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2018

ANNUAL REPORT CENTER FOR PRIMARY HEALTHCARE RESEARCH COMPETENCE CENTER FOR PRIMARY HEALTHCARE IN SKÃ…NE


Overview

A record year! Organisation Vision Management & mission Passion instead for retirement Top professor takes over the helm

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Competence Center for Primary Healthcare in Skåne

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In numbers PRIMARY CARE IN-SERVICE TRAINING UNIT Resident physicians (ST) Trainee physicians (AT) Workplace training, VFU In-service training Diabetes coordinators SKÅNE FAMILY MEDICINE CONSULTANCY (AKO) KNOWLEDGE CENTER FOR MIGRATION AND HEALTH KNOWLEDGE CENTER FOR CHILD HEALTHCARE KNOWLEDGE CENTER FOR WOMEN’S HEALTH

19 20 21 24 25 26 28 30 36 46 52

04 06 07 08 10 14


CONTENTS

Center for Primary Healthcare Research

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In numbers Academic Knowledge Center, AKC News in brief Research (research leaders & research projects) Doctoral students PhD Thesis Defences Database group Analysis group Molecular biology laboratory The financial perspective Published scientific articles

59 60 66 72 78 81 92 94 98 100 102


Record year! T

he year 2018 was fantastically exciting for the Center for Primary Healthcare Research and the Competence Center for Primary Healthcare, which together with the ten AKC care centers comprises the University ”University clinic primary Clinic Primary Care Skåne. Everyone care Skåne is an especially surely remembers the extraordinarily comprehensive research and positive evaluation educational resource that is of Sweden’s National Board of Health without equal in Sweden and and Welfare as can be an example for unireferred to in last versity units within general year’s annual report (see quote opposite). After the nomedicine/primary care. It has mination to the advantages in that it is a University Hospital platform for research within Unit, we have had several visits from primary care as well as edudifferent regions in Sweden, which cation (undergraduate, AT, ST wanted to become familiar with and in-service training) and our mo-

skills development in a broad sense.” ANNUALREPORT2018

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del. A delegation from Western Götaland visited CPF for a full day to understand how we worked. I also visited Region Uppsala and Uppsala University to discuss our model for research and development. We have a platform for ongoing training of 408 ST doctors in family medicine ably supported by 12 study directors. We also work with undergraduate studies, inservice training, lectures, seminars, webinars, general medical consultants (AKO) and the video library. The Knowledge Center (KC) for Migration and Health, KC for Child Health Care and KC for Women's Health, which are all part of the Competence Center for primary care, conduct very important work. You can read all about their activities in the yearbook you are holding. We work closely together within the platform, not just in the com-


nomics, gastroenterology, heart disease, thrombosis diseases, diabetes and other common diseases in primary care. Among the journals our research was published in were the likes of JAMA Psychiatry, American Journal of Psychiatry, Nature Communications, Lancet Haematology, JAMA Cardiology, International Journal of Cardiology and other highly ranked journals. Since CPF began in October 2008, we have published a total of approximately 1300 scientific articles. The collaboration with the national research school in family medicine continued during the year with several of our colleagues at CPF involved in the network of universities that actively support our administration. The research school increases the quality of our research at CPF and develops the doctoral students' scientific thinking. In total, 12 PhD students held their defense in 2018! This was very satisfying. Let us all congratulate Faiza Siddiqui, Delshad Akrawi, Elżbieta Kaszuba, Rasmus Wæhrens, Maria Fridh, Christine Lindström, Ensieh Memariam, Abrar Ahmad, Miriam Pikkemaat, Madelaine Törnquist Agosti, Gawain Heckley and Ye Zhang.

Happy reading! Jan Sundquist, Director, Professor and Family Physician

This will be my last foreword for our yearbook because I will step down as director on April 30th 2019. My successor, who takes over the baton, will be Professor Kristina Sundquist. She has unanimous support and been appointed by the board representatives from Region Skåne and Lund University to be my successor (read more on page 14). I shall continue to work for CPF as a senior professor and full-time expert to continue driving my externally financed project, which you can read more about on page 10. There are plenty more things of interest from 2018 to read about in this yearbook, which is bulkier than ever before, to reflect the many activities that occur at the Competence Center for Primary Care in Skåne and the Center for Primary Health Care Research.

ANNUALREPORT2018

mon management team but also in joint projects. I wish to state that these collaborations are necessary to implement evidencebased methods within care. I’m always keen to emphasize that most of our employees are clinically active and thus their competence benefits primary care while researchers can seek stimulation from the clinical soil where the best research ideas are born. The researchers at CPF have many important collaborations both nationally and internationally, which have been created or deepened throughout the year. During 2018 we continued with exchanges of students, researchers and academic teachers, especially in the collaborations we have with Shimane University and Kyoto Sangyo University in Japan and at Virginia Commonwealth University, Stanford University and the German Cancer Research Center. In 2018 we received large external grants (VR, NIH, ERC, HLF, Kamprad foundation) as well as ALF grants, which made it possible for a very high scientific production. This made 2018 a successful year that yielded new recruits and further development of our research unit. Last year we published 134 scientific articles in international journals of high renown. The year's research resulted in several important publications with focus on primary care psychiatry and addiction, health eco-

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ORGANISATION

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

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VISION

CENTER FOR PRIMARY HEALTHCARE RESEARCH (CPF) To counduct groundbreaking clinical research for primary care of highest quality and help benefit a healthier population as a result.

COMPETENCE CENTER FOR PRIMARY CARE IN SKÃ…NE (KCP) Equal health, equal treatment and highly competent staff.

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VISION

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Management and Mission The Center for Primary Healthcare Research (CPF) and the Competence Center for Primary Healthcare in Skåne are important resources for knowledge development and clinical processes in both public and private primary healthcare. Therefore, competition neutrality is of the highest importance.

T

he 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 management division Primary Healthcare Sund within Region Skåne. CPF and KCP have a joint management

team to create an environment with an emphasis on collaboration and synergies that make for an optimal use of resources.

CPF’S AND KCP’S MANAGEMENT TEAM w Jan Sundquist, professor & director w Kristina Sundquist, professor & research leader w Patrik Midlöv, professor & research leader w Eva Pulverer Marat, unit head (PUE) w Marie Köhler, unit head (KC child healthcare &

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KC women’s health)

w w w w w

Jenny Malmsten, unit head (KC Migration & health)

healthcare)

Sten Tyrberg, team leader (AKO) Emelie Stenman, team leader (AKC) Anna Kjellbom, team leader (KC women’s health) Kathy Falkenstein-Hagander, team leader (KC child


The role of the board CPF is based on a collaboration between Region Skåne and Lund University. The board members lead the work regarding strategic and comprehensive planning. This means that it makes decisions about the direction of the research that CPF intends to conduct and the board also draws up an operational plan and is responsible for the required follow-up of CPF’s operations and management of financial resources.

CPF’S BOARD From left in the picture: REPRESENTATIVES OF LUND UNIVERSITY:

w w w

Dean and professor Kristina Åkesson, Lund University Senior Professor Lars H Lindholm, Umeå University (Chairman) Professor Bodil Ohlsson, Lund University

REPRESENTATIVES OF REGION SKÅNE:

w Professor Jerzy Leppert, Uppsala University w Professor Birgit Rasmussen, Lund University w Head of Research & Education & Associate Professor,

Richard Frobell, Region Skåne (missing in picture)

w

Professor Jan Sundquist, Director (Rapporteur)

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Photo: Johan Bävman

Passion instead for retirement 10


He is a fearless, determined and energetic pioneer in primary care research with enthusiasm that is inspirational. Professor Jan Sundquist will soon retire but has no plans to stop working. “My prospects have never been better and I look forward to continuing my research for many more years,” he says.

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is post as director for CPF and KCP will draw to a close in April 2019. But that doesn’t mean that Professor Sundquist will enjoy a quiet retirement. The change, as Sundquist says, means a switch from double full-time to perhaps 60 hours a week. "I think it's dangerous to go from one extreme to another. There is so much that must be done and explored," he laughs.

Seeing the bigger picture

Launched academic network nodes He was long tempted by the idea to create meeting places in the form of academic network nodes for connecting staff and students in primary care to preclinical and clinical researchers at universities and colleges. It’s a concept that he first launched in Stockholm and then in Skåne with AKC. The concept is now on export around the country and also to China and Japan. "More and more people realise that we have to find methods that bring academia, education and research results in place in primary care and also become better to pick up on suggestions from the staff that can be brought back to academia," says Jan.

Interest in migration began early Jan and his research group have for many years had a reputation for migration research. It was at the Norra Fäladen healthcare center in Lund where the interest was aroused. Many Latin Americans

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Driven and always trying to see the bigger picture are some of Jan Sundquist's trademarks; the whole time with primary care as a base. Twice he has accepted the challenge to build and develop outstanding research units for primary care - first in Stockholm and subsequently in Skåne. Both times with a handful of eager enthusiasts that have grown to hundreds with new missions and administrations constantly added. "It has been incredibly enjoyable and stimulating. In Skåne, in particular, I think we have succeeded in achieving a mix of clinical patient centric development work, research and education with epi-

demiological and research excellence," he says. According to Sundquist, the success is due to having committed, competent staff and strong backing from the board, Region Skåne and Lund University. If he’s got a hint of a good idea, then he is a man of action that does not always follow expected norms. Starting the country's only experimental laboratory in general medicine and primary care is an example. At first the reception was lukewarm and the initial lab was built on a limited budget minded scale. "Today the lab is equipped with the latest technology so that we can identify genetic variants, epigenetic factors and inflammatory biomarkers associated with diseases such as cancer, chronic mental illness, type 2 diabetes, obesity and cardiovascular diseases," says Jan. By then connecting this data to demographic and medical data, researchers can get an idea of how gen- and environmental interactions govern the course of the disease. "It is absolutely superb," says Sundquist.

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already with the first contact and I continue to work with it," says Jan.

Long-term, creative relationship

lived in the area and Jan noticed that they had a different need for care than other patient groups; he began to investigate why. As Jan wanted to work with the best in the field, he wrote to Brian Jarman at Imperial College in London. Once invited, he went to the UK and set up a research plan that in 1994 resulted in a thesis at Lund University. The research career continued two years later at Stanford University, USA where he would also later become a guest professor "It was perhaps a bit cocky, but I wrote and asked if I could get my post-doc there, and everyone at home told me I would never have a chance. But it went my way. The experience from there was invaluable and shaped me as a researcher. I got a good feeling

Early on, Jan Sundquist understood that he couldn't just rely on data from a few health centers and the surrounding area. He established contact with Sven-Erik Johansson at Statistics Sweden in Stockholm, whom he knew excelled at statistics and epidemiology. Thoughts arose and have been followed-up over the years. In Stockholm he learnt further about research in tandem with his future wife, Professor Kristina Sundquist. The two have worked side side-by-side for almost 20 years now. "It's a great benefit to me personally and for Swedish research in family medicine that we met. Perfect match," says Jan. Together they have hatched and formatted ideas and written many research applications throughout the years. "Without Kristina's hard work and scientific clarity, CPF would

not be what it is today. I am very happy that she has been appointed as my successor, he says. Time and again, Jan emphasizes the benefit that over the years he has been given the opportunity to hire and meet so many different brilliant brains, both at KCP and CPF. According to Jan, the whole point of having a collective organisation is that you think together and approach problems from different angles. "The right person with the right attitude and competence can be an injection for the whole group," he says. Today, CPF has a strong reputation and attracts people from all over the world looking for collaborations. "It is often about development and combining research fields. We are strong in certain areas and there is no need to be experts on everything. We instead get connected to talented people in other fields. That approach can also spill over into other things. For example, it raises the level of scientific discourse and the research as

The school study will last for 20 years so I intend to carry on for a while yet! ANNUALREPORT2018

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JAN SUNDQUIST AFTER RETIREMENT: Senior professor well as the quality of seminars," says Jan Sundquist.

DOES TO UNWIND: Mindfulness every day and taking an education in mindfulness CBT at Oxford University

Age only a number

LEISURE INTERESTS: Family, cooking, good wines, gardening, and exercise LIKES: Films, literature and art DETESTS: Bureaucracy SECRET TALENT: Speaks Spanish fluently

Photo: Johan Bävman

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Curiosity rarely comes with an age limit especially after 700 published articles and many millions in external grants that will continue after Jan steps down. After the summer, he was informed that he was assigned the ERC Advanced Grant the European Research Council to the tune of €2.5 million (see page 71). The ERC Advanced Grant aims to support well-established research leaders to do world-class innovative research projects. He got the grant to identify factors at multiple levels that can protect from mental ill health and abuse in first and second generation immigrants. "Kristina and I were buying groceries when we received the message. At first we were shocked and then became very happy. It is a recognition for the entire CPF. Personally, it feels a bit like the circle has been closed. It was here in Skåne that everything started and within this particular area that I started my research path," he says. Parallel to the ERC project, Jan will also work with a large clinical project where researchers are studying the mental health and long-term effects of mindfulness among school children in Skåne. "I want to carry out the school study. It will last for 20 years so I intend to carry on for a while yet," concludes Jan Sundquist.

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Photo: Johan Bävman

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Kristina Sundquist becomes the new director for KCP and CPF.


Top professor takes over the helm She works as a general practitioner and is one of the country's most active researchers in family medicine with over 600 published articles, large external grants and several international awards. Now Kristina Sundquist will become the director for CPF and KCP. On May 1, 2019, she takes up her new post in MalmĂś.

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"We have a very good cooperation in the region - at all levels. The success we have achieved over the years is a mix of regional teamwork and an external global outlook with prominent research groups and universities," says Kristina Sundquist.

Qualified The incoming director was born in the Bulgarian capital of Sofia, and moved to Sweden as a child where she grew up in Vasteras. After her medical education, she got a job at Karolinska University Hospital in Stockholm. After getting her PhD in 2003, things moved fast. Kristina became an associate professor

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aving been involved and built up CPF from the outset, it is the most enjoyable and most important job that I have had. Now in my new role I will continue working in developing research work within the region of primary care at its base, which feels like an honour and is exciting, says Kristina Sundquist. According to her, there are many talented and dedicated employees at CPF, AKC and KCP that all contribute enormously. It gives her confidence that the close cooperation with staff in primary care, patients, Region SkĂĽne and Lund University and many others will continue to develop further.

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There are opportunities everywhere, all the time. Make sure to sniff them out and dare to go outside your comfort zone.

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in 2005, and in 2007 she became the country's youngest professor in family medicine. In 2010 she came to Malmรถ to take up her professorship in family medicine. She has been a guest professor at Stanford University for three years. Today she holds the title of guest professor at the School of Medicine at Mount Sinai in New York and at Shimane University in Izumo, Japan. Kristina is an in-demand lecturer and has been the supervisor for ten doctoral students. An important measure of her success is that she has been granted large external funds for her ideas, including on three occasions from the American National Institutes of Health,

which is unique for a Swedish researcher.

Operating on several levels Having an open mind, establishing contacts and taking chances when they arise are some factors that have led her to where she is today; it is strategy she also advises others to follow. "There are opportunities everywhere, all the time. Make sure to sniff them out and dare to go outside your comfort zone," says Kristina. She also emphasizes the importance of operating at many levels simultaneously. Local, regional, national and out in the world addressing issues that are relevant for primary care that can be answered in many different ways. At the lab, in major registry studies, clinical studies in primary care and advanced geographical analyses of individual neighbourhood areas are linked to individual disease diagnoses.


"Our research team would never have been so successful if we didn't work hard and purposefully on many levels and with many people and administrations in Sweden, but also internationally. It gives a synergy effect," she says.

Strengthening ties further Nothing is so good that it can't become better. In the future she aims for CPF and KCP to strengthen their international relations and local networks further. Increased investment in common scientific seminars and editorial conferences are paramount. "It is necessary to have an effect on applications. Some believe that the science speaks for itself and that it is enough to just have a good idea to get funding; it is almost never enough. You have to sharpen the idea, describe it comprehensively, build the narrative and explain the benefits. This I learnt from my

mentor, Marilyn Winkleby at Stanford University, and is something I continue with," says Kristina She believes in open communication and freedom with responsibility, which she says can drive forward results and get people to perform. "The power of a decision comes when everyone understands the idea and delivers together," says Kristina Sundquist. Despite the tough schedule she does not want to ease off on her own research. For example, a large clinical study on heart failure study in some 20 health centers is currently in progress. One day a week she works as a

general practitioner at Granens health center in Malmö. “Continuing with clinical work is important for me because it is in the meetings with the patients that many of my scientific ideas are born, and where I can bring back knowledge from studies and development work,” she concludes. "My wonderful healthcare center manager, Ingrid Svenning, must probably bear with me even in the future," laughs Kristina.

KRISTINA SUNDQUIST

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TITLE: Professor of family medicine and incoming administration director of CPF and KCP LEISURE: The family as well as field target shooting ROLE-MODEL: Varies, but right now Inga-Britt Ahlenius STRENGTH: Spurred on by setbacks DETESTS: Snobbery ON THE NIGHTSTAND RIGHT NOW: The American Wing

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COMPETENCE CENTER FOR PRIMARY HEALTH CARE IN SKÅNE The Competence Center for Primary Healthcare in Skåne (KCP) provides inservice training, AT (trainee physician) and ST (resident physician) training, family medicine consultancy activities, further 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: ANNUALREPORT2018

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PRIMARY HEALTHCARE TRAINING UNIT SKÅNE FAMILY MEDICINE

CONSULTANCY, REGION SKÅNE (AKO)

KNOWLEDGE CENTER, MIGRATION AND HEALTH SERVICES

KNOWLEDGE CENTER FOR CHILD HEALTHCARE SERVICES

KNOWLEDGE CENTER FOR WOMEN’S HEALTHCARE SERVICES


THE FINANCIAL PERSPECTIVE OPERATIONS

REVENUE COSTS

w Primary Care Training Unit

20 906 464

17 971 432

2 935 032

6 736 803

6 665 310

71 493

12 312 507

11 813 448

499 059

w Knowledge Center for Child Healthcare Services

5 381 612

4 987 985

393 627

w Knowledge Center for Women’s Healthcare Services

7 468 422

5 632 545

1 835 877

w AKO – Skåne Family Medicine Consultancy, Region Skåne w Knowledge Center, Migration and Health Service

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Newsletters about children in vulnerable conditions published by the Knowledge Center of Child Healthcare

visits to AKO guidelines on Skåne Care’s website

50 activities for

resident physicians arranged by the primary care in-service training unit

education activities and lectures at the learning center migration and health

1 700

internships within adminstrative centered education

1 470

visits to AKO’s webinars

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staff from different administrations participated in the knowledge center for women’s health education

PROFIT/DEFICIT

253 337

70

555

KCP

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PRIMARY HEALTHCARE

TRAINING UNIT The primary care unit is co-located within CPF. The unit is responsible for AT/ST training, coordination in diabetes care, in-service training questions and administrative training. VISION "We want to create an environment of equal health, equal treatment and a highly competent staff.” PRIMARY CARE IN-SERVICE TRAINING UNIT: Number of employees: 9 individuals (6 full-time positions) 12 ST study directors (4 full-time positions) 5 AT study directors (1,15 full-time positions)

2018

RESIDENT PHYSICIAN ACTIVITIES (ST) 23 in-service training days with 981 participants 5 ST one-day meetings with 1 803 participants TRAINEE PHYSICIAN ACTIVITIES (AT) 94 seminars AT-brunch with 113 participants 11 full-day practical skills sessions (Practicum) FURTHER EDUCATION FOR OTHER EMPLOYEES 49 courses with 2017 participants Average grade for the courses – VT 2017 4.4 and HT 4.6; scale 1-5 VFU, WORKPLACE TRAINING 1700 student placements 2 courses in pedagogical supervisor model Peer Learning DIABETES COORDINATORS 4 in-service training days with 277 participants 64 diabetes certified units

GOAL 2018 ANNUALREPORT2018

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w Increase the quality of the supervisory and the knowledge of skills evaluation methods in the ST program w Work for a more optimal additional training allocation for the ST doctor and increase the number of additional training allocations w For AT doctors to be better prepared through ‘Practical’ days and get optimal learning w Be well versed in good diabetes care through improvement projects, networking meetings and in-service training w Good student satisfaction and well-educated future employees w Support the development of methods that improve the pedagogical meeting - Peer Learning w Production of three video films and eight webinars


PRIMARY HEALTHCARE TRAINING UNIT

In a short time, the number of resident physicians has more than doubled. Today there are more than 408 doctors in Skåne training to become specialists in family medicine. For everything to run smoothly requires a well-oiled administration. This is where ST coordinator, Helle Fredlund, plays an important role.

ST-ACTIVITIES

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She’s there all the way

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PRIMARY HEALTHCARE TRAINING UNIT

W

hen Helle started the number of resident physicians in Skåne was 120 and a great deal was required to build a functioning administration for the 400+ ST doctors who are currently in training. During the course of five years they will become specialists in family medicine, but because they must do the specialist service part-time it can take, on average, six years. “There are many steps to take before the ST-training is finished. The unit hires after a Pre-ST has been approved by the ST study directors regarding education grants from the central office. When that is done the educational responsibility is with us and the ST study directors. We also make sure that the ST agreement signed by all parties,” says Helle Fredlund.

Strong digital portfolio

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The prospective specialist is usually supervised by the same director of studies throughout the years. The director of studies is responsible for the education plan that is drawn up and holds an annual

interview with the ST physician. Documents and communication are collected in the ST forum: “It is an obligatory digital portfolio which we have been using since 2012, it was done by a GP as an ST project,” Helle Fredlund (left) explains Helle, who and Eva Pulverer-Marat. is responsible for the ST forum for family medicine in Skåne. It is a fantastic tool. All documents Skåne’s 12 ST study directors. are collected there, all courses, On the agenda stands devetraining plan, the annual report; lopment, documentation and everything is there. routine preparation. Both the doctors and the study directors highly appreClear organization ciate the ST forum. The benefits Helle and Eva Pulverer-Marat, of the digital portfolio were also Head of Unit for Primary care noted by Region Skåne, which education unit, along with a has now started its own pilot dozen others, are included in version in KRYH. A key part of the evaluation panel. the ST forum is the automated It was appointed by Region summation of how long the ST Skåne’s staff committee to service has been in operation. estimate the need of new ST “It has taken time to build subsidies and to devise all workup the ST forum to places. Prior to the calculation, what it is today. questionnaires are sent out to Now it is diffiall units to answer how many cult to imagine district doctors are in service, administering the number of retirements ST services and relocations,” comments without this Eva Pulverer-Marat. Last year strong digital there were 60 new ST education support," says grants, of which 15 went to dual Helle. specialists. Once a month A dual specialist is a doctor the ST unit holds who is, for example, a specialist meetings with in lung medicine in the hospital,


PRIMARY HEALTHCARE TRAINING UNIT

We have good and dedicated study directors!

OUR ST STUDY DIRECTORS From left: Cecilia Palmlund, AnnaLena Herrlander, Gunnar Sandström, Clary Hägglund, Helle Fredlund, Elisabeth Jaenson, Eva Pulverer-Marat, Håkan Sjöholm, Karin Ekelund, Fredrik Modig, Jakob Järhult och Staffan Larsson. (David Götestrand, Karen Vibe och Per Jonsson missing from picture)

successful in raising interest in family medicine.”

Good rating The SPUR survey of SUND 2018 shows that the ST-training within Skånevård Sund, division of primary care, is of high quality. SPUR stands for the Specialist Education Council, an examination function in LIPUS (the Doctors' Institute for Professional Development in Healthcare), where the own profession examines the quality of caregivers' AT and ST . In Sund, within the primary care division, ST doctors are more positive in their estimation whether the quality corresponds to expectations of ST and education programs, tutoring, documentation and follow-up than

other divisions” with the results referred to in the SPUR surve. KRYH got a high grading when it was implemented in 2016. In SUS primary care, SPUR was done but the results are not ready. But there is still space for improvement. The so-called additional training allocation is affected by long queues. After about 1.5 years in the ST program, the doctor should do additional training allocation work in, for example, paediatric medicine, or psychiatry. “It's hard to find such places. Perhaps in the future, it will be possible for two doctors to share additional training in certain specialties. But to get rid of the queues has become more targeted, so you get more out of a shorter placement," says Helle.

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but who wants to become a specialist in family medicine and work within primary care. The units are given a larger grant for these specialists. In 2018 there were educational grants from the group office to 327 full-time positions, but because many have part-time services, the grant could support 408 ST doctors. All units report each month the number of ST hours, so the group office can continually calculate if there is a possibility to supplement with new ST services during the year. “We have good and committed directors of studies. They are fine role models and do good promotion of the ST service. Each director of studies is responsible for between 20-50 resident physicians," says Eva. "In the study director organization, we arrange AT brunches twice per year, which have been popular, and we have been

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PRIMARY HEALTHCARE TRAINING UNIT

TRAINEE PHYSICIAN ACTIVITIES (AT) During 2018, a total of 176 AT physicians were placed for six months in primary care in Skåne. Five AT study directors worked with ongoing quality assurance of the training places. There were 94 training seminars held locally for AT physicians. The number of AT services increased in Region Skåne last year, which is of course noticed in primary care. More and new healthcare centers welcomed an AT physician to carry out their placements and this worked well. The AT study directors regularly visit the AT physicians at the workplace to make sure that the educational environment and the quality of the training is optimal. In Skåne, the training of practical skills for AT doctors is carried out at the beginning of their primary care placement in collaboration with Practicum Clinical Skills Centers Region Skåne. The courses are comprised of 1-2 days and consisted of practical elements in minor surgery, spirometry/allergy test, orthopaedic status, eye and ear microscopy. The training has received good evaluations and included 11 full days. In addition to these courses, regular seminars were organized with a total of 94 seminars for the different areas. Some examples of content in the seminars were skin diseases, assessment of dizziness, and prolonged pain. At the AT brunches, 113 AT physicians attended lectures and discussions on primary care in Skåne. These meetings aim to increase interest and boost recruitment to ST services in family medicine.

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PRIMARY HEALTHCARE TRAINING UNIT

FURTHER EDUCATION (VFU) This unit covers all student categories in addition to medical students. The VFU coordinator represents the link between primary care operations and Skåne’s three centres of learning. One of the roles of the coordinator is to harness quality development and act as a support for managers and employees relating to VFU. Large demands have been placed on the administration to offer further education of high-quality as this comprises 30-50% of time spent in several medical education programs. Education in the pedagogical supervisor model Peer Learning has been completed in Kristianstad and Lund. The education was previously conducted in Malmö. w 6 nurses at 3 units and teachers from the university, LU, were educated in Lund w 8 nurses at 4 units and teachers from the university, HKR, were educated in Kristianstad. A regional VFU group has been formed where primary care is involved. In this group VFU issues and common policy issues are discussed. In 2018, VFU places were coordinated for a total of approximately 1,700 students within all primary care services – both public and private.

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PRIMARY HEALTHCARE TRAINING UNIT

IN-SERVICE TRAINING UNIT

Knowledge packs Now there is a clinical introduction year for all nurses at the health care centers with a fixed program on offer involving supervision at the unit and established training programs. The initiative was launched in 2018.

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ow we hope what we have will become something that the administrations really use," says Eva Drevenhorn, district nurse and senior lecturer at health sciences in Lund and, from the start of 2019, inservice training coordinator at

the primary care education unit (PUE). After many years of extensive in-service training for Region SkĂĽne, she is now leaving PUE. The new co-ordinator is Anette Helm, who is also a district nurse. "We arrange training courses every semester for all of the

district nurses and nurses, for example, triage education for all new employees," says Anette Helm. Triage is the medical assessment of the patient's needs which the nurses do upon the patient’s arrival to ensure they get the right level of care. The education has spanned a great

Eva Drevenhorn (left) and Anette Helm.

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PRIMARY HEALTHCARE TRAINING UNIT trained nurses. As a result, we have introduced the clinical introductory year because the administration managers and the HR department came to the conclusion that that was probably what was needed to get the nurses to really stay within primary care, says Anette.

Specialist knowledge in steps The clinical introduction year means an introductory program with education to increase the safety of new employees nurses in primary care. As a support, they have a supervisor at the healthcare center and one fixed program via primary care training unit, PUE. But what happens next? "We have created a career ladder, or rather, we have adjusted the career ladder that I was involved in working on in the 1990s," Eva explains. It shows how nurses enter the administration and grow with experience in six specified steps. One of the steps is to gain specialist knowledge and then start to run a special department. In the education for district nurses in Lund this knowledge is included, but not for nurses - in general, the professional competence of district nurses’ is comparatively much more extensive. "I provide support for the operations within Region Skåne that are applied to starting special departments", says Eva Drevenhorn.

Motivating conversation Another area that Eva has devoted much work time is to teach motivational conversations to staff, or MI, Motivational

Grow with experience in six stages

!

Interviewing, as it is known - the methodology was founded in the 1990s in the USA, Australia and England. It came to Sweden in the early 2000s. Eva adds, “It's about putting processes in place that lead to healthy behaviours among patients. It's about getting the patient to understand what needs to be done. All change work happens in the brain.” Eva Drevenhorn has over the years trained thousands of people primarily in primary care in motivational talks: "I have given courses in different contexts, for example, three-day basic courses where we blend theory and practice in role-play exercises. It's intense training days", says Eva. "But it takes energy to convince patients to change their behaviour. If in your profession you learn to become a more conversational partner, then you save energy and have a more relaxed work situation," she says. Thus, energy can be saved for something else – a fine result of education and an improvement of the working day for many

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deal of demand. Last year, for example, courses were held regarding dermatology, wound care as well as hypertension. A huge effort for nurses focused on triage of mental illness. During spring 2019, there will be education regarding ear-nosethroat and allergies. The great demand for inservice training means that the courses are quickly filled, but in a survey, which was carried out in autumn 2018, about 50% of respondents said they had a hard time attending the courses due to time constraints. The survey is available as a report on PUE's website where you can read more. Providing the support in the training program has been Eva Drevenhorn and the new training co-ordinator Anette Helm, and the reference group where unit manager Eva PulvererMarat and four district nurses are included. The reference group for education is available also for other professional fields such as occupational therapist, physiotherapist, curator, psychologist, dietician and medical secretaries in primary care. All the groups work in a similar way to plan and arrange training in collaboration with PUE. "We meet once or twice per semester. In 2018, for example, we got requests for blood pressure measurement from nurses, so we held courses last autumn and will have more courses on the subject in spring 2019,"says Anette. "District nurses and nurses are the largest category of caregivers within Region Skåne", comments Eva Drevenhorn. Equally, there is an extremely large shortage of specially

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PRIMARY HEALTHCARE TRAINING UNIT

DIABETES COORDINATORS CERTIFICATION

During 2018, there were 64 of Region Skåne’s 159 healthcare units that met the requirements for certification. These units were awarded 20,000 kronor annually, received a diploma to display in the waiting room and named in 1177 healthcare guide as a certified diabetes clinic. The purpose of the certification is to ensure quality in the care of people with diabetes. Skåne continues to be first in Sweden and several county councils plan to introduce certification for diabetes services. Information about certification can be found at: www.vardgivare. skane.se, click on health and healthcare, health center and certification. Regular enquiries are sent to administration managers of non-certified units if they want support for getting the unit certified. It usually appears that time is the problem; that the unit lacks the diabetes nurses or that the diabetes nurse does not have enough time for the number of diabetes patients present listed at the unit. They do not meet the so called guide number. There are several health centers that lack a diabetes nurse because of recruitment difficulties. A problem that may need to be resolved in the region during the forthcoming year.

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Two district nursing students have within the framework for their education written a master's dissertation about what certification has meant for the unit. They conducted 12 interviews with diabetes nurses at certified units. It emerged that certification meant opportunities, but also challenges due to staff shortages. The obligatory courses arranged by the diabetes coordinators were appreciated and considered to be important.

IMPROVEMENT WORK

Four improvement projects reached their conclusion during the year. A decision to test a new variant in the form of learning seminars outside of the unit’s NDR data (National Diabetes Register) with diabetes nurses from a couple of health centers that are close to each other. This would start with a half day as one pilot project.

NETWORK

Diabetes coordinators participated and organised networking events for diabetes nurses in different places in the region.


PRIMARY HEALTHCARE TRAINING UNIT

EDUCATION

Two half-day training courses for the diabetes team about diabetes and kidneys as well as diabetes and cardiovascular disease were carried out during the spring in Malmö and in Helsingborg. There were a total of 117 participants involved on the two occasions. Two training days (full days) were conducted during the autumn at Stiftsgården in Höör on insulin treatment in primary care with a total of 160 participants.

An intensive collaboration with system operations and administration specialists within IT and PMO (the journal system Profdoc Medical Office) took place continuously during the year for quality assurance of data transmission from PMO to NDR. It started as a pilot project with eight units and since November 5 has been introduced on all primary care units in Region Skåne. The transfer has worked well.

GUIDELINES

Regional visit and referral routines for type 2 diabetes have been revised. These are available on the healthcare provider website.

NEWSLETTER & WEB

Newsletters have continued to be sent out to the units' diabetes nurses. Diabetes coordinators now also have a website under PUE where the newsletters can be found as well as PP presentations from training days.

INSULIN ADJUSTMENT

The diabetes co-ordinators were involved in a regional group with the mission to develop insulin procedure in the programming language Pascal.

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A full day in the auditorium about NDR was carried out via “Expert Group for Diabetes” on April 5 for children and adult clinics as well for primary care together with individuals from the Register Center/NDR in Gothenburg. Preferences about a new NDR day in the future, which will be a half-day, will be divided into primary care and specialist clinic, adult/child. Training for diabetes nurses “Pharmacology in diabetes 7.5 credits” at the advanced level was conducted at the University in Kristianstad with the support of the diabetes coordinators. 33 students were involved in the course during autumn. It was the first course on the subject that was conducted in Skåne.

NDR – NATIONAL DIABETES REGISTRY

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AKO

SKÅNE FAMILY MEDICINE CONSULTANCY

AKO Skåne family medicine consultancy, Region Skåne (AKO) is a resource for all doctors in Hälsovalet. Together with Region Skåne’s vision we work for a safer, easier and more equal care that develops and expands skills development and standardizes care guidelines for primary care based on national clinical knowledge support that is easily accessible and available. .sätt. AKO Skåne's goal document for 2018 – 2019 is about:

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w COMPETENCE DEVELOPMENT To meet the GPs’ needs for competence development for them to be able to offer the patient person-centered evidence-based safe care. w CARE GUIDELINES To formulate the common Skåne evidence- based easily accessible guidelines for general practitioners. w COLLABORATION To contribute to creating routines so that Region Skåne's various administrations can each be used jointly in the best way. w AKO WEBSITE To create an easily accessible IT site with easily searchable, interesting and adequate information for Hälsovalets doctors in knowledge management, collaboration and competence development.

FAST FACTS 10 personnel working at AKO’s central operation. 44 family medicine consultants within 22 medical divisions distributed locally to Skåne’s different hospitals. 90 local education responsible doctors at many healthcare centers. 39 continued education courses, 5 of which are regional courses in Family Medicine Plus 1,402 participants in AKO’s education. 234 published AKO health guidelines; 100 of which were new in 2018. 8 SVFs, standardised care processes in cancer, published in 2018, a total of 30. 253 337 visits to AKO-guidelines on Caregiver Skåne. 15,340 views of 21 self-produced videos since their respective publication. 8 live webinars during 2018, which were viewed 1,470 times. 64 medical questions & answers, of which 23 were new in 2018.


AKO

SKÅNE FAMILY MEDICINE CONSULTANCY

COMPETENCE DEVELOPMENT Local in-service training

As of 2018, local training is a full-day event in Skåne's various regions: Helsingborg: 8 events with a total of 423 participants. Kristianstad: 9 events with a total of 198 participants. Lund: 4 events with a total of 287 participants. Malmö: 4 events with a total of 307 participants. Examples of subjects at the local in-service training: w Shoulder theme w Natural remedies and interactions w National Clinical Knowledge Support Primary Care, NKKP as well as standardized care processes cancer, SVF w Anaemias w Stroke – new care program

KNOWLEDGE MANAGEMENT Questions & Answers

There are 64 questions and answers, of which 23 were new in 2018.

AKO care guidelines

Work on national guidelines adapted to Region Skåne continued in 2018. 100 new guidelines have been published, in total there are more than 230 guidelines. Abridged versions are also made for SVF, standardized care process cancer, where 8 new have been published in 2018.

National knowledge support primary care

26 recommendations published at national level with clinical knowledge support from the southern health care region.

Regional in-service training

AKO day

In 2018, the annual AKO day also invited all of the locally educated responsible physicians. The occasion was held in Helsingborg. The program concerned the future of primary care, group discussions on in-service training and assignments as family medicine consultant and the ongoing project SDV, Skåne’s digital care system. The day included 41 participants.

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Regional in-service training, Family Medicine Plus, is arranged for an entire day and has been held on five occasions with 146 participants. The regional days have covered: w Heart vessels w Primary care gynaecology w Headaches and dizziness w Kidney failure and thyroid diseases w Traffic medicine

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SKÅNE FAMILY MEDICINE CONSULTANCY

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Clear and structured ANNUALREPORT2018

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"Making texts as clear as possible is a stimulating challenge," says Tina Runeke, family medicine consultant and medical editor of AKO Skåne.

ina Runeke is a specialist in family medicine at the medical group, Munka Ljungby. Together with Johanna Cederholm, also a specialist in family medicine (at Dalby health center, established the first editorial for GPs’ guidelines in Region Skåne and in the course of five years, within the AKO organisation with Sten Tyrberg at the helm, it has become more than 200 published guidelines! "We started discussing the structure during 2013–2014. There had been guidelines before but as a newsletter, Clinic News. We instead wanted to create a knowledge support based on diagnoses and how as a doctor they should act outside these. We worked on and carried out a uniformed, standardized knowledge support," explains Tina Runeke. When the new platform Caregivers in Skåne was launched on December 2, 2014 they had previously published Clinical News – about 100 texts – that were then transferred to the new, standardized template and published online. "It was the start. Then we worked on updating and editing and of course also writing new guidelines. When Region Skåne, for example, publishes regional care program, we pick out the parts that concern primary care and make abridged versions for AKO," says Tina.

Must have high usability The purpose is that the guidelines should be concise, easy to read and structured in a similar way. They should be useful in clinical every-


SKÅNE FAMILY MEDICINE CONSULTANCY day life that support the work. "The guidelines must be valid throughout Skåne. They are written by primary care physicians for primary care physicians," says Tina Runeke. During 2018, AKO published no less than 92 guidelines, both new and updated, and in some cases were larger revisions. Alongside this work, Tina Runeke is also on the board for the southern healthcare region national clinical knowledge support, which is under preparation. For Tina's part, it pertains to child and adolescent health: "I had already written one set of guidelines in the area concerning health of children and young people as something we could start with. That sources both national and international guidelines; it is important with a scientific anchoring. Simultaneously, we publish texts for the national knowledge support, so we also update AKO's guidelines."

AKO

It is very inspiring and fun that the guidelines are used!

Large effort for AKO working 40 percent and Tina Runeke is committed to 30 percent. "I think it's great fun to write structured information so that it becomes as clear as possible. I hope that it can simplify everyday work-life somewhat for my colleagues, so that not everybody needs to sit in their own corner and Google," Tina says. That general practitioners really find the knowledge they need is shown in the latest visitor statistics. The guidelines had 250,000 search results last year. "It is very inspiring and enjoyable that the guidelines are used," she says.

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The work is extensive, and in addition to the national guidelines, it is partly about the local guidelines in Skåne, partly the regional care programs and partly the standardized care course (SVF) for cancer, which is published in an abridged version for primary care with focus on typical cancer symptoms and when they should be referred. "We work a lot with this. The standardized care processes are a piece of the puzzle in the work to quickly find the cancer patients in primary care, something that gave good results here in Skåne," says Tina. Colleague, Johanna Cederholm, is now a medical editor

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AKO

Super teacher! Christian Anker-Hansen is full of ideas and energy. As a GP in Lund he is one that is always developing and strengthening the family medicine consultancy administration in Skåne.

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The webinars are a good example of effective learning.

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he collegial support is central to him. ”Books and the web all have merit, but ask a colleague when you have a problem that you are thinking about,” recommends Christian Anker-Hansen. Christian has been an orthopaedist since 2008 and will in 2019 become a double specialist, i.e. also family medicine specialist. In his everyday life he works at Capio specialist clinic in Eslöv and at the healthcare center Norra Fäladen in Lund. ”Being a double specialist is an exciting one and a good combination and something that Region Skåne encourages. In primary care it is forward thinking,” says Christian. To become a family medicine consultant was a natural evolution for Christian AnkerHansen because he comes

from an academic environment. Having evidence-based knowledge has always been important. ”The healthcare centers must cooperate with each other. AKO has an impressive range of courses to offer,” says Christian Anker-Hansen, who became a family medicine consultant in 2016. In the hospitals you often go around three and three together, but at the health centers you can sit alone in your corner. This must be able to change!


SKÅNE FAMILY MEDICINE CONSULTANCY

Today he is one of the 2500 members from all over Sweden in the Facebook group “Doctors in family medicine” where they discuss unidentified patient cases and, for example, work environment. ”Why not have one group for Skåne? There we would be able to discuss difficult cases or discuss articles we read and tips on courses,” Christian suggests. There are a number of health centers, so-called FQ groups, for physical meetings and discussions. But such discussion groups don’t exist everywhere. ”I have worked as a doctor for 19 years. It is constant learning. Every fifth year the data changes. We need the whole time to get tips on what is new in our area of expertise. A central journal club in Skåne could help,” says Christian. Local journal clubs where new articles are presented and discussed that is available locally

both in hospitals and healthcare centers. ”But AKO might be helpful in starting a central journal club, perhaps as a newsletter, a blog or a type of webinar? I give courses in orthopaedics around Sweden and read articles every week. Many of my patients are also well-prepared,” says Christian. Christian Anker-Hansen emphasizes taking responsibility for your own lifelong learning. During summers, he attends the annual American Academy of Orthopedic Surgeon's Congress. In the United States, where doctors have to maintain their licence to practice through a point-based, self-directed learning (CPD, Continuing Professional Development), and these kind of congresses have many lessons. ”It refers to always being well-prepared, Christian concludes with a smile and hurries back to the healthcare center.”

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Christian is not only engaged in AKO work. He is an author of textbooks, award-winning teacher and produces educational films on YouTube that get thousands of views and hosts webinars for AKO. ”The webinars are a good example of effective learning where you can really concentrate. The web is also good for learning, but above all for social networking,” says Christian. He believes that in the future you have to be in primary care to make more use of each other’s competences. Taking care of colleagues' knowledge is important. As a medical student, Christian was trained in problem-based learning. If he got stuck on a problem, he got on the phone and asked someone in his network with a lot of knowledge and know-how. ”Ask a colleague when you have a problem that you're thinking about,” concludes Christian.

AKO

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KCP

KNOWLEDGE CENTER FOR MIGRATION & HEALTH

KNOWLEDGE CENTER FOR MIGRATION & HEALTH ANNUALREPORT2018

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The unit works with a long-term view regarding migration issues within healthcare in Region Skåne. The mission includes asylum seekers, new arrivals, people without papers and those that live in hiding but also established migrant groups that have long been in Sweden. The goal of the department is equal and safe care for people from other countries, and to promote equal standards of care across the whole region.


KNOWLEDGE CENTER FOR MIGRATION & HEALTH

KCP

In-service training Knowledge center for migration and health offers knowledge support on strengthening the healthcare staff’s knowledge of migration-related issues in healthcare. During the center’s third administration year the demand for education increased significantly. During 2018 more than 60 educational initiatives have been carried out and lectures held, which is more than double compared to 2017.

An active equality conduct – the basis for equal care During 2018, the knowledge center for migration and health collaborated with HR strategists at the group office concerning an education initiative in active measures in working life. The purpose has been to inform and educate about the changes in discrimination legislation, but also to initiate prevention and promotion work against discrimination for equal treatment, both from an employee and a patient perspective. Three half-day courses were carried out among HR-related personnel, which in turn led to greater training efforts for management teams within the management of medical service, group office and Ystad hospital. During 2019, work continued on developing anti-discrimination work.

Inspiration Days During 2018 two inspirational days were held. In May, one was organised together with the knowledge center for lifestyle habits and disease prevention – an inspirational day about lifestyle habits in a migration perspective and in November together with the migration school at the knowledge center there was a day held about dementia concerning human rights in health care.

Introduction Education

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Knowledge center migration and health has developed an introductory education in migration that provides basic knowledge about why it is important to have a migration perspective in healthcare. The education is for everyone who works in health care, whether it is in the role of caregiver, administrative staff, manager or another strategic function. The in-service training is given several times a year and more are planned for 2019.

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KCP

KNOWLEDGE CENTER FOR MIGRATION & HEALTH

Development work Equal health care from a migration perspective In April 2018, the knowledge center for migration and health released the report “Equal health care from a migration perspective”. In the report, the knowledge center highlights migration and health and how the right to equal care can be followed up within health care and how working with quality indicators in Region Skåne can be developed from a migration perspective. The need for the report is based on the research that shows that in Sweden today there are differences regarding which healthcare you receive, based on which country you were born. The report can be downloaded in its entirety from www.skane.se/kcmigration under the headline reports and analyses.

An important book about care On October 25, 2018, the knowledge center on migration and health released the book “An important book on care – method handbook on supporting unaccompanied young people”. It is a method handbook that is based primarily on the specific life situation of unaccompanied children and young people. The contents are based on current research and partly on interviews, focus groups and workshops with unaccompanied young people and staff who work with the target group. The purpose of the method manual is that it should be able to provide guidance on specific issues and support when existing methods and working methods are considered insufficient or are not adapted to the vulnerable situation many unaccompanied young people are in.

Birth registration The knowledge center for migration and health has produced information aimed towards parents that are paperless and are waiting for children or have recently had children. The background to this is that there have been cases in Skåne where paperless parents had difficulty in proving that they were parents of their own children, due to insufficient birth registration. In the work to produce information, the knowledge center for migration and health is supported by a lawyer at Region Skåne and specialist supervisors at the Swedish Tax Agency.

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The information about the birth registration is available at Vårdguiden 1177 and can also act as support for healthcare professionals who meet this target group. The information will be translated in the future to several languages.


KNOWLEDGE CENTER FOR MIGRATION & HEALTH

KCP

Collaboration National network for migration, health and healthcare Together with the Transcultural Center in Stockholm County Council and the Learning Center for migration and health in the Västra Götaland region, the center commenced in April 2018 a national network for migration, health and health care. In October, the network was expanded with representatives from Region Örebro and Region Uppsala. In spring 2019, Region Dalarna will be added. The purpose of the network is to create a common platform for knowledge exchange, be a forum for discussing current issues and for that to be a common national voice on issues concerning migration and health.

Government-wide collaboration The knowledge center for migration and health participates in a pilot study on increased social preparedness in the event of a sharp increase in refugees that is financed by the Swedish Civil Contingencies Agency (MSB) and implemented by the Migration Board. The preliminary study is the basis for a development project application, which will lead to an inter-agency collaboration in the event of a new refugee situation similar to 2015. Region Skåne is part of what is called the smaller partnership, a group which consists of various government representatives from, for example, the police, the customs authorities and Region Gotland. Region Skåne is represented in this context of healthcare. Study trips financed by project funds from the MSB have also been carried out. Region Skåne participated in a trip to Greece to study the refugee situation and visited refugee camps on the island of Lesbos.

Network with civil society The network, which started in autumn 2018, is a starting point for being able to formalise a collaboration, where all participants can access information and experiences on the issue of equal care for migrants.

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KCP

KNOWLEDGE CENTER FOR MIGRATION & HEALTH

Knowledge boost! "During 2018, our training efforts increased significantly," says Kristina Sjöholm, social worker and developer at the Knowledge Center for Migration and Health. Vis-a-vis 2017, we did more than twice as many courses.

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´ Kristina Sjöholm (left) and Selma Gušic.


KNOWLEDGE CENTER FOR MIGRATION & HEALTH

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everyone in healthcare with morning and afternoon classes, which one can take part in subsequently if you don’t have the opportunity the same day. “We go through the different phases of the migration process

Interpreter training met with great interest.

in the training, how it affects health and how it can lead to mental illness,” says Gušic. ´ In the spring of 2018, Selma began education with an anti-discrimination perspective - how to build an administration that does not close doors for some people? How can the structures change so that everyone can enter? "The education addresses active measures in the discrimination legislation; it is the preventive work against discrimination. The legislation was renewed on January 1, 2017 and emphasises that employers must be more active in the work towards discrimination. I have carried out education for HR staff, but also other parts of Region Skåne," she says. Next in line are the Regional Executive Committee and the management group of Ystad Hospital. The knowledge center for migration and health raises the level of knowledge for the administrations within the framework of current issues, but also works constantly with the problems of how knowledge increases lead to lasting changes. "We both want to raise the knowledge and follow-up of what then happens in the administration," emphasizes Kristina. In 2019, the development of education work will continue. There is a wait for more education about using an interpreter and a report on interpreted healthcare meetings in Region Skåne will also be produced where the interpreting work is described in different perspectives. "We will look at language interpretation from the patient's perspective, interpreter's perspective, educational needs and interpretation as a tool for the staff," concludes Kristina.

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o provide training in the best way, adaptability is required as the education can be everything from a full day to an hour's introduction at the workspace. The number of participants can vary between 20 and 100s. Sometimes it can be difficult to gather the entire staff for a single training session, so the training is tailored to your wishes and time. "When we get an inquiry it is often broad and wide in terms of content. We plan out the need required for the specific event so that we know what is in demand. An education often leads to more," says Kristina Sjöholm. Her colleague, Selma Gušic, ´ political scientist and developer, agrees: "We have a long-term goal to provide more education and training to be more available. At the same time, we know that isolated measures do not always give the most; it really is a change in the administration work as needed," says Selma Gušic. ´ The knowledge center for migration and health therefore works also with method development and wants to implement more in-depth efforts. "Sometimes we ourselves create in-service training for all staff, for example, using an interpreter in healthcare," says Kristina. Selma adds, “The interpreter training was met with great interest, it's a pretty practical question that is easy to relate to. We also introduced introductory courses in the area of migration and health and these will continue in 2019." The introduction is structured as a full day of training for

KCP

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KCP

KNOWLEDGE CENTER FOR MIGRATION & HEALTH

LONG AWAITED BOOK

Supporting unaccompanied youth

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That “An Important Book About Care” is vital and filling a need is shown in its consumption. The first edition of 2000 copies were published at the end of 2018 and demand was intense with the book being snapped up. The three ´ authors, Sabina Gušic, Ida Gunge and Johan Andersson are already preparing for a new edition!

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t was Sabina Gušic, ´ who was working as a psychologist at Region Skåne's team for war torn and torture affected children and young people who had the brainwave for the book. Her PhD thesis was an exploration of dissociative experiences in multitraumatized war-refugee youth: "I feel like I do not exist” – Adolescent Dissociative Experiences and the Importance of Trauma Type, Attachment, and Migration Background. "Sabina and I sketched an outline of the book in spring 2017," says Ida Gunge, human rights researcher at the Knowledge Center for migration and health. "We wanted to make one concrete method handbook that is easy to look up for different professional organisations – for example in healthcare, non-profit organizations and municipalities, so they have an opportunity

for a common starting point and thus easier to cooperate." Their thought was to be able to use the book from different perspectives and their needs were realized. The book is very simple to navigate and uses colour coding of the chapters. But the road to the finished book was long. "We started by doing an inventory of what information was out there. Then we held focus groups and workshops for staff from the municipality, healthcare and non-profit organisations. We also interviewed unaccompanied youths that we established contact with via Malmö City and the City Mission," says Ida. Progress continued and in December 2017 Johan Andersson joined the working group. He also works as a psychologist at Region Skåne's team for war torn and torture affected child-


KNOWLEDGE CENTER FOR MIGRATION & HEALTH

KCP

From left: Johan Andersson, ´ Ida Gunge, Sabina Gušic.

the unaccompanied youth and the experiences of the professionals. Care emerged as a central them.” Many unaccompanied children and young people have a very uncertain life situation and carry with them intense experiences that affect their health. Therefore, the professional care they receive becomes extra important. Hence, the

book’s title: "An important book on care" – a method handbook to support unaccompanied youth. When the 250-page book came out at the end of 2018, the 2000 copies were snapped up all over Sweden. "We are now working on adjustments to the book and planning a new edition," says Ida. But Ida, Sabina and Johan are also working on education based on the book. During 2018, they made tailor-made lectures and these will continue in 2019. "Our lecture concept starts from several different perspectives; psychological and trauma conscious perspective, but also an asylum and human rights perspective," concludes Ida. A great deal of work has been done and ended up in An Important Book About Care. And that work continues.

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ren and youth. In 2018 the trio devoted themselves to writing and got financial backing from FINSAM's departments in Lund and Malmö; the money covered costs for the layout, illustrations and printing of the book. FINSAM stands for financial coordination and is a coordinating association that consists of the Swedish Public Employment Service, the Swedish Social Insurance Agency, municipality and region, all working together for financial collaboration within the area of welfare and rehabilitation. "We wrote the book independent of the research in the field and it’s material that we collected via surveys, interviews and focus groups," says Johan Andersson. He adds, “We also used ourselves as reference groups for text reviews. We noticed that there was a great need to document

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KNOWLEDGE CENTER FOR MIGRATION & HEALTH

UN highlights Knowledge Center for Migration & Health

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KNOWLEDGE CENTER FOR MIGRATION & HEALTH

KCP

After a five-day visit in Sweden from 23-27 April 2018, with meetings in Malmö and Stockholm, the Knowledge Center for Migration and Health was hailed as an example of “good practices” by the UN’s independent expert on human rights and international solidarity.

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he expert in human rights and international solidarity, Obiora C. Okafor, visited Sweden for the first time together with Claire Mathellié, both from the office of the UN High Commissioner for human rights (OHCHR, Office of the United Nations High Commissioner for Human Rights). The office is one part of the UN Secretariat and was established in 1993 with its’ head office in Geneva. The pair met representatives from different organizations to investigate how Sweden is working to promote international solidarity and external development cooperation with a human rights perspective. In Malmö, the Knowledge Center for Migration and Health participated in a meeting with representatives from Malmö City that worked

with equal opportunities and sustainable development. From the Knowledge Center for Migration and Health, Ida Gunge, human rights researcher, attended together with Tove Lundberg, psychologist. They presented the Knowledge Center’s mission to work for equal care and the challenges that the unit will focus on in the future. "We discussed the regulations for paperless and asylum seekers, the importance of using an interpreter and the need to increase knowledge about torture-related injuries as well as mental illness in children and young people who have moved to Sweden," says Ida Gunge.

Obiora Okafor and Claire Mathellié were curious and asked questions to know more. In a press release sent out at the end of the Swedish visit Obiora Okafor said: “I was also very pleased to learn about the establishment of a Knowledge Centre for Migration and Health by Region Skåne that aims to help advance the cause of providing more equal and safe care to people from other countries, and that especially put the emphasis on newcomers’ mental health status, with a specific attention to those fleeing war and conflict zones, who experienced torture and ill-treatment, or who escaped an oppressive situation.” In June 2019, the OHCHR will publish a report about the visit to Sweden.

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We discussed the regulations for paperless and asylum seekers and the need to increase knowledge.

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KCP

KNOWLEDGE CENTER FOR CHILD HEALTHCARE

CHILD HEALTHCARE KNOWLEDGE CENTER In three comprehensive regional missions related to vulnerable children (children as next of kin, children who are ill and health surveys at the request of the social services) the unit provides support for development within the entire health care system in SkĂĽne. During the year, in-service training, support through collaborations and analyses were made.

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KNOWLEDGE CENTER FOR CHILD HEALTHCARE

KCP

Goal The goal is to create equal high quality care throughout the region in order to increase the conditions for equal health for children.

In-service training Several thousand people have participated in the different knowledge center programs.

Cooperation Newsletter The Child Healthcare Knowledge Center began during 2018 a collaboration with the Knowledge Center for Women’s Health, which involved an increased participation in parent groups in maternal and child health care, and started with a research-based report jointly with the Knowledge Center for Women’s Health.

w Five newsletters for employees within BHV and other interested parties were released. w In addition, four newsletters were issued about children in vulnerability to interested employees in healthcare.

Annual Report

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Child Health Care in Skåne annual report 2017, describes the administration’s year at the child health care centers (BVC) around Skåne. The health of the youngest is described using different indicators. The report revealed increasing inequality regarding access to BHV for children in socioeconomically vulnerable areas that receive fewer home visits, their parents participate to a lesser extent in parenting groups and the families more often fail to attend the visit when the child turns four.

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Forum with children's health in focus "The perception of healthcare has changed. Competency in the personal treatment of patients in care and families at the child healthcare center (BHV) is about both medical knowledge and treatment, where the individual's abilities are utilised and their own power to change is highlighted. Preventive and health promotion work has become even more important, and the Knowledge Center BHV is an important player for child healthcare in Skåne," says team leader Kathy Falkenstein-Hagander.

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large part of the knowledge center’s work is everyday knowledge sup port to the administrations in the region to child healthcare nurses and doctors. Cooperation with the maternal child healthcare psychologists is an important part of the work. "We provide support in different ways. For example, we have a comprehensive external monitoring about children's health. We follow the information flow on different organizations' websites and via their newsletter, and then we filter out what’s important and convey it in our popular newsletter for the administrations," says Kathy. The newsletter is published five to six times a year. A recently

reader survey showed that the newsletter has a very positive reception. December 2018’s newsletter provided many interesting topics; an update on the method material about equal parenting, information about the

national survey about obesity among children, smoking habits of infants’ parents, the new legislation regarding nurses' right to prescribe drugs, a presentation of the neonatal units and also the new breastfeeding unit in Malmö.


KNOWLEDGE CENTER FOR CHILD HEALTHCARE also come from above, including from The National Board of Health and Welfare or the Public Health Agency such as when it comes to vaccination against rotavirus (which causes gastric illnesses among young children). Via the country's knowledge centers, information is distributed to the child care centers on how to give the vaccine and how to inform parents. Each year, introductory courses are conducted on two occasions for all new employees within child health care with five days for doctors and six days for nurses. The training days are scattered throughout the term and provide a good overview of the child health program. Kathy points out, “We make sure that the competence is the same everywhere regardless of where in Skåne you are.” There are 147 child healthcare centers in Skåne with about 350 nurses and a similar number of doctors. A clever tool for the competence work is the Child Health Forum, a half-day arrangement that is run six times per term at different places in Skåne: "The Child Health Forum is a collaboration with the profession out in the field. We invite and facilitate and then there will be discussion around various issues such as the staff bring with them – 'how do you?' – and then it becomes a knowledge exchange, for example, between BHV nurses, who usually have a lonely job. It is good to experience that one is not is alone in your challenges in everyday work," says Kathy. About three times a year, there is also a forum for managers in child health care with similar information given at all other forums.

Kathy Falkenstein-Hagander.

You can say that we are ambassadors for children rights and support their health.

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The Knowledge Center BHV has also tasks concerning children in vulnerability, children as nextof-kin to parents with ill health or addiction or children that are ill. All this involves training for the entire healthcare system. In addition, the center works with in-service education on health examinations, upon request by social services, in order for the system to function in the region so that children placed in social care get a medical examination. But the knowledge center’s work area extends further: "Every year we train thousands of people in Skåne. We are responsible for education about the preventive work from birth until the child starts school, but also up to 18 years of age in the case of children who are ill or if they have relatives that are in different, difficult situations," says Kathy. Information and in-service training work is very extensive. "Every year we get thousands of questions from the administrations to our mailboxes. There are many similar issues, so we start perhaps some training on that subject. Then we work multidisciplinary in several major and smaller teams. We have a paediatrician, general practitioners, nurses, social worker, administrator and psychologists in the team," adds Kathy. An example of a question the administration received was about vaccination, for example if a child needs to supplement one vaccination program with some doses. The Knowledge Center BHV is always careful to bring a solid reasoning around the issues because the goal is to increase expertise outside the administrations. But educational directives can

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Increase participation in parent groups "In the autumn of 2019, we will give midwives and nurses within the maternal and child health services new tools for interacting in their parent groups,” says Åsa Lefèvre and Petra Pålsson. Both are healthcare developers at the Knowledge Center for child health care and knowledge center for women's health.

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sa Lefèvre, with a basis in nursing, defended her PhD in 2016 in that subject. Petra Pålsson is a midwife and in her ongoing doctoral studies studies the parental preparations before the first time after delivery. At present, both are working on how to develop group leadership. "Today, fewer than half of all children's parents participate

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in parent groups in Skåne. We want you to be able to reach a few more. Everyone doesn't want to go to group meetings, but very many parents still mention that they would like to go," says Åsa Lefèvre. For the midwives at the midwife clinics and the BHV nurses, the challenges are great - how to reach in a better way, for example, people with a high Care Reception Need Index (CNI)?

Åsa Lefèvre (left) and Petra Pålsson.

The index is a social deprivation index based on various sociodemographic factors. A high CNI points to a risk for increased ill health. The variables can be, among others, about low education, unemployment or if you have recently moved. "We know that group participation is lower at these receptions. This creates great challenges," says Åsa. Another challenge is to increase the participation of fathers in the groups at the child care centers after the pregnancy. During the pregnancy, however, there are more fathers participating in the groups at the midwife clinic. Group leaders also have to know how to support those who can be in the minority of the groups, e.g. young parents or parents with disabled children. "Another challenge is when you have an interpreter in the group, says Åsa. Or the movement in the group, at the child healthcare center there are groups with small children – all


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and now she is educating herself together with Petra in the role of group leader. "We want to help the staff to get better tools to help them to succeed make parents to be active in the groups and thus also make sure the parents get what they want out of the groups. We want to change the input mode for the midwives and the BHV nurses so they know the strength of group leadership and teach more about their role in the group different phases," explains Åsa. The group leader role comes in the midst of the midwives and the rest of the BHV nurses’ extensive work. At present, most do not have much education in this and studies show that many feel insecure in the group leader role, regardless of how long you have worked, and the training demanded. "Being a group leader means responsibility and as a group leader you need to understand its role," says Petra. The group leader role includes creating conditions for a safe and good climate in the group where the participants are willing to share their thoughts and experiences, and the create good opportunities for support and learning. There is a lot of research that shows that parents learn more easily from each other. Sometimes one can hear some say that the 'group was as it was'. Managing a group is not always easy. "But we want the course to provide the tools so they can more easily take account for the fact that there are different individuals sitting in the group," comments Åsa. "And that it is

permitted to think that being a group leader is difficult." Parental support is partly provided before birth, and afterwards. In Skåne there are more than 80 midwife clinics, with 200-250 midwives. However, these are not linked with the approximately 150 childcare centers, except with the popular Family Centers, which sometimes has many and different resources for parents, for example, special parenting groups for young parents, adoptive parents or parents of twins. In total in Skåne there are around 350 child healthcare nurses, and as of summer 2019 will be given the opportunity together with midwives to apply for the leadership course that will be given on two occasions in autumn 2019. "We have mixed groups in the education so the professions can meet and create networks, and later on can ask each other for tips and advice how to solve different situations. They give a lot to each other during the training. The networks can become a common arena to meet and can lead to new forms of cooperation," concludes Petra.

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of a sudden someone becomes sad or nappies must be changed!" Midwives and nurses within child health care (BHV) may each have six to seven parent groups per year. The midwife unit meets groups between one and five times and in child health care around 6-10 times. Midwives and the BHV nurses will now be offered training to be strengthened in their roles as group leaders. "The parental-based support will be different if the group is open or closed. In the open group, where the members come and go, you rarely get the safety that can occur in a closed group, where you get to know each other," says Åsa. Petra adds, “In the closed group, the core of participants is the same and that they meet on repeated occasions expands the parents’ social network. In a wellfunctioning group, it becomes a supportive atmosphere." The group-based parenting support also provides a normalization of the parenting challenges. The parent identifies themselves with other parents and see that others have the same experiences. Studies have shown that many parents feel isolated today and that parenting groups can lead to a broader social network. But the central question is: how can we create a safe climate in the parenting group? Åsa defended her PhD in groupbased parenting at child care centers,

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KNOWLEDGE CENTER FOR WOMEN’S HEALTH

KNOWLEDGE CENTER FOR WOMEN’S HEALTH Its’ mission involves support for midwife units in issues such as sexual and reproductive health, maternity care, contraception, cervical cancer prevention and sexually transmitted diseases. The support involves education, work with care networks and regional guidelines as well as collaborative work and counselling.

Regional guidelines The Knowledge Center for women's health is responsible for the regional medical guidelines that form the basis for the work at the midwife unit. In 2018, a total of 11 guidelines were revised and work is constantly ongoing to review all the guidelines. ANNUALREPORT2018

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BreastNewsletter feeding push for women's health In 2018 the Knowledge Center for women's health worked on a regional breastfeeding push for Region Skåne. Together with the Knowledge Center for child healthcare, they are now working on the front foot to promote breastfeeding in Skåne with the goal of trying to turn around the decreasing breastfeeding rate in the region. Full-time breastfeeding for six months is recommended by the WHO and has good health effects for both mother and child. The proportion of full-time breastfeed children at six months of age was 15.4 percent in Skåne.

The Knowledge Center for women's health spreads evidence-based and current news about sexual and reproductive health in one newsletter and during 2018 published five editions.


KNOWLEDGE CENTER FOR WOMEN’S HEALTH

Sexual and reproductive health

In-service training Introductory Education

In 2018 the Knowledge Center for women's health held introductory training for newly-employed midwives and doctors working at the midwife clinics in the region. The training consisted of two full days and has been offered at two occasions, in Malmö (May) and Helsingborg (November).

Prenatal diagnostics

In the autumn of 2018, the Knowledge Center for women’s health arranged a training day on the theme of prenatal diagnostics, ethics and communication. The lecture deepened knowledge concerning interpreted conversations. More than 200 employees from midwife clinics participated

Training on efforts for vulnerable women

The Knowledge Center for women's health has started an education initiative with a focus on efforts for women living in socioeconomic vulnerability. The initiative aims to focus on the effects of socioeconomic vulnerability on sexual and reproductive health and which “solutions” are available for how to work more actively for an equal healthcare system.

ANNUALREPORT2018

Sexual and reproductive health in Skåne: annual report 2017. The report, which describes health measures and care utilization for the administration year 2017, was produced and published. The report describes the sexual and reproductive health in Skåne based on the operations at the midwife clinics in Skåne and is based on register data from the pregnancy register, the National Board of Health and Welfare as well as the national quality register for prevention of cervical cancer.

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The Knowledge Center for Women’s Health had a packed 2018 conducting its’ implementation work within Region Skåne. For the midwife units, new guidelines have been adopted around foetal diagnostics have been in use at the center.


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ntil last year, prenatal diagnosis with CUB was combined with an ultrasound and blood test, and offered to all women aged 33 years or over, explains team-leader Anna Kjellbom, equality specialist in family medicine at the health center Rosengården. But from the 1st March 2018, the combined ultrasound and biochemical (CUB) test is offered in the screening for the most common chromosomal aberrations to everyone, irrespective of age. Against this background, we carried out at the Knowledge Center for women's health an education initiative aimed towards all midwives in maternity care in autumn 2018. The decision to extend the offer was a political decision for the offer to be more equal, even younger women can give birth

to children with chromosomal abnormalities where down syndrome is most common. Foetal diagnostic examinations are performed at ultrasound clinics at the five hospitals in Skåne, and there are also some private ultrasound clinics. There are midwives in maternity care that have the task early in pregnancy to provide information about foetal diagnosis, both what the examination is aimed for, how it goes and what the result can be. An information exchange should lead to the parent or the parents to take a so-called informed choice. "This can be a difficult task for the midwives to inform the parents in the best way," says Anna Kjellbom. It requires good communication competence and it can be made difficult considering the time pressure, which can happen. It is much like other information

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that should be factored into the assigned visit such as lifestyle habits, diet, smoking and more. Parents varying prior knowledge can sometimes be a challenge. It is much to come by in a short time. CUB tests are performed during the period of weeks 11 to 14 of pregnancy, and give a result that assesses the likelihood of the child having a chromosomal abnormality. Parents can then have more conclusive examinations and when a chromosomal abnormality is confirmed they can make a decision about whether to abort or continue with the pregnancy. "You can abstain, if you want, from that part of chromosome control that is about down syndrome, but still gain access

Helén Simonsson (left) and Anna Kjellbom

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to other diagnostics," explains Helén Simonsson, midwife coordinator. "In the education we focus on explaining what the woman is waiting on during the examination,"says Helén. An important question is

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how to prepare prospective parents to go from joy to grief if the situation is such. Genetics expert at Karolinska University Hospital, Charlotta Ingvoldstad Malmgren, gave lectures regarding this and similar issues. She emphasised that chromosome diagnostics should be presented as an offer rather than a recommendation so that the parents themselves are the ones who make such an important decision. She also pointed out that midwives, in order to be able to offer information that enables one to make informed choice, also need to know how it can be to become a parent of a child with down syndrome. Many children with down syndrome today can live a good life. In tandem with the training day, there was a focus on conversations with an interpreter. There are currently too few interpreters with high quality

interpreter training in Region Skåne. Many interpreters used in Region Skåne have as little as one day of training. Midwife clinics frequently use telephone interpreters, which can be an advantage due to privacy. The quality of the interpretations is variable and there is a risk that important information can be lost. Lecturer Ingrid Fioretos, ethnologist and researcher at Lund University, raised a lot of vital research that showed that much can be wrong or get lost in an interpreted call. "Ingrid emphasized the importance to always request the most competent interpreters to minimize the risk of errors in the exchange of information," says Anna. For the many midwives in attendance, this was new information and was very thought-provoking. It had been assumed that the interpreter who have more solid credentials. The intention now is to set higher requirements and that way it can lead to improved communication with patients who speak other languages.

Promote Equal Care For the Knowledge Center Women's Health, it is a big challenge to struggle with being able to contribute implementation of equal care. Their annual report

stated that it is connected to socioeconomic factors such as level of education, country of birth and municipality with one row of health measures during pregnancy as well as with regard to health-seeking and access to care. The results of the report are worrying: "Our mission is to promote and work for an equal sexual and reproductive health in the region, and what we can do is work for an equal care. The report shows that much needs to be done," says Anna. The socioeconomic differences are noticed throughout the country and are not unique to Skåne. A few years back a national investment conducted via SKL, Sweden's municipalities and county councils, to strengthen childbirth care and women's health with investment of many millions throughout the country. "The knowledge center got a grant of SEK 100,000 from the SKL pot to conduct a training initiative for basic maternity health care within priority areas to strengthen women's health," says Anna Kjellbom. The vote was for women's health and socioeconomic vulnerability. The efforts started with a full lecture day on December 10 and subsequent follow-up workshops that will continue on track throughout 2019. The training day in December was a success with over 100 participants from different professional groups and units: midwives and doctors from closed and open care, counsellors, psychologists, family centers, representatives from Malmö


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City, ambulatory units (that work with pregnant women with addiction) and primary care.

Great socioeconomic differences have an impact

knowledge, which is important to have with them to be able to adapt care so that it becomes more equal," emphasizes Anna Kjellbom. The efforts continue and will carry on in 2019 with workshops covering, abuse during pregnancy and how migration and trauma can affect parenting and pregnancy with invited lecturers from the Haga clinic in Gothenburg and the Red Cross in Malmö. Malin Skoog, Lund University and district nurse/developer at the knowledge center child health care, will hold a workshop to discuss the importance of the correlation to talk about mental illness with foreign-born women. Then the center continues its’ important work for equal care.

Lectures, numbers and factors clarify differences

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During the training day, Karin Källén, professor in clinical epidemiology at Lund university as well as a commissioner at the National Board of Health and Welfare, discussed the epidemiological situation referring to the importance of socio economic factors for women and children post pregnancy. The socioeconomic differences are noticeable in area after area. Obesity and smoking are correlated to education length but also country of birth. Women born outside Europe receive a lower degree of care due to mental ill-health or fear of childbirth despite higher incidence of both these issues among this group Karin Källén also showed a connection between the mother's length of education and risk for perinatal death. This prompted a lot of discussions and thoughts. Torbjörn Hjort, senior lecturer at the School of Social Sciences, Lund University, spoke with a family focus on poverty and economic vulnerability in Sweden. It's the women in the families who bear the greatest responsibility and neglect their own needs to try to increase the family’s standard of living. "His lecture showed how numbers and factors get under the skin of the people. It is about strong feelings like guilt and shame and about the desire to fit in and belong," says Helén.

Birgitta Essén, senior physician and professor in international female and maternal healthcare at Uppsala University, showed during the training day how by adding an anthropological perspective you can work for an equal care. Birgitta Essén has done a lot of research about women born in the south Sahara; a group with an increased risk of a variety of childbirth complications and also death in connection with childbirth compared with Swedish women. She emphasized the importance of daring to ask and explore in the meetings and not to have preconceptions. "The day contributed to

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CENTER FOR PRIMARY HEALTH CARE RESEARCH


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The Center for Primary Healthcare Research carries out, with primary care as its base, world leading research through an active exchange of knowledge that is comprised of basic research, epidemiology and patient-oriented research. The administration also includes the Academic Knowledge Center, in-service training, supervision, seminars and the Nordic region’s first experimental laboratory based on primary health care. 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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ST (resident physician) courses in research methods

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Published scientific articles

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Research leaders

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PhD thesis defences

million kronor external grants

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Academic Knowledge Centers (AKC)

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ACACADEMIC KNOWLEDGE CENTER

The Academic Knowledge Center The Academic Knowledge Center (AKC) is a network of 10 healthcare centers across Skåne. At every AKC there is a postdoctoral AKC coordinator. We attempt to reach out to all who are interested in acquiring the knowledge and scientific know-how to support with scientific supervision, tips and contacts.

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AKC

w Capio Citykliniken Helsingborg Söder

w Stefan Bremberg

w Medical Ethics

w Healthcare Center Lomma

w Susanna Calling

w Epidemiology, EBM, e-health

w Healthcare Center Laröd, Helsingborg

w Veronica Milos Nymberg

w Medications, EBM, e-health

w Healthcare Center Husensjö, Helsingborg w Miriam Pikkemaat

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Orientation

Coordinators

w Cardiovascular disease, diabetes

w Healthcare Center Sorgenfri, Malmö

w Beata Borgström Bolmsjö

w Medications, e-health

w Healthcare Center Sorgenfri, Malmö

w Annika Brorsson

w Qualitative methodology

w Healthcare Center Sorgenfri, Malmö

w Louise Bennet

w Migration and health, diabetes

w Healthcare Center Näsby, Kristianstad

w Rickard Ekesbo

w Cardiovascular disease, gastrointenstinal disease

w Healthcare Center Norra Fäladen, Lund

w Ulf Jakobsson

w Gerontology, elderly care and long-term sick

w Healthcare Center Måsen, Lund

w Tommy Jönsson

w Diet

w Healthcare Center Tåbelund, Eslöv

w Anders Halling

w Epidemiology, COPD, multimorbidity

w Healthcare Center Tåbelund, Eslöv

w Sara Modig

w Medications and elderly

w Healthcare Center Löddeköpinge

w Moa Wolff

w Yoga and hypertension, e-health

w CPF

w Emelie Stenman

w Team Leader AKC


ACACADEMIC KNOWLEDGE CENTER

13 coordinators were ready! At each AKC there is one or several AKC coordinators with a PhD that those who work in primary care can turn to you if you need scientific guidance or are just in need of a sounding board regarding research questions.

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doctors and other healthcare professionals should grasp how to combine the best available evidence with the patient's individual situation and own expertise – this is so they can be able to offer primary care patients the best possible care and treatment. Professor Ulf Jakobsson's research school for nurses, occupational therapists and physiotherapists has been ongoing throughout the year with one seminar a week and all participants have made their own project. You can read more about this elsewhere in the yearbook. AKC is a network of committed lecturers, researchers, teachers and supervisors. Do not hesitate to contact them if you want to know more!

ACTIVITIES AT 10 ACADEMIC KNOWLEDGE CENTERS

w Four introductory courses in medical science and quality management for resident physicians. w Test out research course for nurses, occupational therapists and physiotherapists. w 26 scientific group supervisions. w Supervision of 20 PhD students. w Supervision of 45 resident physician manuscripts. w Supervision of nurses, district physicians, pharmacists & physiotherapists doing projects in primary care. w Supervision of student work. w 22 scientific publications. w Lectures. w Journal clubs. w Study visits.

CONTACT Look out for activities this spring on the website and in the education catalogue! You are also welcome to contact an AKC coordinator or AKC team leader Emelie Stenman (below), e-mail: emelie.stenman@med.lu.se

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n 2018 two new AKC coordinators joined the team: Sara Modig, district doctor at the healthcare center Tåbelund and Miriam Pikkemaat, district doctor at the healthcare center Husensjö. Now there are 13 coordinators all over Skåne. Perhaps AKC’s most important forum is the open, free group supervision for those who do projects in primary care and are welcome to discuss scientific methodological issues. The vision is that all ST doctors, who write a paper, should visit such a seminar at least once together with their clinical supervisor. In that way AKC can help many more. Another training initiative at AKC is “Order a seminar” where you can order seminars with different themes for a workplace meeting or a collegiate meeting as FQ group. During the autumn, three AKC coordinators attended an education in “Teaching Evidence-Based Medicine” at Oxford University and in spring 2019 will start an EBM course in primary care. The idea is that

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Concrete suggestions and creative ideas "As the vast majority of patients in the future care will be found with us in primary care, the research and education efforts need to follow. This is where AKC fills an important role." That's what Miriam Pikkemaat says, who is a relatively new AKC coordinator.

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KC is an important link to attach together clinical research, development issues and in-service training with everyday life at the healthcare centers. Within the network, there is the opportunity to bring scientific findings and turn them into practice by identifying clinical issues and capturing good ideas according to Miriam Pikkemaat. She defended her thesis in 2017 and quickly got involved with AKC. Since April 2018, she has with two other coordinators in northwestern SkĂĽne's primary care a mission to support colleagues in research issues and with in-service education in various themes as well as supervision. In total, there are 50 administration hubs in the catchment region.

"It's great fun. I'm driven to develop new ideas and find exciting issues and solutions to complex problems in close cooperation with others," says Miriam Pikkemaat. To also work in the clinic is a given; two to three days a week she works as a general practitioner. "I want to maintain contact with patients. It is valuable in my work as coordinator and as a researcher. But it also works vice versa. Being an AKC coordinator and researcher enriches my clinical service and doing that means I can to a greater extent help improve healthcare," says Miriam. Three times per term are offered to all in the catchment region that wants to discuss research ideas in the seminar. Even if it has gone a little slowly to promote the activities, those


ACACADEMIC KNOWLEDGE CENTER who have come to the meetings have been very positive. "I find that interest in research exists, but that many feel unsure how to go about it. This forum is good because then we can discuss, knock about ideas and establish contacts," says Miriam. At the last meeting, for example, a physiotherapist had the idea of motivating patients to do self-training on their own terms

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through tips sent via SMS. "Other ideas has been to map the pattern of what people are seeking treatment for at the evening and weekend units and find out which ones are diabetic patients that do not reach target values for lipids and why. The headlines are concrete and hopefully the AKC can contribute to safer answers," concludes Miriam Pikkemaat.

Biomarkers can predict complications with diabetes Miriam's own research interest was sparked during her time as an ST doctor in Skaraborg. Her focus is mainly on different aspects of type 2 diabetes.

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and the hormone copeptin play in newly debuted diabetes. Around 400 patients with newly diagnosed type 2 diabetes have been followed. "With the help of blood tests we have been able to show that copeptin can predict the risk for future kidney complications and that high C-peptide values are associated with a higher cardiovascular mortality in newly debuted diabetics. In the future, it can hopefully help us to customize treatment and identify high-risk diabetics already with a diagnosis to follow-up these extra carefully. But more research is needed," says Miriam. Being hit by a chronic illness often means a radical lifestyle

change in the person's life. In a study, she has therefore also examined the patients' experiences of living with type 2 diabetes. The answers surprise her. "My study shows that the patients felt more concerned about how to start with insulin and that, for example, not being able to drive, read books or other practical problems, than with the disease itself," she says. The results of the research have influenced her work as a doctor she says. "I ask a few other questions in meetings with my diabetic patients than I did before and give more room to inform about insulin and addressing concerns," says Miriam.

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ore and more people are living with type 2 diabetes in Sweden and the increase will probably continue as we are living longer. And even though the treatment has become more effective and survival rates over time has improved, people with diabetes still have poorer health development than the population in general, says Miriam Pikkemaat. She has been studying for several years, not just risk factors, but also factors that affect the risk of complications. Among other things, she has been interested in the role of biochemical risk markers such as C-peptide

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AKC at the forefront Tåbelund AKC is far ahead when it comes to adopting future challenges within primary care. The staff are encouraged to do improvement efforts and a large amount of doctoral work and prominent research is underway.

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e have a strong education and research climate with many involved. It is fun and gives us rings in the water and adds value to our clinical administrations. In spring we had two professors, three others who are PhDs, a doctoral student and many with educational assignments, says AKC coordinator Sara Modig. Right now she is responsible for several research projects.

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For example, examining the need for drug reviews among older people living in their own homes, if acute dizziness among elderly people may be due to underlying depression and about health centers updating the patients’ drug lists. "You can say that it is a niche in our AKC. Older, frail, multimorbid patients with many different medicines make them the most vulnerable. Therefore, it is important to study drug use, what the consequences are and how it can be improved," says Sara Modig. Tåbelund's AKC is responsible for supervising scientific queries from staff in the geographical area around Lund. Together with Löddeköpinge AKC, a couple of open seminars are offered per term. ST doctors can get help with their scientific work, but it is also important to pick up on health professionals’ research interests. In collaboration with the emergency clinic there will be a cross-professional group from Tåbelund's AKC learning how to write an overview article.

Other activities offered from CPF via the AKC coordinators is a number of permanent seminars with different themes that staff in primary care can order for its workplace. Current themes range from basics in hypothesis testing and biostatistics to stomach problems and intestine symptoms and drug safety. "The idea is to get a deeper understanding in certain areas. The seminars are free and we can get out to a workplace meeting or lunch meeting," says Sara Modig, who likes to share effective measures to improve drug safety in primary care. The common networking meetings with all of the region’s AKC coordinators and staff from CPF is different as Sara appreciates. Sara divides her time in her roles as a district doctor, a researcher, AKC coordinator and her work for the region's drug council. Hard to combine everything? No, Sara sees only benefits. "The different parts are knitted together and provide added value for each other," she says.


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Sara Modig.

Ask elderly patients if they take common painkillers! A large study by Sara Modig and her research colleague showed that many elderly people regularly take non-prescription painkilling antiinflammatory drugs such as Voltaren or Ipren, which can increase the risk of acute or permanently impaired kidney function.

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the elderly use non-prescription NSAIDs regularly or recurring if necessary. Of these, almost half had lowered kidney function. "That probably means that many older people use unsuitable painkillers without knowing it. NSAID drugs allow fluid to accumulate in the body so that the heart is under strain and the kidneys risk being knocked out," says Sara Modig. She emphasizes the importance of doctors always asking the question about nonprescription drugs when they meet an elderly patient.

"Otherwise, it's easy to miss the chance to get information about possible risky use. It is a simple question that can be decisive," says Sara Modig. Adequate advice at pharmacies is also an important part and to avoid giving, for example, Ipren for muscle pain. Paracetamol is more suitable as a painkiller for elderly. "It's about avoiding that more people end up at risk especially those who also use other drugs that may become dangerous with low kidney function," she concludes.

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ara does not consider that lack of time should prevent doctors and other health professionals from asking simple questions to elderly patients about which drugs they use. In a recently published study, she showed that many elderly people regularly use nonprescription anti-inflammatory drugs and can therefore increase the risk of harming renal function. 1 798 people from the GĂ…S project (Good Aging in Scania) were examined. The results show that 6% of

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CPF NEWS IN BRIEF

Introductory course in medical science and quality management Hi ST doctors! Did you know that the CPF has an eight-day introductory course in medical science and quality management? The course is run four times a year with 25 participants per course, reviewed and approved by LIPUS (2018 we had the 30-course anniversary!). It opens into a project plan for the scientific work and the participants get a taste of many different areas such as statistics, science theory, ethics and evidence-based medicine. The course usually fills up fast so keep an eye out for course dates on CPF's website: www. cpf.se. Hope to see you soon!

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Published in esteemed journals During 2018, we published 134 scientific articles in international journals of very high calibre. Since November 2008 we have published over 1300 scientific articles, which makes CPF one of the most scientifically most active research units in the north. This year's research has resulted in several important publications with a focusing on primary care psychiatry and addiction, health economics, cancer, heart disease, thrombosis diseases, diabetes and others common diseases in primary care. The journals we were published in were: JAMA Psychiatry, American Journal of Psychiatry, Nature Communications, Lancet Haematology, JAMA Cardiology, International Journal of Cardiology, and other journals with a high impact factor.


NEWS IN BRIEF

CPF

Guest lecture: The doctor and sick leave In October, CPF was visited by district physician Karin Starzmann, who received her PhD in February at the University of Gothenburg with her thesis “The physician and the sickness certification”. Her research is about how doctors handle sick leave and various factors that matter if a patient goes on sick leave. Among other things, she suggested that the sick leave teams take over complex sick leave case; something that has been highlighted in the Swedish medical journal Läkartidningen. In the lecture, which attracted about 50 participants from Skåne's health centers, Karin talked about which concepts the Swedish social service requests and how to help WHO's classifications that the National Board of Health has translated into the Swedish version, namely “Classification of functional permits, disability and health” published in 2015. It was a greatly appreciated lecture with many fruitful conversations.

Karin Starzmann, MD, general practitioner, visited CPF on October 10.

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CPF NEWS IN BRIEF

The importance of family history for heart failure Heart failure is known to cluster in some families but it is unclear whether this depends on transmission of genes or lifestyle. By studying adopted people and both their biological parents and adoptive parents, the current research shows that it is genetic heredity that is the dominant factor in the case of familial incidence of heart failure.

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esearchers working at Lund University and Region SkĂĽne presented new research results based on registry studies in July 2018. The study was a collaboration between researchers at CPF research as well as doctors active in the specialties of internal medicine and cardiology. "The results of our study do not mean that your own lifestyle does not matter to an individual risk of heart failure, but it suggests that the risk that is transferred to families mainly occurs via the genes and that genetic factors explain 26 percent of the total heart rate incidence in Sweden," says Magnus Lindgren, district physician and doctoral student at Lund University, and led the study. Magnus Lindgren and research colleagues studied Swedish-born adopted persons with the help of the Swedish multi-generation register that was linked to both their biological parents and their adoptive parents. A total of 21 643 adopted men and women, all born between 1942 and 1990, were followed along with their parents between the years 1964 and 2015 regarding the incidence of heart failure registered in the inpatient register, which forms a part of the Swedish patient register. The risk of heart failure in adoptees with at least one biological parent with heart failure in the study was 45% higher compared to the control group without a biological parent with heart failure. However, there was no increased risk in individuals with adoptive parents who had suffered from heart failure compared to the corresponding control group.


NEWS IN BRIEF

CPF

Economic benefits with mindfulness treatment in groups The need for psychotherapy for patients at healthcare centers is extensive, but compromised by a lack of psychotherapists. A new study from CPF and the health economics unit at Lund University has shown economic benefits with mindfulness treatment performed on a group basis and individual mindfulness exercises in the home, as an alternative to individual therapy, which is mainly about cognitive behavioural therapy (CBT).

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A five-point scale measured health-related factors in five quality of life areas: mobility, self-care, common activities, pain discomfort and anxiety/depression. Those who received mindfulness treatment in groups had significantly lower health and societal costs compared to the control group, which has become customary treatment, during the eightweek period. For example, the healthcare sector could save 1001 kronor per person during the trial period. "There was no significant difference in the QALY benefit between the two groups," says Sanjib Saha, postdoc researcher at the department for health economics at Lund University. The mindfulness study has been led by Professor Jan Sundquist at CPF and was conducted at 16 healthcare centers in SkĂĽne. ANNUALREPORT2018

he study, which was published in the British Journal of Psychiatry, is the first economic evaluation of mindfulness in group therapy and is based on a randomized – i.e. with random selection - clinical examination performed within primary care where group therapy has been compared to individual CBT therapy for patients with depression, anxiety or stress and adjustment disorders. The financial evaluation was carried out by a research group led by health economics professor Ulf Gerdtham. The study covered both health and socioeconomic costs. The health-related quality of life was assessed based on so-called quality-adjusted life years (QALYs, Quality-Adjusted Life-Years). Measurements were done at the beginning of the study and at a follow-up eight weeks later.

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Effect of heat waves on health In a new registry study from CPF, researchers investigated how heat waves affect mortality in Sweden.

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he results showed a clear increase in mortality on those days when the temperature exceeded +27 degrees. In addition, the risk of premature death during heatwaves was greater in northern than in the southern parts of the country and in socioeconomically vulnerable areas according to the study. "We have used the levels that the Swedish Meteorological and Hydrological Institute (SMHI) starts from when they issue warnings about high temperatures and evaluations of mortality increases nowadays SMHI's heat warning system is based on epidemiological studies from the Stockholm area, while we in our study used data from all over Sweden. We can therefore show that the effect of heat on mortality differs between different parts of the country," says Daniel Oudin Åström. Åström is the first author of the study that was conducted during his time as a postdoctoral researcher at CPF. "We see in our material that heatwaves increase mortality by about 10% in Götaland and Svealand, while the increase in Norrland is about 30% during comparable days. One reason for the higher effects of heat in Norrland could be that the inhabitants of the north are

more unaccustomed to these temperatures," says Daniel. Previous Swedish research about the impact of heatwaves on health has not studied how those with coronary artery disease can cope with stresses that high temperatures involve. " With high temperatures the body regulates its own temperature through, among other things, increased sweating, which in turn leads to increased stress on the heart. When we specifically studied mortality in people with coronary heart disease, we found that mortality in coronary artery disease increased by about 10 percent in heatwaves over 27 degrees," explains Kristina Sundquist, professor at CPF. For residents in socioeconomically vulnerable areas, the researchers found the effect of heat waves were more powerful than for residents in other areas. "We already knew that the neighbourhood area socioeconomic structure affects the health of individuals but that these individuals are also more affected by heat waves is something we can as the first research group now demonstrate for Swedish conditions," emphasises Daniel Oudin Åström.


NEWS IN BRIEF

CPF

Prestigious grant Professor and district physician Jan Sundquist has been awarded the European Research Council’s ERC Advanced Grant worth SEK 25.6 million. ERC Advanced Grants (ERC AdG) are awarded to the most established and world-leading research leaders to support excellent and innovative research.

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Jan Sundquist and his colleagues will identify factors at several levels in the neighbourhood area and with peers and family that can protect against mental illness and addiction in first and second generation immigrants. "Getting such a large grant for research at Lund University, CPF, is very gratifying and recognition to our platform that was created through a collaboration between Lund University and Region Skåne 10 years ago. But it is also an acknowledgment to all those who are active at the research platform," says Jan Sundquist. "The grant gives my employees and I the opportunity to develop research at Lund University with an emphasis on mental illness and addiction to vulnerable individuals. The grant also means an opportunity to test new ideas together with the most eminent colleagues that can be raised," concludes Jan Sundquist.

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rofessor Jan Sundquist is researching, among other things, on disease mechanisms and treatment of depression, anxiety and stress related disorders, which are common conditions among patients in primary care. Answering medical issues that are relevant in particular in primary care, Jan Sundquist and his research colleagues work with different scientific methods, e.g. advanced statistical methods for complex analyses of registry data, clinical randomized studies, experimental studies, and implementation of new treatment methods in primary care. All of which are possible at CPF. The project that Jan Sundquist has received the ERC AdG is titled “Neighbourhood area, impact of peers and family on mental illness and abuse by immigrants and their children”.

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Heredity, environment and alcohol Researcher Alexis C. Edwards, Associate Professor at the Virginia Institute for Psychiatric and Behavioural Genetics, held in October an appreciated and well-attended lecture during her visit to CPF, which she conducts research with. The lecture focused on how genetics and the environment interact the development of alcohol abuse.

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n cooperation with Kristina Sundquist and Jan Sundquist, Alexis conducts studies concerning the link with alcohol abuse and suicide, as well as alcohol abuse and depression. These studies are based on different Swedish registers and she works with two of CPF's statisticians: Henrik Ohlsson and Sara Larsson Lönn. Considerable focus is on investigating the effects of the relationship related and environmental impacts in the development of alcohol and drug abuse. "I have a broad interest in improving our understanding of biological and environmental risk factors for psychiatric and substance abuse diseases and to clarify the mechanisms of

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psychiatric co-morbidity," says Alexis Edwards. She adds, “With Sara and Henrik, I have had the opportunity to investigate the effects of relationship-related and environmental impacts on alcohol and drug abuse; we are also investigating the factors that can cause increased risk of suicidal behaviour.” "We hope that our results can contribute to identify possible targets for prevention measures and treatment, by giving insight into the circumstances under which individuals can be particularly vulnerable to these outcomes," she concludes. Alexis Edwards is part of Professor Kenneth Kendler's research group, which has a longstanding history of collaboration with CPF.


RESEARCH

CPF

Research leaders The research leaders at CPF during 2018. Read more about their research and teaching at www.cpf.se.

NAME

WORKPLACE

RESEARCH AREA

w Anders Beckman, Associate Professor w Healthcare Center Lunden

w Medical care research and pedagogic research

w Anders Halling, Professor

w Healthcare Center Tåbelund

w Epidemiology, COPD, multimorbidity

w Susanna Calling, Associate Professor

w Healthcare Center Lomma

w Epidemiology, EBM, e-health

w Ashfaque Memon, Associate Professor w CPF

w Experimental research

w Bengt Zöller, Professor

w Healthcare Center Granen

w Cardiovascular disease

w Henrik Ohlsson, Associate Professor

w CPF

w Epidemiology, genetically and environmentally oriented application

w Jan Sundquist, Professor

w Healthcare Center Sorgenfri

w Mental disease and substance abuse in primary healthcare

w Jianguang Ji, Associate Professor

w CPF

w Alcohol and the family environment, epidemiology & cancer

w Juan Merlo, Professor

w Social epidemiology

w Social epidemiology

w Kristina Sundquist,Professor

w Healthcare Center Granen

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 Healthcare Center Södervärn

w Professional development

w Martin Lindström, Professor

w Social Medicine

w Social capital and health

w Patrik Midlöv, Professor

w Healthcare Center Tåbelund

w Medications and the elderly

w Ulf Gerdtham, Professor

w Health Economics

w Health Economics

w Ulf Jakobsson, Professor

w Healthcare Center Norra Fäladen w Elderly 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 ANNUALREPORT2018

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CPF RESEARCH

A very safe and open atmosphere characterises the discussions in Professor Ulf Jakobsson's group for try-out-research for primary care personnel. In other words – an academic dialogue of the highest calibre. That the atmosphere is cheerful is an extra bonus.

Good academic dialogue

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hese meetings were taken on by me to set up and start a project. I had gone for a while and had an urge to learn more about research so Ulf’s mail that you could send in an application for interest was timely!” says Malin Danekl, physiotherapist and urotherapist at Törnrosen Center in Malmö. In October 2018, the group met for the sixth time since its inception in February. For several hours, they presented the status in their different projects and receive – and give – comments. During the discussions, no stone is left unturned, nothing is left to chance, and the questions are relevant and

all the time lead forward. The meeting room is full of energy. The group consists of Karolina Lucander, physiotherapist at the Törnrosen healthcare center in Malmö, Malin Dankel, physiotherapist and urotherapist from same healthcare center, Sara-Stina Tegnander, nurse at health medical center in Hjärup, Minea Maurin, district nurse at the Sjöcrona healthcare center in Höganäs, Maria Eggeling, who works as a physiotherapist at the health center "Bokskogen i Bara" and Martin Ringsten, physiotherapist at the healthcare center at Södra Sandby. Malin has issued 30 questionnaires to Somali women and is working now on the data

collection stage of the project. She recently visited, together with an interpreter, a group of women in a Somali association in its health center vicinity and got a positive response. The project is about urinary incontinence and urinary bladder problems. In the project she wants to find out how just Somali women perceive such problems: "Very few of them are looking for care with us but still there are many of them who have given birth to many children and obesity is not uncommon. This often results in urinary incontinence," explains Malin. The goal of her survey is to get a grip on how the need looks and how the care can meet it.


RESEARCH

CPF

From left: Martin Ringsten, Malin Dankel, Maria Eggeling, Sara-Stina Tegnander, Minea Maurin, Karolina Lucander and Ulf Jakobsson.

"I have a master's degree in medical science and I was curious about how to go further, so getting the chance to get hands on was perfect! And yes, I want to get a PhD now," says Martin. The group meets a week before going to an annual conference at the pain forum in Umeรฅ and Martin has just finished with a poster that he has done. He will also hold a talk at the conference. Now he wants to know what the group believes about the issues from the researchers, what can he expect? An interesting conversation takes its own beginning from the graphical compilation on the poster of his survey, which is about which pain treatment methods elderly patients with long-term pain use. The 403 responders have had a long-term pain for about 10 years. The group focuses on how Martin presents the data vis-avis the survey scale for grading how, for example, the treatment has helped. Which difference is actually much and relatively much? But the clinical everyday life is never far away when the

group meets, everything can immediately be highlighted in a daily patient situation. "How would you do it again if you got the chance to make a new study?," wonders Karolina Lucander, physiotherapist at the healthcare center Tรถrnrosen in Malmรถ. In a future study, perhaps Martin will bring questions about treatment methods suggests someone. The subject of Martin's poster and study has clearly involved everyone at the table. Partly to be more immersed in the study's results, partly to discuss pain in general and long-term pain as such. How to help patients best? "This support at work, not least by Ulf, you don't find anywhere else here. We dare everyone to say what we think," says Martin Ringsten. He gets support in those thoughts by Malin Dankel: "These meetings have given me a push forward. In a later phase we will probably get a greater need for individual supervision," she concludes.

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After the meeting with a group of women, she will meet two of them for a new interview. "So far it has been easier than I thought. They identified genital mutilation as an underlying cause of the problems. I do not set myself issues. Some have difficulties with seepage or obstructions in the urinary tract," says Malin. In the conversation with the group she gets support and encouragement. Ulf Jakobsson leads the dialogue in a low-key way that enables the conversation to flow. There are group discussions about interviewing techniques and transcription. Everyone has comments, everyone is interested, and besides the engaged atmosphere there is another important factor; namely the lack of time pressure: everyone has time to discuss their projects and everything is discussed properly. Martin Ringsten is a physiotherapist at Sรถdra Sandby healthcare center. He snapped up the opportuniy about try-outresearch because he wanted to know how to do research.

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CPF RESEARCH

"We hope to make the patients more involved through improved feedback, so they better understand why one is given a certain treatment or to prevent disease development," says professor Patrik Midlรถv, who leads the research project PERHIT, a randomised study on person-centered care, high blood pressure and information technology.

Mobile phone as support in blood pressure treatment

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RESEARCH

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he abbreviation PERHIT stands for PERsoncentredness in hypertension management using Information Technology. The research study has received large grants: 10 million kronor from the Kamprad family foundation, 1.6 million kronor from the Swedish Research Council and half a million kronor from the Heart-Lung Foundation. "Our focus right now is to optimize the treatment of chronic diseases in primary care with information technology. We are investigating the feedback between patient and caregiver. Can IT improve treatment outcomes?", says Patrik Midlöv

The goal: 36 health centers

computers and mobiles. "It’s a lot of coordination in the project,” says Patrik Midlöv. "We receive a lot of material and have many measuring points in our randomized, controlled study where half of the 900 participants are included in the intervention group and the other half in a control group," says Patrik. For a year, the researchers take blood tests on three different occasions. "We get blood pressure data from the start date and onward, several questionnaires should also be answered and, in addition, the health economy is evaluated," says Patrik.

Promising pilot study The project group includes, besides Patrik, also Ulf Malmqvist, Region Skåne, administration director with clinical studies Forum South, Peter Nilsson, Lund University, professor and physician at the emergency center, Mikael Hoffmann, Östergötland, doctor and head of the foundation NEPI – drug epidemiology network, Karin Kjellgren, professor of nursing at Linköping university and Ulrika Bengtsson, senior lecturer at the University of Gothenburg. "They did what became a promising pilot study in this topic and then subsequently heard of to me because they wanted to have a clear foundation in primary care and move forward with in-depth studies," says Patrik. Resident physician Ulrika Andersson at the Löddeköpinge health center is affiliated as a doctoral student in the ongoing study. If the project gets positive results, Patrik and his colleagues are contemplating to continue with similar studies in other chronic diseases, such as diabetes, COPD or heart failure: "We hope to improve monitoring in a good way and raise awareness of the patients in a new manner by mixing person-centered primary care with ehealth," concludes Patrik.

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In the study, which runs from 2018-2020, includes patients from - for the moment - 22 healthcare centers in Region Skåne, Västra Götaland, Östergötland and Jönköping. The goal is 36 healthcare centers. During the study, the paPatrik Midlöv. tients monitor their blood pressure on a daily basis for eight weeks The data is uploaded by the patient and via software to the doctor doing the treatment and a nurse, but of course also back to patient who can follow the results via curves that show the daily blood pressure variation. The patient also writes information about how she or he feels, but can also through the software get reminders and tips on diet and exercise. It is not about an app in the true sense, but is a web-based service that can be reached by both

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PHD STUDENTS

Newly Enrolled PhD Students 2018

ULRIKA ANDERSSON, Specialist physician, E-health with treatment for high blood pressure in primary care. Supervisor: Patrik Midlöv. OLOF CRONBERG, Specialist physician, Diagnosis related prescription of antibiotics with infections in primary care Supervisor: Katarina Hedin. WUQING HUANG, Msc, Adverse health outcomes in offspring of cancer survivors. Supervisor: Jianguang Ji. HANNES KONHKE, Resident physician, Medical continuity in Swedish primary care Supervisor: Anders Beckman. MIA SCHOLTEN, Specialist physician, Heart failure treatment within primary care. Supervisor: Anders Halling.

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KRISTOFER SIGURDSSON Specialist physician, How does primary care affect conditions of the inhabitants’ health and use of community resources? Supervisor: Patrik Midlöv.


PHD STUDENTS

CPF

Earlier Enrolled PhD Students

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. HELÉN ARVEHAMMAR, Social scientist, Municipal differences in elderly care. Main supervisor: Martin Lindström. JAKOB AXELSSON, Administrator/Public Health Planner, Social capital and sexual orientation. Main supervisor: Martin Lindström.

GABRIELLA CALERES, Specialist physician, Elderly drug treatment – information transfer and follow-up in primary healthcare. Main supervisor: Patrik Midlöv. PEDRO CARRERA BASTOS, The role of western diet on intestinal permeability measured by zonulin, including possible associations with the metabolic syndrome and and autoimmune diseases. Main supervisor: Jan Sundquist.

LINA EJLERTSSON, Recovery in work: An intervention project for better health among coworkers in primary healthcare. Main supervisor: Annika Brorsson

MARIA GLANS, Pharmacist, Risk factors for the readmittance of elderly hospital patients. Main supervisor: Patrik Midlöv.

ARTIN ENTEZARJOU, Trainee Physician, Digital triage and digital visits to the health care center. Main supervisor: Patrik Midlöv.

HENRIK GRELZ, District physician, Group therapy for physical inactivity in primary healthcare. Main supervisor: Patrik Midlöv

MAELÁN FONTES VILLALBA, Food and the metabolic syndrome in Western and non–Western populations. Focus on adipokines and glucagon. Main supervisor: Jan Sundquist.

HELENA ISBERG KORNFÄLT, Specialist physician, Urinary tract infections in primary healthcare. Main supervisor: Anders Beckman.

PER-OLA FORSBERG, Specialist physician, Neighbourhood influence on cardiovascular health. Main supervisor: Kristina Sundquist

MAGNUS LINDGREN, Specialist physician, Epidemiological studies on heart failure, Main supervisor: Bengt Zöller.

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STEN AXELSSON FISK, Trainee physician, Social theoretical and epidemiological perspectives on chronic obstructive pulmonary disease in Sweden. Main supervisor: Juan Merlo.

SIXTEN BORG, Statistician, Disaggregation and indirect estimation methods on data for health economic models and economic evaluation, with applications to inflammatory bowel disease and diabetes. Main supervisor: Ulf Gerdtham.

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PHD STUDENTS CHRISTOPHER NILSSON, Trainee physician Aspects of ethnicity on blood pressure regulating mechanisms and kidney function. Main Supervisor: Louise Bennet. SOFIA NILSSON, Speech therapist, Language development disorders in childhood and adolescence and health and healthcare utilisation later in life: A multilevel and lifecourse approach. Main supervisor: Ulf Gerdtham. PETER NYMBERG, Specialist nurse, Opportunistic screening and intervention, cardiovascular disease. Main supervisor: Bengt Zöller. SARA OLOFSSON, MSC, Methodological studies on willingness to pay for risk reduction. Main supervisor: Ulf Gerdtham.

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JON PALLON, Specialist physician, Throat pain among children and young adults. Main supervisor: Katarina Hedin

JESPER ALEX PETERSEN, Materialistic/post-materialistic 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. FERDINDO PETRAZZUOLI, Dementia management in European primary care. Main supervisor: Hans Thulesius. PER ROSENGREN, ATlTrainee physician, An epidemiological study of supraventricular tachycardia. Main supervisor: Bengt Zöller. MIA SCHOLTEN, Specialist physician Heart failure treatment within primary care Supervisor: Anders Halling. SOFIE SCHÖN PERSSON, Public health scientist Working relationships and interaction with the workplace Main supervisor: Ingemar Andersson. CECILIA SJÖSTEDT, Specialist physician, Individual, family and neighbourhood factors and mental illness. Main supervisor: Xinjun Li.

KRISTINE THORELL, Improving pharmacological care in the elderly population. Main Supervisor: Anders Halling. FRIDA THORSÉN, Specialist physician Stress related poor health among young people. Main supervisor: Kristina Sundquist. CARIN TILLMAN, Specialist physician, Pharmaceutical continuity during treatment of diabetes. Main super-visor: Anders Beckman. LEILA WALEIJ, Pharmaceutical chemist, Drug treatment and drug related problems in frail, elderly patients. Main supervisor: Patrik Midlöv. HANNA WICKSTRÖM, Specialist physician, TeleUlcer: Telemedicine and RiksSår (Swedish quality register for treatment resistant sores): Modern sore treatment for patients and staff. Main supervisor: Patrik Midlöv. SOFIA ZETTERMARK, Gender studies, Use of hormonal anticonceptives and psychical health in young women: An intersectional approach. Main supervisor: Juan Merlo.


DISSERTATION

PhD Thesis Defences 2018

CLINICAL MEDICINE WITH FOCUS ON FAMILY MEDICINE ABRAR AHMAD, MSC, Identification of genetic biomarkers for the risk prediction of recurrent venous thromboembolism. Main supervisor: Ashfaque Memon. DELSHAD AKRAWI, Specialist physician in family medicine, Epidemiology of kidney failure and glomerulonephritis in Sweden: Hereditary and nonhereditary factors. Main supervisor: Bengt Zöller.

One of many who held their defence in 2018: Maria Fridh together with main supervisor professor Maria Rosvall and cosupervisor professor Martin Lindström.

ENSIEH MEMARIAN, Specialist physician, Obesity and bariatric surgery in Sweden. Sociodemographic aspects and neighbourhood deprivation. Main supervisor: Xinjun Li. MIRIAM PIKKEMAAT, Specialist physician, Complications in type 2 diabetes – Biomarkers versus patients’ thoughts and experiences. Main supervisor: Kristina Bengtsson Boström. RASMUS WAEHRENS, Specialist physician, Epidemiology of Irritable Bowel Syndrome Hereditary and non-hereditary factors. Main supervisor: Bengt Zöller. SOCIETAL MEDICINE CHRISTINE LINDSTRÖM, Specialist physician, Social capital health care providers and unmet health care needs. Main supervisor: Martin Lindström.

PUBLIC HEALTH SCIENCES MADELAINE TÖRNQUIST AGOSTI, Public health planner Finding one’s own strength. Workplace health promotion through BELE – a program for promoting work-life balance among female professionals in human service organizations. Main supervisor: Ann-Christin Janlöv. FAIZA SIDDIQUI, M.d, Prevention of type 2 diabetes and poor mental health amongst immigrants from the Middle-East to Sweden. Main supervisor: Louise Bennet. PUBLIC HEALTH SCIENCES WITH FOCUS ON SOCIAL MEDICINE MARIA FRIDH, Specialist physician, Bullying, violence and mental distress among young people. Cross sectional population based studies in Scania, Sweden. Main supervisor: Maria Rosvall.

PUBLIC HEALTH SCIENCES WITH FOCUS ON HEALTH ECONOMICS GAWAIN HECKLEY, Msc, Health, inequality and the impact of public policy. An empirical investigation of the health and health inequality impacts of education and drinking age laws. Main supervisor: Ulf Gerdtham. YE ZHANG, Msc, An assessment of renal replacement therapy: A registerbased study on equality of access, cost, effectiveness, and costeffectiveness of kidney transplantation in Sweden.Main supervisor: Ulf Gerdtham.

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ELŻBIETA KASZUBA, Family physician, Heart failure in patients with chronic obstructive pulmonary disease with special reference to primary care. Main supervisor: Anders Halling.

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DISSERTATION

Focus on physical activity rewarded "The most important results from my PhD project are firstly the high prevalence of anxiety and depression among MiddleEastern immigrants compared to the native Swedes and that it is associated with physical inactivity in the immigrant group but not in native Swedes which means that physical activity can be potentially used to improve mental health in this group."

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his is what Faiza Siddiqui said on September 27th during her PhD defence in public health science with the thesis “Prevention of type 2 diabetes and poor mental health amongst immigrants from the Middle-East to Sweden�. "Using a randomized controlled design, the project demonstrated the efficacy of a culturally-adapted lifestyle intervention approach in improving insulin sensitivity and lowering bodyweight and LDL-cholesterol levels in diabetes prone MiddleEastern immigrants," says Faiza. The lifestyle intervention reduced potential type 2 diabetes and also reduced the risk of cardiovascular diseases. "We also showed that such an intervention not only leads to increase in light-intensity


DISSERTATION

physical activity but also produces favourable trends in sedentary behaviour and dietary intake in the intervention group compared to the control group." "Last but not the least, the intervention had a positive effect on mental health in this group. Considering the high burden of type 2 diabetes and poor mental health among Middle-Eastern immigrants, we believe that our findings are very promising in terms of type 2 diabetes prevention and promotion of mental health in this group," continues Faiza.

CPF

to travel and explore countries that I had not visited before but also met and listened to people who are well-known within diabetes research and to whom I always looked up to as a PhD student." However, there were also challenging times where things would not work out as expected. "I think it is important to stay positive in those times and believe in yourself and not to be afraid to ask for help," says Faiza. Faiza Siddiqui.

Why did you choose this particular subject for your thesis?

"For people who are planning to start a PhD, I would tell them that it is not a smooth ride but it is doable and it is fun! If you are coming in, come with full motivation and never give-up. Also aim for work-life balance as there is nothing more important than your family life. At the end, you will feel proud of yourself, so see all the bumps in this ride as an opportunity to move forward," says Faiza. As for the future, Faiza is open to many new opportunities. "I am open to both academia and the private sector. I am particularly interested in clinical trials and considering my medical education and my experience with research, I see myself contributing within that area,"says Faiza.

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"During my Masters in Public Health, I developed an interest in type 2 diabetes prevention as diabetes has taken an epidemic form during past few decades. Personally, some of my family members got diagnosed with type 2 diabetes during that period, so that also motivated me," says Faiza. After finishing her Master’s studies, Faiza got in touch with her supervisor Louise Bennet as she was leading the MEDIM project which focussed on diabetes among Middle-Eastern immigrants residing in MalmÜ from different perspectives such as risk factors, and most importantly what we can do to reduce this high risk for diabetes. "This was very close to my in-

terests and I am very happy that this project has shown results that can be used in primary healthcare and community setting," she says. For Faiza, her time as a doctoral student was a fouryear journey both literally and figuratively. "I live in Denmark so other than days when I worked from home, I had to cross Ă–resund bridge to be at the university. That was an interesting experience! It was hectic but on the positive side you get to meet new people and most importantly you get some personal time where you can read or reflect. Overall it was a huge learning experience," she says. "I also really enjoyed attending conferences in Iceland and Portugal where I presented my research. I not only got a chance

Have you any tips for people thinking about starting a PhD?

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DISSERTATION

"Our results showed that genetic variants have a sex specific role in risk prediction of VTE recurrence. Moreover, we have developed a multiple genetic risk score (GRS) consisting of multiple genetic variants identified in our research for the risk prediction of VTE recurrence. If validated, this GRS can be used to stratify VTE patients according to high and low risk of VTE recurrence." The words of Abrar Ahmad on November 9th when he held his PhD thesis defence.


DISSERTATION

CPF

Risk assessment of recurrence of blood clots

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brar’s thesis was entitled “Identification of genetic biomarkers for the risk prediction of recurrent venous thromboembolism. Risk prediction of recurrent VTE”. His main supervisor was associate professor Ashfaque Memon. Venous thromboembolism (VTE) is the third most frequent cardiovascular disease. Each year about half a million people die because of this disease in Europe only. This disease often reoccurs, and the rate of recurrence is about 30% in 10 years. Anticoagulant drugs are used to prevent the VTE recurrence. These drugs, however, are a double edged sword, they save the patients from VTE recurrence at the cost of the risk of severe bleeding. "The predictive models/biomarkers identified so far are not enough to precisely categorize

the VTE patients according to the risk of VTE recurrence, therefore, the clinicians are not able to efficiently stratify patients according to low and high risk of VTE recurrence to tailor the therapy accordingly," says Abrar. Therefore, there is a need for identification of new biomarkers for the risk prediction of VTE recurrence. Abrar adds, “Since the heritability of VTE is quite high (5060%) and the hereditary factors lead to a lifelong risk of VTE recurrence, the aim of my project was to identify the unknown genetic biomarkers for the risk prediction of VTE recurrence and that sounded very interesting to me. "If I have a chance and more funding, I would like to sequence the whole genome for identification of genetic biomarkers to develop a predictive model of VTE recurrence," says Abrar.

Abrar Ahmad.

ABRAR’S TIPS FOR PROSPECTIVE PHD STUDENTS TIP 1: You should know that you are going to commit to the topic of your research for comparatively longer period, so you must have a real interest in the project you are going to work with. TIP 2: With your specific projects, it’s always good to try to get involved in other projects going on in your research group to broaden your knowledge and skill base. TIP 3: Start thinking early about which career you are interested in after the completion of your PhD studies, e.g. academia or industry. Depending on this, you can choose seminars, courses etc.

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At present Abrar is working with diabetic complications. Diabetes mellitus is a lifelong, incapacitating disease affecting multiple organs. "We are focusing on the effect of diabetes on vasculature (macro- and micro-vessels) and to identify the possible mechanisms involved in the disease development and to improve diagnosis, prevention and treatment of diabetes, with the common goal to deliver precision medicine," says Abrar.

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DISSERTATION

Tough to determine heart failure diagnosis In the thesis “Heart failure in patients with chronic obstructive pulmonary disease with special reference to primary care” Elżbieta Kaszuba investigated whether the tools available in primary care are adequate to be able to diagnose heart failure in COPD patients.

Elżbieta Kaszuba.

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he question was prompted by her everyday experience as a doctor in primary care. It can be easy to miss heart failure with COPD because the symptoms are similar and the consequences are poorly investigated in previous . research, says Elzbieta Kaszuba, a doctor at the Samariten education center in Karlshamn. The purpose of the thesis was to describe diagnostic and epidemiological aspects of COPD and simultaneous occurrence of heart failure and to evaluate impedance cardiography as a method that could be applied for assessment of cardiac function in patients with heart failure in primary care in a simple way. . In her thesis work, Elzbieta Kaszuba conducted the investigation in primary care. The study included 75 individuals so it is difficult to generalize the results and that is necessary for follow-up studies. But the study points to difficulties that general practitioners have in making a safe heart failure diagnosis "There is a need for cheaper and simpler alternatives or increased access to the kind of cardiography needed today for a safe heart failure diagnosis," she says. . Elzbieta defended her thesis on February 16, 2018. Main supervisor was Professor Anders Halling.


DISSERTATION

CPF

IBS – an underdiagnosed disease Rasmus Wæhrens held his PhD thesis defence on May 23 with the thesis “Epidemiology of Irritable Bowel Syndrome - Hereditary and nonhereditary factors.” His conclusion is that Irritable Bowel Syndrome (IBS) is an underdiagnosed disease in primary care.

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and that genetic factors play an important role in the risk of being affected by IBS. In addition, environmental factors, perinatal and socioeconomic, also may be important for the development of IBS. The result of one of the dissertation’s subarticles indicated that doctors in primary care do not enough often makes the diagnosis of IBS in their patients. It can partly be due a lack of knowledge about the diagnostic criteria for IBS, partly it may be because of uncertainty about what to do to help the patient and that IBS is perceived as a complex condition, where psychological reasons play a role, which can then take time

to handle. IBS is a disease that more often affects women; even the gender perspective can be a contributory factor says Rasmus Wæhrens. The root cause for IBS is not known. Many examinations have pointed to disturbances in movement pattern in the intestine, on increased sensitivity in the gut, on altered gut flora and on infections of the intestine. The relationship between the brain and the intestine has become increasingly clear and in the latest diagnostic criteria from 2016, IBS has changed from being a functional disorder, i.e. without known biological background, to a brain intestine disturbance.

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BS – irritable bowel syndrome – is a common, chronic bowel disease characterized by recurring abdominal pains at least once a week during the last three-month period. The abdominal pain is related to emptying the intestine. IBS has a great impact on each individual patient and affects largely their daily life. Patients are often frustrated with not having control over the symptoms and may be afraid that it can be serious. Quality of life for the individual IBS patient is significantly affected. In his thesis, Rasmus showed that family history of IBS can be a risk factor for the disease

Rasmus Wæhrens.

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DISSERTATION

“Regardless of the family's socioeconomic situation, there exists a risk increase for obesity in children living in socially vulnerable areas,” says Ensieh Memarian, who defended her PhD on May 4th with the dissertation “Obesity and bariatric surgery in Sweden, Sociodemographic aspects and neighborhood deprivation”.

Child obesity more common in deprived areas

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hat vulnerable residential area had a negative effect was one of the results of her PhD thesis. Her research also showed that obese people, with BMI over 40, underwent obesity surgery to an equally high degree regardless of socioeconomic differences. Gastric bypass is the most common method for bariatric surgery in Sweden. "This suggests that Swedish healthcare has succeeded in achieving an equal care for the entire population in this respect," says Ensieh Memarian, who is a specialist in family medicine at the Sorgenfri center in Malmö. However, one of her articles showed that immigrants are a group with a lower probability that will undergo obesity surgery vis-à-vis Swedes. But the result is

not entirely clear. "In my first part of my work, we found a connection between child obesity and type of residential area. This means that children living in socioeconomic vulnerable residential areas have a higher risk of becoming overweight, independent of the family's socioeconomic position, compared with those who live in socioeconomic affluent areas," she says. The effect of the residential area on child obesity can be explained by the unsafe housing areas that hinder daily physical activity. It may also be due to proximity to fast food restaurants that contribute to unhealthy eating habits. Neighbours and friends that the individual socialises with on a daily basis can also contribute to unfavourable lifestyle habits.


DISSERTATION

CPF

I contacted CPF and did the test-outresearch service for a half year..

I was offered the doctoral student opportunity," says Ensieh. For those thinking about doing research, Ensieh has a few tips Ensieh Memarian. and emphasises that planning is key when you work simultaneously in the clinic. "Apply to the research school! Do different types of studies! At the end, when I sat down and finished writing the thesis, I also worked at the same time. It was very hard to write part-time and work at the healthcare center, it was a challenge both physically and mentally. My tip is to write full-time and have the text ready in a few weeks," says Ensieh.

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Ensieh Memarian’s interest in the subject was sparked whilst working as resident physician and she did work in basic research methodology. She also had patients suffering from obesity and common accompanying diseases such as diabetes and hypertension. After surgery both diabetes and hypertension often disappeared or the medication was reduced. The good results of the obesity operations made her want to study more, and she became more immersed in the subject together with associate professor Susanna Calling, who later became one of her co-supervisors. Main supervisor was associate professor Xinjun Li at CPF. "I contacted CPF and did the test-out-research service for half a year. It went well and so

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DISSERTATION

Hereditary factors significant for chronic kidney disease ANNUALREPORT2018

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"I was surprised when I realised that severe kidney failure has a major heredity component," says Delshad Akrawi, specialist in family medicine and operations manager for Öresund doctors in Malmo. On May 17th, he defended his thesis “Epidemiology of kidney failure and glomerulonephritis Sweden – Hereditary and non-hereditary factors.”


DISSERTATION

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Delshad greatly enjoyed his doctoral period. He was well prepared – already during his medical education in Linköping his studies had a research focus and he was also a summer doctoral student doing cell biology. Principal supervisor, associate professor Bengt Zöller at CPF, met Delshad in Ystad when they shared a workplace at the medical clinic. "You get a good network of colleagues and researchers during the doctoral period. In addition to the development, I learned a great deal about statistics and epidemiology. But I also had fantastic supervisors and

committed colleagues!," says Delshad. He adds, “What is distinctive for CPF is that there is a lot of warmth and an atmosphere that everyone shares the same interest about research, which gives a dynamic in your research process. It is just means to go in and ask about someone who has encountered a problem!” He has advice for those who are thinking about applying for doctoral programs: "Always be curious! Start looking for more knowledge. It is just the start! And it is much more fun than you think!"

Delshad Akrawi.

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o calculate familyrelated risk had not been done earlier, but now it turns out that it is a big risk factor for diabetes and high blood pressure – if your relatives have had kidney failure. "It is of public interest to map out the reasons that then results in a form of treatment. However, my analysis of living environments and neighbourhood area showed they are a small part of the disease. It is individuals and family ties that are crucial," says Delshad. In other words, the important underlying factors for kidney failure are genetics, environment and lifestyle. "Yes, it is clearly shown in the adoption study I did during my doctoral studies. Genetics play a greater role than the environment, but kidney failure is affected by both factors. However, the risk for developing kidney failure is as much as 59% percent if a first-degree family member has the disease," says Delshad. That Delshad Akrawi chose this topic for his research studies was due to the disease showing up in his everyday clinical work "I had patients with different kidney values, but when it was investigated it turned out that their renal function was normal. It highlighted a problem - when should you actually refer to a specialist clinic? My thesis has given me new tools in my work as a doctor. When I meet a patient with kidney issues today, I actively ask and watch carefully the patient's first-grade circle that relates to family members and heredity for kidney failure," says Delshad.

CPF

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DATABASE GROUP

Database Group:

Electronic questionnaires to thousands of schoolchildren The mindfulness project has now included more than a thousand students from the dozens of participating primary schools in Sküne. It is a longitudinal study where the students answer questionnaire questions from preschool class right up to year nine. Students receive different questionnaires per age category (pre-school class - year 2, grade 3–5 and grade 6-9) to suit the students' different maturity levels as well as possible.

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uring 2018, the database group has introduced electronic web surveys as a complement to paper questionnaires. For the first year in the study, students answered all the questions in paper surveys but to save the environment as well as manual input work and to make the study easier to administer to users, we now have web surveys in cases where the schools have computers and internet connection available for students. To further facilitate the students in answe-

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ring the questionnaires, we will investigate the possibility of being able to answer the questionnaires via a mobile phone app as a complement to the computer. The electronic web survey system has one database for each primary school and thus provides a number of administrative functions per school so that it is easier to keep track of which students responded to respective questions in the various questionnaires. You can also do automatic mailing to the students with a unique link to each student to


DATABASE GROUP

ensure that the right student responds to the right questionnaire in this long-term study that follows the students’ mental health during all the years they have participated in the study from preschool class to year 9. Pupils in the youngest age category may respond to the questionnaires together with their parents (and the mail that is sent out with the unique survey links goes to the pupil's parents). For the older pupils from year three and up, the students answer the questionnaires independently without having their parents present. Staff from the mindfulness project visit each class that is included in the study and are in every individual classroom with the school teacher when the pupils complete the questionnaires. The questionnaire reply is sent via an encrypted line to the electronic survey system's SQL database that is operated by the Faculty of Medicine's IT department at Lund University. Database administrators Helene Brandt and Mats-Åke Persson administer the databases by age category and school in the electronic survey system. All of the schools’ input questionnaires are checked, anonymised and grouped on a regular basis through SAS programming. In connection with the SAS program, the controlled data is transferred to an aggregate analysis dataset by age category in a secure and encrypted SQL database. Statistician Karolina Palmér is responsible for all analyses in study. The database group includes the database administrators Helene Brandt and Mats-Åke Persson and Klas Cederin, GIS engineer.

CPF

Server environment moved to Lund Data Center CPF's server park was moved from CRC Malmö to LDC in Lund in May 2018. This has resulted in better and faster support from server technologies when upgrading hardware as well as with acute problems that require physical access to computers, because the support department in Lund is manned every day and the technicians can avoid having to transport from Lund to Malmö. During the autumn, a new Windows server was installed, which has received a positive reception from the researchers for its’ improved performance. Access to data is now governed by AD permissions and all events are logged in accordance with the GDPR requirements.

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ANALYSIS GROUP

Broad collaboration The analysis group, which consists of statisticians and database managers, collaborates on planning of studies, building of databases and analyses. Whether it's small or large datasets, there is close collaboration between the analysis group and the clinical researchers.

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ANALYSIS GROUP

CPF

Analysis group collaborators Back row from left: Xinjun Li, researcher, associate professor, Mats-Åke Persson, database administrator, Helene Brandt, database administrator. Front row from left: Klas Cederin, GIS-engineer, Karolina Palmér, statistician, Mirnabi Pirouzifard, statistician, associate professor, Henrik Ohlsson, statistician, associate professor, Sara Larsson Lönn, statistician, PhD, Jianguang Ji, researcher, associate professor.

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be answered from the registers and a significant part of the medical research is based on analysis of collected data from clinical studies. One example is the current mindfulness project where survey data are collected annually from school students in grade F-9. To be able to analyse collected material and draw conclusions, good planning is required to do the study along with close cooperation with project coordinators, research nurses and other colleagues. "It is important as a statistician to get in as early as possible in such a large project. Meticulous planning is crucial to get a good study design and the right number of study participants to be able to answer issues," says Karolina Palmér. During 2018 more schools were recruited for the mindfulness project and about 1,700 students have now agreed to join

the study. The analysis group also has close cooperation with the experimental primary care lab at CPF. In 2018, the cooperation has resulted in, among other things, analyses of genetic risk models for recurrent venous thromboembolism and identification of biomarkers for patients with depression. In addition to supporting researchers in their scientific activities, the statisticians are also active within the teaching of doctors and postgraduate students, that knowledge of statistical methods are a necessary tool to be able to plan, analyse and evaluate quantitative studies. "A big part of our work as a statistician is to be a sounding board and coach for research clinics. It requires great collaboration and that you can communicate statistical issues in an educational way," says Mirnabi Pirouzifard.

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ost of the projects are analyses from start to finish and involve study design, data management, statistical analysis, interpretation of results and writing of a scientific article. In other projects, they are only involved in a part of the process. Much of the research at CPF is register based and the group has been built up over the years with a unique combined competence on how these records can be used in the best way. The Swedish registers are a gold mine for research that has resulted in CPF, in addition to local projects, having several joint collaborations with international research groups. The analyses are then performed by the analysis group in Sweden, however, always in close collaboration with the researcher. Some scientific issues cannot

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ANALYSIS GROUP

Karolina PalmĂŠr and Mirnabi Pirouzifard.

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"Be prepared that it will take time to sink in"


ANALYSIS GROUP

CPF

"A basic knowledge and understanding of the statistics opportunities and limitations are an important prerequisite for good research and research projects." That's what Karolina Palmér, biostatistician at CPF says.

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I feel such joy every time an ST doctor or doctoral student obtained relevant results that they can present in a final report or study," says Mirnabi Pirouzifard. Biostatisticians at CPF are an equal part of mission to help research groups and doctoral students. All or parts of the road – from problem formulation, study planning and sample calculations via data management, programming, construction of datasets and analysis for interpretation and presentation of the results. According to Karolina it is a good investment to let a statistician be present when the study is at the idea stage. "The choices you make here are crucial for what results are possible to get out of the study. The question formulation must be made concrete, refined and tightened. In the design phase, you decide which selection of data to include and which analytical methods should be used," says Karolina Palmér. Mirnabi Pirouzifard says that he looks at his job to be an explorer and that it is a journey you do together. "In a research group you need to be both methodically strong within statistics and also have a lot of experience in clinical studies and diseases. It is very

important that the two forms of knowledge expertise are not isolated from each other," he says. One example is the large ongoing mindfulness project with schoolchildren in Skåne. If cancer diagnoses can be done faster through new working methods is another, as well as observational studies on how heredity affects different diseases. "Several of the hereditary studies also include how to develop new methods for difficult problems that should be able to be solved better, which is very exciting for me as a statistician and can in the end hopefully improve for patients to get the right treatment," says Mirnabi Pirouzifard. Large and small, on the surface and in depth. Both think that they are at the right place and are expectant for 2019.

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ogether with colleague Mirnabi Pirouzifard at CPF, Karolina works part of the time offering support in different ways to resident physicians with the scientific work that they must do to be approved as a specialist. "It's about, among other things, to teach elementary statistics, basic methods and simpler applications, to offer consultations and help to get started with statistics program and exam project plans," says Karolina Palmér. Both Karolina and Mirnabi are aware that statistics can be perceived as difficult and incomprehensible. Their advice is to be prepared that it takes time to apply the knowledge and that you best assimilate it by reasoning and testing it out. "Prerequisites vary. The needs are also diverse. But my experience is that the more concrete and practical the needs and issues are that the statistics become more exciting and motivating," says Mirnabi Pirouzifard. The education tasks are something that both greatly appreciate. "It's rewarding because many need our help. If I only contribute a small piece of the puzzle,

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MOLECULAR MEDICINE LABORATORY

Own lab CPF is the only family medicine institution in Sweden that has its own molecular medicine laboratory. We also have our own biobanks department. The lab is open to clinically effective researchers and molecular medicine/ translational researchers. Two of the researchers summarize the lab’s activities in 2018.

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Guidance with individual treatment options Xiao Wang, MD, PhD, researcher at the laboratory During 2018, I have investigated the role of circulating miRNAs in venous thromboembolism (VTE) recurrence. We have identified 12 plasma miRNAs that may have the potential to serve as novel, non-invasive predictive biomarkers for VTE recurrence in Malmö Thrombosis Study (MATS study). Most of them are involved in platelets and the TGFβ pathways. Therefore, we suggested that antiplatelet therapy needs to be considered for VTE patients who had discontinued anticoagulant treatment. In the mindfulness study, I investigated the role of cytokine macrophage migration inhibitory factor (MIF) levels in depression and anxiety. We found that higher plasma MIF levels at baseline may differentially predict better longterm outcomes with psychotherapeutic interventions for depression, anxiety or stress- and adjustment disorders. It may serve as a biological marker that can guide treatment selection for personalized treatment of psychiatric disorders.


MOLECULAR MEDICINE LABORATORY

CPF

Circulating DNA in cancer Ashfaque Memon, MD, PhD, Associate Professor and head of the laboratory

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Last year in 2018, we worked on various projects in the lab which including genetic and protein biomarkers of venous thromboembolism and also the role of circulating DNA (both mitochondria and nuclear DNA) in cancer as well as identification of diagnostic and prognostic biomarkers for abdominal aortic aneurysm in collaboration with department of vascular diseases, Sküne University hospital with Prof Anders Gottsäter. In addition, we worked with the role of inflammatory biomarkers and microRNAs in response to mindfulness therapy given to patients with depression, anxiety, or stress and adjustment disorders. In total, seven papers were published in reputable journals such as British Journal of Hematology, Journal of Thrombosis and Thrombolysis, Gene as well as International Journal of Neuropsychopharmacology. Here are some of our results: We screened 92 protein biomarkers in an effort to identify diagnostic biomarkers for deep vein thrombosis (DVT), a blood clot that forms in deep veins, and mostly occurs in the lower extremities. We identified multiple novel biomarkers and showed that combination of biomarkers identified in in our study can serve better than the previously available diagnostic biomarker (D-dimer). Our work on venous thromboembolism has been previously described by my research colleague, Xiao Wang. In cancer project, we sequenced mitochondrial DNA and identified multiple novel mutations associated with risk of breast cancer. In house assays have been developed and the identified novel mutations are now being validated in breast cancer from a large cohort and their role in early diagnosis of breast cancer is being assessed, the project is ongoing. Finally, the first PhD student from our lab graduated in November 2018 and recruitment of a new PhD student is underway.

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FINANCIAL PERSPECTIVE

THE FINANCIAL PERSPECTIVE EXTERNAL COUNCIL GRANTS FORTE

STATE BUDGET GRANT 2018 984 000

w Ulf Gerdtham VETENSKAPSRÅDET

w Patrik Midlöv

901 000

w Ulf Gerdtham

625 000

w Ulf Jakobsson

574 000 172 000

2 400 000

w Juan Merlo

w Jan Sundquist

1 000 000

TOTALT

w Kristina Sundquist

1 000 000

ALF-MEDEL HEART & LUNG FOUNDATION 400 000

w Bengt Zöller KAMPRAD FOUNDATION/HLF

5 700 000

w Patrik Midlöv CANCER FOUNDATION

600 000

w Jianguang Ji INTERNATIONAL GRANTS NATIONAL INSTITUTES OF HEALTH w Kristina Sundquist

6 300 000

w Jan Sundquist

1 200 000

EUROPEAN RESEARCH COUNCIL 5 000 000

ANNUALREPORT2018

OTHERS w Jan Sundquist

700 000

w Ulf Jakobsson

100 000 26 084 000

GRANT 2018

w Jan Sundquist

1 488 000

w Kristina Sundquist

1 233 000

w Ulf Gerdtham

991 000

w Bengt Zöller

572 000

w Martin Lindström

569 000

w Louise Bennet

532 000

w Patrik Midlöv

500 000

w Ji Jianguang

467 000

TOTAL

100

3 672 000

700 000

w Jianguang Ji

TOTAL EXTERNAL

1 400 000

w Jan Sundquist

w Juan Merlo

w Jan Sundquist

GRANT 2018

6 352 000


FINANCIAL PERSPECTIVE

CPF

REGIONAL GRANTS (TKR) REVENUE Regional grant, CPF Funding for salaries Regional research funds Total revenues Region Skåne

BUDGET 2018

RESULT 2018

12 558 5 461 180 18 199

12 910 5 333 180 18 423

2 595 1 247 1 348

Other revenues – Compensation for temporary personnell – Other, e.g. compensation for supervision TOTAL REVENUES

20 794

2 235 1 143 1 092 20 658

EXPENSES PERSONNEL EXPENSES Combined services Cost for AKC private Cost for AKC public Research time public/private OPERATING COSTS IT costs, LU and RS & telephony Travel costs, costs and accommodation Postage, printing, office supplies, advertising Lab material TOTAL COSTS

19 066 3 305 524 1 627 1 339 765 546 50 129 40 19 831

18 895 3 017 497 1 685 1 384 791 499 57 130 105 19 686

360 603

365 533

20 794 0

20 584 74

RENT FOR PREMISES OVERHEADS COSTS TOTAL COSTS SURPLUS/DEFICIT

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PUBLISHED ARTICLES 2018

CPF

FAMILY MEDICINE 1.

Ahmad A, Memon AA, Sundquist J, Svensson, Zöller B, Sundquist K. Fat mass and obesity-associated geners9939609

polymorphism is a potential biomarker of recurrent venous thromboembolism in male but not in female patients.

Gene. 2018 Mar 20;647:136-142.

2.

Ahmad A, Sundquist K, Palmér K, Svensson PJ, Sundquist J, Memon AA. Risk prediction of recurrent venous throm

boembolism: a multiple genetic risk model. J Thromb Thrombolysis. 2018 Oct 27.

3.

Ali M, Ajore R, Wihlborg AK, et al. The multiple myeloma risk allele at 5q15 lowers ELL2 expression and increases

ribosomal gene expression. Nat Commun. 2018 Apr 25;9(1):1649.

4.

Axmon A, Sandberg M, Ahlström G, Midlöv P. Fall-risk-increasing drugs and falls requiring health care among older

people with intellectual disability in comparison with the general population: A register study. PLoS One. 2018 Jun

19;13(6):e0199218

5.

Bandapalli OR, Paramasivam N, Giangiobbe S, et al. Whole genome sequencing reveals DICER1 as a candidate pre

disposing gene in familial Hodgkin lymphoma. Int J Cancer. 2018 Oct 15;143(8):2076-2078.

6.

Bao X, Hanson AL, Madeleine MM, et al. HLA and KIR Associations of Cervical Neoplasia. J Infect Dis.

2018 Nov 5;218(12):2006-2015

7.

Bennet L, Franks PW, Zöller B, Groop L. Family history of diabetes and its relationship with insulin secretion and

insulin sensitivity in Iraqi immigrants and native Swedes: a population-based cohort study. Acta Diabetol. 2018

Mar;55(3):233-242.

8.

Bennet L, Lindström M. Self-rated health and social capital in Iraqi immigrants to Sweden: The MEDIM population-

based study. Scand J Public Health. 2018 Mar;46(2):194-203.

9.

Bjerkeli PJ, Vicente RP, Mulinari S, Johnell K, Merlo J. Overuse of methylphenidate: an analysis of Swedish pharmacy

dispensing data. Clin Epidemiol. 2018 Nov 9;10:1657-1665.

10. Brandt J, Borgquist S, Almgren P, et al. Thyroid-associated genetic polymorphisms in relation to breast cancer risk in

the Malmö Diet and Cancer Study. Int J Cancer. 2018 Apr 1;142(7):1309-1321.

11. Caleres G, Bondesson Å, Midlöv P, Modig S. Elderly at risk in care transitions When discharge summaries are poorly

transferred and used – a descriptive study. BMC Health Serv Res. 2018 Oct 11;18(1):770.

12. Caleres G, Strandberg EL, Bondesson Å, Midlöv P, Modig S. Drugs, distrust and dialogue -a focus group study with

Swedish GPs on discharge summary use in primary care. BMC Fam Pract. 2018 Jul 25;19(1):127.

doi: 10.1186/s12875-018-0804-8.

13. Calling S, Johansson SE, Midlöv P, Memon AA, Sundquist J, Sundquist K. Women's Health in the Lund Area

(WHILA) study. Health problems and acute myocardial infarction in women - A 17-year follow-up study. Maturitas.

2018 Sep;115:45-50.

14. Catalano C, da Silva Filho MI, Frank C. et al. Investigation of single and synergic effects of NLRC5 and PD-L1 variants

on the risk of colorectal cancer. PLoS One. 2018 Feb 6;13(2):e0192385.

15. Catalano C, da Silva Filho MI, Jiraskova K, et al. Short article: Influence of regulatory NLRC5 variants on colorectal

cancer survival and 5-fluorouracil-based chemotherapy. Eur J Gastroenterol Hepatol. 2018 Aug;30(8):838-842.

16. Chattopadhyay S, Thomsen H, da Silva Filho MI, et al. Enrichment of B cell receptor signaling and epidermal growth

factor receptor pathways in monoclonal gammopathy of undetermined significance: a genome-wide genetic

interaction study. Mol Med. 2018 Jun 11;24(1):30

17. Chattopadhyay S, Hemminki O, Försti A, Sundquist K, Sundquist J, Hemminki K. Impact of family history of cancer on ANNUALREPORT2018

risk and mortality of second cancers in patients with prostate cancer. Prostate Cancer Prostatic Dis. 2018 Sep 5.

18. Chattopadhyay S, Sud A, Zheng G, Yu H, Sundquist K, Sundquist J, Försti A, Houlston R, Hemminki A, Hemminki K.

Second primary cancers in non-Hodgkin lymphoma: Bidirectional analyses suggesting role for immune dysfunction.

Int J Cancer. 2018 Nov 15;143(10):2449-2457.

19. Chattopadhyay S, Yu H, Sud A, Sundquist J, Försti A, Hemminki A, Hemminki K. Multiple myeloma: family history and

mortality in second primary cancers. Blood Cancer J. 2018 Aug 7;8(8):75.

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PUBLISHED ARTICLES 2018

CPF

20. Chattopadhyay S, Zheng G, Hemminki O, Försti A, Sundquist K, Hemminki K. Prostate cancer survivors: Risk and

mortality in second primary cancers. Cancer Med. 2018 Oct 1.

21. Chattopadhyay S, Zheng G, Sud A, Yu H, Sundquist K, Sundquist J, Försti A, Hemminki A, Houlston R, Hemminki K.

Risk of second primary cancer following myeloid neoplasia and risk of myeloid neoplasia as second primary cancer: a

nationwide, observational follow up study in Sweden. Lancet Haematol. 2018 Aug;5(8):e368-e377

22. Edwards AC, Ohlsson H, Svikis DS, Sundquist J, Sundquist K, Kendler KS. Protective Effects of Pregnancy on Risk of

Alcohol Use Disorder. Am J Psychiatry. 2018 Nov 29:appiajp201818050632.

23. Ejlertsson L, Heijbel B, Troein M, Brorsson A. Variation, companionship and manageability important for recovery

during working hours: A qualitative focus group study. Work. 2018;61(1):149-156. doi: 10.3233/WOR-182783.

24. Ekvall Hansson E, Beckman A. Fractures among patients with dizziness - a ten-year follow-up. BMC Geriatr. 2018 Feb

2;18(1):35.

25. Ersson A, Beckman A, Jarl J, Borell J. Effects of a multifaceted intervention QI program to improve ICU performance.

BMC Health Serv Res. 2018 Nov 7;18(1):838

26. Funestrand H, Liu R, Lundin S, Troein M. Substandard and falsified medical products are a global public health threat.

A pilot survey of awareness among physicians in Sweden. J Public Health (Oxf). 2018 Jun 1.

27. Garmy P, Clausson EK, Nyberg P, Jakobsson U. Insufficient Sleep Is Associated with Obesity and Excessive Screen

Time Amongst Ten-Year-Old Children in Sweden. J Pediatr Nurs. 2018 Mar - Apr;39:e1-e5.

28. Gielen M, Hageman GJ, Antoniou EE, Nordfjall K, et al. Body mass index is negatively associated with telomere

length: a collaborative cross-sectional meta-analysis of 87 observational studies. Am J Clin Nutr. 2018 Sep

1;108(3):453-475. doi: 10.1093/ajcn/nqy107.

29. Hamano T, Li X, Lönn SL, Nabika T, Sundquist J, Sundquist K. Is familial risk for depression confounded by individual

and familial socioeconomic factors and neighborhood environmental factors? A 7-year follow-up study in Sweden.

Psychiatry Res. 2018 Aug;266:30-35.

30. Hemminki K, Hemminki O, Försti A, Sundquist J, Sundquist K, Li X. Familial Risks Between Urolithiasis and Cancer.

Sci Rep. 2018 Feb 15;8(1):3083.

31. Hemminki K, Hemminki O, Försti A, Sundquist K, Sundquist J, Li X. Familial risks for gallstones in the population of

Sweden. BMJ Open Gastroenterol. 2017 Dec 29;4(1):e000188.

32. Hemminki K, Hemminki O, Koskinen AIM, Försti A, Sundquist K, Sundquist J, Li X. Familial risks in and between stone

diseases: sialolithiasis, urolithiasis and cholelithiasis in the population of Sweden. BMC Nephrol. 2018 Jul 3;19(1):158.

33. Huhn S, da Silva Filho MI, Sanmuganantham T, et al. Coding variants in NOD-like receptors: An association study on

risk and survival of colorectal cancer. PLoS One. 2018 Jun 21;13(6):e0199350.

34. Huss L, Butt ST, Almgren P, et l. SNPs related to vitamin D and breast cancer risk: a case-control study. Breast Cancer

Res. 2018 Jan 2;20(1):1.

35. Ji J, Chen T, Sundquist J, Sundquist K. Type 1 Diabetes in Parents and Risk of Attention Deficit Hyperactivity Disorder

in Offspring: A Population-Based Study in Sweden. Diabetes Care. 2018 Jan 26. pii: dc170592.

36. Ji J, Sundquist J, Sundquist K. Association between post-diagnostic use of cholera vaccine and risk of death in pro

state cancer patients. Nat Commun. 2018 Jun 18;9(1):2367.

37. Ji J, Sundquist J, Sundquist K. Congenital malformation in offspring of female cancer survivors: a national cohort

study. Eur J Cancer Prev. 2018 Jan 24.

study. Eur J Cancer Prev. 2018 Jan 12.

39. Ji J, Sundquist J, Sundquist K. Increased incidence of inguinal hernia in offspring of female survivors of childhood

central nervous system tumors. Int J Cancer. 2018 Feb 24.

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38. Ji J, Sundquist J, Sundquist K. Family history of autoimmune diseases and risk of gastric cancer: a national cohort

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40. Ji J, Sundquist J, Sundquist K. Use of terbinafine and risk of death in patients with prostate cancer: A population-

based cohort study. Int J Cancer. 2018 Sep 27.

41. Junuzovic M, Rietz A, Jakobsson U, Midlöv P, Eriksson A. Firearm deaths in Sweden. Eur J Public Health. 2018 Jul 27. 42. Karriker-Jaffe KJ, Ohlsson H, Kendler KS, Cook WK, Sundquist K. Alcohol availability and onset and recurrence of

alcohol use disorder: Examination in a longitudinal cohort with co-sibling analysis. Alcohol Clin Exp Res. 2018 Apr 18.

43. Kaszuba E, Odeberg H, Råstam L, Halling A. Impact of heart failure and other comorbidities on mortality in patients

with chronic obstructive pulmonary disease: a register-based, prospective cohort study. BMC Fam Pract. 2018 Nov

24;19(1):178. doi: 10.1186/s12875-018-0865-8.

44. Kendler KS, Larsson Lönn S, Salvatore JE, Sundquist J, Sundquist K. The impact of parenthood on risk of registration

for alcohol use disorder in married individuals: a Swedish population-based analysis. Psychol Med. 2018 Oct 25:1-8.

45. Kendler KS, Lönn SL, Salvatore J, Sundquist J, Sundquist K. The Origin of Spousal Resemblance for Alcohol Use

Disorder. JAMA Psychiatry. 2018 Feb 7.

46. Kendler KS, Ohlsson H, Bacanu S, Sundquist J, Sundquist K. The risk for drug abuse, alcohol use disorder, and psy

chosocial dysfunction in offspring from high-density pedigrees: its moderation by personal, family, and community

factors. Mol Psychiatry. 2018 Jun 21.

47. Kendler KS, Ohlsson H, Fagan AA, Lichtenstein P, Sundquist J, Sundquist K. Academic Achievement and Drug Abuse

Risk Assessed Using Instrumental Variable Analysis and Co-relative Designs. JAMA Psychiatry. 2018 Sep 5.

48. Kendler KS, Ohlsson H, Lichtenstein P, Sundquist J, Sundquist K. The Nature of the Shared Environment. Behav

Genet. 2018 Dec 8.

49. Kendler KS, Ohlsson H, Lichtenstein P, Sundquist J, Sundquist K. The Genetic Epidemiology of Treated Major

Depression in Sweden. Am J Psychiatry. 2018 Jul 19:appiajp201817111251. IF=13.391

50. Kendler KS, Ohlsson H, Sundquist K, Sundquist J. Sources of Parent-Offspring Resemblance for Major Depression in

a National Swedish Extended Adoption Study. JAMA Psychiatry. 2018 Feb 1;75(2):194-200.

51. Kharazmi E, Babaei M, Fallah M, Chen T, Sundquist K, Hemminki K. Importance of tumor location and histology in

familial risk of upper gastrointestinal cancers: a nationwide cohort study. Clin Epidemiol. 2018 Sep 4;10:1169-1179.

52. Kharazmi E, Chen T, Fallah M, Sundquist K, Sundquist J, Albin M, Weiderpass E, Hemminki K. Familial risk of pleural

mesothelioma increased drastically in certain occupations: A nationwide prospective cohort study. Eur J Cancer. 2018

Sep 6;103:1-6.

53. Kumar A, Bandapalli OR, Paramasivam N, et al. Familial Cancer Variant Prioritization Pipeline version 2 (FCVPPv2)

applied to a papillary thyroid cancer family. Sci Rep. 2018 Aug 2;8(1):11635.

54. Larsen LB, Sonderlund AL, Sondergaard J, Thomsen JL, Halling A, Hvidt NC, Hvidt EA, Mønsted T, Pedersen LB, Roos

EM, Pedersen PV, Thilsing T. Targeted prevention in primary care aimed at lifestyle-related diseases: a study protocol

for a non-randomised pilot study. BMC Fam Pract. 2018 Jul 21;19(1):124. doi: 10.1186/s12875-018-0820-8.

55. Lenander C, Bondesson Å, Viberg N, Beckman A, Midlöv P. Effects of medication reviews on use of potentially

inappropriate medications in elderly patients; a cross-sectional study in Swedish primary care. BMC Health Serv Res.

2018 Aug 7;18(1):616.

56. Li X, Sjöstedt C, Sundquist J, Zöller B, Sundquist K. Familial association of attention-deficit hyperactivity disorder with

autoimmune diseases in the population of Sweden. Psychiatr Genet. 2018 Nov 6.

57. Li X, Sundquist J, Hamano T, Sundquist K. Family and neighborhood socioeconomic inequality in cryptorchidism and

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hypospadias: A nationwide study from Sweden. Birth Defects Res. 2018 Dec 18.


PUBLISHED ARTICLES 2018

CPF

58. Li X, Sundquist J, Zöller B, Sundquist K. Dementia and Alzheimer's disease risks in patients with autoimmune

disorders. Geriatr Gerontol Int. 2018 Jul 25.

59. Li X, Sundquist J, Zöller B, Sundquist K. Familial Risks of Glaucoma in the Population of Sweden. J Glaucoma. 2018

Jun 26.

60. Lindgren MP, PirouziFard M, Smith JG, Sundquist J, Sundquist K, Zöller B. A Swedish Nationwide Adoption Study of

the Heritability of Heart Failure. JAMA Cardiol. 2018 Jul 11.

61. Lindgren MP, Smith JG, Li X, Sundquist J, Sundquist K, Zöller B. Familial Mortality Risks in Patients With Heart Failure-

A Swedish Sibling Study. J Am Heart Assoc. 2018 Dec 18;7(24):e010181.

62. Long EC, Lönn SL, Sundquist J, Sundquist K, Kendler KS. The role of parent and offspring sex on risk for externalizing

psychopathology in offspring with parental alcohol use disorder: a national Swedish study. Soc Psychiatry Psychiatr

Epidemiol. 2018 Jul 17.

63. Mahmoudpour SH, Bandapalli OR, da Silva Filho MI, et al. Chemotherapy-induced peripheral neuropathy: evi

dence from genome-wide association studies and replication within multiple myeloma patients. BMC Cancer. 2018

Aug 15;18(1):820.

64. McGee EE, Castro FA, Engels EA, et al. Associations between autoimmune conditions and hepatobiliary cancer risk

among elderly US adults. Int J Cancer. 2019 Feb 15;144(4):707-717.

65. Memon AA, Gilliver SC, Borre M, Sundquist J, Sundquist K, Nexo E, Sorensen BS. Soluble HER3 predicts survival in

bladder cancer patients. Oncol Lett. 2018 Feb;15(2):1783-1788.

66. Memon AA, Sundquist K, PirouziFard M, Elf JL, Strandberg K, Svensson PJ, Sundquist J, Zöller B. Identification of

novel diagnostic biomarkers for deep venous thrombosis. Br J Haematol. 2018 Apr 19.

67. Nawagi F, Söderberg M, Berggren V, Midlöv P, Ajambo A, Nakasujja N. Sociodemographic Characteristics and Health

Profile of the Elderly Seeking Health Care in Kampala, Uganda. Curr Gerontol Geriatr Res. 2018 May 16;2018:4147509.

68. Niazi Y, Thomsen H, Smolkova B, et al. Genetic variation associated with chromosomal aberration frequency: A

genome-wide association study. Environ Mol Mutagen. 2019 Jan;60(1):17-28

69. Nymberg P, Ekvall Hansson E, Stenman E, Calling S, Sundquist K, Sundquist J, Zöller B. Pilot study on increased

adherence to physical activity on prescription (PAP) through mindfulness: study protocol. Trials. 2018 Oct 17;19(1):563.

70. Oudin Åström D, Sundquist J, Sundquist K. Differences in declining mortality rates due to coronary heart disease by n

eighbourhood deprivation. J Epidemiol Community Health. 2018 Jan 12. pii: jech-2017-210105

71. Oudin Åström D, Åström C, Forsberg B, Vicedo-Cabrera AM, Gasparrini A, Oudin A, Sundquist K. Heat wave-related

mortality in Sweden: A case-crossover study investigating effect modification by neighbourhood deprivation. Scand J

Public Health. 2018 Sep 26:1403494818801615.

72. Packness A, Halling A, Hastrup LH, Simonsen E, Wehberg S, Waldorff FB. Socioeconomic position, symptoms of

depression and subsequent mental healthcare treatment: a Danish register-based 6-month follow-up study on a

population survey. BMJ Open. 2018 Oct 3;8(10):e020945.

73. Packness A, Waldorff FB, Christensen RD, Hastrup LH, Simonsen E, Vestergaard M, Halling A. Correction to: Impact of

socioeconomic position and distance on mental health care utilization: a nationwide Danish follow-up study. Soc

Psychiatry Psychiatr Epidemiol. 2018 Jul 10.

74. Rajabi M, Mansourian A, Pilesjö P, Åström DO, Cederin K, Sundquist K. Exploring spatial patterns of cardiovascular

disease in Sweden between 2000 and 2010. Scand J Public Health. 2018 Aug;46(6):647-658.

75. Ranstad K, Midlöv P, Halling A. Active listing and more consultations in primary care are associated with shorter mean

hospitalisation and interacting with psychiatric disorders when adjusting for multimorbidity, age and sex. Scand J Prim

Health Care. 2018 Sep;36(3):308-316. ANNUALREPORT2018

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76. Ranstad K, Midlöv P, Halling A. Active listing and more consultations in primary care are associated with reduced

hospitalisation in a Swedish population. BMC Health Serv Res. 2018 Feb 9;18(1):101

77. Riihimäki M, Thomsen H, Sundquist K, Sundquist J, Hemminki K. Clinical landscape of cancer metastases. Cancer

Med. 2018 Oct 16.

78. Rosengren P, Li X, Sundquist J, Sundquist K, Zöller B. Hospitalization rate of paroxysmal supraventricular tachycardia

in Sweden. Ann Med. 2018 Sep 7:1-29.

79. Saha S, Jarl J, Gerdtham UG, Sundquist K, Sundquist J. Economic evaluation of mindfulness group therapy for

patients with depression, anxiety, stress and adjustment disorders compared with treatment as usual. Br J Psychiatry.

2018 Nov 23:1-7.

80. Salvatore JE, Larsson Lönn S, Sundquist J, Sundquist K, Kendler KS. Genetics, the Rearing Environment, and the

Intergenerational Transmission of Divorce: A Swedish National Adoption Study. Psychol Sci. 2018

Jan 1:956797617734864.

81. Salvatore JE, Lönn SL, Long EC, Sundquist J, Kendler KS, Sundquist K, Edwards AC. Parental Alcohol Use Disorder

and Offspring Marital Outcomes. Addiction. 2018 Jul 31.

82. Sud A, Chattopadhyay S, Thomsen H, Sundquist K, Sundquist J, Houlston RS, Hemminki K. Familial risks of primary

myeloid leukemia, myelodysplasia and myeloproliferative neoplasms. Blood. 2018 Jul 10. pii: blood-2018-06-858597.

83. Sud A, Thomsen H, Orlando G, et al. Genome-wide association study implicates immune dysfunction in the

development of Hodgkin lymphoma. Blood. 2018 Nov 8;132(19):2040-2052.

84. Sundquist J, Palmér K, Memon AA, Wang X, Johansson LM, Sundquist K. Long-term improvements after mindfulness-

based group therapy of depression, anxiety and stress and adjustment disorders: A randomized controlled trial. Early

Interv Psychiatry. 2018 Jul 3.

85. Sundquist K, Ahmad A, Svensson PJ, Zöller B, Sundquist J, Memon AA. Polymorphisms in PARK2 and MRPL37 are

associated with higher risk of recurrent venous thromboembolism in a sex-specific manner. J Thromb Thrombolysis.

2018 Apr 18.

86. Traulsen LK, Halling A, Bælum J, Davidsen JR, Miller M, Omland Ø, Sherson D, Sigsgaard T, Thilsing T, Thomsen G,

Skadhauge LR. Determinants of persistent asthma in young adults. Eur Clin Respir J. 2018 Jun 5;5(1):1478593.

87. Vijayakrishnan J, Studd J, Broderick P, et al. Genome-wide association study identifies susceptibility loci for B-cell

childhood acute lymphoblastic leukemia. Nat Commun. 2018 Apr 9;9(1):1340.

88. Wang X, Sundquist K, Palmér K, Hedelius A, Memon A, Sundquist J. Macrophage Migration Inhibitory Factor and

microRNA-451a in Response to Mindfulness-Based Therapy or Treatment as usual in Patients with Depression,

Anxiety or Stress- and Adjustment Disorders. Int J Neuropsychopharmacol. 2018 Jan 24

89. Watari T, Hirose M, Midlöv P, Okayama M, Yoshikawa H, Onigata K, Igawa M. Japan can learn from the Swedish

primary care doctor fostering system. J Gen Fam Med. 2018 Jul 28;19(5):183-184.

90. Went M, Sud A, Försti A, et al. Identification of multiple risk loci and regulatory mechanisms influencing susceptibility

to multiple myeloma. Nat Commun. 2018 Sep 13;9(1):3707.

91. Went M, Sud A, Speedy H. et al. Genetic correlation between multiple myeloma and chronic lymphocytic leukaemia

provides evidence for shared aetiology. Blood Cancer J. 2018 Dec 21;9(1):1.

92. Westerlind B, Östgren CJ, Mölstad S, Midlöv P, Hägg S. Use of non-benzodiazepine hypnotics is associated with falls

in nursing home residents: a longitudinal cohort study. Aging Clin Exp Res. 2018 Oct 19.

93. Wickström HL, Öien RF, Fagerström C, Anderberg P, Jakobsson U, Midlöv PJ. Comparing video consultation with

inperson assessment for Swedish patients with hard-to-heal ulcers: registry-based studies of healing time and of

waiting time. BMJ Open. 2018 Feb 15;8(2):e017623.

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94. Wändell P, Carlsson AC, Gasevic D, Holzmann MJ, Ärnlöv J, Sundquist J, Sundquist K. Socioeconomic factors and

mortality in patients with atrial fibrillation-a cohort study in Swedish primary care. Eur J Public Health. 2018 May 9.

95. Wändell P, Carlsson AC, Holzmann MJ, Ärnlöv J, Sundquist J, Sundquist K. Associations between relevant cardio

vascular pharmacotherapies and incident heart failure in patients with atrial fibrillation: a cohort study in primary

care. J Hypertens. 2018 Jun 4

96. Wändell P, Carlsson AC, Holzmann MJ, Ärnlöv J, Sundquist J, Sundquist K. The association between relevant co-

morbidities and prevalent as well as incident heart failure in patients with atrial fibrillation. J Cardiol. 2018 Jan 18. pii:

S0914-5087(18)30003-0.

97. Wändell P, Carlsson AC, Holzmann MJ, Ärnlöv J, Sundquist J, Sundquist K. Mortality in patients with atrial fibrillation

and common co-morbidities - a cohort study in primary care. Ann Med. 2018 Mar;50(2):156-163.

98. Wändell P, Carlsson AC, Li X, Gasevic D, Ärnlöv J, Holzmann MJ, Sundquist J, Sundquist K. Heart failure in immigrant

groups: a cohort study of adults aged 45 years and over in Sweden. Scand Cardiovasc J. 2018 Nov 16:1-23.

99. Wändell P, Carlsson AC, Li X, Gasevic D, Ärnlöv J, Holzmann MJ, Sundquist J, Sundquist K. Atrial fibrillation in im

migrants under the age of 45 y in Sweden. Int Health. 2018 Oct 26.

100. Wändell P, Carlsson AC, Sundquist J, Sundquist K. Antihypertensive drugs and relevant cardiovascular pharma

cotherapies and the risk of incident dementia in patients with atrial fibrillation. Int J Cardiol. 2018 Jul 21. pii: S0167-

5273(18)32760-8.

101. Wändell P, Carlsson AC, Sundquist J, Sundquist K. Effect of Levothyroxine Treatment on Incident Dementia in Adults

with Atrial Fibrillation and Hypothyroidism. Clin Drug Investig. 2018 Dec 14.

102. Wändell P, Carlsson AC, Sundquist J, Sundquist K. The association between relevant comorbidities and dementia in

patients with atrial fibrillation. Geroscience. 2018 Jun 22.

103. Yadav P, Merz M, Mai EK, et al. Cytogenetic aberrations in multiple myeloma are associated with shifts in serum im

munoglobulin isotypes distribution and levels. Haematologica. 2018 Apr;103(4):e162-e164.

104. Zhang L, Yu H, Hemminki O, Försti A, Sundquist K, Hemminki K. Familial Associations in Testicular Cancer with Other

Cancers. Sci Rep. 2018 Jul 18;8(1):10880.

105. Zheng G, Chattopadhyay S, Försti A, Sundquist K, Hemminki K. Familial risks of second primary cancers and

mortality in ovarian cancer patients. Clin Epidemiol. 2018 Oct 11;10:1457-1466.

106. Zheng G, Hemminki A, Försti A, Sundquist J, Sundquist K, Hemminki K. Second primary cancer after female breast

cancer: Familial risks and cause of death. Cancer Med. 2018 Nov 26.

107. Zheng G, Yu H, Kanerva A, Försti A, Sundquist K, Hemminki K. Borderline ovarian tumors share familial risks with

itself and invasive cancers. Cancer Epidemiol Biomarkers Prev. 2018 Jul 17. pii: cebp.0503.2018.

108. Zheng G, Yu H, Kanerva A, Försti A, Sundquist K, Hemminki K. Familial risks of ovarian cancer by age at diagnosis,

proband type and histology. PLoS One. 2018 Oct 3;13(10):e0205000.

109. Zheng G, Yu H, Kanerva A, Försti A, Sundquist K, Hemminki K. Familial Ovarian Cancer Clusters with Other Cancers.

Sci Rep. 2018 Aug 1;8(1):11561.

110. Zöller B, Melander O, Svensson PJ, Engström G. Factor V Leiden paradox in a middle-aged Swedish population: A

prospective study. Vasc Med. 2018 Feb;23(1):52-59.

111. Zöller B, Ohlsson H, Waehrens R, Sundquist J, Sundquist K. Association of irritable bowel syndrome and venous

thromboembolism. Scand J Gastroenterol. 2018 Jun - Jul;53(7):784-789.

112. Zöller B. Prevalence and in silico analysis of missense mutations in the PROS1 gene in the Swedish population: The

SweGen dataset. Thromb Res. 2018 Aug;168:28-30. ANNUALREPORT2018

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PUBLIC HEALTH AND HEALTH ECONOMICS 113. Axelsson Fisk S, Mulinari S, Wemrell M, Leckie G, Perez Vicente R, Merlo J. Chronic Obstructive Pulmonary Disease in Sweden: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy. SSM Popul Health. 2018 Mar 20;4:334-346 114. Christian CS, Gerdtham UG, Hompashe D, Smith A, Burger R. Measuring Quality Gaps in TB Screening in South Africa Using Standardised Patient Analysis. Int J Environ Res Public Health. 2018 Apr 12;15(4). pii: E729. 115. Fridh M, Lindström M, Rosvall M. Associations between self-injury and involvement in cyberbullying among mentally distressed adolescents in Scania, Sweden. Scand J Public Health. 2018 May 1:1403494818779321. 116. Hernández-Yumar A, Wemrell M, Abásolo Alessón I, González López-Valcárcel B, Leckie G, Merlo J. Socioeconomic differences in body mass index in Spain: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy. PLoS One. 2018 Dec 10;13(12):e0208624. 117. Jarl J, Desatnik P, Peetz Hansson U, Prütz KG, Gerdtham UG. Do kidney transplantations save money? A study using a before- after design and multiple register-based data from Sweden. Clin Kidney J. 2018 Apr;11(2):283-288. 118. Jarl J, Gerdtham UG, Desatnik P, Prütz KG. Effects of Kidney Transplantation on Labor Market Outcomes in Sweden. Transplantation. 2018 Aug;102(8):1375-1381. 119. Lindström C, Rosvall M, Lindström M. Differences in unmet healthcare needs between public and private primary care providers: A population-based study. Scand J Public Health. 2018 Mar 1:1403494818762983. 120. Lindström M, Rosvall M. Addictive behaviors, social and psychosocial factors, and electronic cigarette use among adolescents: a population-based study. Public Health. 2018 Feb;155:129-132. 121. Lindström M, Rosvall M. Economic stress and low leisure-time physical activity: Two life course hypotheses. SSM Popul Health. 2018 Apr 16;4:358-364 122. Lindström M, Rosvall M. Economic stress in childhood and suicide thoughts and suicide attempts: a population-based study among adults. Public Health. 2018 Oct;163:42-45. 123. Lorenz MW, Gao L, Ziegelbauer K, et al.Predictive value for cardiovascular events of common carotid intima media thickness and its rate of change in individuals at high cardiovascular risk - Results from the PROG-IMT collaboration.PLoS One. 2018 Apr 12;13(4):e0191172. 124. Merlo J, Wagner P, Austin PC, Subramanian SV, Leckie G. General and specific contextual effects in multilevel regression analyses and their paradoxical relationship: A conceptual tutorial. SSM Popul Health. 2018 May 19;5:33-37.

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125. Persson S, Dahlquist G, Gerdtham UG, Steen Carlsson K; Swedish Childhood Diabetes Study Group. Why childhood-onset type 1 diabetes impacts labour market outcomes: a mediation analysis. Diabetologia. 2018 Feb;61(2):342-353. 126. Psouni E, Perez Vicente R, Dahlin LB, Merlo J. Psychotropic drug use as indicator of mental health in adolescents affected by a plexus injury at birth: A large population-based study in Sweden. PLoS One. 2018 Mar 21;13(3):e0193635. 127. Saha S, Bejerholm U, Gerdtham UG, Jarl J. Cost-effectiveness of supported employment adapted for people with affective disorders. Nord J Psychiatry. 2018 Apr;72(3):236-239 128. Saha S, Gerdtham UG, Siddiqui F, Bennet L. Valuing a Lifestyle Intervention for Middle Eastern Immigrants at Risk of Diabetes. Int J Environ Res Public Health. 2018 Feb 27;15(3). pii: E413. 129. Saha S, Grahn B, Gerdtham UG, Stigmar K, Holmberg S, Jarl J. Structured physiotherapy including a work place intervention for patients with neck and/or back pain in primary care: an economic evaluation. Eur J Health Econ. 2018 Aug 31. 130. Salami F, Lee HS, Freyhult E, Elding Larsson H, Lernmark ร…, Tรถrn C; TEDDY Study Group. Reduction in White Blood Cell, Neutrophil, and Red Blood Cell Counts Related to Sex, HLA, and Islet Autoantibodies in Swedish TEDDY Children at Increased Risk for Type 1 Diabetes. Diabetes. 2018 Nov;67(11):2329-2336. 131. Siddiqui F, Koivula RW, Kurbasic A, Lindblad U, Nilsson PM, Bennet L. Physical Activity in a Randomized Culturally Adapted Lifestyle Intervention. Am J Prev Med. 2018 Aug;55(2):187-196. 132. von Schreeb S, Merlo J, Psouni E. Natural frequencies improved diagnostic inference among medical students i Sweden Lakartidningen. 2018 Mar 16;115 133. Zettermark S, Perez Vicente R, Merlo J. Hormonal contraception increases the risk of psychotropic drug use in adolescent girls but not in adults: A pharmacoepidemiological study on 800 000 Swedish women. PLoS One. 2018 Mar 22;13(3):e0194773. 134. Zhang Y, Gerdtham UG, Rydell H, Jarl J. Socioeconomic Inequalities in the Kidney Transplantation Process: A Registry-Based Study in Sweden. Transplant Direct. 2018 Feb 2;4(2):e346.

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CPF

KCP


Annual Report 2018 CPF, Center for Primary Healthcare Research KCP, Competence Center for Primary Care in Sküne www.cpf.se www.vardgivare.skane.se/kompetens-utveckling/ sakkunniggrupper/primarvard-i-skane/ Š

CPF & KCP

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Profile for Center for Primary Health Care Research

Annual Report CPF · KCP 2018  

Established in 2008 as a collaborative venture between Region Skåne and Lund University, the Center for Primary Health Care Research (CPF) i...

Annual Report CPF · KCP 2018  

Established in 2008 as a collaborative venture between Region Skåne and Lund University, the Center for Primary Health Care Research (CPF) i...