Comparison of Framingham 10-year cardiovascular risks in Sweden- and foreign-born primary health care patients in Sweden.

BACKGROUND: The prevalence of cardiovascular disease around the world varies by ethnicity and region of birth. Immigrants living in Sweden may have a higher prevalence of cardiovascular diseases than native-born Swedes, but little is known about their actual cardiovascular risk. This study aimed to examine the relationship in Sweden between 10-year cardiovascular risk and birthplace. METHOD: This cross-sectional study was based on cardiovascular risk factor data obtained from the 4D Diabetes Project, a Programme 4D subproject in Sweden. Participants were recruited from two primary healthcare centres in Stockholm without a history of diabetes or pre-diabetes. The outcome variable was 10-year cardiovascular risk based on the calculation of a Framingham Risk Score with six risk factors: age, sex, LDL, HDL, BP, diabetes and smoking for each participant. Multiple linear regression was performed to generate ß-coefficients for the outcome. RESULTS: There was an average of 8.86% cardiovascular risk over 10 years in Sweden-born participants and a 5.45% 10-year risk in foreign-born, (P < 0.0001). Foreign-born participants were about 10 years younger (mean age 46 years vs. 56 years, P < 0.001), with a significantly higher proportion of smokers (23.9% vs. 13.7%; P = 0.001). To be born in Sweden (with parents born in Sweden) was significantly associated with a 10-year cardiovascular risk in the crude model (ß- coefficient = 3.40, 95% CI 2.59-4.22; P < 0.0001) and when adjusted for education and alcohol consumption (ß- coefficient = 2.70 95% CI 1.86-3.54; P < 0.0001). Regardless of the birthplace, 10-year cardiovascular risk was lower for those with higher education compared to those with less than 10 years of education. CONCLUSION: This study found a relationship between 10-year calculated cardiovascular risk and place of birth. Sweden-born participants had a higher association with 10-year cardiovascular risk than foreign-born participants. These results contradict previous reports of higher rates of CVD in residents of Middle-Eastern countries and Middle-Eastern immigrants living in Sweden.

Medical students' perception of learning from patient encounters in primary health care; a qualitative interview study.

BACKGROUND: Clinical practice gives medical students opportunities to develop clinical skills and to gain insight into their future profession as a physician. Students in the medical programme at Karolinska Institutet in Sweden had clinical practice in primary health care in nine of their 11 semesters. The aim of this study was to explore medical students' perceptions of learning from patient encounters in a primary health care context. METHODS: The study was a qualitative inductive interview study. The 21 participating medical students were from their 3rd, 4th and 5th (final year) year of the study programme. A semi-structured interview guide was used. The data analysis was performed with qualitative content analysis. RESULTS: The overarching theme of the study was: The individual patient encounters are the key to learning in primary health care. The patient encounters presented both useful opportunities and challenges that could contribute to the students' professional development. The following four categories were found: 1. Patient encounters in are instructive, rewarding and challenging. Practising in primary health care provided experience in meeting and communicating with a wide variety of patients. Students described it being challenging to trust in their own clinical competence and feeling a responsibility towards the patients. 2. Encounters with patients in primary health care provide opportunities for gradual professional development. Students had the opportunity of increasing independence based on their level of clinical competence. They experienced a progression in their professional development after each period in primary health care. 3. A committed supervisor plays a significant role in learning. Committed supervisors who set aside time for supervision, offered support, and encouraged the student, played an important role in the student's learning. 4. Learning in primary health care and learning in hospitals complement one another. It could be difficult for the students to sort out exactly where they learnt different things as they perceived that learning in primary health care and in hospitals complemented one another. CONCLUSIONS: The students' encounters with authentic patients in primary health care gave them recurring opportunities to develop communication skills and to be trusted to work on their own under supervision, giving them guidance on their way to becoming future physicians.

Changes in physical activity levels and relationship to balance performance, gait speed, and self-rated health in older Swedish women: a longitudinal study.

BACKGROUND AND AIM: Physical activity levels in older people often decrease and may mean impaired physical functioning leading to an increased fall risk. The aim of this study was to investigate self-reported change in physical activity dose and deterioration in balance performance, gait speed, and self-rated health (SRH) in older women between two time points in a follow-up study. METHODS: A cohort of community-living women, aged 69-79 years (n = 351) were evaluated by questionnaire and clinical tests on balance, gait speed, and SRH at baseline. One hundred and eighty-six women were followed-up by these tests 8.5 years after inclusion. The non-parametric Wilcoxon signed-rank test and Mann-Whitney U test were used for the analysis. RESULTS: The greatest changes were seen in one-leg standing time (OLST) with eyes closed (- 60%) and eyes open (- 42%). The population was divided into high exercise (HE, n = 49) and low exercise (LE, n = 51) groups. At baseline the HE group had an OLST of 19 s with eyes open and 3 s with eyes closed. In the LE group, these values were 7.3 s and 2 s. At follow-up, differences between HE and LE concerning tandem walk forwards (steps) (HE = 8.5; LE = 2.5) and backwards (HE = 11; LE = 3.5) emerged. The HE group estimated SRH (VAS-scale) 30 mm higher at baseline and 17 mm higher at follow-up than the LE group. CONCLUSION: Greater physical activity seems to be an important predictor for maintaining physical function and SRH in older women.

Two methods of evaluating mandibular trabecular pattern in intraoral radiographs and the association to fragility fractures during a 47-year follow up.

In this longitudinal cohort study, we explored the association of fragility fractures to sparse trabecular bone pattern in intraoral radiographs using two methods, a visual and a semi-automated. Our aim was to study both sexes and to include younger age-groups, during a follow-up time of 47 years. The cohort consisted of 837 men and women aged 18-65 years, with intraoral radiographs from 1970-1971. The trabecular pattern was assessed in the mandibular premolar region with a visual and a semi-automated method. Data on fragility fractures were acquired from the Swedish National Patient Register for 47 years of follow-up time. Sparse trabecular pattern was found in 2.2% of the cohort using the visual method, and 18% were deemed at 'risk of osteoporosis' using the semi-automated method. A total of 132 individuals suffered at least one fragility fracture during the follow-up period. We found no significant association between fractures and sparse trabecular pattern using either method. This study shows that visual assessment, as a predictor of future fractures, may not be a suitable method for individuals of all ages and sexes. As for the semi-automated method, there is still very limited evidence for its fracture predictive ability.

Primary care consultations on emotional distress - a part of the acculturation process in patients with refugee backgrounds: a grounded theory approach.

BACKGROUND: Considering the global refugee crisis, there is an increasing demand on primary care physicians to be able to adequately assess and address the health care needs of individual refugees, including both the somatic and psychiatric spectra. Meanwhile, intercultural consultations are often described as challenging, and studies exploring physician-patient communication focusing on emotional distress are lacking. Therefore, the aim was to explore physician-patient communication, with focus on cultural aspects of emotional distress in intercultural primary care consultations, using a grounded theory approach, considering both the physician's and the patient's perspective. METHODS: The study was set in Region Stockholm, Sweden. In total, 23 individual interviews and 3 focus groups were conducted. Resident physicians in family medicine and patients with refugee backgrounds, originating from Somalia, Syria, Afghanistan and Iraq, were included. Data was analysed using a grounded theory approach. RESULTS: Over time, primary care patients with refugee backgrounds seemed to adopt a culturally congruent model of emotional distress. Gradual acceptance of psychiatric diagnoses as explanatory models for distress and suffering was noted, which is in line with current tendencies in Sweden. This acculturation might be influenced by the physician. Three possible approaches used by residents in intercultural consultations were identified: "biomedical", "didactic" and "compensatory". They all indicated that diagnoses are culturally valid models to explain various forms of distress and may thus contribute to shifting patient perceptions of psychiatric diagnoses. CONCLUSIONS: Physicians working in Swedish primary care may influence patients' acculturation process by inadvertently shifting their perceptions of psychiatric diagnoses. Residents expressed concerns, rather than confidence, in dealing with these issues. Focusing part of their training on how to address emotional distress in an intercultural context would likely be beneficial for all parties concerned.

Virtual patients reflecting the clinical reality of primary care - a useful tool to improve cultural competence.

BACKGROUND: Virtual patients are educational tools that may be described as case-based interactive computer simulations of clinical scenarios. In terms of learning outcomes, improved clinical reasoning skills and knowledge acquisition have been shown. For further exploring the role of virtual patients in medical education, a greater focus on context-specific cases, combined with suitable educational activities, has been suggested. A knowledge gap has been identified in cultural competence in primary care. As primary care physicians are often the main medical providers for patients with refugee backgrounds, they would probably benefit from improved training focusing on how to apply cultural competence in everyday work. Using virtual patient cases, as a complement to clinical training, may be one way forward. The aim of this study was therefore to explore a learner perspective on the educational use of a virtual patient system designed to contribute to training in cultural competence in a primary care context. METHODS: Three virtual patient cases portraying patients with refugee backgrounds were developed. The cases addressed various issues and symptoms common in primary care consultations, while also incorporating intercultural aspects. The system also provided the informants with individualized feedback. Primary care physicians and medical students were invited to test the cases and participate in an interview about their experience. Data was analyzed using qualitative content analysis. RESULTS: The analysis generated the theme Virtual patients might help improve cultural competence in physicians and medical students by complementing knowledge gained through the informal curriculum. Informants at different educational levels found it suitable as a tool for introducing the topic and for reflecting on one's own consultations. It could also compensate for the predominant informal manner of learning cultural competence, described by the informants. CONCLUSIONS: Virtual patients could be useful for gaining cultural competence in a primary care context. Advantages that could benefit learners at both pre- and post-graduate levels are decreased dependence on the informal curriculum and being presented with an illustrative way of how cultural competence may be applied in the consultation.

The informal curriculum of family medicine - what does it entail and how is it taught to residents? A systematic review.

BACKGROUND: The informal curriculum is a seemingly well-explored concept in the realm of medical education. However, it is a concept with multiple definitions and the term "the hidden curriculum" is often used interchangeably. In short, they both refer to the implicit learning taking place outside the formal curriculum, encompassing both a trickling down effect of organizational values and attitudes passed on by a mentor or colleague. While the informal curriculum is a recurrent theme in medical education literature; it is seldom discussed in Family Medicine. As the informal curriculum is likely to be highly influential in the forming of future family practitioners, our aim was to explore the area further, with respect to the following: which elements of the informal curriculum are applicable in a Family Medicine context and what educational interventions for Family Medicine residents, visualizing the various educational elements of it, have been performed? METHODS: We conducted a systematic review comprising iterative literature searches and a narrative synthesis of the results. RESULTS: Twenty articles, published between 2000 and 2019, were included in the analysis which resulted in three partly interrelated themes comprising the informal curriculum in Family Medicine: gaining cultural competence, achieving medical professionalism and dealing with uncertainty. The themes on cultural competence and uncertainty seemed to be more contextual than professionalism, the latter being discussed in relation to the informal curriculum across other medical disciplines as well. Formalized training for Family Medicine residents in aspects of the informal curriculum appeared to be lacking, and in general, the quality of the few interventional studies found was low. CONCLUSIONS: Important aspects of being a family practitioner, such as cultural competence and dealing with uncertainty, are learned through a context-dependent informal curriculum. In order to ensure a more uniform base for all residents and to reduce the impact of the individual supervisor's preferences, complementary formalized training would be beneficial. However, to date there are too few studies published to conclude how to best teach the informal curriculum. TRIAL REGISTRATION: The systematic review was registered with Prospero; registration number CRD42018104819.

Conditions for interprofessional education for students in primary healthcare: a qualitative study.

BACKGROUND: Primary healthcare in Sweden and worldwide has a diverse structure with many kinds of healthcare units involved. This is a challenge for collaboration between different professions in primary healthcare, as the different healthcare professions often work in silos. Interprofessional education (IPE) in the context of primary healthcare is less studied than IPE at hospitals and most of the studies in primary healthcare have focused on collaboration between general practitioners and nurses. The aim of this study was to describe how healthcare students perceived conditions for IPE in primary healthcare. METHODS: Qualitative group interviews were used and a total of 26 students, recruited on a voluntary basis participated in four group interviews with students mixed from study programmes in nursing, physiotherapy, occupational therapy and medicine. Students from the study programme in medicine were in their second to eleventh semesters of 11 semesters in total, whilst students from the occupational therapist, physiotherapist and nursing programmes were in their fourth to sixth of six semesters in total. RESULTS: Our findings indicated one theme: Students perceived a need for support and awareness of IPE from both study programmes and clinical placements. Five categories were found to belong to the theme. Students' tunnel-vision focus on their own profession may have affected their ability to collaborate with students from other professions. The nature of the patients' healthcare problems decided if they were perceived as suitable for IPE. Clinical supervisors' support for and attitude towards IPE were important. The hierarchy between different professions was perceived as a hindrance for seeking help from the other professions. The students asked for more collaboration between different study programmes, in order to gain knowledge about the roles and responsibilities of the other professions. CONCLUSIONS: In conclusion, students in this study considered it essential for different study programmes and clinical placements to be more aware of the opportunities for and importance of IPE. The study identified conditions that were required for IPE in primary healthcare that may be helpful for healthcare teachers and clinical supervisors to better understand how students perceive IPE in primary healthcare, thus facilitating the planning of IPE.

High Serum Insulin-Like Growth Factor-Binding Protein 1 (IGFBP-1) is Associated with High Fracture Risk Independent of Insulin-Like Growth Factor 1 (IGF-I).

High serum levels of IGFBP-1 are related both to low body mass index (BMI) and to low insulin-like growth factor 1 (IGF-I), which both in turn are related to low bone mineral density (BMD) and to increased fracture risk. However, we have found no previous prospective studies on IGFBP-1 and fracture risk. Despite its name, IGFBP-1 is not only just a binding protein but also has its own IGF-independent effects, e.g., stimulating osteoclast differentiation. IGFBP-1 might have an IGF-related and/or an IGF-independent association to fracture risk. This is a population-based prospective cohort study with a ten-year follow-up of 351 women aged 69-79 at inclusion. Fracture and mortality data were collected from national health care registers. IGFBP-1 had a positive linear relation to the risk of both hip fractures and "major osteoporotic fractures" including fractures of the hip, spine, shoulder, and wrist. The age-adjusted hazard ratio (HR) for a hip fracture was 1.46 (95 % CI 1.08-1.99) for one SD increase in IGFBP-1. The corresponding age-adjusted HR for major osteoporotic fractures was 1.33 (95 % CI 1.05-1.69). The relation between IGFBP-1 and fracture risk was not confounded by either IGF-I or BMI. Femoral neck BMD, however, mediated 56 % of the total "effect" of IGFBP-1 on hip fracture risk. In conclusion, IGFBP-1 had a positive linear relation to fracture risk, partly mediated by BMD but not related to IGF-I or BMD. This implies that IGFBP-1 might be an important factor in bone turnover and that further studies on this would be valuable.

Medical students' feedback regarding their clinical learning environment in primary healthcare: a qualitative study.

BACKGROUND: An increasing part of medical students' learning takes place in primary healthcare (PHC) but little is known about how the students perceive PHC as a clinical learning environment. This study aimed to explore medical students' perceptions of the clinical learning environment in PHC and how these vary with stage of education. METHODS: Free-text course evaluation comments from students in nine different semesters during spring 2014 were analysed using qualitative content analysis. The students had placements in PHC from the first semester, progressing through the whole 5.5 year medical programme, and this was their main clinical training environment during the final 11th semester. RESULTS: In total, 800 students (56%) agreed to participate in the study and 437 of these (54%) provided comments. Two overall themes were identified: the supervisor was the central factor that determined the meaningfulness of the placement at all stages of the education, and basic prerequisites for perceived clinical learning were to have an active role in an authentic clinical context and to be trusted to work independently with patients. The three main categories found under these themes were: i) the perceived relationship with the supervisor; ii) the perceived journey to become a doctor; and iii) the perceived structure and culture. CONCLUSION: The supervisor's role was perceived as central at all stages of the education but the focus changed for other aspects, related to the students' professional development. The need for trust and independence in patient work increased towards the end of the education.

Adaptation and validation of the instrument Clinical Learning Environment and Supervision for medical students in primary health care.

BACKGROUND: Clinical learning takes place in complex socio-cultural environments that are workplaces for the staff and learning places for the students. In the clinical context, the students learn by active participation and in interaction with the rest of the community at the workplace. Clinical learning occurs outside the university, therefore is it important for both the university and the student that the student is given opportunities to evaluate the clinical placements with an instrument that allows evaluation from many perspectives. The instrument Clinical Learning Environment and Supervision (CLES) was originally developed for evaluation of nursing students' clinical learning environment. The aim of this study was to adapt and validate the CLES instrument to measure medical students' perceptions of their learning environment in primary health care. METHODS: In the adaptation process the face validity was tested by an expert panel of primary care physicians, who were also active clinical supervisors. The adapted CLES instrument with 25 items and six background questions was sent electronically to 1,256 medical students from one university. Answers from 394 students were eligible for inclusion. Exploratory factor analysis based on principal component methods followed by oblique rotation was used to confirm the adequate number of factors in the data. Construct validity was assessed by factor analysis. Confirmatory factor analysis was used to confirm the dimensions of CLES instrument. RESULTS: The construct validity showed a clearly indicated four-factor model. The cumulative variance explanation was 0.65, and the overall Cronbach's alpha was 0.95. All items loaded similarly with the dimensions in the non-adapted CLES except for one item that loaded to another dimension. The CLES instrument in its adapted form had high construct validity and high reliability and internal consistency. CONCLUSION: CLES, in its adapted form, appears to be a valid instrument to evaluate medical students' perceptions of their clinical learning environment in primary health care.

Virtual patients in primary care: developing a reusable model that fosters reflective practice and clinical reasoning.

BACKGROUND: Primary care is an integral part of the medical curriculum at Karolinska Institutet, Sweden. It is present at every stage of the students' education. Virtual patients (VPs) may support learning processes and be a valuable complement in teaching communication skills, patient-centeredness, clinical reasoning, and reflective thinking. Current literature on virtual patients lacks reports on how to design and use virtual patients with a primary care perspective. OBJECTIVE: The objective of this study was to create a model for a virtual patient in primary care that facilitates medical students' reflective practice and clinical reasoning. The main research question was how to design a virtual patient model with embedded process skills suitable for primary care education. METHODS: The VP model was developed using the Open Tufts University Sciences Knowledgebase (OpenTUSK) virtual patient system as a prototyping tool. Both the VP model and the case created using the developed model were validated by a group of 10 experienced primary care physicians and then further improved by a work group of faculty involved in the medical program. The students' opinions on the VP were investigated through focus group interviews with 14 students and the results analyzed using content analysis. RESULTS: The VP primary care model was based on a patient-centered model of consultation modified according to the Calgary-Cambridge Guides, and the learning outcomes of the study program in medicine were taken into account. The VP primary care model is based on Kolb's learning theories and consists of several learning cycles. Each learning cycle includes a didactic inventory and then provides the student with a concrete experience (video, pictures, and other material) and preformulated feedback. The students' learning process was visualized by requiring the students to expose their clinical reasoning and reflections in-action in every learning cycle. Content analysis of the focus group interviews showed good acceptance of the model by students. The VP was regarded as an intermediate learning activity and a complement to both the theoretical and the clinical part of the education, filling out gaps in clinical knowledge. The content of the VP case was regarded as authentic and the students appreciated the immediate feedback. The students found the structure of the model interactive and easy to follow. The students also reported that the VP case supported their self-directed learning and reflective ability. CONCLUSIONS: We have built a new VP model for primary care with embedded communication training and iterated learning cycles that in pilot testing showed good acceptance by students, supporting their self-directed learning and reflective thinking.

The estimated 10-year risk of first-onset cardiovascular disease in Swedish-born and non-Swedish-born primary healthcare patients.

BACKGROUND: SCORE2 has been introduced as an updated risk assessment tool for calculating the 10-year risk of first-onset cardiovascular disease (CVD). However, it does not account for ethnicity or socioeconomic status, known to affect CVD risk. This study investigated and compared SCORE2 estimates in Swedish-born and non-Swedish-born primary healthcare patients. The second aim was to examine if several risk factors could explain differences in CVD risk between the groups. METHODS: This was an observational, cross-sectional study. Data were obtained from the 4D Diabetes Project study, providing a total of 444 participants aged between 40 and 69 years. All participants had complete risk variable data necessary for the SCORE2 tool and no history of previous CVD. Descriptive analysis was conducted to compare distributions of risk factors between Swedes and immigrants and odds ratios of risk factors amongst these two groups in correlation to elevated CVD risk were calculated using logistic regression. RESULTS: Swedish-born patients showed a significantly higher risk of elevated CVD risk estimates (≥ 2.5% CVD risk increase for individuals < 50 years, respectively, ≥ 5% for individuals aged 51-69) than the non-Swedish-born population, even after adjustment for educational level (OR = 1.61, 95% CI 1.08-2.39). Weekly alcohol consumption implicated a risk of being classified as high risk of CVD risk, regardless of country of birth (OR = 1.93 CI 1.25-3.00). However, Swedes accounted for most of the alcohol consumption (62.6% vs. 19.6%). No other explanatory variable showed significance in association with elevated CVD risk. CONCLUSIONS: Swedish-born patients were found to be at higher risk of an increased 10-year CVD risk. The association of alcohol consumption with elevated CVD risk needs to be further studied in longitudinal studies in representative populations, notably among Sweden's diverse ethnic groups.

Association between sexual dysfunction and vitamin D in Swedish primary health care patients born in the Middle East and Sweden.

The present study investigated primary care patients and compared self-reported sexual health in Swedes and Middle Easterners; analysed differences within and between the groups and analysed differences in 25-hydroxyvitamin D [25(OH)D] levels between the groups. 522 patients responded to a health questionnaire that included items on sexual health: 225 Middle Easterners from Iran, Iraq, and Turkey and 297 Swedes. Logistic regression was used to calculate the odds ratio (OR). Middle Easterners reported less sexual dysfunction than Swedes, and 75.8% of them and 18.9% of Swedes presented a 25(OH)D of < 50 nmol/L. The crude OR for reporting sexual dysfunction was 70% higher in Swedes compared to Middle Easterners (OR 1.70, 95% CI 1.15-2.50). This OR remained significant after adjustment for age, gender, waist circumference, and reported sexual desire. However, the significance disappeared after additional adjustment for 25(OH)D. In both groups, more females than males reported insufficient sexual desire. More female Middle Easterners reported sex life dissatisfaction. More female Swedes reported sexual dysfunction. Vitamin D could explain an association between gender and sex life dissatisfaction in Middle Easterners, and age could explain an association between gender and sexual dysfunction in Swedes. Age, waist circumference, and 25(OH)D levels were significant covariates in the logistic regression models. Results from the present study suggest that 25(OH)D variation partly explains differences in sexual dysfunction between the groups and between genders within the groups. Vitamin D therapy should be investigated to determine if these results are clinically useful.

Patients' thoughts about assessment of fracture risk in a dental setting using FRAX-a qualitative interview study.

FRAX is a tool based on questions that identifies persons at risk of fragility fractures. We interviewed patients about their thoughts on doing FRAX in a dental setting. They were generally positive but had some concerns that need to be considered before introducing FRAX in a dental setting. PURPOSE: To investigate patients' thoughts about assessing the risk of fragility fractures using the FRAX tool in a dental setting. Sweden has a high incidence of fragility fractures, but many of these are preventable. The most common method for identifying persons with a high risk of sustaining fragility fractures is FRAX, a validated instrument for assessing the risk of suffering fragility fractures within 10 years. In the Nordic countries, most of the adult population has regular contact with their dentist, which could be useful in identifying high-risk individuals. METHODS: A qualitative inductive approach to content analysis, with individual semi-structured interviews, was used. Seven women and three men, aged 65-75 years, were interviewed and assessed with FRAX. RESULTS: An overarching theme was that patients considered a FRAX assessment in the dental setting a good service but doubted that the dentists would have the interest, time, and knowledge to do it. The patients had little knowledge and experience of osteoporosis and fragility fractures. They were positive towards assessing the fracture risk with the FRAX instrument. If they were found to have a high fracture risk, they expected the dentist to send a referral for further investigation and to collaborate in the risk assessment with their family physician. They thought risk assessment in a dental context would be a good service if the fee was the same as that in primary care. CONCLUSION: Most participants were positive about having FRAX and other health assessments done in the dental clinic, but this study shows that patients have concerns that need to be addressed before introducing FRAX in this context.

Medical Students' Learning About Other Professions Using an Interprofessional Virtual Patient While Remotely Connected With a Study Group: Mixed Methods Study.

BACKGROUND: Collaboration with other professions is essential in health care education to prepare students for future clinical teamwork. However, health care education still struggles to incorporate interprofessional education. Distance learning and virtual patients (VPs) may be useful additional methods to increase students' possibilities for interprofessional learning. OBJECTIVE: This study had two aims. The first was to assess if an interprofessional VP case could facilitate medical students' learning about team collaboration in online groups. The second was to assess how students experienced learning with the VP when remotely connected with their group. METHODS: A mixed methods design was used. The VP case was a 73-year-old man who needed help from different health professions in his home after a hip fracture. Questionnaires were answered by the students before and directly after each session. Qualitative group interviews were performed with each group of students directly after the VP sessions, and the interviews were analyzed using qualitative content analysis. RESULTS: A total of 49 third-year medical students divided into 15 groups participated in the study. Each group had 2 to 5 students who worked together with the interprofessional VP without a teacher's guidance. In the analysis of the group interviews, a single theme was identified: the interprofessional VP promoted student interaction and gave insight into team collaboration. Two categories were found: (1) the structure of the VP facilitated students' learning and (2) students perceived the collaboration in their remotely connected groups as functioning well and being effective. The results from the questionnaires showed that the students had gained insights into the roles and competencies of other health care professions. CONCLUSIONS: This study demonstrates that an interprofessional VP enabled insights into team collaboration and increased understanding of other professions among student groups comprising only medical students. The interprofessional VP seemed to benefit students' learning in an online, remote-learning context. Although our VP was not used as an interprofessional student activity according to the common definition of interprofessional education, the results imply that it still contributed to students' interprofessional learning.

Fasting plasma glucose and serum 25-hydroxy vitamin D levels in individuals with Middle Eastern and Swedish descent.

Purpose: To determine fasting plasma glucose and serum 25-hydroxyvitamin D (s-25(OH)D) levels and associations between abnormal fasting plasma glucose levels and inadequate s-25(OH)D levels in individuals of Middle Eastern and Swedish descent. Methods: Observational study with individuals without a diabetes diagnosis, 54.5% of Swedish descent and 45.5% of Middle Eastern descent. In total, 830 participants from two primary healthcare centres in Flemingsberg and Jakobsberg, which are southern and northern suburbs, respectively, of Stockholm, Sweden were included in the study. Results: Prevalence of inadequate s-25(OH)D levels (at or below 50 nmol/L) was 67.2% among those of Middle Eastern descent and 20.5% among those of Swedish descent (P < 0.001). S-25(OH)D levels correlated weakly positively with fasting plasma glucose levels (ρ = 0.20, P = 0.002) in individuals of Middle Eastern descent. Being of Middle Eastern descent (OR 6.7, 95% CI 4.3-10.4) and having abnormal fasting plasma glucose (OR 1.8, 95% CI 1.2-2.9) were independent predictors of having inadequate s-25(OH)D levels. Conclusions: Healthcare in Sweden should consider testing fasting plasma glucose and s-25(OH)D levels, particularly in individuals of Middle Eastern descent. The unclear relationship between vitamin D and glucose levels warrants investigation. Supplementary Information: The online version contains supplementary material available at 10.1007/s40200-023-01226-0.

Long term association of hip fractures by questions of physical health in a cohort of men and women.

We do not know if fracture predicting factors are constant throughout life, if they can be assessed earlier in life, and for how long. The aim was to study the association between questions about health status and mobility and fragility fractures in a cohort during a 35-year follow-up. A cohort of 16,536 men and women in two age groups, 26-45 and 46-65 years old, who answered five questions of their physical health status in postal surveys in 1969-1970. We obtained data on hip fractures from 1970 to the end of 2016. We found most significant results when restricting the follow-up to age 60-85 years, 35 for the younger age group and 20 years for the older. Men of both age groups considered "at risk" according to their answers had a 2.69 (CI 1.85-3.90)- 3.30 (CI 1.51-7.23) increased risk of having a hip fracture during a follow-up. Women in the younger age group had a 2.69 (CI 1.85-3.90) increased risk, but there was no elevated risk for women in the older age group. This study shows that questions/index of physical health status may be associated with hip fractures that occur many years later in life, and that there is a time span when the predictive value of the questions can be used, before other, age-related, factors dominate. Our interpretation of the results is that we are studying the most vulnerable, who have hip fractures relatively early in life, and that hip fractures are so common among older women that the questions in the survey lose their predictive value.

The Effect of Group Training or Spinal Orthosis on Quality of Life and Potential Plasma Markers of Pain in Older Women With Osteoporosis. A Randomized Controlled Trial.

Objective: Primary purpose was to examine the effects of exercise and use of a spinal orthosis on quality of life (QoL). Secondary, to explore the effects of above-mentioned interventions on plasma levels of potential markers of pain: substance P (SP), calcitonin gene-related peptide (CGRP), and interleukin-6 (IL-6). Design: Randomized controlled trial. Setting: Community-dwelling women in Stockholm. Participants: A total of 113 women aged 60-93 years suffering from back pain and self-reported osteoporosis (n=113). Interventions: The randomized controlled trial was 3-armed: participation in an equipment exercise group, treatment with an activating spinal orthosis or controls. The intervention time was 6 months. Main Outcome Measures: QoL (QUALEFFO-41 and SF-36), plasma levels of SP, CGRP, and IL-6 measured at baseline and after 6 months in all 3 arms. Results: No improvement of QoL was found. Comparing change in mobility (QUALEFFO-41), the effect in least squares means was lower in the spinal orthosis group compared with controls. In the exercise group, the role emotional score (SF-36) deteriorated during the intervention. Effect size varied between 0.02 and 0.6. There was no change in the levels of CGRP or SP, while IL-6 levels were lower at 6 months in the spinal orthosis group compared with the other groups. At least 1 previous vertebral fracture was verified by X-ray in 46 women. Conclusion: The interventions showed none or negative effect on QoL, which was unexpected. The modest effect size may prompt a cautious interpretation. We found a lowering of IL-6 levels in the spinal orthosis group, but more studies are needed.

Association between self-rated health and the risk of hip fracture and mortality in a cohort of older women during a 10-year follow-up.

Fragility fracture of the hip is associated with reduced functional status and mortality. Poor self-rated health (SRH) might be such an indicator. Our aim was to study if SRH was associated with hip fractures and all-cause mortality within the next 10 years in community-dwelling older women. A population-based sample of 350 women aged between 69 and 79 years (median 72.4) assessed their SRH by answering the question "How would you rate your health right now" by putting a mark on a visual-analogue scale (0-100 mm). Information on hip fracture and mortality over the next 10 years was retrieved from health care registers. The association between SRH and hip fracture and all-cause mortality was tested with a Cox proportional hazards regression model. SRH was divided into low, intermediate, and high (reference) assessed SRH. During the study, 40 hip fractures and 72 deaths occurred. The median value of SRH was 62 mm (IQR 50-81 mm). The age-adjusted hazard ratio (HR) for hip fracture was significantly higher in the group with low and intermediate SRH; HR: 3.17 (95% CI 1.25-8.01), and HR: 2.75 (95% CI 1.08-7.04), compared with high SRH. Adding bone mineral density (at the femoral neck) gave even greater risk. We did not find the hypothesized association between SRH and mortality. In our study, SRH indicated a higher risk of future hip fracture in older women. SRH might be a marker that could add information about the risk of hip fracture independently of bone mineral density.