Hans Thulesius

Screening for posttraumatic stress disorder symptoms among Bosnian refugees

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

Balancing: A Basic Process in End-of-Life Cancer Care

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

Diagnostic delay in pediatric malignancies--a population-based study.

This study describes the discovery and diagnosis of malignant tumors from a primary care perspective in a Swedish county. Between 1984 and 1995, 68 children between the ages 0-16 years were diagnosed with a malignant tumor giving an incidence of 14/100000. Patient records from both primary care and hospital were analyzed for 64 children. Leukemia was diagnosed in 25 children, and brain tumors in 22 children. In 68% of the children the diagnostic process was initiated in primary care, and in 32% in specialist care. Median parents delay (time from first symptoms to first consultation), and median doctors delay (time from first consultation to diagnosis) were 5 and 3 weeks for children with brain tumors, and 1 and 0 weeks for children with leukemia. Median lag time (parents + doctors delay) was 9 weeks for patients with brain tumors and 3 weeks for children with leukemia.

Explaining variation in cancer survival between 11 jurisdictions in the International Cancer Benchmarking Partnership: a primary care vignette survey

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

Depression, obesity, and smoking were independently associated with inadequate glycemic control in patients with type 1 diabetes.

OBJECTIVE The aim of this study was to explore the associations between inadequate glycemic control of diabetes and psychological, anthropometric, and lifestyle variables in a population-based cohort of type 1 diabetes patients. DESIGN Cross-sectional study. METHODS In this study, 292 patients with type 1 diabetes, aged 1859 years, participated. psychological data were assessed by self-report instruments: Hospital Anxiety and Depression Scale and Toronto Alexithymia Scale-20. Anthropometrics, blood analyses, data from medical records, and data from the Swedish National Diabetes Registry were collected. RESULTS Self-reported depression (adjusted odds ratio (AOR) 4.8), obesity (AOR 4.3), and smoking (AOR 3.0) were independently associated with inadequate glycemic control of diabetes (HbA1c>8.6%). Gender-stratified analyses showed that self-reported depression (AOR 19.8) and obesity (AOR 7.0) in women and smoking in men (AOR 4.2) were associated with HbA1c>8.6%. Alexithymia, antidepressant medication, and physical inactivity were associated with HbA1c>8.6% only in bivariate analyses. Alexithymia, self-rated anxiety, physical inactivity, and absence of abdominal obesity were associated with self-reported depression. CONCLUSIONS Depression was the only psychological factor independently associated with HbA1c>8.6%. The association was of comparable importance as obesity and smoking, well-known risk factors for inadequate glycemic control and diabetes complications. The association between depression and HbA1c>8.6% was particularly strong for women. Alexithymia, which is a relatively stable personality trait, was associated with depression. In the future care of patients with diabetes, psychological aspects should be considered alongside anthropometrics and lifestyle factors in order to achieve the goals for HbA1c.

Affect School for chronic benign pain patients showed improved alexithymia assessments with TAS-20

BackgroundAlexithymia is a disturbance associated with psychosomatic disorders, pain syndromes, and a variety of psychiatric disorders. The Affect School (AS) based on Tomkins Affect Theory is a therapy focusing on innate affects and their physiological expressions, feelings, emotions and scripts. In this pilot study we tried the AS-intervention method in patients with chronic benign pain.MethodsThe AS-intervention, with 8 weekly group sessions and 10 individual sessions, was offered to 59 patients with chronic non-malignant pain at a pain rehabilitation clinic in Sweden 2004-2005. Pre and post intervention assessments were done with the Hospital Anxiety and Depression scale (HAD), the Toronto Alexithymia Scale-20 (TAS-20), the Visual Analogue Scale for pain assessment (VAS-pain), the European Quality of Life health barometer (EQoL) and the Stress and Crisis Inventory-93 (SCI-93). After the group sessions we used Bergdahls Questionnaire for assessing changes in interpersonal relations, general well-being and evaluation of AS.ResultsThe AS intervention was completed by 54 out of 59 (92%) patients. Significant reductions in total TAS-20 post-test scores (p = 0.0006) as well as TAS-20 DIF and DDF factors (Difficulties Identifying Feelings, and Difficulties Describing Feelings) were seen (p = 0.0001, and p = 0.0008) while the EOT factor (Externally Oriented Thinking) did not change. Improvements of HAD-depression scores (p = 0.04), EQoL (p = 0.02) and self-assessed changes in relations to others (p < 0.001) were also seen. After Bonferroni Correction for Multiple Analyses the TAS-20 test score reduction was still significant as well as Bergdahls test after group sessions. The HAD, EQoL, SCI-93, and VAS-pain scores were not significantly changed. The AS-intervention was ranked high by the participants.ConclusionsThis pilot study involving 59 patients with chronic benign pain indicates that the alexithymia DIF and DDF, as well as depression, social relations and quality of life may be improved by the Affect School therapeutic intervention.

Learner-centred education in end-of-life care improved well being in home care staff: a prospective controlled study

The aim of this controlled study was to evaluate a 1-year learner-centred educational project in end-of-life care for home care staff in a rural district of Sweden. Another rural district in the same region served as a control area. A 20-item questionnaire measuring attitudes towards end-of-life care was designed, and the Hospital Anxiety and Depression (HAD) scale was used to measure mental well being. Increased agreement to 18 of 20 attitude statements was seen in the education group, while 2 of 20 items showed a decreased agreement in the control group. Test retest reliability of the 20-item questionnaire was good (r =0.92). The total HAD score decreased from 8.3 pretest to 5.3 post-test in the education group (95% CI=2.1– 3.7; P<0.001), and was 6.8 for both years in the control group. Our study shows that a comprehensive educational programme not only improved attitudes towards end-of-life care, but also the mental well being of the home care staff.

Teaching medical ethics: what is the impact of role models? Some experiences from Swedish medical schools

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

Waiting management at the emergency department - a grounded theory study

BackgroundAn emergency department (ED) should offer timely care for acutely ill or injured persons that require the attention of specialized nurses and physicians. This study was aimed at exploring what is actually going on at an ED.MethodsQualitative data was collected 2009 to 2011 at one Swedish ED (ED1) with 53.000 yearly visits serving a population of 251.000. Constant comparative analysis according to classic grounded theory was applied to both focus group interviews with ED1 staff, participant observation data, and literature data. Quantitative data from ED1 and two other Swedish EDs were later analyzed and compared with the qualitative data.ResultsThe main driver of the ED staff in this study was to reduce non-acceptable waiting. Signs of non-acceptable waiting are physical densification, contact seeking, and the emergence of critical situations. The staff reacts with frustration, shame, and eventually resignation when they cannot reduce non-acceptable waiting. Waiting management resolves the problems and is done either by reducing actual waiting time by increasing throughput of patient flow through structure pushing and shuffling around patients, or by changing the experience of waiting by calming patients and feinting maneuvers to cover up.ConclusionTo manage non-acceptable waiting is a driving force behind much of the staff behavior at an ED. Waiting management is done either by increasing throughput of patient flow or by changing the waiting experience.

The European General Practice Research Network Presents the Translations of Its Comprehensive Definition of Multimorbidity in Family Medicine in Ten European Languages

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