got off to a flying start. They hardly managed to open their doors in September 2015 before the situation with thousands of recently arrived refugees who were to be offered health examinations within three months became acute. The healthcare staff needed tools and know-how – and quickly! – This shows that the new operation is important and much needed, says the new unit head, Jenny Malmsten. The Knowledge Center for Migration and Health was operated on a small scale by a project leader who had to develop training courses in health examinations at short notice. It was necessary then and still is now for the personnel to learn more about purely practical matters such as printed forms to be filled out and other formalities, as well as which tests are to be taken. – Time is also devoted to important questions concerning meeting patients and expectations, says Jenny, The operation is to serve personnel in the Skåne Region’s hospitals and primary healthcare centers, support the implementation of policies and applications, arrange training and educational programs, evaluate

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and ensure the quality of the efforts made, and spread information to individuals in other countries. In other words, a tall order! – Yes, but it is becoming more and more important to consider issues concerning migration in all public functions. And this is here and now, says Jenny Malmsten, and continues: – Just in Malmö, about 40% of the inhabitants are foreign-born or have two parents who are foreign-born. It is therefore important that migration doesn’t become just another perspective to take into consideration, but something to be considered in practically all contexts. Jenny doesn’t want to jump the gun and declare an official program just yet. She first wants to acquaint herself with the actors and target groups in the region and get a picture of the needs. She says she wants to tap into the “silent pool of knowledge” that she thinks is sure to exist among both personnel and foreign-born patients, but which perhaps has not been committed to writing. A method to capture precisely this item is something she calls the ‘research circle.’ She has good experiences with it from the time she spent at the Welfare Department in the

It Is Becoming More and More Important to Take Account of Matters Concerning Migration

City of Malmö, where she worked on issues concerning national minorities and antidiscrimination. – The method is good for identifying strengths and things that work, for adapting to target groups, packaging, and teaching and, not least, for spreading knowledge. Both patient and personnel perspectives are important, says Jenny Malmsten. As for training courses, she hopes to set a somewhat more inclusive tone where not only medical aspects are focused on. – More keys to intercultural savvy in healthcare are needed. Reflecting on one’s own role as a caregiver and understanding one’s role in communication is also important for being able to establish a good relationship with the patients, says Jenny. She thinks that it is important to point out that the Knowledge Center is not only supposed to work on refugee problems, but on migration problems in general. Organizationally, the operations come under the Competence Center for Primary Healthcare in Skåne and are to be co-

located with the Knowledge Center for Child Healthcare and Women’s Healthcare Services at Möllevången in Central Malmö. Together with Jenny, since February 2016, there are a nurse, a public health expert, and an administrator on the site. In total, the operation is to be manned by 6–8 coworkers. – I also want to let that decision mature. But we need a mix of different competences with both clinical experience and a societal orientation, says Jenny Malmsten. Apart from caregivers, some important partners are, among others, Infectious Disease Control Skåne, Malmö University College, the Migration Board, and the Employment Office. – We need to work together to create and spread knowledge about what it means to work with health issues from a migration perspective. It is a matter of finding the best possible preconditions for promoting the health of migrants, that of both newly arrived ones and those who have been in Sweden for a longer period of time, concludes Jenny Malmsten.

THE KNOWLEDGE CENTER FOR MIGRATION AND HEALTH strives for a more equal and secure healthcare for individuals from other countries. Offers knowledge support with a focus on strengthening health and medical care personnels’ knowledge of migration matters in healthcare. Jenny Malmsten, Unit head (photo).

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CENTER FOR PRIMARY HEALTHCARE RESEARCH 28

The Center for Primary Healthcare Research is to carry out, with primary care as its base, worldleading research through an active exchange of knowledge, comprising basic research, epidemiology, and patient-centered clinical research. In addition to research, the remit includes the Academic Knowledge Centers, related projects, support to researchers, scientific guidance, seminars, and Scandinaviaâ&#x20AC;&#x2122;s first experimental laboratory based on primary healthcare. Units of the Center for Primary Healthcare Research w Central Operations and Supporting Functions w Academic Knowledge Centers, AKC w Experimental Laboratory

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had Research (CPF) fic re a hc lt ea H ry rima ienti The Center for P citing year. We published 110 sc which , ss ex a a fantastically tional journals of very high cl ntia ie articles in intern ce 2008, there have been 800 sc cally n fi is remarkable. Si akes us one of the most scienti m s hi T . fic articles. nits in the world u h rc a se re e iv act inithout our fine se w le ib ss po en be ve taba This would not ha highly competent coworkers, da ith a w h frastructure wit trators, coordinators, and so on, h. rc is a se in re m handlers, ad highest level of e th to F CP g passion for raisin atulate two new professors: n ngr This year, we co Jakobsson and Family Physicia ive ct lf a U e 10 rs u ve District N s that we now ha althcare, n ea m s hi T v. lรถ imary he Patrik Med with CPF and pr in primary d te ec n n co rs so profes nation ust be the most in the which is by far mily medicine. To all this, it m dents u fa healthcare and out of our total of 47 doctoral st ! n ic ve st se year. Fanta added that eses during the th r ei th ed d en def ce is the ntific competen n ie sc el ev -l gh hi r fo give Another voucher external grants that we were of dvances a ge to ta n lead ca , a high percen li a r te in , which knowduring the year, ent blood clots and expand our ctors fa ev l in our work to pr w heredity and environmenta ho ledge concerning currence of alcohol abuse. oc e th interact in noted. search have been nfirmed re in ts en hm is earlier co Several accompl e fact that the t and eating dith h it w o d to s One ha ievemen e family een scholastic ach connection betw ly explained by genetics and th socially ke sorders is most li her is the fact that children in of ot n A r risk environment. siderably greate foren co a n ru s d oo exposed neighborh h mental ill-health. First and ily, m wit being afflicted tter of circumstances in the fa rence. a fe m if d a a is lso makes most, this l environment a a ti en d si re e th but ager Operations Man Jan Sundquist,

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COWORKERS

51 RESEARCH LEADERS

110 SCIENTIFIC ARTICLES

acamedic knowledge CENTERs

27, 2

External funding for research

million sek

PHD THESIS DEFENSES

2 42 480

NEW PROFESSORS A total of 10 professors are now connected with CPF

ANALYSES Number of analyses (data points) performed in our own experimental primary healthcare laboratory

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AKC â&#x20AC;&#x201C; the Link between Academia and Primary Healthcare The Academic Knowledge Center (AKC) is a network of 10 healthcare centers spread throughout SkĂĽne. They are important links between academia and primary healthcare. At each AKC, there is a postdoctoral AKC coordinator who offers academic supervision. We attempt to reach out to all who are interested in acquiring the knowledge and scientific know-how needed to support with scientific supervision and contacts.

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The researcher network AKC is a link between the Center for Primary Healthcare Research (CPF) and Skåne’s healthcare centers. As stated above, we attempt to reach out to all who are interested in the knowledge and scientific know-how needed to support them with scientific supervision, tips, and contacts. An important forum is our group supervision programs held at healthcare centers throughout Skåne, where the AKC coordinators coach on research and development topics. During 2015, we extended invitations to 25 group supervision programs. Once or twice a year, AKC arranges halfday courses in different subjects. This year the theme was Probiotics, Diet, and Health, for which we invited the external lecturers, Professor Bengt Jeppsson and the Dietician Kerstin Hultén. In September, AKC and AKO (Local Cooperation Ambassadors) had a joint day of lectures where AKC coordinators presented their various areas of research. The AKC coordinators’ research has dealt with such subjects as the Elderly and Pharmaceuticals, Multimorbidity, Chronic Pain, Diet and Diabetes, Telemedicine and Wound Treatment, Yoga, and Antibiotics in Respiratory Tract Infections. AKC coordinators were co-authors of some 40 scientific articles published by CPF in 2015. The AKC coordinator, Veronica Milos, published an article in the Swedish journal, Allmänmedicin (Family Medicine), in which she reflected on her thesis concerning adherence to treat-

PLANS AND IDEAS

w w w w w

BRIEF FACTS

ment recommendations. AKC Coordinator Staffan Lindeberg co-authored the book, Nutrition and Cardiometabolic Health, and also participated in the development of the healthcare program dealing with overweight in the Skåne Region. During the year, the AKC coordinators supervised 28 resident physician projects. We have also supervised doctoral students and healthcare personnel in various professional groups. The scientific supervision of resident physicians’ scientific compositions is usually carried out by postdoctoral researchers. At the end of the year, a compensation system for the supervision of resident physicians was introduced, whereby the postdoctoral researcher’s employer receives a fixed remuneration for 20 hours of supervision via the Competence Center for Primary Healthcare in Skåne. – We hope that this will result in more resident physicians being able to receive scientific support. But we also want the clinical supervisors to be able to feel more involved and serve as “sounding boards,” says Emelie Stenman, AKC teamleader.

Expanding the operation to comprise 11 AKCs Group supervision programs throughout Skåne – on at least 24 occasions during the year Four introductory courses for resident physicians A day of training for all primary healthcare personnel in how to apply the guidelines of the National Board of Health and Wellfare Develop our knowledge of evidence-based medicine and learn how to teach evidence-based medicine

ACADEMIC KNOWLEDGE CENTER 10 Academic Knowledge Centers, see next page.

Two theme seminars for primary healthcare:

Two courses in scientific methodology for clinical resident physician supervisors. 25 group supervisions/ open seminars throughout the region. AKC coordinators have supervised: 24 PhD students and 28 resident physicians. The projects have dealt with questions encountered in primary healthcare, e.g., the effect of various diets on health, heart failure, renal disease, IBS, and yoga.

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New Approach Necessary! Swedish medical care does not look the same as before. The research work must adapt to this. The academic knowledge centers are a step in the right direction. This is what AKC coordinator Stefan Bremberg thinks.

That the research should be done to a greater extent in the primary healthcare setting where most of the patients actually are is something that Stefan, from the Capio City Clinic Helsingborg South, considers to be self-evident. He is convinced that the AKCs will yield much useful knowledge

AKC

about the major endemic diseases, new methods of treatment and ways of working. – The key to success is to start on a small scale and test step by step. I can help with giving the projects a scientific touch and a stamp of quality, e.g., support in formulating aims and relevant

COORDINATORS

questions and elaborating a simple and tangible approach, says Stefan. According to him, a master thesis can be a good beginning. – Once a little idea has been tested and turns out well, it may be possible to expand on it and apply for funding, says Stefan.

ORIENTATION

w Capio Citykliniken Helsingborg Söder

w Stefan Bremberg

w Medical ethics

w Healthcare Center Sorgenfri, Malmö

w Annika Brorsson

w Qualitative methodology

w Healthcare Center Lomma

w Susanna Calling

w Living habits, cardiovascular disease, epidemiology

w Healthcare Center Näsby, Kristianstad

w Rickard Ekesbo

w Cardiovascular disease, gastrointestinal disease

w Healthcare Center Norra Fäladen, Lund

w Ulf Jakobsson

w Gerontology, care of the elderly and chronically ill

w Healthcare Center Sankt Lars, Lund

w Staffan Lindeberg

w Diet and living habits

w Healthcare Center Tåbelund, Eslöv

w Patrik Midlöv

w Drugs and the elderly

w Healthcare Center Södervärn

w Anders Halling

w Epidemiology, COPD, multimorbidity

w Healthcare Center Ystad

w Bengt Zöller

w Cardiovascular disease, epidemiology

w Healthcare Center Laröd

w Veronica Milos Nymberg

w Drugs and antibiotic resistence

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He thinks that projects such as FIRST and the Mindfulness Study, in which many healthcare centers are involved, are examples of successful projects, as well as the resident physicians’ research projects. The 6 hours that Stefan works as a coordinator are spent on meetings, e-mail contacts, and supervision of resident physicians’ scientific projects. Most of this time is spent on planning and holding open, themebased seminars for personnel at the approx. 40 healthcare centers included in his AKC network. In his attempts to reach more, he and several other AKC coordinators have invited themselves to meetings with operations managers, to

resident physician forums, and to training days. Alongside his AKC duties, Stefan is Chief of Medicine at Capio Local Healthcare. And ever since he started to study medicine, the relationship between the patient and the doctor has always interested him. It therefore seems quite natural that his research has focused primarily on studying how family physicians in Sweden identify and react to possible ethical conflicts in their everyday work. He would like to take up that line of research again. – This sphere of interest is always timely, he thinks. – When medical ethics is discussed in the media, it is usually about difficult, truly vital questions. In

The Key to Success Is to Start on a Small Scale.

primary healthcare, it is the more everyday questions that are posed: what is “right?” and what is “wrong?” says Stefan. This may apply to the demand to follow medical guidelines and pharmaceutical lists, and to drawing boundary lines concerning medical responsibility when patients demand various medical procedures. In particular, he thinks that the patients’ and fellowcitizens’ expectations and how the right to self-determination are respected should be the object of more research. – Working in healthcare provides an unusually exciting opportunity to combine scientific knowledge with a fundamentally humanistic view of mankind, says Stefan Bremberg and continues: – But when those of us who are involved in healthcare are called on to justify our actions, we often refer to our responsibility for promoting the general benefits of medicine and to do no harm and follow recommendations than to the patients’ right to self-determination. These perspectives should be able to go hand in hand better. A constant striving toward better results is the foundation for research-oriented primary healthcare. In order to attain higher quality, better results, and broad-based legitimacy and to inspire enthusiasm, Stefan would like to see AKC operations taken into consideration and rewarded more distinctly. – We capture and help to advance the R&D work, and if the criteria are satisfied, this can result in both a stamp of quality and extra resources according to the add-on principle, concludes Stefan Bremberg.

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Published in Respected Journals During 2015, we published 110 scientific articles in international journals of very high class. Since 2008, we have published 800 scientific articles. That makes us one of the most scientifically active research units in the world.

Appointments District Nurse ULF JAKOBSON was appointed Professor of Health and Healthcare Science at the Faculty of Medicine, Lund University. Read more on page 38. District Physician PATRIK MIDLÖV was appointed Professor of Family Medicine at the Institution for Clinical Sciences, Malmö. Read more on page 40. HENRIK OHLSSON, statistician at CPF, was appointed Associate Professor at Lund University. PER ROSENGREN, intern at the Healthcare Center Granen, has been assigned to the first position as Researcher Trainee Physician in Family Medicine in Skåne. He will do the research at CPF with Associate Professor Bengt Zöller as supervisor.

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Research during the year has resulted in several important publications with a focus on primary care psychiatry and abuse (JAMA Psychiatry, American Journal of Psychiatry, Journal of the American Academy of Child and Adolescent Psychiatry, and Psychological Medicine), cardiovascular disease (International Journal of Cardiology, Heart), experimental research (J Thromb Haemost, Thromb Haemost, Clin Epigenetics), and cancer epidemiology (Blood, Leukemia, JAMA Dermatology).

With One Foot in Primary Healthcare A high percentage of the researchers are clinically active as, for example, physicians, nurses, and physiotherapists and thus their competence becomes beneficial for primary healthcare while at the same time the researchers can find stimulation in the clinical breeding ground where the best research ideas are born.

Over SEK 27 Million in External Grants! External grants are extremely important for our operations since they provide the financial means for first-class research and, at the same time, vouch for the high scientific competence at CPF. For example, during 2015, Associate Professor and Family Physician Bengt Zöller and Associate Professor Ashfaque, together with their colleagues at Kristianstad University College and the Malmö Coagulation Department, received SEK 1.2 million from the Heart & Lung Foundation to study mutations in patients who have had blood clots at a young age. This can lead to advances in the treatment of such clots. Professor Kristina Sundquist was granted USD 2 million (ca. SEK 18 million) by the National Institutes of Health (NIH) to study, together with Professor Kenneth Kendler at Virginia Commonwealth University and Dr. Katherine Karriker-Jaffe at Public Health

plans and ideas

w w w w w w w w

Institute, Oakland, CA, how heredity and environmental factors interact in the genesis of alcohol abuse. The project will yield new knowledge about how alcohol abuse can be prevented – an important assignment for primary healthcare. Swedish Research Council grants: 7 Other council grants : 3 (Forte FAS) International grants, NIH/EU: 3 Heart & Lung Foundation: 1 Others: 9

Total external grants: SEK 27.16 million

Cardiovascular diseases, arrhythmias, and thromboembolic diseases Mental illness, alcohol and drug abuse Cancer in primary healthcare – clinical, epidemiological, and experimental studies Study on antibiotic use in primary healthcare Effect of reviewing medicines for the elderly in primary healthcare Intervention projects for better health among coworkers in primary healthcare Migration, ethnic enclaves, and mental health of children and young people Studies on mindfulness and compassion

Vårdcentral CPF

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Unique Appointment Meet Ulf Jakobsson, Skåne’s first district nurse to beappointed professor. But he will not be giving up his clinical work at the Norra Fäladens Healthcare Center.

My Interest Was Sparked During Basic Training.

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Since 2009 he has been employed at CPF where he renders combined services including research, teaching, and clinical work as a district nurse at the Norra Fäladen Healthcare Center in Lund. He is also AKC coordinator. In September, 2015, he was appointed Professor of Healthcare Science on the Medical Faculty of Lund University. He has a background as a nurse with a specialist diploma as a district nurse and a master’s degree in statistics. Ulf’s research is mainly focused on two fields: gerontology/ elderly care and chronic illness. – At the time being, I am planning a new research study on multimorbidity in primary healthcare, says Ulf. Down through the years, Ulf has worked on many studies and instructed and supervised students and doctoral candidates. What played a decisive role in his choosing a research orientation? – My interest was sparked during basic training as a nurse when the examination for the diploma was to take place. It was the method and the scientific approach that was

exciting! I felt that it was something that I wanted to continue with, says Ulf.

Joy in Getting People to Understand It was not just research that became Ulf Jakobsson’s focus. He instructs in both pharmacology and biostatistics and supervises doctoral students. – The PhD candidates have their own driving energy. It is rather the case that you give them the opportunity to develop, thanks to the training in research. Much of the responsibility lies with the doctoral students themselves. He stresses the joy of getting people to understand, of making things comprehensible for the listener. – Statistics is a subject that many people fear will be difficult, but after a recent final examination in a course on statistics, there were many students who said that they had discovered how interesting and rewarding the subject is, although it is difficult, says Ulf, who appreciates being able to develop as a pedagogue and stresses the importance of listening to the students.

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Patrik Is on the Side of the Elderly He is a role model and inspirer in the fight for better quality in the elderly’s use of drugs. Patrik Midlöv, recently appointed Professor of Family Medicine, today possesses a unique competence and network that reaches far beyond Tåbelund’s Healthcare Center in Eslöv.

Already during his specialist training in family medicine, Patrik Midlöv could confirm that there are many uncertainties concerning elderly patients’ medicines. That’s the way it is. And nearly 20 years later, he sees no final deadline for attempting to make a difference for the most vulnerable elderly. – We have seen fantastic developments with great medical and technical advances. But the elderly are often multimorbid and therefore use many medicines. At the same time, they are more sensitive to most drugs. This makes it difficult to strike a good balance between risk and utility. Much too often, this leads to unsuitable drug combinations, too high or too low doses or entirely unnecessary medicines, says Patrik. Therefore, according to Patrik, we must base decisions on evidence, follow up on what we do and change attitudes and priorities. It is also a matter of bringing about good cooperation and routines that actually work in daily care and spark greater incitement for, for instance, more home visits. Within the most immediate decades, the proportion of 80-year-olds and elderly persons will double. – That makes it more important to have an overall approach, whereby one sees the patients’ whole disease profile, says Patrik Midlöv.

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He started as a resident physician at Tåbelund’s Healthcare Center in Eslöv in 1997. He worked at the same site as Family Physician and operations manager, and nowadays also as AKC coordinator. In parallel with his clinical work, he has been interested the whole time in studying more systematically the prescription of drugs for elderly patients. – If you start a drug treatment, you ought to be responsible for evaluating its efficacy and side effects, on all levels, thinks Patrik. The first study he made showed that 40% of the patients living in special accommodations had at least one medicine for which no documentation could be found. Then it is difficult to change, discontinue, or increase the dose, Patrik points out. The research continued. In his doctoral thesis, Patrik showed, among other things, that one fifth of the drug prescriptions were erroneous after the elderly were discharged from hospital. By checking the flow of information and introducing a so-called medicine report, the number of healthcare visits and hospitalizations due to inappropriate medicines decreased. The medicine report is a description of the changes that have been made, and why, in the patients drug treatment in

If You Start a Drug Treatment, You Ought to Be Responsible for Evaluating Its Efficacy and Side Effects.

connection with inpatient care periods. Today a decision has been made in the Skåne Region requiring that patients who are discharged from inpatient care must be given a written medicine report. – But compliance with the decision varies, says Patrik. From the results reported in the thesis, it was also obvious that the communication in the case records between different caregivers had great shortcomings. – We who work in primary care were unable to detect possible changes in prescriptions which were entered in the computerized case records because the primary healthcare centers and hospitals in Skåne have separate case record systems. And there, one is still treading water. The dream is therefore now as then: that “one patient – one case record” should become a reality. – All parties would win with that. All available information about each patient gives rise to surer and more comprehensive support for decision-making, says Patrik. In later years, Patrik’s field of research has also been expanded to studies on cardiovascular diseases in primary healthcare – inter alia, studies on whether yoga has an effect on patients with high blood pressure and whether physical activity affects patients with hypertension. Like most researchers at the CPF, Patrik has always kept one foot in the world of clinical reality. – You don’t become a good researcher without simultaneous clinical experience, he says. Tåbelund in Eslöv was among the first to become an AKC. – This is felt to be extremely positive and we have a good development-friendly spirit in the field. Just at Tåbelund’s Healthcare Center there are now five postdoctoral coworkers and one doctoral student, says Patrik Midlöv. As an AKC coordinator, he thinks that he has a better chance to lower the threshold for collaboration and communication between primary healthcare and academia.

– Earlier, the first step was considered to be rather big. Via AKC and the support from CPF, experiences and knowledge can be exchanged in an entirely different way than before, says Patrik Midlöv. The projects that have come into existence since the beginning are very concrete and down to earth. For example, one district nurse at a healthcare center has initiated a study that is expected to lead to more effective treatment of peripheral vascular disease and leg ulcers in diabetics. As coordinator, Patrik also helps with arranging courses in research methodology and seminars for healthcare personnel where no question is too small or too stupid. He thinks, however, that individual consultation is most useful. – It often gives rise to better possibilities of digging deeper and testing an idea. If I can help in making more people interested in research, I am satisfied, says Patrik. The conversation ended with some recommendations for the future: that research should become just as burning an issue in primary healthcare as in inpatient care and that more assistant professorships and combination services should be appointed so that, as a researcher in primary healthcare, one can remain there and work clinically. – It’s time for us to take the baton. We have wide-ranging research groups, we meet patients from the whole spectrum, both with respect to their life situation and their health status, and we can do patientcentered research, says Patrik Midlöv.

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The Research Leaders Here we present the research leaders at CPF during 2015. Read more about their research and teaching at www.cpf.se.

w Anders Beckman, Associate Professor w Healthcare Center Lunden w Anders Halling, Professor

w Healthcare Center Södervärn

w Ashfaque Memon, Associate Professor w CPF w Bengt Zöller, Associate Professor

w Healthcare Center Vellinge

w Eva Ekvall Hansson, Associate Professor w Private Reception

w Medical care research and pedagogic research w Epidemiology, COPD, multimorbidity w Experimental research w Cardiovascular disease w Vertigo and disturbed balance in the elderly

w Henrik Ohlsson, Associate Professor

w CPF

w Jan Sundquist, Professor

w Healthcare Center Sorgenfri, Malmö w Mental disease and substance abuse in primary healthcare

w Jianguang Ji, Associate Professor

w ALF Service

w Alcohol and the family environment, epidemiology

w Juan Merlo, Professor

w Public Health Work

w Social epidemiology

w Kristina Sundquist, Professor

w Healthcare Center Granen, Malmö w Social and physical environment and cardiovascular disease

w Louise Bennet, Associate Professor

w Healthcare Center Limhamn

w Diabetes and cardiovascular disease

w Margareta Troein, Professor Emeritus

w Södervärns Healthcare Center

w Professional development

w Maria Rosvall, Associate Professor

w Public Health Work

w Social medicine and health policy

w Martin Lindström, Professor

w Public Health Work

w Social capital and health

w Patrik Midlöv, Professor

w Healthcare Center Tåbelund, Eslöv w Drugs and the elderly

w Sigvard Mölstad, Professor

w Healthcare Center Höör

w Staffan Lindeberg, Associate Professor w Healthcare Center St Lars

w Epidemiology, genetically and environmentally oriented applications

w Antibiotic resistance in primary healthcare w Diet, diabetes, and cardiovascular disease

w Ulf Gerdtham, Professor

w Health Economics

w Health economics

w Ulf Jakobsson, Professor

w Healthcare Center Norra Fäladen

w The elderlys’ health

w Xinjun Li, Associate Professor

w CPF

w Molecular epidemiology, cardiovascular disease, and cancer

w Xiao Wang, MD, PhD

w CPF

w Experimental research

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Research Projects On pages 43–49, we present some of the year’s projects at CPF.

Inequality in the Prescription of Medicine for Atrial Fibrillation Depending on Where One Lives – There is a distinct inequality in the prescription of medicine for atrial fibrillation depending on where one lives, says Professor Kristina Sundquist. Comprehensive register studies show how adults with atrial fibrillation in socially well-off communities are prescribed warfarin and statins more often than patient who live in socially exposed communities. Patients with atrial fibrillation in such communities are prescribed aspirin more often than their equivalents in socially well-off communities. – The results of our study indicate an inequality in medication, says Kristina Sundquist. More resources are required in primary healthcare in areas with lower socioeconomic status so that the differences in the prescribing of the best blood-thinning agents can be equalized. The article was published in the International Journal of Cardiology.

The Residential Area Affects both Physical and Mental Health.

Children in Socially Exposed Residential Areas Run a Greater Risk of Being Afflicted with Mental Ill-Health Researchers at the Center for Primary Healthcare Research in Malmö investigated, together with researchers at Stanford and Virginia Commonwealth University, the family’s (both genetics and family environment) and the residential area’s role in the mental health of children and young people. The researchers followed half a million Swedish children during a period of 11 years. The results show that the residential area plays a role, but not as big a one as the family. They also saw that the risk for a behavioral disturbance is two times greater in socially exposed areas than in well-off ones. The study was presented in the Journal of Psychiatric Research.

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Professor Kristina Sundquist’s Research Group Was Awarded 2 million dollars by the National Institutes of Health (NIH).

Significance of Heredity and Environmental Factors in Alcohol Abuse Professor Kristina Sundquist’s research group was awarded 2 million dollars (approx. 18 million Swedish kronor) by the National Institutes of Health (NIH) for studying, together with Professor Kenneth Kendler at Virginia Commonwealth University and Dr. Katherine Karriker-Jaffe at the Public Health Institute, Oakland, California, how heredity and environmental factors interact in the occurrence of alcohol abuse.

Bread Protein Blocks Satiety Tommy Jönsson, Family Physician at Healthcare Center Måsen, and active at CPF, was awarded SEK 400,000 by the Dr P. Håkansson Foundation for his research on how bread protein blocks satiety. – We have shown that bread protein in the form of gluten prevents human subjects’ satiation hormone, leptin, from binding to its receptor, says Tommy Jönsson. – This could block regulation of satiation by the brain and lead to obesity and the development of associated diseases such as diabetes and cardiovascular disease.

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Gene Mutations in Patients with Venous Thrombosis Associate Professors Bengt Zöller and Ashfaque Memon have received, together with their colleagues at Kristianstad University College and the Malmö Coagulation Department, SEK 1.2 million to study gene mutations in patients who contract the disease at a young age without having any of the known risk factors.

Tonsillitis Study at Seven Healthcare Centers Sore throat is a common infection caused by streptococci, which is treated in Sweden with penicillin for 10 days. The rationale for treating it is, however, flawed. Therefore, in September 2015, Professor Sigvard Mölstad started a randomized study in which treatment with penicillin for 5 is compared with the current standard treatment for 10 days. Our assumption is that the treatments are equal. The result of the shorter treatment time can be that the use of antibiotics would be reduced by approx. 3.5 metric tons per year in Sweden. The study is conducted at 7 healthcare centers in Skåne in collaboration with healthcare centers in Kronoberg and Västra Götaland. The study is financed by the Public Health Authority.

Genetics and the Family Environment Explain the Connection between Scholastic Achievement and Eating Disorders An extensive register study showed that the earlier demonstrated connection between scholastic achievement and eating disorders is explained by genetics and the family environment. â&#x20AC;&#x201C; As far as we know, this study is the largest one up to now that has examined the connection between scholastic results and eating disorders, says Professor Kristina Sundquist. For a long time, high scholastic achievement has been associated with an increased risk for anorexia and bulimia, but the causation has been unclear. The study in question showed that high achievement in school can be associated with an increased risk for anorexia and bulimia among females and an increased risk for anorexia among males, but that, on the other hand, there is no causal connection.

The Study Is Based on Registers Comprising Over 1.8 Million Persons and 11,000 Cases of Eating Disorders

â&#x20AC;&#x201C; When we expanded the analysis to include sibling pairs in which one of the siblings was afflicted with eating disorders, we could see that the association between school grades and eating disorders disappeared. Thus, the sibling who had eating disorders did not have, on average, higher school results, comments Kristina Sundquist. Thus, the analyses indicate that the association between scholastic achievement and eating disorders depends on genetic or environmental/familial risk factors which predispose to both high scholastic achievement and eating disorders. The study was based on registers comprising over 1.8 million persons born in Sweden between 1972 and 1990, and about 11,000 cases of eating disorders, and was published in the Journal of the American Academy of Child and Adolescent Psychiatry.

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He has published over 200 scientific articles in respected journals like JAMA and the Lancet. Yet, he is a little shy. It is not the glamor in the winner’s circle that is the carrot for Associate Professor Xinjun Li. The driving force is his curiosity about why certain individuals run a greater risk of being afflicted by disease than others.

A Humble Guy with a Great Interest in Epidemiology

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Xinjun Li became fascinated by epidemiology early on. It was also this engagement that brought him to Sweden in the 1990s. Today his research includes several fields, such as autoimmune disease and the effect of residential areas and social environments on our health, among other things, mental disorders, diabetes, and cardiovascular diseases. – Epidemiological studies give rise to unforeseen possibilities to evaluate both disease states and treatments for many patients over a long period of time and, by checking for various other factors, you can draw more reliable conclusions. Sweden of course also has the advantage of having a lot of registers that are not available in other countries, says Xinjun Li. – I think that it is exciting as a researcher to try to find answers to these types of questions by careful analysis of large quantities of information from registers and other types of studies at CPF, he says.

It all started in an entirely different place. Xinjun Li grew up under simple living conditions in Ning Xia Province in Northwestern China. The firm determination of his parents to give him the opportunity to continue his studies and become a physician led him to Shanghai. There he took his MD degree in 1985. From the beginning, his mind was set on becoming a clinically active physician. But during his studies, he discovered a subject that he fell for: epidemiology. – I thought it was so exciting. Epidemiology can clarify and relate the individual perspective to a social perspective. There is an almost endless breadth of measurements that can be used and questions that can be answered with the aid of epidemiological tools, he says with low-pitched fervor. After taking his degree, he remained at the university and taught for seven years. Later on, he received an offer that changed everything: an opportunity to continue his studies and research in cancer epidemiology at Umeå University in Sweden. – From the beginning, it was a matter of chance that I got into cancer research, he says. Later I have really become fascinated by its being such a complex and exciting field.

A successful team attracted It was the reason why he didn’t hesitate when the Finnish Professor Kari Hemminki wondered if he wanted to come to Stockholm and Karolinska Institutet. After defending his thesis, he made an important and decisive move. He contacted Professors Jan Sundquist and Kristina Sundquist.

Xinjun Li finds it – I knew that they difficult to pick out a had access to large dasingle project that he is tabases and also had especially satisfied with. a successful research As a researcher, one is team, says Xinjun Li. most often only a little And he was accepEpidemilogy cog in the great wheel of ted, first in Stockholm Give Rise to research, he thinks. But and, during later if he had to choose one, years, also in Malmö Unimagined it is the study that was at the Center for Possibilities published in JAMA a Primary Healthcare few years ago. It showed Research. As of today, that individuals who are there has been close to afflicted with autoimmune diseases, a total of 200 scientific articles, such as rheumatoid arthritis, psomany both nationally and interriasis, and juvenile diabetes, in the nationally recognized. early years of life ran a higher risk First and foremost, the of developing Parkinson’s disease researchers have been able to later in life. show that where we live plays a role for our health. An example is when the researchers showed that the risk of being afflicted with autism and epilepsy was 30% and 12% higher, respectively, for children and young people between 2 and 17 years of age living in socially exposed residential areas than for the young in more well-off areas. – It probably involves a lot of different things that affect the results in the exposed areas, such as low levels of income and education in the family, but also factors in the residential area itself, such as a poor outdoor environment and criminality, says Xinjun Li. Another study showed that the risk of a behavioral disorder is twice as large in socially exposed areas than in well-off ones. – Here one can ponder whether initiatives by society at large should begin to focus more on social structures that can perhaps attack the unfavorable development one sees, for example, in mental disorders, says Xinjun Li.

Regarding kinship and mental disease Xinjun Li is not ready to lean back and feel satisfied. Just now the research is all about going forward with the results from earlier studies on the mental health of children and young people. This time, the focus is on the connection between kinship and mental disease. The researchers are to study families for several generations back in time and also include half siblings and cousins to see if there is any pattern. – By studying close kinships, common upbringing and shared living environments, we will try to figure out the significance of heredity and the environment for the development of different types of mental disorders, says Xinjun Li. Teaching and supervision of doctoral candidates are other tasks that he will not discontinue. – I really like to teach and have always been interested in pedagogy. That was the way I started my career after taking my MD degree, concludes Xinjun Li.

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FIRST Is to Prevent Stroke Caused by Atrial Fibrillation

Professor Kristina Sundquist is project leader in an atrial fibrillation study, FIRST, comprising 25 healthcare centers in the whole of Skåne. The aim is to increase the number of patients with atrial fibrillation who are getting adequate anticoagulant treatment with the aim of decreasing the number who come down with stroke. In the study, patients with atrial fibrillation who perhaps are not getting the proper treatment with anticoagulants that they should have are identified. The healthcare centers receive information about their patients so they can quickly call in those who are in need of a review in a new investigation. After three months, an audit takes place at the healthcare center with a cardiologist who helps the doctors to solve “tricky” cases and discusses various treatment alternatives. The project was in progress during 2014–2015 and all 25 healthcare centers have been checked. In a scientific follow-up, we will check on the participants in the study who have agreed to being selected from national registers for analyzing risks of stroke and other disease. We will also study the moderating effect that education, income, country of birth, and residential area have on any discovered complications and comorbidity.

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Evaluation of the Diagnostic Center The Diagnostic Center (DC) at the Kristianstad Central Hospital is Sweden’s first fast track for patients with suspected serious disease without organ-specific symptoms. The patients are remitted to the DC from nearby healthcare centers. At the DC, the patients undergo thorough investigations to identify the underlying causes of the symptoms as quickly as possible. In case of cancer, it is of the utmost importance to make an early diagnosis. The DC opened in October, 2012, in the form of a project at the initiative of the Regional Cancer Center South. The CPF is now evaluating the project under the leadership of Professor Jan Sundquist. The goal was to recruit 60 patients diagnosed with cancer and that number was reached in August, 2015. The analysis and compilation are in progress, inter alia, with a comparison of individuals who have been treated for cancer at the Helsingborg Clinic. In this year’s last issue of the Swedish journal, Allmänmedicin (Family Medicine), we published an article about the DC and an inquiry that was carried out to capture family physicians’ opinions.

Sweden’s First Fast Track for Patients with Suspected Serious Disease without OrganSpecific Symptoms

Courses in Research Methodology During the year, the CPF has offered university courses in fundamental research methodology for resident physicians and other research-interested personnel who wish to go deeper into research and perhaps even study for a PhD degree, as well as a Skåne Region-financed introductory course that is tailor-made for facilitating resident physicians’ scientific papers.

Fundamental Research Methodology This preparatory course in research is provided by IKVM (the Institution for Clinical Sciences, Malmö), together with the CPF, for personnel in primary healthcare. It includes 30 university college credits and is given part-time during three semesters. The course has existed for over 20 years and has played an important role in increasing the scientific competence of many in primary healthcare and in recruiting doctoral students. A large proportion of doctoral students who are clinically active in primary healthcare have taken this course. It consists of theoretical instruction and a scientific project. The content of the course includes, inter alia, literature searching, scientific theory, biostatistics, epidemiology, and qualitative methodology.

Inroductory Course in Medical Science and Quality Work

Four times a year, CPF gives a course in research methodology for resident physicians from all specialties and from the whole country with places for 25 participants per course. The course comprises five teacherled days, extending over approximately two months and ending with a project plan for the resident physicians’ scientific projects. During 2015, we had 78 participants in the course. 2015 was the fifth year in a row that we gave the course, which came about thanks to the initiative of the Skåne Region and the Physicians’ Institute for Professional Development in Healthcare because of a lack of all-inclusive alternatives to the obligatory course component. The course’s group supervisions, lectures, and examinations involve nearly the whole of CPF’s research and personnel staff and many think it is a nice way to keep up to date with science and evidence-based medicine.

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More Atrial Fibrillation Patients Than Expected Got the Right Care If patients with atrial fibrillation get the right medicine, thousands of cases of stroke can be prevented. But not even half get the treatment they need. Family Physician Beatrice Segerstein Asker wanted to know the situation among patients at her own Healthcare Center in Arlรถv. The result? Better than expected: about 80% had the right medicine, which satisfies national targets. 50

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When Family Physician Beatrice Segerstein Asker at the Arlöv Healthcare Center had completed CPF’s introductory course in research methodology and it was time to do her scientific resident physician’s project, the choice of subject came naturally. – Atrial fibrillation is complex and an endemic disease, where many are investigated, treated, and followed up in primary healthcare, thinks Beatrice. Unfortunately, undertreatment is usual, which can give rise to serious health problems and increase the risk of dying prematurely and entirely unnecessarily. There are also reports indicating that low-risk groups are overtreated. – The positive aspect is that if you keep track of your patients and offer modern stroke-preventing drug treatment, it will save both lives and money. When Beatrice was asked to join the FIRST Project (see page 48), she seized the opportunity immediately. Over 13,000 patients are listed at her Healthcare Center. Of these, 384 had the diagnosis atrial fibrillation – which is at the level of the national average of 3%. 205 of the listed patients at the healthcare center had been diagnosed by their family physician and 184 in inpatient care. More men than women had atrial fibrillation, but slightly more women over age 70 were undertreated. However, according to national recommendations, as many as 80 of the patients received the correct treatment with the coagulation-inhibiting drugs, warfarin and the new so-called NOAC drugs. – These are pleasing results and vouch for our being good at detecting atrial fibrillation, rendering the diagnosis, and treating it correctly, says Beatrice Segerstein Asker. She believes that the reason for this good result can be explained by the fact that the Healthcare Center has good doctor continuity. Good collaboration between the Anticoagulant Reception in Malmö can also be significant. Why there were, nevertheless, 20% undertreated patients, the majorty of which

The More There Are of Us Who Are Active in the Work, the Greater the Chance We Will Come to Grips with the Problem.

were elderly women, is something about which Beatrice can only speculate. – It is probably due to several things. One can be our own deficiencies. Another possibility is that some patients hesitate about being treated with anticoagulants, when preparations like warfarin are often a demanding treatment for the patient and can give rise to dangerous side effects, she says. But when correctly set, according to Beatrice, they are helpful for many. And the new blood-thinning drugs that emerged in 2011 have proven to be at least just as effective. They also have the advantage of not affecting the patient’s way of life in the same way as warfarin since they do not require regular checks or dietary adjustments and are affected to a significantly lower degree by treatment with other medicines. As a result of Beatrice’s project work, colleagues and resident physicians in and outside of Arlöv have begun to discuss more about which routines one should follow to become even better at treating atrial fibrillation. For support, Beatrice has formulated a one-page-long quick-reference guide. Among other things, it contains contact information about how to proceed when starting to use anticoagulants. – It is very pleasing that so many have shown their interest. The more there are of us who are active in the work, the greater the chance we have to come to grips with the problem. In any case, now they can’t say that they don’t know how to do to give the correct treatment, she chuckles. Her project work has created an interest in more studies – which was not self-evident from the beginning. – No, not at all. That fervor was extinguished a few years ago after some bad experiences. But now it has been awakened again. The support by my scientific supervisor, Kristina Sundquist, has been astonishing and made it possible for me to think that I can re-evaluate my decision. If it would be in any way possible to combine this with my clinical work, it would be fantastic, concludes Beatrice Segerstein Asker.

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PhD Thesis Defenses 2015

Åsa Chaikiat, Resident Physician in Family Medicine ”Diabetes: sociodemographic predictors, comorbidity and causes of death”. Main Supervisor: Kristina Sundquist.

Increased Risk for Diabetes in Exposed Residential Areas

Jessica Skoog, Specialist Physician in Family Medicine “Analysis of factors of importance for drug use ”. Main Supervisor: Anders Halling.

High Drug Use among Women, the Elderly, and the Lowly Educated The thesis investigated which factors, other than purely medical ones, can affect the use of pharmaceuticals. It is well-known, for instance, that gender and socioeconomics affect the use of drugs. Earlier studies have seldom included the morbidity of the patients, but in Jessica’s project, the morbidity of the patients was taken into consideration. This was done via the ACG system, which is used in Skåne, among other regions, to calculate the optional healthcare allowance. Among other things, it can be seen from the results that, although the morbidity of the patients was taken into consideration, women, the elderly, and individuals with low levels of education and income use pharmaceuticals to a greater extent.

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It has been known for some time now that both depression and cardiovascular disease are associated with diabetes. But now, for the first time, the significance of the residential area has been included in a Swedish study. The results are based on wideranging basic data from population, drug, and patient registers, as well as basic data from a large number of healthcare centers in, among other places, Stockholm. Among other things, the thesis shows that diabetes is associated more often with cardiovascular disease in residential areas with low status than in other residential areas. Even when it comes to mortality among inhabitants with diabetes, there was a connection which indicated an increased risk for premature death when the individual lived in a residential area with low status.

Kristina Hansen, Physician ”A life course perspective on health in childhood and adulthood with special focus on health effetct of smoking”. Main Supervisor: Maria Rosvall.

Continued Need for Preventing and Reducing Smoking Both national and regional surveys show distinct and persistent social differences in health and living habits, including smoking. Based on a course-of-life perspective, the connection was studied between socioeconomic exposure, tobacco exposure, and health, as well as developments related to health. The results point out the need for continued work to prevent and reduce smoking and exposure to smoking. An increased knowledge of the effect of early and/or prolonged exposure to the risk factors increases the possibilities for effective preventive measures and improved public health.

Sanjib Saha, MPH, Health Economist ”Lifestyle Intervention from a health economics perspective (Nutrition and/or Physical activity)”. Main Supervisor: Ulf Gerdtham.

Elin Taube, Licensed Nurse Loneliness: an essential aspect of the wellbeing of older people: Experiences, Causes, Effects, and Prevention Main Supervisor: Ulf Jakobsson.

Health-Economic Analysis Gave Important Information about Lifestyle Intervention

Loneliness Prevalent among the Elderly and Leads to Ill-Health

A lifestyle intervention that changes dietary habits and physical activity is generally effective when it comes to preventing, reducing, or delaying the development of type 2 diabetes mellitus (T2DM) and cardiovascular diseases (CVDs). The thesis shows that certain lifestyle interventions are useful in the long run in terms of reduced resource consumption, as well as an increased quality of life. In order to spare health and medical care’s limited resources, the decision-makers should consider conducting lifestyle interventions in primary healthcare for individuals with a high risk for CVD and T2DM.

Martin Lindström, Professor of Social Medicine Health Policy ”All that’s mine I carry with me. Early life disease and adult health in Sweden during 250 years”. Main Supervisor: Tommy Bengtsson.

Exposure to Infections Early on in Life Affects Health Later in Life The aim was to study exposure early on in life to impaired growth factors during the fetal stage and exposure to infectious diseases during infancy (age 0–1), which can lead to chronic inflammation, and to relate this to health and mortality among older adults in Sweden. Among other things, the results showed that those who were exposed to severe epidemics of airborne infectious diseases during the year of infancy had an increased risk of premature death at the age of 55–80 years.

The thesis indicates that over half of the elderly persons stated that they felt lonely to some extent. The results also show that those who felt lonely had considerably more health problems and a poorer mental health status than those who did not experience loneliness. Those who felt lonely also paid more visits to doctors in outpatient care and to emergency departments.

Xiangdong Liu, MD “Associations of type 2 diabetes mellitus with cancer and autoimmune diseases: A population based epidemiological study in Sweden” Main Supervisor: Jianguang Ji

Increased Risk of Cancer for Diabetics The thesis shows that the risk of contracting 24 different types of cancer was higher for patients with type 2 diabetes compared with the rest of the population. In addition, patients with both type 2 diabetes and cancer had a higher mortality than the patients who only contracted cancer. The analyses also showed that cancer patients who had been diagnosed earlier with type 2 diabetes had a poorer prognosis than patients who did not have this kind of diabetes. It can also be seen from the thesis that the risk of being afflicted with type 2 diabetes was greater in patients with autoimmune diseases, which indicates that chronic inflammation may play a role in the development of diabetes. – Type 2 diabetes comprises risk factors similar to those of cancer. For example, overweight and stress, says Xiangdong Liu. It is not clear, however, whether or not the relationships are due to shared risk factors, genes, or the metabolic disturbances or are entailed by the disease.

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Marking Timeâ&#x20AC;Ś annualreport2015

– It’s exciting, says Beata Borgström Bolmsjö before the approaching defense of her thesis. The time spent as a doctoral student has been inspiring, fun, and informative. It’s awful that it’s coming to an end. There is no way you can ignore Beata’s joy coupled with an emerging feeling of missing the time gone by. April 29, 2016, is the date for the defense of her thesis. – It’s been a fantastic phase of my life with the possibility of combining the practical work at the healthcare center with being here and able to get involved in scientific concepts, Beata continues. As Family Physician and Specialist in Family Medicine, 60% of her work is done at the Healthcare Center Sorgenfrimottagningen in the middle of Malmö. Her thesis is entitled “Aspects of Treatment and Care of Nursing Home Residents – Challenges and Possibilities”. Beata has taken a closer look at the care of the elderly in special housing for the elderly. – I have four different areas of focus: How are heart failure, undernourishment, and renal function treated and how do the physicians experience the elderly. The last-mentioned study is based on interviews with physicians, in which they compare their work in special housing for the elderly with their work with patients at the healthcare center. – In Sweden, the elderly in special housing are of course very sick, but the doctors experience their work there as being more beneficial than at the healthcare center; they have a better overall view of the sick since they can evaluate, for example, progressive changes in their medication, Beata Bogström Bolmsjö explains.

Her interest in research was awakened when she took a course in basic research methodology which is given at the Institution for Clinical Sciences in Malmö. – As a family physician, you of course have a wide range of interests – it’s all interesting! I came into contact with Patrik Midlöv, who became my main supervisor, and was given the opportunity to take part in the work in a study on elderly persons for whom he was responsible, and that’s how I got started with my thesis. During 2015, Beata spent eight weeks in Australia as a so-called predoc. Through the National School of Research in Family Medicine, she was helped to get in contact with a professor in the country. During those eight weeks, she was able to focus entirely on her research while at the same time being able to study the Australian form of housing for the elderly. – I was able to participate in their research groups, I wrote and worked on my own studies there and also started to write a new article alongside the thesis. It was extremely inspiring, Beata tells us. Beata is now working on the summary of her thesis and making all other preparations before both the preliminary defense on March 30th and the defense itself barely a month later.

It Has Been a Fantastic Opportunity to Combine the Work at the Healthcare Center with Being Able to Get Involved in Scientific Concepts.

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Newly Enrolled PhD Students 2015

Peter Nymberg – Opportunistic Screening and Intervention, Cardiovascular Disease. Main supervisor: Bengt Zöller. Per Rosengren – Cardiac Arrythmia. Main supervisor: Bengt Zöller.

Earlier Enrolled PhD Students

Abrar Ahmad, MS, Risk Prediction of Cardiovascular Diseases: A Multibiomarker Approach. Main supervisor: Jan Sundquist. Delshad Akrawi, Specialist Physician in Family Medicine – An Epidemiological Study of the Importance of Hereditary and NonHereditary Factors for Chronic Kidney Disease in Sweden. Main supervisor: Bengt Zöller.

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Carl Antonson, Resident Physician – Mindfulness as a Method for Increasing Mental Well-Being and Cognitive Performance and Reducing Stress among High School Students: A Prospective, Controlled Pilot Study. Main supervisor: Kristina Sundquist Annika Astermark, Licensed Physiotherapist – Biomarkers of Degenerative Disc Disease and Effects of Intervention. Main supervisor: Eva Ekvall Hansson. Henrik Axelson, MS, Essays on the Impact of Targeted Social Health Insurance: Evidence from Vietnam. Main supervisor: Ulf Gerdtham. Jakob Axelsson, Administrator/Public Health Planner – Social Capital and Sexual Orientation. Main supervisor: Martin Lindström. Sixten Borg, BS in Mathematics/Statistics – Disaggregation and Indirect Estimation Methods on Data for HealthEconomic Models and Economic Evaluation, with Applications to Inflammatory Bowel Disease and Diabetes. Main supervisor: Ulf Gerdtham.

Beata Borgström Bolmsjö, Resident Physician in Family Medicine – Risk Factors and Drug Therapy in Elderly Patients with Multiple Diseases in Special Housing. Main supervisor: Patrik Midlöv. Pedro Carrera Bastos, The Role of Western Diet in Intestinal Permeability Measured by Zonulin, Including Possible Associations with the Metabolic Syndrome and Autoimmune Diseases. Main supervisor: Staffan Lindeberg. Lina Ejlertsson, Recovery in Work: An Intervention Project for Better Health among Coworkers in Primary Healthcare. Main supervisor: Annika Brorsson Maelán Fontes Villalba, Food and the Metabolic Syndrome in Western and Non–Western Populations: Focus on Adipokines and Glucagon. Main supervisor: Staffan Lindeberg. Maria Fridh, Doctoral Work – Determinants of Mental Illness among Adolescents and Young Adults with a Special Focus on Exposure to Violence and Bullying. Main supervisor: Maria Rosvall.

Henrik Grelz, District Physician – Group Therapy for Physical Inactivity in Primary Healthcare. Main supervisor: Patrik Midlöv. Gawain Heckley, MS – Essays on the Demand for and the Effect of Alcohol. Main supervisor: Ulf Gerdtham. Elzbieta Kaszuba, Comorbidity of Heart Failure and Chronic Obstructive Pulmonary Disease: Possibility of Using Impedance Cardiology as a Method of Investigation in Patients with Heart Failure. Main supervisor: Anders Halling. Gustav Kjellsson, Inequality, Health, and Smoking. Main supervisor: Ulf Gerdtham. Marie Köhler, Pediatrician – Small Children in the Danger Zone: A Social Perspective on Health and Healthcare. Main supervisor: Maria Rosvall. Caroline Larsson, Licensed Physiotherapist, MS in Gerontology – Kinesiophobia, Physical Activity and Chronic Pain in Older People. Main Supervisor: Ulf Jakobsson.

Cecilia Lenander, Pharmacist – Safe Use of Drugs in Primary Healthcare. Main supervisor: Patrik Midlöv.

Ensieh Memarian, Specialist in Family Medicine – Obesity Surgery in Sweden: The Effect of Socioeconomics. Main Supervisor: Xinjun li.

Magnus Lindgren, Resident Physician in Family Medicine – Epidemiological Studies on Heart Failure. Main supervisor: Bengt Zöller.

Sara Olofsson, MS – Methodological Studies on Willingness to Pay for Risk Reduction. Main supervisor: Ulf Gerdtham.

Christine Lindström, Physician – Studies on Social and Administrative Contexts Influencing Health. Main supervisor: Martin Lindström.

Sofie Persson, MS –Social and Economic Consequences of Childhood-Onset of Type 1 Diabetes. Main supervisor: Ulf Gerdtham.

Sofia Nilsson, Speech Therapist – Language Development Disorders in Childhood and Adolescence and Healthcare Utilisation Later in Life: A Multilevel and Life Course Approach. Main Supervisor: Juan Merlo.

Ferdindo Petrazzuoli, Dementia Management in European Primary Care. Main supervisor: Hans Thulesius.

Marie Nilsson, Health-Promoting Interaction between Work and Private Life. Main supervisor: Kerstin Blomquist. Nermin Mahmoud Mohamed Ghith, MPh, EMPh, CPhQ – MultiLevel Analyses in the Evaluation of Health Care Performance. Main supervisor: Juan Merlo.

Jesper Alex Petersen, Researcher, Trainee Physician – Materialistic/ Postmaterialistic Values and Health, as Well as Longitudinal Studies on Health Effects of the Introduction of School Lunches in Sweden in 1946–1973. Main supervisor: Martin Lindström. Karin Ranstad, For Whom Is It Important to Choose a Physician or Primary Healthcare Provider in Sweden? Main supervisor: Anders Halling.

är följande doktorander inskrivna

Denis Selan, Implementation of Individual Healthcare Plans: Preconditions for Introduction in Municpal and Primary Healthcare. Main Supervisor: Ulf Jakobsson. Cecilia Sjöstedt, Specialist Physician in Family Medicine – Individual, Family, and Neighborhood Factors and Mental Illness. Main supervisor: Xinjun Li. Frida Thorsén, Specialist in Family Medicine – Mindfulness As a Method for Increasing Mental Well-Being and Cognitive Performance and Reducing Stress among High School Students: A Prospective Controlled Pilot Study. Main Supervisor: Kristina Sundquist. Mia Tyrstrup, Resident Physician in Family Medicine – Mapping Resistant Bacteria in the Upper Respiratory Tract in Children in Primary Care in Relation to Antibiotic Use. Main supervisor: Sigvard Mölstad. Kristine Thorell – Improving Pharmacological Care in the Elderly Population. Main supervisor: Anders Halling.

Leila Waleij, Pharmaceutical Chemist – Drug Treatment and Drug-Related Problems in Frail, Elderly Patients. Main supervisor: Patrik Midlöv. Rasmus Waehrens, Specialist Physician in Family Medicine – An Epidemiological Study on the Importance of Hereditary and NonHereditary Factors in Irritable Bowel Syndrome (IBS). Main supervisor: Bengt Zöller. Maria Wemrell, MS (Anthropology) – An Anthropological Perspective on the Epidemiological Discourse Concerning Risk. Main Supervisor: Juan Merlo.

Hanna Wickström, TeleUlcer: Telemedicine and RiksSår (Swedish Quality Register for Treatment-Resistant Sores): Modern Sore Treatment for Patients and Personnel. Main supervisor: Patrik Midlöv. Moa Wolff, Specialist Physician in Family Medicine – Yoga as a Treatment in Primary Healthcare. Main supervisor: Patrik Midlöv.

Sedan

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Experimental Research Laboratory CPF is the only family medicine institution in Sweden that has its own molecular medicine laboratory. This makes it possible for us to analyze blood samples from participants in our studies without needing to stand in line at outside laboratories. We also have our own biobank department. The laboratory is open to clinically active researchers and molecular medicine/translational researchers. In CPF’s evaluation of the Diagnostic Center, molecular analyses of blood samples from the study participants are performed. DNA from these patients (a total of 290) has been extracted and has begun to be analyzed in our laboratory. A method that we have made use of is digital droplet PCR (ddPCR), with which one can carry out absolute quantifications of specific DNA targets with high precision. Development of the methodology is an important part of the work and prior to analyzing the samples, a new method was established for simultaneous quantification of the absolute number of DNA copies of both mitochondrial and nuclear DNA in the blood. This is an important improvement because an analysis of both types of DNA at the same time in the same experiment reduces the methodological variations, compared with when they are performed separately. The goal is to be able to diagnose possible cases of cancer in patients earlier than can be done today. In collaboration with Peter J. Svensson and Assoiate Professor Bengt Zöller, samples have been analyzed from a study called Score. It includes patients who have sought care for suspected venous thrombosis (blood

During 2015 publicerades six scientific articles were published in collaboration with several local researchers.

clots). The aim was to discover analyses that could distinguish patients with a strong clinical suspicion of thrombosis so that only such patients would have to undergo timeconsuming leg examinations. During the year, additional analyses were made of so called microRNA in the material. Among other things, we have found two microRNAs that differ significantly between patients with and without thrombosis. Abrar Ahmad researches mainly on venous thromboembolism (VTE). He identifies VTE-specific deviations in genes that are involved in coagulation and vascular function and investigates the role they have in VTE and in the risk for relapse. Docent Ashfaque Memon, Professor Jan Sundquist, Professor Kristina Sundquist, and the cancer researcher, Associate Professor Lao Saal, have jointly formulated a project to investigate genetic deviations in circulating tumor DNA for the prediction of breast cancer and how early deviations can be detected in comparison with the clinical manifestation of cancer. – The hypothesis is that changes in circulating tumor DNA can be detected much earlier than when the cancer becomes visible in a clinical diagnostic test, explains Ashfaque Memon.

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Research Databases At CPF a new database is created for each new project from national and regional register data. Thanks to these databases, we can follow people’s family life patterns for several generations and study different interdisciplinary relationships and how the social and biological legacy affects people.

An example is Whila (Women’s Health in the Lund Area), a database comprising 6 917 women, whose samples were collected in 1995–2000 in Dalby. The samples are now kept in the Biobank Department at CPF and are used in studies on, inter alia, cardiovascular diseases.

Project Databases for Register Research During the year, a new project database has been created for Professor Kristina Sundquist’s project, “Heredity, Family Factors, Living Environment, Comorbidity, and Cancer 1958–2018”. The new database contains data from the National Board of Health and Welfare, Statistics Sweden, and the conscription registers.

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Databases for Clinical Projects and Smaller Research Studies It is the task of the database team to create analytical datasets and build databases for epidemiological and other clinical projects run by research leaders at CPF or healthcare personnel, often resident physicians. An example of this is the Diagnostic Center Project, the Atrial Fibrillation Project (FIRST) and the unique Swedish-Bulgarian Child Psychology Project, along with other projects. Our project assistant, Per Condelius, creates electronic entry forms and databases and our database administrators, Helene Brandt and Mats-Åke Persson, take care of the databases and create analytical datasets for the researchers. The database team also includes GIS engineer, Klas Cederin. – This is an extremely important form of support for the clinical researchers regarding how their personal data is to be stored and processed safely, says Kristina Sundquist.

Upgrading of Server Environment With the aid of external research funds, we have also invested in an expanded storage system and a new powerful server for programming and statistical analysis using our databases. The entire database and server environment meets the Data Inspection’s strong demands for data security, back-up handling, firewall, and virus protection.

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Smart Storage System During the past year, we have introduced some new intelligent software â&#x20AC;&#x201C; IBMâ&#x20AC;&#x2122;s Easy Tier, to increase the performance when using data that we work most actively with. Easy Tier is an advanced, modern system that is connected to our servers and our storage system (Storage Area Network). The new Easy Tier system sees to it that the data we work with most actively are saved automatically on superfast SDD disks. The data we work less with is stored on the slower semi-fast SAS disks, and data that we almost never use are stored on the slowest SATA disks.

Virtualization of the Server Environment During 2015, we started a so-called virtualization of our server environment. Virtualization signifies, inter alia, that you can have several virtual servers on one physical server (server hardware). That makes for more cost-effective, more flexible, simpler, and safer server management.

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Geographical Data and Area Studies GIS Engineer Klas Cederin builds geographical databases that contain aggregated geographical and socioeconomic data such as population density, proximity to parks, collective traffic, gyms, libraries, etc. Sweden is divided into approx. 9000 geographical areas that are analyzed in our studies concerning the effect of the residential areas on health. Kristina Sundquist has supervised a number of research students who have conducted studies on walkability in Stockholm. The concept “walkability” means approximately “walk-friendliness” and is defined by a number of geographical variables. In 2015 a study was conducted that showed a connection between proximity to fast food restaurants, bars, and pubs and type 2 diabetes. To help them do so, the researchers used so-called Geographical Information System (GIS) tools. Geographical information describing the situation for activities in the service and trade industries has been used for a long time by Kristina Sundquist’s research group. These are variable data which are constantly being updated – today the research group has at its disposal information from 2005 to 2013.

– It is a matter of some 200,000 different objects all around Sweden that are updated regularly and describe trade affiliation, addresses, and coordinates, explains GIS Engineer, Klas Cederin at CPF. The sources are Statistics Sweden’s Business Register, the Companies Registration Office, and the National Tax Board. The thing that is unique about these data is that they are supplemented with self-reported information.

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Analytical Support A significant part of the medical research is based on analyses of collected data, often in large quantities. This carries with it the possibility to study and analyze new connections with, and explanations of, ill-health, but also poses great challenges. Regardless of whether they are small or large amounts of data, close cooperation is required between clinical researchers and statisticians in order to be able to meet these challenges.

– As statisticians, we help with, for example, study design, the method of analysis, and interpretation of the results in projects where the collected data contain the information that the researcher is interested in, says Henrik Ohlsson, biostastistician and associate professor. Since our possibilities are, thanks to our large registers, much better than those in many other countries, we are also one of the most advanced research groups when it comes to the use of statistical methods to measure causal relationships in observational studies, but also to study aggregation and the transfer of various diseases between different types of relatives. Besides supporting researchers in their scientific activities, the work of the statistician involves teaching and conveying the significance of statistical methods to physicians and student researchers since these are necessary tools to be able to plan, analyze, and evaluate quantitative studies. The analysis group is involved as supervisors for medical students in their MS essays, as co-supervisors for doctoral students and teachers of statistics in courses at different

annualreport2015

We Have Extensive Analytical Support and Our Statisticians Have Close Cooperation with the Researchers

levels, for instance, the introductory course in medical science and quality work aimed at resident physicians. – The major portion of my work is to serve as a “sounding board” and coach for clinicians doing research at the healthcare center and to develop tools that can be used in ST projects and smaller clinical studies, says Mir Nabi Pirouzi Fard, statistician at CPF since September 1, 2014. The statisticians also collaborate a lot with researchers in the Experimental Laboratory which has been at CPF since 2011 and is used to study the molecular and physiological mechanisms of the diseases treated in primary healthcare. – During 2015, I have analyzed, among other things, how mindfulness affects telomeres and mitochondrial DNA and microRNA’s diagnostic potential for venous thromboembolism, says Biostatistician Karolina Palmér. The analytical group also includes the statistician, Sara Larsson, PhD, and the associate professors, Xinjun Li and Jianguang Ji, and Klas Cederin, GIS engineer.

International Collaboration Seminar with award-winning researcher Kenneth Kendler, Professor at Virginia Commonwealth University is one of the most cited and award-winning researchers in the world in the field of psychiatry and drug abuse. Kendler and CPF have collaborated for a rather long time on several research projects that have garnered international attention. His research focuses on the genetics behind mental disorders and drug abuse. He visited CPF at the end of August and held, in connection with that visit, a highly appreciated seminar.

Bonding with Japan Several times during the year, CPF was visited by Japanese researchers from Shimane University in Japan. Dr. Naomi Nakajama was among them on two of the occasions and visited several special housings for the elderly in Lund and Malmö. The visitors were impressed by the personnel’s devotion to the work and how the patients with dementia are cared for in a home-like environment. By way of continuing the cooperation, Professor Margareta Troein Töllborn will visit Shimane in April, 2016. Kristina Sunquist’s and Bengt Zöller’s two visitors found time to write a whole article during their two-week visit in September, 2015.

annualreport2015

The Financial Perspective EXTERNAL

estimated

Result

COUNCIL GRANTS

grants

2015

Forte FAS

2016

2015

w Kristina Sundquist

1 780 000

1 750 000

w Jan Sundquist

900 000

w Ulf Gerdtham

183 333

987 000

w Jan Sundquist

1 900 000

900 000

2 204 000

w Kristina Sundquist

1 000 000

w Juan Merlo

1 825 000

w Martin Lindström

700 000

2 000 000

w Ulf Gerdtham

1 550 000

w Bengt Zöller

700 000

1 500 000

3 200 000

6 700 000

500 000

400 000

w Jan Sundquist

500 000

w Ulf Jakobsson

350 000

100 000

w Patrik Midlöv

200 000

820 000

w Sigvard Mölstad

200 000

w Margareta Troein

1 213 000

1 178 000

w Louise Bennet

150 000

w Juan Merlo

100 000

w Martin Lindström

1 700 000

400 000

21 310 000

27 164 000

NIH w Jan Sundquist NIH/Ellison w Kristina Sundquist

6 400 000

EU w Jan Sundquist HLF w Bengt Zöller others

w Tommy Jönsson Total external

21 751 333

annualreport2015

STATE BUDGET

2016

2015

ALF-grants

2016

2015

w Jan Sundquist

991 000

969 000

w Jan Sundquist

1 275 000

1 260 000

w Ulf Jakobsson

457 000

447 000

w Kristina Sundquist 1 051 000

1 027 000

w Patrik Midlöv

637 000

334 000

w Bengt Zöller

425 000

442 000

w Ulf Gerdtham

525 000

514 000

w Martin Lindström

433 000

425 000

w Margareta Troein

404 000

w Louise Bennet

434 000

423 000

w Sigvard Mölstad

637 000

805 000

w Patrik Midlöv

500 000

w Juan Merlo

130 000

w Jianguang Ji

452 000

516 000

Total

3 377 000

3 603 000

Total

4 570 000

4 593 000

REVENUES Revenues, Region Skåne Regional grant, CPF Funding for salaries Total revenues, Region Skåne Other revenues whereof outsourcing of personnel Total REVENUES

budget 2015

results 2015

BUDGET 2016

12 000 5 334

112 000 5 343

112 300 5 350

17 334 1 451 1 451 18 785

17 343 2 801 2 235 20 144

17 650 2 360 2 360 20 010

18 411 2 768 503 1 168 2 470

18 024 3 184 511 1 501 1 608

1 130 620

1 206 250

42 471

30 886

161 19 541 5

40 19 230 200

EXPENSES 17 386 Personnel expenses 2 741 whereof, comb. services (as agreed) whereof, cost for AKC private caregiver 260 1 411 whereof, AKC public caregiver whereof, research time, public and 2 471 private 692 Operating expenses 192 whereof, IT costs, LU and RS plus telephone whereof, travel expenses, board and 40 lodging, postage, printed matter, office 460 material, advertisements, etc. whereof laboratory equipment/material 0 18 078 Total amount 200 Rent for premises Overhead (OH) costs

507

580

Total costs

18 785

20 053

20 010

SURPLUS/DEFICIT

annualreport2015

PUBLISHED SCIENTIFIC ARTICLES 2015

Family Medicine 1.

Babaei M, Fallah M, Sundquist K, Hemminki K. Histological concordance in familial central nervous system tumors:

Evidence from nationwide Swedish Family-Cancer Database. Cancer Epidemiol. 2015 Jun;39(3):334-9.

Carlsson AC, Wändell P, Gasevic D, Sundquist J, Sundquist K. Neighborhood deprivation and warfarin, aspirin and

statin prescription - A cohort study of men and women treated for atrial fibrillation in Swedish primary care. Int J

Cardiol. 2015 May 6;187:547-52.

Chen T, Fallah M, Försti A, Kharazmi E, Sundquist K, Hemminki K. Risk of Next Melanoma in Patients With Familial

and Sporadic Melanoma by Number of Previous Melanomas. JAMA Dermatol. 2015 Feb 11.

Chen T, Fallah M, Jansen L, Castro FA, Krilavicuite A, Katalinic A, Eisemann N, Emrich K, Holleczek B, Geiss K,

Eberle A, Sundquist J, Brenner H, Hemminki K; GEKID Cancer Survival Working Group. Distribution and risk of the

second discordant primary cancers combined after a specific first primary cancer in German and Swedish cancer

registries. Cancer Lett. 2015 Dec 1;369(1):152-66.

Crump C, Sundquist J, Sieh W, Winkleby MA, Sundquist K. Fetal growth and subsequent maternal risk of colorectal

cancer. Cancer Epidemiol Biomarkers Prev. 2015 Aug;24(8):1184-9.

Crump C, Sundquist J, Sieh W, Winkleby MA, Sundquist K. Fetal growth and subsequent maternal risk of thyroid

cancer. Int J Cancer. 2015 Sep 17.

Crump C, Sundquist J, Sieh W, Winkleby MA, Sundquist K. Perinatal risk factors for acute myeloid leukemia. Eur J

Epidemiol. 2015 Jun 26.

Crump C, Sundquist K, Winkleby MA. Transnational research partnerships: leveraging big data to enhance US

health. J Epidemiol Community Health. 2015 Mar 12.

Fallah M, Kharazmi E, Pukkala E, Tretli S, Olsen JH, Tryggvadottir L, Sundquist K, Hemminki K. Familial risk of non-

Hodgkin lymphoma by sex, relationship, age at diagnosis and histology: a joint study from five Nordic countries.

Leukemia. 2015 Oct 6. doi: 10.1038/leu.2015.272.

10.

Foltyn Zadura A, Memon AA, Stojanovich L, Perricone C, Conti F, Valesini G, Bogdanovic G, Hillarp A, Shoenfeld

Y, Sundquist J, Leffler J, Svensson PJ, Trouw LA, Blom AM. Factor H Autoantibodies in Patients with

Antiphospholipid Syndrome and Thrombosis. J Rheumatol. 2015 Oct;42(10):1786-93.

11.

Frank C, Fallah M, Chen T, Mai EK, Sundquist J, Försti A, Hemminki K. Search for familial clustering of multiple

myeloma with any cancer. Leukemia. 2015 Oct 9.

12.

Frank C, Fallah M, Sundquist J, Hemminki A, Hemminki K. Population Landscape of Familial Cancer. Sci Rep. 2015

Aug 10;5:12891

13.

Friberg D, Lundkvist K, Li X, Sundquist K. Parental poverty and occupation as risk factors for pediatric

sleep-disordered breathing. Sleep Med. 2015 Sep;16(9):1169-75.

14.

Hamano T, Li X, Tanito M, Nabika T, Shiwaku K, Sundquist J, Sundquist K. Neighborhood Deprivation and Risk of

Age-Related Eye Diseases: A Follow-up Study in Sweden. Ophthalmic Epidemiol. 2015 Oct;22(5):308-20.

15.

Hamano T, Onoda K, Takeda M, Sundquist K, Yamaguchi S, Nabika T. Geographic Elevation and Cognitive Function

among Elderly Residents in Rural Mountainous Areas: Shimane CoHRE Study. Int J Environ Res Public Health. 2015

Oct 23;12(10):13365-71.

16.

Hamano T, Tominaga K, Takeda M, Sundquist K, Nabika T. Accessible Transportation, Geographic

Elevation, and Masticatory Ability Among Elderly Residents of a Rural Area. Int J Environ Res Public Health. 2015

Jun 26;12(7):7199-207.

17.

Hemminki K, Försti A, Sundquist K, Li X. Cancer of unknown primary is associated with diabetes. Eur J Cancer

Prev. 2015 May 18.

18.

Hemminki K, Liu X, Försti A, Sundquist J, Sundquist K, Ji J. Subsequent Type 2 Diabetes in Patients with

Autoimmune Disease. Sci Rep. 2015 Sep 9;5:13871.

19.

Hemminki K, Sundquist K, Sundquist J, Ji J. Risk of cancer of unknown primary after hospitalization for

autoimmune diseases. Int J Cancer. 2015 Dec 15;137(12):2885-95.

20.

Ji J, Sundquist J, Sundquist K. Association of alcohol use disorders with amyotrophic lateral sclerosis: a Swedish

national cohort study. Eur J Neurol. 2015 Jan 29.

annualreport2015

21.

Ji J, Sundquist J, Sundquist K. Association of tamoxifen with meningioma: a population-based study in Sweden.

Eur J Cancer Prev. 2015 Jan 30.

22.

Ji J, Zöller B, Giaccia A, Haile R, Sundquist J, Sundquist K. Risk of breast cancer among patients with bioprosthetic

or mechanical valve replacement: a population-based study in Sweden. Breast Cancer Res Treat. 2015 Oct 17.

23.

Johansson SE, Midlöv P, Sundquist J, Sundquist K, Calling S. Longitudinal trends in good self-rated health: effects

of age and birth cohort in a 25-year follow-up study in Sweden. Int J Public Health. 2015 Mar;60(3):363-73.

24.

Jönsson T, Memon AA, Sundquist K, Sundquist J, Olsson S, Nalla A, Bauer M, Linse S. Digested wheat gluten

inhibits binding between leptin and its receptor. BMC Biochem. 2015 Jan 20;16(1):3.

25.

Kendler KS, Ji J, Edwards AC, Ohlsson H, Sundquist J, Sundquist K. An extended Swedish national adoption study

of alcohol use disorder. JAMA Psychiatry. 2015 Mar 1;72(3):211-8.

26.

Kendler KS, Lönn SL, Lichtenstein P, Sundquist J, Sundquist K. Psychological strength assessed in late

adolescence and risk for criminal behavior: a Swedish prospective cohort and twin analysis. Psychol Med. 2015

Aug 6:1-10.

27.

Kendler KS, Lönn SL, Maes HH, Lichtenstein P, Sundquist J, Sundquist K. A Swedish Population-Based Multivariate

Twin Study of Externalizing Disorders. Behav Genet. 2015 Oct 22.

28.

Kendler KS, Lönn SL, Maes HH, Morris NA, Lichtenstein P, Sundquist J, Sundquist K. A national Swedish longi

tudinal twin-sibling study of criminal convictions from adolescence through early adulthood. Twin Res Hum Genet.

2015 Jun;18(3):227-33.

29.

Kendler KS, Lönn SL, Sundquist J, Sundquist K. Smoking and Schizophrenia in Population Cohorts of Swedish

Women and Men: A Prospective Co-Relative Control Study. Am J Psychiatry. 2015 Nov 1;172(11):1092-100.

30.

Kendler KS, Maes HH, Lönn SL, Morris NA, Lichtenstein P, Sundquist J, Sundquist K. A Swedish national twin study

of criminal behavior and its violent, white-collar and property subtypes. Psychol Med. 2015 Aug;45(11):2253-62.

31.

Kendler KS, Ohlsson H, Maes HH, Sundquist K, Lichtenstein P, Sundquist J. A population-based Swedish Twin and

Sibling Study of cannabis, stimulant and sedative abuse in men. Drug Alcohol Depend. 2015 Jan 28.

32.

Kendler KS, Ohlsson H, Mezuk B, Sundquist K, Sundquist J. A Swedish National Prospective and Co-relative Study

of School Achievement at Age 16, and Risk for Schizophrenia, Other Nonaffective Psychosis, and Bipolar Illness.

Schizophr Bull. 2015 Jul 31. pii: sbv103.

33.

Kendler KS, Ohlsson H, Sundquist J, Sundquist K. IQ and Schizophrenia in a Swedish National Sample: Their

Causal Relationship and the Interaction of IQ With Genetic Risk. Am J Psychiatry. 2015 Mar 1;172(3):259-65.

34.

Kendler KS, Ohlsson H, Sundquist J, Sundquist K. Triparental Families: A New Genetic-Epidemiological Design

Applied to Drug Abuse, Alcohol Use Disorders, and Criminal Behavior in a Swedish National Sample.

Am J Psychiatry. 2015 Feb 20.

35.

Kendler KS, Ohlsson H, Sundquist K, Sundquist J. Environmental clustering of drug abuse in households and

communities: multi-level modeling of a national Swedish sample. Soc Psychiatry Psychiatr Epidemiol. 2015 Feb 24.

36.

Kendler KS, Turkheimer E, Ohlsson H, Sundquist J, Sundquist K. Family environment and the malleability of

cognitive ability: a Swedish national home-reared and adopted-away cosibling control study. Proc Natl Acad Sci U

S A. 2015 Apr 14;112(15):4612-7.

37.

Kharazmi E, Fallah M, Pukkala E, Olsen JH, Tryggvadottir L, Sundquist K, Tretli S, Hemminki K. Risk of familial

classical Hodgkin lymphoma by relationship, histology, age, and sex: a joint study from five Nordic countries.

Blood. 2015 Oct 22;126(17):1990-5.

38.

Kharazmi E, Hemminki K, Pukkala E, Sundquist K, Tryggvadottir L, Tretli S, Olsen JH, Fallah M. Cancer Risk in

Relatives of Testicular Cancer Patients by Histology Type and Age at Diagnosis: A Joint Study from Five Nordic

Countries. Eur Urol. 2015 Aug;68(2):283-9.

39.

Leijon M, Midlöv P, Sundquist J, Sundquist K, Johansson SE. The longitudinal age and birth cohort trends of

regular exercise among adults aged 16-63 years in Sweden: a 24-year follow-up study.

Popul Health Metr. 2015 Jul 29;13:18.

40.

Li X, Sundquist J, Hamano T, Zöller B, Sundquist K. Neighbourhood Deprivation, Individual-Level and Familial-Level

Socio-demographic Factors and Risk of Congenital Heart Disease: A Nationwide Study from Sweden. Int J Behav

Med. 2015 May 1.

annualreport2015

PUBLISHED SCIENTIFIC ARTICLES 2015

41.

Li X, Sundquist J, Zöller B, Sundquist K. Neighbourhood Deprivation and Risk of Childhood Visual Impairment:

A Nationwide Study from Sweden. J Preg Child Health. 2015.

42.

Litchfield K, Thomsen H, Mitchell JS, Sundquist J, Houlston RS, Hemminki K, Turnbull C. Quantifying the heritability

of testicular germ cell tumour using both population-based and genomic approaches. Sci Rep. 2015 Sep 9;5:13889.

43.

Liu X, Hemminki K, Försti A, Sundquist J, Sundquist K, Ji J. Cancer risk and mortality in asthma patients:

A Swedish national cohort study. Acta Oncol. 2015 Jan 22:1-8.

44.

Liu X, Hemminki K, Försti A, Sundquist K, Sundquist J, Ji J. Cancer risk in patients with type 2 diabetes mellitus

and their relatives. Int J Cancer. 2015 Jan 21.

45.

Martinsson A, Li X, Andersson C, Nilsson J, Smith JG, Sundquist K. Temporal trends in the incidence and prognosis

of aortic stenosis: a nationwide study of the Swedish population. Circulation. 2015 Mar 17;131(11):988-94.

46.

Memarian E, Sundquist K, Calling S, Sundquist J, Li X. Country of origin and bariatric surgery in Sweden during

2001-2010. Surg Obes Relat Dis. 2015 Mar 28. pii: S1550-7289(15)00084-2.

47.

Mezuk B, Li X, Cederin K, Concha J, Kendler KS, Sundquist J, Sundquist K. Ethnic enclaves and risk of

psychiatric disorders among first- and second-generation immigrants in Sweden. Soc Psychiatry Psychiatr

Epidemiol. 2015 Nov;50(11):1713-22.

48. Narod SA, Kharazmi E, Fallah M, Sundquist K, Hemminki K. The risk of contralateral breast cancer in daughters of

women with and without breast cancer. Clin Genet. 2015 Apr 29.

49.

Skoog J, Midlöv P, Beckman A, Sundquist J, Halling A. Indication for pharmacological treatment is often lacking: a

cross-sectional study on the quality of drug therapy among the elderly. BMC Geriatr. 2015 Oct 8;15:117

50.

Sundquist J, Li X, Ohlsson H, Råstam M, Winkleby M, Sundquist K, Kendler KS, Crump C. Familial and neighbor

hood effects on psychiatric disorders in childhood and adolescence. J Psychiatr Res. 2015 Jul-Aug;66-67:7-15.

51.

Sundquist K, Sundquist J, Svensson PJ, Zöller B, Memon AA. Role of family history of venous thromboembolism

and thrombophilia as predictors of recurrence: a prospective follow-up study. J Thromb Haemost. 2015 Sep 26.

52.

Sundquist K, Wang X, Svensson PJ, Sundquist J, Hedelius A, Larsson Lönn S, Zöller B, Memon AA. Plasminogen

activator inhibitor-1 4G/5G polymorphism, factor V Leiden, prothrombin mutations and the risk of VTE recurrence.

Thromb Haemost. 2015 Aug 6;114(6).

53.

Wang X, Sundquist K, Hedelius A, Palmér K, Memon AA, Sundquist J. Circulating microRNA-144-5p is associated

with depressive disorders. Clin Epigenetics. 2015 Jul 22;7(1):69.

54.

Wolff M, Memon AA, Chalmers JP, Sundquist K, Midlöv P. Yoga’s effect on inflammatory biomarkers and metabolic

risk factors in a high risk population - a controlled trial in primary care. BMC Cardiovasc Disord. 2015 Aug 19;15:91.

55.

Zöller B, Ji J, Sundquist J, Sundquist K. Alcohol use disorders are associated with venous thromboembolism. J

Thromb Thrombolysis. 2015 Jan 21.

56.

Zöller B, Li X, Ohlsson H, Ji J, Sundquist J, Sundquist K. Family history of venous thromboembolism as a risk factor

and genetic research tool. Thromb Haemost. 2015 Nov 2;114(5):890-900.

57.

Zöller B, Li X, Sundquist J, Sundquist K. Familial transmission of chronic obstructive pulmonary disease in

adoptees: a Swedish nationwide family study. BMJ Open. 2015 Apr 13;5(4):e007310.

58.

Zöller B, Ohlsson H, Sundquist J, Sundquist K. Family history of venous thromboembolism is a risk factor for

venous thromboembolism in combined oral contraceptive users: a nationwide case-control study. Thromb J. 2015

Oct 21;13:34.

59.

Zöller B, Palmer K, Li X, Sundquist J, Sundquist K. Family history of venous thromboembolism and risk of

hospitalized thromboembolism in cancer patients: A nationwide family study. Thromb Res. 2015 Sep;136(3):573-81.

60.

Zöller B, Sundquist J, Sundquist K, Crump C. Perinatal risk factors for premature ischaemic heart disease in a

Swedish national cohort. BMJ Open. 2015 Jun 2;5(6):e007308.

annualreport2015

61.

Borgström Bolmsjö B, Jakobsson U, Mölstad S, Ostgren CJ, Midlöv P. The nutritional situation in Swedish nursing

homes - a longitudinal study. Arch Gerontol Geriatr. 2015 Jan-Feb;60(1):128-33.

62.

Bolmsjö BB, Strandberg EL, Midlöv P, Brorsson A. ”It is meaningful; I feel that I can make a difference” -

A qualitative study about GPs’ experiences of work at nursing homes in Sweden. BMC Fam Pract. 2015 Aug

28;16:111.

63.

Gröndal H, Hedin K, Strandberg EL, André M, Brorsson A. Near-patient tests and the clinical gaze in decision-

making of Swedish GPs not following current guidelines for sore throat - a qualitative interview study. BMC Fam

Pract. 2015 Jul 4;16:81.

64.

Hallgren J, Ernsth Bravell M, Mölstad S, Östgren CJ, Midlöv P, Dahl Aslan AK. Factors associated with increased

hospitalisation risk among nursing home residents in Sweden: a prospective study with a three-year follow-up. Int J

Older People Nurs. 2015 Dec 10.

65.

Lenander C, Bondesson Å, Midlöv P, Viberg N. Healthcare system intervention for safer use of medicines in elderly

patients in primary care-a qualitative study of the participants’ perceptions of self-assessment, peer review, feed

back and agreement for change. BMC Fam Pract. 2015 Sep 4;16:117.

66.

Midlöv P, Höglund P, Eriksson T, Diehl A, Edgren G. Developing a Competency-based Curriculum in Basic and

Clinical Pharmacology - A Delphi Study among Physicians. Basic Clin Pharmacol Toxicol. 2015 Jun 29.

67.

Modig S, Holmdahl L, Bondesson Å. Medication reviews in primary care in Sweden: importance of clinical

pharmacists’ recommendations on drug-related problems. Int J Clin Pharm. 2015 Nov 18. [Epub ahead of print]

68. Neumark T, Brudin L, Mölstad S. Antibiotic prescribing in primary care by international medical graduates and

graduates from Swedish medical schools. Fam Pract. 2015 Jun;32(3):343-7.

69.

Pikkemaat M, Melander O, Mölstad S, Garberg G, Boström KB. C-peptide concentration, mortality and vascular

complications in people with Type 2 diabetes. The Skaraborg Diabetes Register. Diabet Med. 2015 Jan;32(1):85-9.

70.

Persson LG, Lingfors H, Nilsson M, Mölstad S. The possibility of lifestyle and biological risk markers to predict

morbidity and mortality in a cohort of young men after 26 years follow-up. BMJ Open. 2015 May 6;5(5):e006798.

71.

Samuelsson E, Odeberg J, Stenzelius K, Molander U, Hammarström M, Franzen K, Andersson G, and Midlöv P. The

effect of pharmacological treatment for urinary incontinence in the elderly and frail elderly: A systematic review.

Geriatr Gerontol Int. 2015; 15: 521–534.

72.

Tell D, Engström S, Mölstad S. Adherence to guidelines on antibiotic treatment for respiratory tract infections in

various categories of physicians: a retrospective cross-sectional study of data from electronic patient records. BMJ

Open. 2015 Jul 15;5(7):e008096.

73.

Bennet L, Groop L, Franks PW. Country of birth modifies the association of fatty liver index with insulin action in

Middle Eastern immigrants to Sweden. Diabetes Res Clin Pract. 2015 Oct;110(1):66-74.

74.

Beck, I. Jakobsson, U. Edberg, A-K. Applying a palliative approach in residential care: effects on nurse assistants’

work situation. Palliative & Supportive Care 2015; 13 (3): 543-553.

75.

Garmy P, Jakobsson U, Carlsson KS, Berg A, Clausson EK. Evaluation of a school-based program aimed at

preventing depressive symptoms in adolescents. J Sch Nurs. 2015 Apr;31(2):117-25.

76.

Månsson C, Jakobsson U, Lundqvist P. Translation and psychometric evaluation of a Swedish version of the

parental stressor scale PSS: NICU. Scand J Caring Sci. 2015 Apr 28.

77.

Orrung Wallin, A. Jakobsson, U. Edberg, A-K. Job strain and stress of conscience among nurse assistants working

in residential care. Journal of Nursing Management. 2015; 23 (3): 368-379.

78.

Rudnicki M, Laurikainen E, Pogosean R, Kinne I, Jakobsson U, Teleman P. A 3-year follow-up after anterior colporr

haphy compared with collagen-coated transvaginal mesh for anterior vaginal wall prolapse: a randomised

controlled trial. BJOG. 2015 Sep 30.

79.

Sandberg M, Jakobsson U, Midlöv P, Kristensson J. Cost-utility analysis of case management for frail older people:

effects of a randomised controlled trial. Health Econ Rev. 2015 Dec;5(1):51.

80.

Sandberg M, Kristensson J, Midlöv P, Jakobsson U. Effects on healthcare utilization of case management for frail

older people: a randomized controlled trial (RCT). Arch Gerontol Geriatr. 2015 Jan-Feb;60(1):71-81.

annualreport2015

PUBLISHED SCIENTIFIC ARTICLES 2015

81.

Stenzelius K, Molander U, Odeberg J, Hammarström M, Franzén K, Midlöv P, Samuelsson E, Andersson G.

The Effect of conservative treatment of urinary incontinence among older and frail older people-A systematic

review. Age Ageing 2015; 44 (5): 736-744.

82.

Taube E, Jakobsson U, Midlöv P, Kristensson J. Being in a Bubble: the experience of loneliness among frail older

people. J Adv Nurs. 2015 Nov 16.

83.

Teleman P, Laurikainen E, Kinne I, Pogosean R, Jakobsson U, Rudnicki M. Relationship between the Pelvic Organ

Prolapse Quantification system (POP-Q), the Pelvic Floor Impact Questionnaire (PFIQ-7), and the Pelvic Floor

Distress Inventory (PFDI-20) before and after anterior vaginal wall prolapse surgery. Int Urogynecol J. 2015

Feb;26(2):195-200.

84.

Hansson EE, Beckman A, Persson L. Does a mineral wristband affect balance? A randomized, controlled,

ouble-blind study. J Otolaryngol Head Neck Surg. 2015 Jun 26;44:26.

85.

Rocca P, Beckman A, Ekvall Hansson E, Ohlsson H. Is the association between physical activity and healthcare

utilization affected by self-rated health and socio-economic factors? BMC Public Health. 2015 Aug 1;15:737.

Public Health and Health Economics 86.

Adlercreutz EH, Wingren CJ, Vincente RP, Merlo J, Agardh D. Perinatal risk factors increase the risk of being

affected by both type 1 diabetes and coeliac disease. Acta Paediatr. 2015 Feb;104(2):178-84.

87.

Bjerkeli PJ, Mulinari S, Merlo J. Testosterone prescribing in the population-a short social epidemiological analysis

in Sweden. Pharmacoepidemiol Drug Saf. 2015 Jul 28.

88.

Cantarero-Arévalo L, Perez Vicente R, Juarez SP, Merlo J. Ethnic differences in asthma treatment among

Swedish adolescents: A multilevel analysis of individual heterogeneity. Scand J Public Health. 2015 Nov 9. pii:

1403494815614749.

89.

Lagerlund M, Merlo J, Vicente RP, Zackrisson S. Does the Neighborhood Area of Residence Influence Non-

Attendance in an Urban Mammography Screening Program? A Multilevel Study in a Swedish City. PLoS One. 2015

Oct 13;10(10):e0140244.

90.

Mulinari S, Bredström A, Merlo J. Questioning the discriminatory accuracy of broad migrant categories in public

health: self-rated health in Sweden. Eur J Public Health. 2015 Jun 13.

91.

Merlo J, Mulinari S. Measures of discriminatory accuracy and categorizations in public health: a response to Allan

Krasnik’s editorial. Eur J Public Health. 2015 Dec;25(6):910.

92.

Mulinari S, Juárez SP, Wagner P, Merlo J. Does Maternal Country of Birth Matter for Understanding Offspring’s

Birthweight? A Multilevel Analysis of Individual Heterogeneity in Sweden. PLoS One. 2015 May 28;10(5):e0129362.

93. Nilsson S, Merlo J, Lyberg-Åhlander V, Psouni E. Psychotropic drug use in adolescents born with an orofacial cleft:

a population-based study. BMJ Open. 2015 Apr 2;5(4):e005306.

94.

Turkiewicz A, Vicente RP, Ohlsson H, Tyden P, Merlo J. Revising the link between proton-pump inhibitors and risk of

acute myocardial infarction-a case-crossover analysis. Eur J Clin Pharmacol. 2015 Jan;71(1):125-9.

95.

Wingren CJ, Merlo J. Improving our knowledge on the risk of congenital malformations in families with celiac di

sease. Clin Gastroenterol Hepatol. 2015 Mar;13(3):615-6.

96.

Zetterqvist AV, Merlo J, Mulinari S. Complaints, complainants, and rulings regarding drug promotion in the United

Kingdom and Sweden 2004-2012: a quantitative and qualitative study of pharmaceutical industry self-regulation.

PLoS Med. 2015 Feb 17;12(2):e1001785.

97.

Eikendal AL, Groenewegen KA, Anderson TJ, Rosvall M, den Ruijter HM, USE-IMT Project group. Hypertension

2015 Apr; 65(4): 707-713.

98.

Fridh M, Lindström M, Rosvall M. Subjective health complaints in adolescent victims of cyber harassment:

moderation through support from parents/friends - a Swedish population-based study. BMC Public Health. 2015

Sep 23;15(1):949.

annualreport2015

99.

Giordano GN, Lindström M. Trust and health: testing the reverse causality hypothesis. J Epidemiol Community

Health. 2015 Nov 6. pii: jech-2015-205822.

100.

Gijsberts CM, Groenewegen KA, Hoefer IE, Rosvall M, den Ruijter HM. Race/ethnic differences in the asociations of

the Framingham risk factors with carotid IMT and cardiovascular events. PLOS One 2015 July 2; 10(7): e0132321.

101.

Hansen K, Lindström M, Rosvall M. Age at smoking initiation and self-rated health among second grade high

school boys and girls in Scania, Sweden, a cross-sectional study. BMC Public Health. 2015 Nov 18;15(1):1143.

102.

Hansen K, Östling G, Persson M, Nilsson PM, Melander O, Engström G, Hedblad B, Rosvall M. The effect of

smoking on carotid intima-media thickness progression rate and rate of lumen diameter reduction. Eur J Intern Med

2015; Nov 5 (Epub ahead of print).

103.

Lindström M, Rosvall M. Parental separation in childhood, social capital, and suicide thoughts and suicide

attempts: A population-based study. Psychiatry Res. 2015 Sep 30;229(1-2):206-13.

104.

Lindström M, Rosvall M. Daily tobacco smoking, alcohol use, and hashish use among adolescents in southern

Sweden: A population-based multilevel study. Addictive Behaviors Reports 2015; 2: 6-12.

Ulf Gerdtham

105.

Dackehag M, Gerdtham UG, Nordin M. Productivity or discrimination? An economic analysis of excess-weight

penalty in the Swedish labor market. Eur J Health Econ. 2015 Jul;16(6):589-601.

106.

Gerdtham, U-G. Lundborg, P. Lyttkens, C. H., Nystedt, P. Do Education and Income Really Explain Inequalities in

Health? Applying a Twin Design. Scand. J. of Economics 00(0), 1–24, 2015.

107.

Hansen, F., Anell, A., Gerdtham, U. G. & Lyttkens, C. H. (2015) The Future of Health Economics: The Potential of

Behavioral and Experimental Economics. Nordic Journal of Health Economics.

108.

Kiadaliri AA, Eliasson B, Gerdtham UG. Does the choice of EQ-5D tariff matter? A comparison of the Swedish EQ-

5D-3L index score with UK, US, Germany and Denmark among type 2 diabetes patients. Health Qual Life

Outcomes. 2015 Sep 15;13:145.

109.

Kjellsson G, Gerdtham UG, Petrie D. Lies, Damned Lies, and Health Inequality Measurements: Understanding the

Value Judgments. Epidemiology. 2015 Sep;26(5):673-80.

110.

Ljungvall Å, Gerdtham UG, Lindblad U. Misreporting and misclassification: implications for socioeconomic

disparities in body-mass index and obesity. Eur J Health Econ. 2015 Jan;16(1):5-20.

annualreport2015

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