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David Nygren,1 Ulrica Mölstad,2 Hans Thulesius,2– 4 Magnus Hillman,5,6 Lars Mikael Broman,7,8 Hanan Tanash,9,10 Mona Landin-Olsson,5,6 Magnus Rasmussen,1 Maria Thunander2,6,11 1Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden; 2Department of Research and Development, Health Care Region Kronoberg, Växjö, Sweden; 3Department of Medicine and Optometry, Linnaeus University, Växjö, Sweden; 4Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden; 5Diabetes Research Laboratory, Biomedical Center, Lund University, Lund, Sweden; 6Department of Clinical Sciences, Endocrinology and Diabetes, Lund University, Lund, Sweden; 7ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; 8Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; 9Department of Clinical Sciences, Respiratory Medicine, Lund University, Malmö, Sweden; 10Department of Respiratory Medicine, Skåne University Hospital, Malmö, Sweden; 11Department of Internal Medicine, Endocrinology, Växjö Central Hospital, Växjö, SwedenCorrespondence: David Nygren, Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden, Tel +4646171192, Fax +4646176002, Email david.nygren@med.lu.seIntroduction: Alpha-1-antitrypsin (AAT) has been shown to inhibit SARS-CoV-2 cell entry and suggested as a therapeutic agent for COVID-19. Furthermore, epidemiological association of high prevalence of Alpha-1-antitrypsin deficiency (AATD) and regional severity of COVID-19-impact has been hypothesized. In our study setting, the estimated prevalence rates of mild (PI*MZ, PI*SS or PI*MS) and moderate-to-severe AATD (PI*ZZ or PI*SZ) are high, 9% and 0.2%, respectively. Our primary aim was to examine the prevalence rate of AATD among hospitalized COVID-19-patients.Methods: In this prospective observational study, enrollment occurred from December 2020 to January 2021 in two COVID-19-units at Skåne University Hospital, Lund, Sweden. Case definition was a patient hospitalized due to COVID-19. Patients were screened for AATD with PI-typing and if results were inconclusive, PCR for the S- and Z-genes were performed. Patients were categorized as severe or moderate COVID-19 and 30-day-mortality data were collected. The primary outcome was prevalence rate of AATD. The secondary outcome investigated association between presence of mild AATD and severe COVID-19.Results: We enrolled 61 patients with COVID-19. Two patients out of 61 (3%) had mild AATD (PI*MZ) and none had moderate-to-severe AATD. 30/61 (49%) had severe COVID-19. Both patients with mild AATD developed severe COVID-19. Yet, presence of AATD was not significantly associated with severe COVID-19 (p=0.24).Conclusion: Mild AATD (PI*MS or PI*MZ) was rare in a small cohort of hospitalized patients with COVID-19 in a study setting with a high background prevalence of AATD.Keywords: alpha-1-antitrypsin, alpha-1-antitrypsin deficiency, COVID-19, SARS-CoV-2, PI-typing, SERPINA1

Anna Segernäs,1,&ast; Johan Skoog,2,&ast; Eva Ahlgren Andersson,3 Sofia Almerud Österberg,4,5 Hans Thulesius,6,7,&ast; Helene Zachrisson2,&ast; 1Primary Health Care Center Ekholmen in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; 2Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; 3Department of Thoracic Surgery and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; 4Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden; 5Department of Research and Development, Region Kronoberg, Växjö, Sweden; 6Department of Clinical Sciences, Malmö, Faculty of Medicine, Lunds University, Lund, Sweden; 7Department of Medicine and Optometry, Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden&ast;These authors contributed equally to this workCorrespondence: Johan Skoog, Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden, Tel +46 10 103 00 00, Email johan.skoog@liu.sePurpose: To evaluate if preoperative assessment with A Quick Test of Cognitive Speed (AQT) could increase the accuracy of predicting delirium after cardiac surgery compared to Mini-Mental State Examination (MMSE), and examine if a composite of variables, including cognitive function and depressive symptoms, could be useful to predict delirium.Patients and Methods: Cardiac surgery was performed in 218 patients (mean age 72 years). Preoperative evaluation involved AQT, MMSE and Hospital Anxiety And Depression Scale (HADS). Postoperative delirium was assessed using Nursing Delirium Screening Scale (Nu-DESC) and Confusion Assessment Method-ICU (CAM-ICU). Logistic regression was performed to detect predictors of postoperative delirium and receiver operator characteristic curves (ROC) with area under the curve (AUC) to determine the accuracy.Results: Postoperative delirium occurred in 47 patients (22%) who had lower MMSE scores (median (range), 27 (19– 30) vs 28 (20– 30), p=0.009) and slower AQT (median (range), 76 (48– 181) vs 70 (40– 182) seconds, p=0.030) than patients without delirium. Predictive power measured as AUC (95% CI) was 0.605 (0.51– 0.70) for AQT and 0.623 (0.53– 0.72) for MMSE. Logistic regression (OR, 95% CI) showed MMSE < 27 points (2.72, 1.27– 5.86), AQT > 70 sec (2.26, 1.03– 4.95), HADS-D > 4 points (2.60, 1.21– 5.58) and longer cardiopulmonary bypass-time (1.007, 1.002– 1.013) to be associated with postoperative delirium. Combining these parameters yielded an AUC of 0.736 (0.65– 0.82).Conclusion: The ability of predicting delirium using AQT was similar to MMSE, and only slightly higher by combining AQT and MMSE. Adding HADS-D and cardiopulmonary bypass-time to MMSE and AQT increased the predictive power to a borderline acceptable discriminatory value. Preoperative cognitive tests and screening for depressive symptoms may help identify patients at risk of postoperative delirium. Yet, there is still a need to establish useful preoperative tests.Keywords: postoperative delirium, cardiopulmonary bypass, Mini Mental State Examination, A Quick Test of Cognitive Speed, The Hospital Anxiety and Depression Scale

Miriam Pikkemaat,1,2 Hans Thulesius,1,3 Veronica Milos Nymberg1,2 1Department of Clinical Sciences, Lund University, Malmö, Sweden; 2CPF, Centre for Primary Healthcare Research, Malmö, Sweden; 3Linnaeus University, Kalmar, SwedenCorrespondence: Veronica Milos NymbergClinical Research Centre (CRC), Skåne University Hospital, Building 28, Floor 11, Jan Waldenströms Street 35, Malmö, 205 02, SwedenTel +46-767700240Email veronica.milos_nymberg@med.lu.seBackground: Research on intentions to use telemedicine in primary care is sparse. This survey study explored primary care physicians’ intentions to use telemedicine by using a newly developed questionnaire: Physician Attitudes and Intentions to use Telemedicine.Methods: An anonymous web-survey with questions focusing on theory-based predictors of behavioral intentions such as Attitudes, Subjective norms and Perceived behavioral control was designed, validated, and sent to all primary care physicians at 160 primary health care centers in southern Sweden from May to August 2019. The questionnaire had 29 subject items (including 49 multiple-choice sub-items). Main outcome measures were intentions to use three domains of telemedicine and correlation between theory-based predictors and behavioral intentions for using telemedicine.Results: The survey was validated by an expert group, amended, and then tested and retested. A majority of the 198 physicians who returned the web-surveys reported that they did not use e-mails (68%), nor video consultations (78%), chat (81%), or text messages (86%) in their everyday patient work. Yet, most physicians described a positive intention to use telemedicine in patient care for all three studied domains with Attitudes and Perceived behavioral control being significant predictors (p< 0.01) for Intentions to use digital contacts (R2 = 0.54), chronic disease monitoring with digital tools (R2 = 0.47) and artificial intelligence (R2 = 0.54). A structural validation of a preliminary instrument – Physician Attitudes and Intention to use Telemedicine (PAIT) – containing 28 sub-items was done by exploratory factor analysis with acceptable explanatory, reliability and sampling adequacy measures. Five factors emerged with Eigenvalues between 1.6 and 11.1 explaining 72% of the variance. Total Cronbach’s alpha was 0.91 and Kaiser-Meyer-Olkirk 0.79.Conclusion: Before the covid-19 pandemic, Swedish primary care physicians reported a low use yet high behavioral intention to use telemedicine in a study where we developed the preliminary instrument Physician Attitudes and Intention to use Telemedicine. Perceived behavioral control had the largest predictive value of behavioral intention to use telemedicine. Thus, interventions aiming to increase the use of digital tools in primary care should possibly focus on empowering physicians’ self-efficacy towards using them.Keywords: telemedicine, survey, primary care, theory of planned behavior

Objectives: To describe changes in Swedish primary care physicians' use of, attitudes and intentions toward digital tools in patient care between 2019 and 2022., Design: A survey using a validated questionnaire measuring physician's intentions to use digital tools based on the theory of planned behavior., Setting: Sample of primary health care centers in southern Sweden., Subjects: Primary care physicians., Main Outcome Measures: Self-reported use and intentions to use, digital tools including digital consultations by text or video, chronic disease monitoring and artificial intelligence (AI) and the associations between attitudes, subjective norms, perceived behavioral control and behavioral intentions to use digital tools, in 2019 compared to 2022., Results: In both 2019 ( n  = 198) and 2022 ( n  = 93), physicians reported high intentions to use digital tools. Self-reported use of video was slightly higher in 2022 ( p  = .03). No other changes were seen in the self-reported use or behavioral intentions to use digital tools., Conclusion: The slow adoption of patient-related digital tools in Swedish primary health care does not seem to be explained by a low intention to use them among physicians. Future research on implementation of digital tools should include a focus on contextual factors such as organizational, technical and cultural barriers.

Aim: To describe nurses' experiences of ethical challenges in relation to thirst in terminally ill patients in specialist palliative care units., Research Design: A qualitative, reflexive thematic design with an inductive analysis was used., Participants and Research Context: Eighteen qualitative interviews with nurses working in six different specialist palliative care units in different hospitals in Sweden were conducted. The interviews were transcribed verbatim and analysed with a reflexive thematic analysis., Results: This study identified four themes that reflect ethical challenges experienced by nurses in the palliative care regarding thirst: Harmful infusions interfere with peaceful dying; conflict between tradition and personal experience; What is the right intervention to quench thirst? and; Lack of standard procedures, competence and interest among team members., Conclusion: Palliative care nurses experience a number ethical challenges in relation to thirst in dying patients. The main challenge is the provision of fluids to dying patients via artificial infusions, which nurses struggle with, as they do not want to interfere with a peaceful dying process., (© 2024. The Author(s).)

The use of digital technologies to deliver primary health care has increased over the past decade. While some technologies have been shown to be medically effective and efficient, the effects of digital primary care on the policy goal of equality in the use of such types of care have not been studied using large register data. The aim of this study was to analyse how digital contacts differ from officebased visits by income as an indicator of socioeconomic status. Specifically, we estimated differences in primary care utilization across income, factors of contribution to these inequalities, and applied a needs-based standardisation of utilization to estimate differences in equity.We used a purposively built consultation level dataset with 726 000 Swedish adult patients diagnosed with an infection, including clinical and sociodemographic variables. Applying concentration indexes (CI) and graphical illustrations we measured how the two types of services are distributed relative to income. We estimated how much of the inequalities were attributed to different sociodemographic factors by decomposing the concentration indexes. Standardised utilization for sex, age and comorbidity allowed for the estimation of horizontal inequity indexes for both types of services.Utilization by the two types of care showed large income inequalities. Office-based visits were propoor (CI -0.116), meaning lowincome patients utilized relatively more of these services, while digital contacts were prorich (CI 0.205). However, within the patient group who had at least one digital contact, the utilization was also propoor (CI -0,101), although these patients had higher incomes on average. The standardised utilization showed a smaller prorich digital utilization (CI 0.143), although large differences remained. Decomposing the concentration indexes showed that education level and being born in Sweden were strong attributes of prorich digital service utilization.The prorich utilization effects of digital primary care may risk undermining the policy goals of access and utilization to services regardless of socioeconomic status. As digital health technologies continue to expand, policy makers need to be aware of the risk., (© 2024. The Author(s).)

Introduction: Enhancing treatment adherence, especially for chronic diseases, can be achieved through therapeutic alliance, potentially elevating the quality of care. An instrument to evaluate the therapeutic alliance could be beneficial in routine clinical settings, educational environments, and extensive research efforts at national and European levels. In this study, we translated therapist and patient versions of the Working Alliance Inventory Short Revised (WAI-SR) into Italian., Methodology: An email-based Delphi method was employed for the English-to-Italian translation, incorporating a forward-backward process. The initial translation team comprised two Italian family physicians proficient in English, a linguist, and a psychiatrist. The forward translation was then reviewed by 18 Italian family physicians through a Delphi process and was subjected to a backward translation by two Italian English teachers. A cultural correspondence was subsequently identified to adjust translations within a national and international framework., Results: All 18 experts fully engaged in the Delphi process, and consensus was achieved by the second Delphi round. A cultural check checked for discrepancies regarding linguistic consistency with other translations and found no difference., Conclusion: This Italian translation of the WAI-SR is expected to support Italian family physicians aiming to enhance their clinical practice and therapeutic outcomes. It could also be a valuable tool for Italian medical students to foster therapeutic relationships and improve their communication skills., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Buono, Sassier, Thulesius, Hoffman, Nabbe, Petek and Le Reste.)

Aims: To describe assistant nurses' experiences of thirst and ethical challenges in relation to thirst in terminally ill patients in specialized palliative care (PC) units., Design: A qualitative, reflexive thematic design with an inductive analysis was used., Methods: Data were collected during November 2021-January 2023. Twelve qualitative interviews with assistant nurses working in five different specialized PC units in different hospitals in Sweden were conducted. The interviews were transcribed verbatim and analysed with a reflexive thematic analysis. The study was guided by the Standards for Reporting Qualitative Research (SRQR)., Results: Two main themes were found in this study. (1) 'A world of practice for thirst relief' where assistant nurses present a task-oriented world where the knowledge of thirst is an experience-based unspoken knowledge where mainly routines rule. (2) Ethical challenges presents different ethical problems that they meet in their practice, such as when patients express thirst towards the end of their life but are too severely ill to drink or when they watch lack of knowledge in the area among other health professionals., Conclusion: Thirst in dying patients is a neglected area that assistant nurses work with, without communicating it. Their knowledge of thirst and thirst relief are not expressed, seldom discussed, there are no policy documents nor is thirst documented in the patient's record. There is a need for nurses to take the lead in changing nursing practice regarding thirst., Patient or Public Contribution: No patient or public contribution., Impact: In palliative care, previous studies have shown that dying patients might be thirsty. Assistant nurses recognize thirst in dying patients, but thirst is not discussed in the team. Nurses must consider the patient's fundamental care needs and address thirst, for example in the nursing process to ensure patients quality of life in the last days of life., Reporting Method: The study was guided by the SRQR. WHAT DOES THIS ARTICLE CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Thirst is a distressing symptom for all humans. However, when a patient is dying, he or she loses several functions and can no longer drink independently. The knowledge from this article contributes to our understanding of current practice and shows an area that requires immediate attention for the improvement of fundamental palliative care delivery., (© 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Introduction: Thirst and dry mouth are common symptoms among patients at the end of life. In palliative care today, there is a focus on mouth care to alleviate thirst. There are no qualitative studies on thirst from a physician's experience, which is why this study is needed., Purpose: This study aimed to explore palliative care physicians' experiences and views of thirst in patients at the end of life., Methods: A qualitative interview study with an inductive approach was carried out. Sixteen physicians working in specialised palliative care units in Sweden were included. The interviews were analysed with a reflexive thematic analysis., Results: The analysis resulted in three basic assumptions regarding thirst: It is dry mouth, not thirst; patients are dry in their mouth and thirsty; and, I do not know if they are thirsty. Further, four different themes regarding how to relieve thirst appeared: drips will not help thirst but cause harm; the body takes care of thirst itself; drips might help thirst; and, mouth care to relieve thirst or dry mouth., Conclusions: The palliative care physicians had different experiences regarding thirst, from thirst never arising, to a lack of awareness. They thought good mouth care worked well to alleviate the feeling of thirst and dry mouth. Most physicians did not want to give patients drips, while some did. This study indicates that there are many unanswered questions when it comes to thirst at end-of-life and that further research is needed., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Friedrichsen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Thirst and dry mouth are common symptoms in terminally ill patients. In their day-to-day practice, palliative care physicians regularly encounter ethical dilemmas, especially regarding artificial hydration. Few studies have focused on thirst and the ethical dilemmas palliative care physicians encounter in relation to this, leading to a knowledge gap in this area., Aim: The aim of this study was to explore palliative care physicians' experiences of ethical challenges in relation to thirst in terminally ill patients., Methods: A qualitative interview study with an inductive approach was conducted. Sixteen physicians working in four different specialised palliative care units and one geriatric care unit in different hospitals in Sweden were interviewed. The interviews were transcribed verbatim and analysed with a reflexive thematic analysis., Results: When presented with an ethical challenge relating to thirst, physicians attempted to balance benefits and harms while emphasizing respect for the patient's autonomy. The ethical challenges in this study were: Starting, continuing or discontinuing drips; lack of evidence and traditions create doubt; and lack of interest and time may result in patient suffering., Conclusions: All physicians in this study reported that "Starting, continuing or discontinuing drips" was the main ethical challenge they encountered, where some were so accustomed to the decision that they had a standard answer ready to offer patients and families. Physicians reported that drips were a symbol of thirst quenching, life and survival but were not necessary in end-of-life care. Others questioned the traditions regarding thirst and emphasised drips in particular., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Aim: To evaluate patients' and family members' perceived support from light and color before, compared with after an evidence-based design (EBD) intervention at an emergency department (ED) using a validated instrument-the Light and Color Questionnaire (LCQ)., Background: EDs offer acute care day and night. Thus, a supportive physical environment where light and color is crucial for how the milieu is experienced is vital. Research is limited on how care settings are perceived as supportive by users., Methods: Quasi-experimental evaluation of the refurbishing and remodeling of an ED by an expert group of nurse managers, nursing staff, nursing researchers and architects in south Sweden. LCQ includes dimensions "maximizing awareness and orientation," "maximizing safety and security," "supporting functional abilities," "providing privacy," "opportunities for personal control" (not for LCQ-Color), and "regulation and quality of stimulation." LCQ was analyzed and compared in 400 surveys from 100 patients and 100 family members before the intervention and 100 patients and 100 family members after the intervention., Results: The LCQ total score significantly improved after the intervention for both patients and family members. Four of the six dimensions of LCQ Light subscale scores were significantly higher for family members, and three of the six dimensions were significantly higher for patients after the intervention. The LCQ Color subscale score showed significant improvements for all five dimensions for both patients and family members after the intervention., Conclusion: This study showed improved perceived support from light and color in the physical environment for patients and family members after an EBD intervention at an emergency department using a validated instrument-the Light and Color Questionnaire.

Background: Evidence is increasing for the use of faecal immunochemical tests (FITs) for occult blood as diagnostic tools when colorectal cancer can be suspected. FITs have been used for this purpose in Swedish primary care since around 2005 despite absence of supporting guidelines. To our knowledge, the extent of this use has not been studied., Objective: To investigate the use of FITs as diagnostic tools, and if the use was related to patient age, sex and travel time from primary care to diagnostic facilities in secondary care., Design: Population-based retrospective study using data from electronic health records., Setting and Subjects: Patients ≥18 years that provided FITs in primary care in five Swedish health care regions during 2015. Driving times from their primary care centres to secondary care were calculated., Main Outcome Measures: The proportion of patients that provided FITs was calculated for each region, different age intervals and grouped driving times., Results: 18,913 patients provided FITs. The proportion of listed patients in the five regions that provided FITs increased with age: 0.86-1.2% for ages <65 years, 3.6-4.1% for ages 65-79 years and 3.8-6.1% for ages ≥80 years. Differences between the regions were small. There was no overall correlation between the proportion of patients that provided FITs and driving time to secondary care., Conclusion: FITs were used extensively in Swedish primary care with a higher use in older age groups. There was no tendency towards a higher use of FITs at primary care centres with longer driving times to secondary care.Key PointsEvidence is increasing for the use of faecal immunochemical tests (FITs) as diagnostic tools when colorectal cancer can be suspected. We investigated the use of FITs in Sweden.FITs were used extensively in primary care especially in older age groups.There were small differences in the use of FITs between five studied health care regions.There was no tendency towards a higher use of FITs at primary care centres with longer driving times to diagnostic facilities in secondary care.

Introduction: To reduce inappropriate polypharmacy, deprescribing should be part of patients' regular care. Yet deprescribing is difficult to implement, as shown in several studies. Understanding patients' attitudes towards deprescribing at the individual and country level may reveal effective ways to involve older adults in decisions about medications and help to implement deprescribing in primary care settings. In this study we aim to investigate older adults' perceptions and views on deprescribing in different European countries. Specific objectives are to investigate the patients' willingness to have medications deprescribed by medication type and to have herbal or dietary supplements reduced or stopped, the role of the Patient Typology (on medication perspectives), and the impact of the patient-GP relationship in these decisions., Methods and Analysis: This cross-sectional survey study has two parts: Part A and Part B. Data collection for Part A will take place in nine countries, in which per country 10 GPs will recruit 10 older patients (≥65 years old) each (n = 900). Part B will be conducted in Switzerland only, in which an additional 35 GPs will recruit five patients each and respond to a questionnaire themselves, with questions about the patients' medications, their willingness to deprescribe those, and their patient-provider relationship. For both Part A and part B, a questionnaire will be used to assess the willingness of older patients with polypharmacy to have medications deprescribed and other relevant information. For Part B, this same questionnaire will have additional questions on the use of herbal and dietary supplements., Discussion: The international study design will allow comparisons of patient perspectives on deprescribing from different countries. We will collect information about willingness to have medications deprescribed by medication type and regarding herbal and dietary supplements, which adds important information to the literature on patients' preferences. In addition, GPs in Switzerland will also be surveyed, allowing us to compare GPs' and patients' views and preferences on stopping or reducing specific medications. Our findings will help to understand patients' attitudes towards deprescribing, contributing to improvements in the design and implementation of deprescribing interventions that are better tailored to patients' preferences., (© 2022. The Author(s).)

Background: Depression is a risk factor for type 2 diabetes (T2D) and cardiovascular disease (CVD). The aims were to explore the prevalence of depression, anxiety, antidepressant use, obesity, Hemoglobin A1c > 64 mmol/mol, life-style factors, pre-existing CVD, in patients with newly diagnosed T2D; to explore associations with depression; and to compare with Swedish general population data., Methods: Multicentre, cross-sectional study., Inclusion Criteria: adults with serologically verified newly diagnosed T2D. Included variables: age, sex, current depression and anxiety (Hospital Anxiety and Depression Scale), previous depression, antidepressant use, obesity (BMI ≥ 30 and ≥ 40 kg/m 2 ), Hemoglobin A1c, pre-existing CVD. Logistic regression analyses were performed., Results: In 1027 T2D patients, aged 18-94 years, depression was associated with age (per year) (inversely) (odds ratio (OR) 0.97), anxiety (OR 12.2), previous depression (OR 7.1), antidepressant use (OR 4.2), BMI ≥ 30 kg/m 2 (OR 1.7), BMI ≥ 40 kg/m 2 (OR 2.3), smoking (OR 1.9), physical inactivity (OR 1.8), and women (OR 1.6) (all p ≤ 0.013). Younger women (n = 113), ≤ 59 years, compared to younger men (n = 217) had higher prevalence of current depression (31% vs 12%), previous depression (43 vs 19%), anxiety (42% vs 25%), antidepressant use (37% vs 12%), BMI ≥ 30 kg/m 2 (73% vs 60%) and BMI ≥ 40 kg/m 2 ) (18% vs 9%), and smoking (26% vs 16%) (all p ≤ 0.029). Older women (n = 297), ≥ 60 years, compared to older men (n = 400) had higher prevalence of previous depression (45% vs 12%), anxiety (18% vs 10%), antidepressant use (20% vs 8%), BMI ≥ 30 kg/m 2 (55% vs 47%), BMI ≥ 40 kg/m 2 (7% vs 3%) (all p ≤ 0.048), but not of current depression (both 9%). Compared to the Swedish general population (depression (women 11.2%, men 12.3%) and antidepressant use (women 9.8%, men 5.3%)), the younger women had higher prevalence of current depression, and all patients had higher prevalence of antidepressant use., Conclusions: In patients with newly diagnosed T2D, the younger women had the highest prevalence of depression, anxiety, and obesity. The prevalence of depression in young women and antidepressant use in all patients were higher than in the Swedish general population. Three risk factors for CVD, obesity, smoking, and physical inactivity, were associated with depression., (© 2022. The Author(s).)

Background: Obesity is a chronic disease with increasing prevalence. We aimed to explore primary care physicians' knowledge and attitudes about obesity and how knowledge and attitudes are associated with confidence and adherence to obesity guidelines and barriers to obesity treatment., Methods: A questionnaire survey was sent by e-mail to 1642 primary care physicians in four regions in Sweden. The survey focused on the physicians' knowledge, attitudes towards obesity, confidence in obesity management, adherence to obesity guidelines and barriers to optimal care. We created different statistical indices for knowledge, attitudes and adherence. To analyse the correlation between these indices, we used linear regression analyses., Results: Replies from 235 primary care physicians yielded a response rate of 14.3%. Most physicians answered correctly that obesity is a disease (91%), that obesity regulation sits in the hypothalamus (70%) and that obesity is due to disorders of appetite regulation (69%). However, 44% of the physicians thought that the most effective weight reduction method for severe obesity was lifestyle changes; 47% believed that obesity is due to lack of self-control, 14% mentioned lack of motivation and 22% stated laziness. Although 97% believed that physicians can help individuals with obesity and 56% suggested that obesity treatment should be prioritised, 87% of the physicians expressed that losing weight is the patients' responsibility. There was a positive association between higher knowledge and better adherence to obesity guidelines (B = 0.07, CI 0.02-0.12, p-value = 0.005) and feeling confident to suggest medication (p < 0.001) or bariatric surgery (p = 0.002). While 99% of the physicians felt confident to discuss lifestyle changes, 67% and 81% were confident to suggest medication or bariatric surgery, respectively. Respondents perceived that the greatest barrier in obesity management was lack of time (69%) and resources (49%)., Conclusion: There was a positive association between Swedish primary care physicians' knowledge and adherence to obesity guidelines and being more confident to suggest obesity treatment. Yet, many physicians had an ambivalent attitude towards obesity management., (© 2022. The Author(s).)

Aims: Because evidence regarding risk stratification predicting prognosis of patients with heart failure (HF) decompensation attended in primary care is lacking, we developed and externally validated a model to forecast death/hospitalization during the first 30 days after an episode of decompensation. The predictive model is based on variables easily obtained in primary care settings., Methods and Results: HEFESTOS is a multinational study consisting of a derivation cohort of HF patients recruited in 14 primary healthcare centres in Barcelona and a validation cohort from primary healthcare in 9 other European countries. The derivation and validation cohorts included 561 and 250 patients, respectively. Percentages of women in the derivation and validation cohorts were 56.3% and 47.6% (P = 0.026), respectively. Mean age was 82.2 years (SD 8.03) in the derivation cohort, and 79.3 years (SD 10.3) in the validation one (P = 0.001). HF with preserved ejection fraction represented 72.1% in the derivation cohort and 58.8% in the validation one (P = 0.004). Mortality/hospitalization during the first 30 days after a decompensation episode was 30.5% and 26% (P = 0.225) for the derivation and validation cohorts, respectively. Multivariable logistic regression models were performed to develop a score of risk. The identified predictors were worsening of dyspnoea [odds ratio (OR): 2.5; P = 0.001], orthopnoea (OR: 2.16; P = 0.01), paroxysmal nocturnal dyspnoea (OR: 2.25; P = 0.01), crackles (OR: 2.35; P = 0.01), New York Heart Association functional class III/IV (OR: 2.11; P = 0.001), oxygen saturation ≤ 90% (OR: 4.98; P < 0.001), heart rate > 100 b.p.m. (OR: 2.72; P = 0.002), and previous hospitalization due to HF (OR: 2.45; P < 0.001). The model showed an area under the curve (AUC) of 0.807, 95% confidence interval (CI): [0.770; 0.845] in the derivation cohort and AUC 0.73, 95% CI: [0.660; 0.808] in the validation one. No significant differences between both cohorts were observed (P = 0.08). Regarding probability of hospitalization/death, three risk groups were defined: low <5%, medium 5-20%, and high >20%. Outcome incidence was 2.7% for the low-risk group, 12.8% for medium risk, and 46.2% for high risk in the derivation cohort, and 9.1%, 12.9%, and 39.6% in the validation one., Conclusions: The HEFESTOS score, based on variables easily accessible in a community setting and validated in an external European cohort, properly predicted the risk of death/hospitalization during the first 30 days after an HF decompensation episode., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Introduction: Postoperative delirium is a common complication after cardiac surgery with cardiopulmonary bypass (CPB). Compromised regulation of the cerebral circulation may be a predisposing factor for delirium. However, the potential relationship between cerebrovascular reserve capacity and delirium is unknown. The aim of this study was to investigate if impaired cerebrovascular reserve capacity was associated with postoperative delirium. Methods: Forty-two patients scheduled for cardiac surgery with CPB were recruited consecutively. All patients underwent preoperative transcranial Doppler (TCD) ultrasound with calculation of breath-hold index (BHI). BHI < 0.69 indicated impaired cerebrovascular reserve capacity. In addition, patients were examined with preoperative neuropsychological tests such as MMSE (Mini Mental State Examination) and AQT (A Quick Test of cognitive speed). Postoperative delirium was assessed using Nursing Delirium Screening Scale (Nu-DESC) in which a score of ≥2 was considered as delirium. Results: Six patients (14%) scored high for postoperative delirium and all demonstrated impaired preoperative cerebrovascular reserve capacity. Median (25th-75th percentile) BHI in patients with postoperative delirium was significantly lower compared to the non-delirium group [0.26 (-0.08-0.44) vs. 0.83 (0.57-1.08), p = 0.002]. Preoperative MMSE score was lower in patients who developed postoperative delirium (median, 25th-75th percentile; 26.5, 24-28 vs. 28.5, 27-29, p = 0.024). Similarly, patients with postoperative delirium also displayed a slower performance during the preoperative cognitive speed test AQT color and form (mean ± SD; 85.8 s ± 19.3 vs. 69.6 s ± 15.8, p = 0.043). Conclusion: The present findings suggest that an extended preoperative ultrasound protocol with TCD evaluation of cerebrovascular reserve capacity and neuropsychological tests may be valuable in identifying patients with increased risk of developing delirium after cardiac surgery., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Bydén, Segernäs, Thulesius, Vanky, Ahlgren, Skoog and Zachrisson.)

Objective: To explore how cancer could be diagnosed in a more timely way., Design: Grounded theory analysis of primary care physicians' free text survey responses to: 'How do you think the speed of diagnosis of cancer in primary care could be improved?'. Secondary analysis of primary care physician interviews, survey responses, literature., Setting: Primary care in 20 European Örenäs Research Group countries., Subjects: Primary care physicians: 1352 survey respondents (2013-2016), 20 Spanish and 7 Swedish interviewees (2015-2019)., Main Outcome Measures: Conceptual explanation of how to improve timeliness of cancer diagnosis., Results: Pluralistic task shifting is a grounded theory of a composite strategy. It includes task sharing - among nurses, physicians, nurse assistants, secretaries, and patients - and changing tasks with cancer screening when appropriate or cancer fast-tracks to accelerate cancer case finding. A pluralistic dialogue culture of comprehensive collaboration and task redistribution is required for effective pluralistic task shifting. Pluralistic task shifting relies on cognitive task shifting, which includes learning more about slow analytic reasoning and fast automatic thinking initiated by pattern recognition; and digital task shifting, which by use of eHealth and telemedicine bridges time and place and improves power symmetry between patients, caregivers, and clinicians. Financial task shifting that involves cost tracking followed by reallocation of funds is necessary for the restructuring and retraining required for successful pluralistic task shifting. A timely diagnosis reduces expensive investigations and waiting times. Also, late-stage cancers are costlier to treat than early-stage cancers. Timing is central to cancer diagnosis: not too early to avoid overdiagnosis, and never too late., Conclusions: We present pluralistic task shifting as a conceptual summary of strategies needed to optimise the timeliness of cancer diagnosis.Key pointsCancer diagnosis is under-researched in primary care, especially theoretically. Thus, inspired by classic grounded theory, we analysed and conceptualised the field: Pluralistic task shifting is a conceptual explanation of how the timeliness of cancer diagnosis could be improved, with data derived mostly from primary care physicians.This includes task sharing and changing tasks including screening and cancer fast-tracks to accelerate cancer case finding, and requires cognitive task shifting emphasising learning, and digital task shifting involving the use of eHealth and telemedicine. Financial task shifting with cost tracking and reallocation of funds is eventually necessary for successful pluralistic task shifting to happen.

Purpose: Cancer research and connected innovation processes often lack a major component; patient participation. We revisit three studies (a-c) in order to explore how Momentary contentment theory may be used to improve patient participation and psychosocial health., Method: We revisited data from the initial (a) classic grounded theory study on Momentary contentment, based on four years of observation and 14 interviews. It explains a way of dealing with life close to death and morbidity. In the imminence of danger the studied culture resembles the context of cancer patients. The two following studies used focus group interviews with (b) 19 cancer patients and (c) 17 relatives of cancer patients in southern Sweden., Results: We suggest a process where cancer patients are taught to be submissive and that the support they receive from health providers may be counterproductive to contentment; a patientification process. We present alternative ways for people to handle issues such as hope, waiting, knowledge gaps and healthcare navigation while living with cancer. We introduce an alternative to patientification and passive patients where active patients create their own safety and truly participates in their care., Conclusions: We propose clinical studies to introduce such a shift from patentification to co-creation of care.

Objective: To analyze changes in primary care utilization as a result of the Covid-19 pandemic. Swedish national register data from 2019 to 2020 on utilization of services were used to compare overall utilization levels and across types of contacts and patient groups. A specific objective was to assess the extent to which remote types of patient consultations were able to compensate for any observed fall in on-site visits. Data were stratified by sex and age to investigate any demographic pattern., Results: Findings show significant reductions in overall utilization of services as the pandemic occurred in the first quarter of 2020. On-site visits fell during the first wave of the pandemic and rebounded thereafter. Patients over 65 years of age appear to have reduced utilization to a larger extent compared with younger groups. Simultaneously, remote contacts increased from around 12% before the pandemic to 17% of the total number of consultations. However, the net effect of changes in service utilization suggests an overall reduction of around 12 percent in the number of primary care consultations as a result of the pandemic. No differences between men and women were observed. Further research will continue to monitor changes in primary care utilization as the pandemic continues., (© 2021. The Author(s).)

Background: General practitioners (GPs) play a key role in managing the COVID-19 outbreak. However, they may encounter difficulties adapting their practices to the pandemic. We provide here an analysis of guidelines for the reorganisation of GP surgeries during the beginning of the pandemic from 15 countries., Methods: A network of GPs collaborated together in a three-step process: (i) identification of key recommendations of GP surgery reorganisation, according to WHO, CDC and health professional resources from health care facilities; (ii) collection of key recommendations included in the guidelines published in 15 countries; (iii) analysis, comparison and synthesis of the results., Results: Recommendations for the reorganisation of GP surgeries of four types were identified: (i) reorganisation of GP consultations (cancelation of non-urgent consultations, follow-up via e-consultations), (ii) reorganisation of GP surgeries (area partitioning, visual alerts and signs, strict hygiene measures), (iii) reorganisation of medical examinations by GPs (equipment, hygiene, partial clinical examinations, patient education), (iv) reorganisation of GP staff (equipment, management, meetings, collaboration with the local community)., Conclusions: We provide here an analysis of guidelines for the reorganisation of GP surgeries during the beginning of the COVID-19 outbreak from 15 countries. These guidelines focus principally on clinical care, with less attention paid to staff management, and the area of epidemiological surveillance and research is largely neglected. The differences of guidelines between countries and the difficulty to apply them in routine care, highlight the need of advanced research in primary care. Thereby, primary care would be able to provide recommendations adapted to the real-world settings and with stronger evidence, which is especially necessary during pandemics.

Background: Obesity prevalence is increasing globally. Bariatric surgery is an effective treatment for severe and complex obesity resulting in significant and sustained weight loss. In Sweden, most bariatric surgery patients are referred by primary care physicians. We aimed to explore barriers for physicians to refer patients with severe and complex obesity for bariatric surgery., Methods: A questionnaire survey was in 2019 emailed to 1100 primary care physicians in the Skåne and Kronoberg regions in south Sweden. The survey focused on referral patterns, knowledge and attitudes towards bariatric surgery and concerns about postoperative complications. We created different statistical indices for referral patterns, knowledge, attitudes and concerns about bariatric surgery. To analyze the correlation between these indices, we did Spearman's correlations and regression analyses., Results: Of 1100 email respondents, we received 157 (14%) completed surveys. Among 157 physician respondents, 73% answered that they had good knowledge about the referral criteria for bariatric surgery, whereas 55 and 60% answered correctly to two items on criteria for bariatric surgery. A majority of respondents (84%) stated that their patients initiated referral to bariatric surgery. Half of the respondents had concerns about postoperative medical and surgical complications, but another half had a positive attitude to bariatric surgery as a treatment for obesity comorbidities. Almost half of the respondents (44%) answered that they needed to learn more about bariatric surgery. We found significant positive correlations between high knowledge and referral patterns (r = 0.292, p < 0.001) and positive attitudes (r = 0.235, p < 0.001) respectively. We found significant reverse correlations between concerns and referral patterns (r = - 0.355, p < 0.001) and between positive attitudes and concerns (r = - 0.294, p < 0.001). In logistic regression high levels of concerns explained low willingness to refer for bariatric surgery (Odds Ratio 0.2, 95% confidence interval 0.1-0.7)., Conclusion: According to this Swedish survey among primary care physicians, high levels of concerns about bariatric surgery among physicians seemed to be a barrier to refer patients with severe and complex obesity for bariatric surgery. Since high knowledge about obesity and bariatric surgery correlated negatively to concerns and positively to favorable attitudes to bariatric surgery, more knowledge about obesity and bariatric surgery is warranted.

Aim: The aim of this study was to develop and evaluate a self-report instrument measuring patients', family members', and staff's perceived support from light and color in the physical environment of an emergency department (ED)-the Light and Color Questionnaire (LCQ)., Background: The physical care environment is an important part of a comprehensive caring approach in all levels of care not only for patients but also for family members and staff. However, no existing self-report questionnaire assessing the extent to which light and color are perceived as being supportive in the physical care environment from the users' perspective was found., Method: The LCQ was developed as part of a pre-post study in which an ED serving 125,000 people was refurbished and remodeled using evidence-based design. The LCQ consists of six items for light and five items for color and assesses awareness/orientation, safety/security, functional abilities, privacy, personal control, and stimulation. The study was carried out in four steps: constructions of items, assessment of face validity, data collection, and data analysis., Result/conclusion: Psychometric evaluation of the two versions, LCQ-Patient/Family member and LCQ-Staff, showed satisfactory content and internal validity (>90%) and high internal consistency (Cronbach's coefficient α = .9) to support the use of the questionnaire for research and development purposes. Explorative factor analysis of a total of 600 questionnaire responses confirmed light and color as distinctive and independent dimensions creating perceptions of more or less supportiveness for respondents. The LCQ instrument may be useful for architects, administrators, and researchers of healthcare environments.

Background: General practitioners (GPs) should regularly review patients' medications and, if necessary, deprescribe, as inappropriate polypharmacy may harm patients' health. However, deprescribing can be challenging for physicians. This study investigates GPs' deprescribing decisions in 31 countries., Methods: In this case vignette study, GPs were invited to participate in an online survey containing three clinical cases of oldest-old multimorbid patients with potentially inappropriate polypharmacy. Patients differed in terms of dependency in activities of daily living (ADL) and were presented with and without history of cardiovascular disease (CVD). For each case, we asked GPs if they would deprescribe in their usual practice. We calculated proportions of GPs who reported they would deprescribe and performed a multilevel logistic regression to examine the association between history of CVD and level of dependency on GPs' deprescribing decisions., Results: Of 3,175 invited GPs, 54% responded (N = 1,706). The mean age was 50 years and 60% of respondents were female. Despite differences across GP characteristics, such as age (with older GPs being more likely to take deprescribing decisions), and across countries, overall more than 80% of GPs reported they would deprescribe the dosage of at least one medication in oldest-old patients (> 80 years) with polypharmacy irrespective of history of CVD. The odds of deprescribing was higher in patients with a higher level of dependency in ADL (OR =1.5, 95%CI 1.25 to 1.80) and absence of CVD (OR =3.04, 95%CI 2.58 to 3.57)., Interpretation: The majority of GPs in this study were willing to deprescribe one or more medications in oldest-old multimorbid patients with polypharmacy. Willingness was higher in patients with increased dependency in ADL and lower in patients with CVD.

Background: Colorectal cancer (CRC) diagnostics are challenging in primary care and reliable diagnostic aids are desired. Qualitative faecal immunochemical tests (FITs) have been used for suspected CRC in Sweden since the mid-2000s, but evidence regarding their effectiveness is scarce. Anaemia and thrombocytosis are both associated with CRC., Aim: To evaluate the usefulness of qualitative FITs requested for symptomatic patients in primary care, alone and combined with findings of anaemia and thrombocytosis, in the diagnosis of CRC., Design and Setting: A population-based cohort study using electronic health records and data from the Swedish Cancer Register, covering five Swedish regions., Method: Patients aged ≥18 years in the five regions who had provided FITs requested by primary care practitioners from 1 January 2015 to 31 December 2015 were identified. FIT and blood-count data were registered and all CRC diagnoses made within 2 years were retrieved. Diagnostic measurements were calculated., Results: In total, 15 789 patients provided FITs (four different brands); of these patients, 304 were later diagnosed with CRC. Haemoglobin levels were available for 13 863 patients, and platelet counts for 10 973 patients. Calculated for the different FIT brands only, the sensitivities for CRC were 81.6%-100%; specificities 65.7%-79.5%; positive predictive values 4.7%-8.1%; and negative predictive values 99.5%-100%. Calculated for the finding of either a positive FIT or anaemia, the sensitivities increased to 88.9-100%. Adding thrombocytosis did not further increase the diagnostic performance., Conclusion: Qualitative FITs requested in primary care seem to be useful as rule-in tests for referral when CRC is suspected. A negative FIT and no anaemia indicate a low risk of CRC., (©The Authors.)

Background: Rectal bleeding is considered an alarm symptom for colorectal cancer (CRC) but it is common and mostly caused by benign conditions. Qualitative faecal immunochemical tests (FITs) for occult blood have been used as diagnostic aids for many years in Sweden when CRC is suspected. The study aimed to evaluate the usefulness of FITs requested by primary care physicians for patients with and without histories of rectal bleeding, in the diagnosis of CRC., Methods: Results of all FITs requested in primary care for symptomatic patients in the Örebro region during 2015 were retrieved. Data on each patient's history of rectal bleeding was gathered from electronic health records. Patients diagnosed with CRC within 2 years were identified from the Swedish Cancer Register. The analysis focused on three-sample FITs, the customary FIT in Sweden., Results: A total of 4232 patients provided three-sample FITs. Information about the presence/absence of rectal bleeding was available for 2027 patients, of which 59 were diagnosed with CRC. For 606 patients with the presence of rectal bleeding, the FIT showed sensitivity 96.2%, specificity 60.2%, positive predictive value 9.8% (95% CI 6.1-13.4) and negative predictive value 99.7% (95% CI 99.2-100) for CRC. For 1421 patients without rectal bleeding, the corresponding figures were 100%, 73.6%, 8.3% (95% CI 5.6-10.9) and 100% (95% CI 99.6-100)., Conclusion: The diagnostic performance of a qualitative three-sample FIT provided by symptomatic patients in primary care was similar for those with and without a history of rectal bleeding. FITs seem useful for prioritising patients also with rectal bleeding for further investigation.