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Atypical fracture of the femur is a well-documented adverse reaction to antiresorptive treatment with bisphosphonates. Although there has been significant gain of knowledge during the past decade, the pathogenesis of this type of fracture is still poorly understood. We present an update on the evidence in regard to epidemiology, pathophysiology, and management of atypical fractures.

There is evidence that Continuous Medical Education (CME) can improve patient outcomes. Interventions involving bundles of activities, such as evidence based routines, new skills and team training of the skills and routines seem to be effective. There is some evidence that healthy staff delivers better care, and that burn-out can be a risk to patients as well as staff. To increase quality and better enforce the need for CME we suggest that education should be part of quality and patient safety organizations.

Driving is the preferred mode for transportation in many parts of the world and may also be the only available alternative. The driver's ability may however be disturbed by many medical conditions. The visual requirements for driving in Sweden is based on the third European driving license directive but also adds more specified requirements of visual field, related to the methods used in health care. On the other hand Sweden has no regular testing of the visual acuity among elderly. Physicians in Sweden are obliged to report unsuitable drivers to the state. Dispensations from the visual field requirements are possible after a positive statement from a medical authority and a successful test in a driving simulator. This test is expensive for the patient (2 000 euro) and only available at one site. Future research of data from the simulations could hopefully create more evidence-based visual requirements to distinguish safe from unsafe drivers.

Stroke rehabilitation has often been based on tradition instead of evidence-based methods in the clinical practice. The recently updated Swedish national stroke guidelines have emphasized the amount of evidence-based stroke rehabilitation that is expected to be implemented in clinical practice. The most important recommendations in regarding stroke rehabilitation are the early support discharge, a structured follow-up at the subacute stage for identifying unmet rehabilitation needs and high intensity task-specific training from early to chronic phases. Meanwhile, we have to use the resource in a most cost-effective ways, such as a newly developed Rehab-Compass, group education for patients and caregivers ("stroke school") and sufficient number of employees of different occupational groups including rehab-assistants, to provide stroke survivors more evidence-based rehabilitation. These inputs will not only improve quality of stroke care but also save the medical and community resource in the near future.

The evidence for the clinical and economical effectiveness of consultation-liaison psychiatry has increased considerably in recent years. However, the development of consultation-liaison psychiatry services in Sweden is lagging behind other countries. Therefore, this article outlines the current state of service development, the potentials of consultation-liaison psychiatry, and the prerequisites for change. Politicians, commissioners and important stakeholders have to realize the potential of a better integration of psychological and physical medicine if the vision of a person-centred and equal care is going to be realised.

One third of all persons attending primary care present mental health issues, and psychiatric diagnoses accounts for 45 % of sick pay in Sweden. It is important that cooperation between primary care and specialized psychiatry units function seamlessly, ensuring patients with mental disorders health care on an adequate level. The cooperation between primary care and specialized psychiatry must become more patient focused, effective and safe. There is an evidence based model for cooperation between primary care and specialized psychiatry not yet tried out in Sweden, the Collaborative Care Model. A national project for validation of the Collaborative Care Model in a Swedish health care setting is planned to be launched by initiative of the Swedish Association of Local Authorities and Regions.

Scrutiny of pulmonary metastasectomy Patients fulfilling the criteria for pulmonary metastasectomy are heavily selected, belong to the benign end of the malignancy spectrum and have automatically a favourable survival. The current five-year survival of 40% is probably due to selection mechanisms, and the possible contribution of surgery is not proven. Further studies are necessary. Sweden seems to have uniquely good conditions to make the necessary investigations.

Medical simulation training - an overview of the evidence Medical simulation training has become an important model for training of technical and non-technical clinical skills, aiming at preventing avoidable mistakes. The evidence for effects of simulation training is increasing, and several systematic reviews on the effect of medical simulation training have been published. This article summarizes the evidence for medical simulation training based on systematic reviews of medical simulation published in the last three years. There is a consistent finding in all systematic reviews that simulation training has a positive effect on learning and skills transfer, and small positive effects on patient-related outcomes. However, there is considerable uncertainty about the strength of evidence of this research, and all systematic reviews reported serious weaknesses in research methods of the included studies. We hope that the newly published guidelines for study design and reporting of medical simulation research can help create a stronger evidence base.

Behind blue eyes - the evidence for ocular nutritional supplements on the Swedish market Health claims for food are harmonized in the European Union by the European Food Safety Authority (EFSA). Nutritional supplements containing vitamin A or B, docosahexaenoic acid or zinc are allowed to state in their marketing that they preserve vision. This decision is based only on studies of cell metabolism and deficiency diseases and not on clinical interventions. A preventive effect on progression of age-related macular degeneration has however been proven with the AREDS-formula, with an absolute risk reduction for severe visual loss of 6% in certain groups. This treatment may however be associated with considerable side effects. Only 2 of the 25 nutritional supplements for preserved vision available on the Swedish market today follows the AREDS-formula. The present marking of ocular nutritional supplements might therefore be misleading for the customer.

Robot-assisted surgery on a broad front - without evidence for being cost-effective Robot-assisted surgery is currently heavily marketed. The HTA centre in Region Västra Götaland has produced five HTA reports regarding use of robot-assisted surgery in different clinical situations (prostatic cancer, benign gynaecological surgery, pediatric pyeloplasty and fundoplication, and rectal cancer), finding weak evidence for a patient value. The current report by Per Carlsson et al confirms that robot-assisted surgery indeed leads to increased costs that are not balanced by augmented patient value, i.e. robot-assisted surgery cannot be regarded as cost efficient. We comment critically on the capricious introduction of new techniques/devices, a procedure that stands in sharp contrast to the strictly formalized system for approval of new drugs.

There are three main points (guidelines, patient safety and taboo of suicide) in the article. Guidelines for meeting suicidal patients presented by the Aeschi group are now available. These are based on the psychology of suicidality and are in line with the issue of client-centeredness in health care. To view suicidality as a patient safety issue also means that suicidal acts can be understood as a form of accident. The taboo of suicide has decreased, which has opened new doors for research.

Bed rest is often prescribed as part of the treatment plan for women with preterm premature rupture of membranes in the hope of avoid-ing premature birth. The purpose of this study was to determine the routine care of these patients in Swedish hospitals.A survey was sent to all hospitals in Sweden with an obstetrics department (n=45). Out of these, 31 answered our survey (69 %). The women were separated into three groups depending on gestation length (22+0-26+6, 27+0-32+6 and 33+0-36+6).Most hospitals chose to admit the women and to recommend total or partial bed rest. The earlier in the pregnancy the rupture occurred, the more likely the patient was to be confined to total bed rest.The study shows that this topic is controversial. Most hospitals use bed rest even though there is no evidence to support that it is of benefit for the patient. More studies in this area are required in order to find an optimal treatment for this patient group.

During recent decades there has been a rapidly growing interest in youths' sedentary behaviour and its association with cardio-metabolic health. Currently there is little-to-no evidence for a cross-sectional and longitudinal association between volume and pattern (bouts and breaks) of objectively measured sedentary behavior and body weight in youth. Likewise, there is little-to-no evidence for a cross-sectional association between volume and pattern of objectively measured sedentary behavior and other markers for cardio-metabolic risk in youth. However, there is sufficient evidence for a cross-sectional and longitudinal association between screen-time and body weight and blood pressure and blood lipids. Furthermore, there is evidence for a cross-sectional association between youths' screen-time and clustered metabolic risk and insulin resistance. Overall, the level of evidence was low and, therefore, caution is required when interpreting the results.

Decreased sexual activity among cardiac patients is frequently reported. Rates of erectile dysfunction among men with cardiovascular disease (CVD) are twice as high as those in the general population with similar rates of sexual dysfunction in females with CVD. Returning to sexual activity is a common concern, and patients frequently request information on how to resume sexual activity. Partners also have considerable concerns, often more so than patients; why sexual counseling is important for both cardiac patients and their partners. In general, healthcare professionals, in caring for patients recognize the importance of discussing sexual function and activity and also express their responsibility to do so, although many healthcare professionals do not know what specific advice to give. Therefore, the intent of a consensus statement made by the American and European heart associations is to summarize current evidence related to sexual counseling in cardiovascular disease, and to provide direction to physicians, nurses, and other healthcare professionals in the practice of sexual counseling.