Primary Health Care Centers In Sweden Research Articles

Experiences of primary care nurses with using a handheld ultrasound device (Vscan) and a remote dielectric sensing (ReDS) device in the assessment of patients with heart failure

Abstract Background Early detection of increased lung fluids is vital to further prevent deterioration and treat worsening of heart failure (HF). However, nurses often face challenges in assessing the status of HF patients, especially in primary care, where specialized competence in cardiology may be lacking and many patients have co-morbidities. The handheld ultrasound device (Vscan) and remote dielectric sensing device (ReDS) have the potential to provide valuable support in these challenges. Purpose To describe the additional value of the information obtained with Vscan and ReDS in primary care, and to identify challenges encountered by nurses in relation to the measurements among HF patients. Methods One nurse in a Swedish primary healthcare centre used both devices on 17 separate occasions during January-June in 2023, involving a total of six patients (mean age 84.5 years, female 67%, NYHA II/III 33%/67%, lung disease 67%). The nurse made notes about the perceived value in the HF assessment and informativeness of the devices and any challenges encountered during the measurements using a self-administered questionnaire. Qualitative data was narratively reviewed and described. Results Information obtained from Vscan images such as pleural effusion and B-lines, and ReDS values contributed to the assessment of the HF status in patients, determining whether their condition worsened, remained stable or improved. These devices helped in verifying and confirming physical examination findings, including lung auscultation and subjective symptoms reported by the patient, such as shortness of breath and leg oedema. Additionally, the information (e.g., high ReDS value and the presence of B-lines) supported decisions on medication optimization, primarily through adjustments of diuretic dosages and initiation of new HF medications. It also helped to distinguish symptoms of asthma or chronic obstructive pulmonary diseases from worsening HF (e.g., presence of shortness of breath without B-lines and low ReDS value of 31). The nurse expressed uncertainty due to limited experience with using the devices, particularly when results from the two devises were not congruent. Trust in ReDS-data evolved over time and initial problems in managing the vest were resolved. Challenges associated with ReDS included difficulties in fitting the vest on patients with abnormal spine features and obesity, and issues arising from patient movements during measurements. Problems with Vscan included the generation and interpretation of ultrasound images, particularly in obese patients. Conclusion Our data suggests that both Vscan and ReDS have the potential to provide valuable information to primary care nurses in the daily management of HF patients, particularly for assessing HF status and optimizing medication. Further studies are needed to assess the effectiveness of these devices in improving patient outcomes in heart failure management in primary care.Handheld portable ultrasound (Vscan)ReDS device

Effects of an interactive web-based support system via mobile phone on preference-based patient participation in patients living with hypertension – a randomized controlled trial in primary care

Objective To estimate the effects of an interactive web-based support system via mobile phone on preference-based patient participation in patients with hypertension treated in primary care (compared with standard hypertensive care only). Design A parallel group, non-blinded, randomized controlled trial, conducted October 2018–February 2021. Besides standard hypertensive care, the intervention group received eight weeks of support via mobile phone to facilitate self-monitoring and self-management, tentatively providing for augmented patient engagement. Setting 31 primary healthcare centers in Sweden. Subjects 949 patients treated for hypertension. Main outcome measures The effects on preference-based patient participation, that is, the match between a patient’s preferences for and experiences of patient participation in their health and healthcare. This was measured with the 4Ps (Patient Preferences for Patient Participation) tool at baseline, after 8 weeks, and at 12 months. Data were registered electronically and analyzed with multilevel ordinal regression. Results At baseline, 43–51% had a complete match between their preferences for and experiences of patient participation. There was an indication of a positive effect by a higher match for ‘managing treatment myself’ at 8-weeks in the intervention group. Such preference-based participation in their health and healthcare was reversed at 12 months, and no further effects of the intervention on preference-based patient participation persisted after 12 months. Conclusion The interactive web-based support system via mobile phone had a wavering effect on preference-based patient participation. There is a prevailing need to better understand how person-centered patient participation can be facilitated in primary care.

Introducing a triage and Nurse on Call model in primary health care – a focus group study of health care staff’s experiences

BackgroundWith the increased demand for health care services and with simultaneous staff shortages, new work models are needed in primary health care. In November 2015, a Swedish primary health care centre introduced a work model consisting of a structured patient sorting system with triage and Nurse on Call. The aim of this study was to describe the staff’s experiences of introducing the triage and Nurse on Call model at the primary health care centre.MethodsFive focus group discussions with staff (n = 39) were conducted 4 years after the introduction of the work model. Groups were divided by profession: medical secretaries, nursing assistants, physicians, primary health care nurses, and registered nurses. The transcribed text from the discussions was analysed using qualitative inductive content analysis.ResultsThe analysis generated one overarching theme: The introduction of triage and Nurse on Call addresses changed preconditions in primary health care, but the work culture, organization, and acquisition of new knowledge are lagging behind. The overarching theme had five categories: (1) Changed preconditions in primary health care motivate new work models; (2) The triage and Nurse on Call model improves teamwork and may increase the quality of care; (3) Unclear purpose and vague leadership make introducing the work model difficult; (4) Difficulties to adopt the work model as it challenges professional autonomy; and (5) The triage and Nurse on Call model requires more knowledge and competence from nurses in primary health care.ConclusionsThis study contributes with knowledge about implications of a new work model in primary health care from the perspective of health care staff. The work model using triage and Nurse on Call in primary health care was perceived by participants to increase availability and optimize the use of resources. However, before introduction of new work models, it is important to identify barriers to and facilitators for successful improvements in the local health care context. Additional education for the health care staff is important if the transition is to be successful. Complementary skills and teamwork, supported by a facilitator seems important to ensure a well-prepared workforce.

Process evaluation of an implementation intervention to facilitate the use of the Swedish Physical Activity on Prescription in primary healthcare

BackgroundThe Swedish Physical Activity on Prescription (PAP-S) is a method for healthcare to promote physical activity for prevention and treatment of health disorders. Despite scientific support and education campaigns, the use has been low. The aim of this study was to perform a process evaluation of an implementation intervention targeting the use of the PAP-S method in primary healthcare (PHC). Specifically, we wanted to evaluate feasibility of the implementation intervention, and its effect on the implementation process and the outcome (number of PAP-S prescriptions).MethodsThis was a longitudinal study using the Medical Research Council guidance for process evaluation of a 9-month implementation intervention among healthcare staff at three PHC centres in Sweden. Data was collected by: participatory observations of the implementation process; questionnaires to the staff before, after and 6 months after the implementation intervention; interviews after the implementation intervention; and number of PAP-S prescriptions.ResultsDuring the implementation intervention, the workplaces’ readiness-to-change and the healthcare staff’s confidence in using the PAP-S method were favourably influenced, as was the number of PAP-S prescriptions. After the implementation intervention, the number of PAP-S prescriptions decreased to about the same number as before the implementation intervention, at two out of three PHC centres. Four of the six implementation strategies appeared to impact on the implementation process: external facilitation; leadership engagement by a committed workplace management; local PAP-S coordinator taking a leading role and acting as local champion; educational outreach concerning how to use the PAP-S method.ConclusionThe implementation intervention was not sufficient to produce sustained change of the healthcare staff’s behaviour, nor did it achieve favourable long-term outcome on the number of PAP-S prescriptions. The healthcare staffs’ sparse knowledge of the PAP-S method prior to the implementation intervention hampered the implementation. More hands-on education in how to use the PAP-S method introduced early in the implementation process is imperative for successful implementation of the PAP-S method. The findings also suggest that committed workplace management and local PAP-S coordinators, taking leading roles and acting as local champions, need to be firmly established at the PHC centres before the external facilitator withdraws.Trial registrationRegistered in the ISRCTN registry with study registration number: ISRCTN15551042 (Registration date: 12/01/2016).

GPs' experiences of phosphatidylethanol in treatment of hypertension: a qualitative study.

Hazardous alcohol use increases the risk of hypertension but is underdetected in primary healthcare (PHC) patients. Use of the biomarker phosphatidylethanol (PEth), which reflects the last 2-3 weeks of alcohol consumption, is increasing in Swedish PHC, but studies exploring its use for hypertension are scarce or missing. To explore GPs' experiences of using PEth to identify hazardous alcohol use in the context of managing hypertension. A qualitative study of GPs (n = 12) experienced in using PEth in hypertension management who were recruited at Swedish primary healthcare centres (PHCC) in 2021. The GPs participated in five focus group interviews. A questioning route was used. The interviews were audio-recorded, transcribed verbatim, and analysed with inductive qualitative content analysis. 'I don't hesitate anymore' was the overall theme, which reflected both the disappearance of GPs' fear that the PEth result might upset the patient, as this rarely occurred, and that the positive effects of PEth predominated in the findings. The theme is underpinned by the following four sub-themes: serving as an eye-opener; improving the dialogue; using with care; and learning by doing. PEth is a useful tool that changed GPs' routines for addressing alcohol and identifying hazardous alcohol use in patients with hypertension managed in PHC. The GPs advocated adopting PEth as a routine test in the treatment of hypertension. However, PEth needs to be used with care to maximise benefit and minimise harm.

Hypertension management in primary health care: a survey in eight regions of Sweden

Purpose To explore hypertension management in primary healthcare (PHC). Design Structured interviews of randomly selected PHC centres (PHCCs) from December 2019 to January 2021. Setting Seventy-six PHCCs in eight regions of Sweden. Main outcome measures Staffing and organization of hypertension care. Methods of measuring blood pressure (BP), laboratory tests, registration of co-morbidities and lifestyle advice at diagnosis and follow-up. Results The management of hypertension varied among PHCCs. At diagnosis, most PHCCs (75%) used the sitting position at measurements, and only 13% routinely measured standing BP. One in three (33%) PHCCs never used home BP measurements and 25% only used manual measurements. The frequencies of laboratory analyses at diagnosis were similar in the PHCCs. At follow-up, fewer analyses were performed and the tests of lipids and microalbuminuria decreased from 95% to 45% (p < 0.001) and 61% to 43% (p = 0.001), respectively. Only one out of 76 PHCCs did not measure kidney function at routine follow-ups. Lifestyle, physical activity, food habits, smoking and alcohol use were assessed in ≥96% of patients at diagnosis. At follow-up, however, there were fewer assessments. Half of the PHCCs reported dedicated teams for hypertension, 82% of which were managed by nurses. There was a great inequality in the number of patients per tenured GP in the PHCCs (median 2500; range 1300–11300) patients. Conclusions The management of hypertension varies in many respects between PHCCs in Sweden. This might lead to inequity in the care of patients with hypertension.

Beliefs about medications when treating hypertension in primary health care: results from “PERson-centredness in hypertension management using information Technology (PERHIT)”

Purpose Hypertension is a major global health concern. Despite of efficient antihypertensive medications a low percentage of patients reach a blood pressure (BP) of <140/90. Nonadherence is a great concern in hypertension treatment and patients’ beliefs about medications has been shown to have a strong impact on adherence. The objective of this study is to examine beliefs about medications and its impact on BP treatment in a group of Swedish primary healthcare patients treated for hypertension with or without an E-health platform. Materials and method In a randomised unblinded controlled trial, 949 patients with hypertension from Swedish primary health care centres were included. The intervention group used a web-based system to support self-management of hypertension for eight weeks. Beliefs about medication questionnaire (BMQ) were administered to all patients at inclusion, 8-week follow up and 1-year follow up. Results Data were collected from the 862 patients who completed the trial. No statistically significant difference was found in BMQ-scores between the intervention and the control group. An association between lower scores in the BMQ subsection ‘General-Harm’ and achieving target BP of <140/90 mmHg were noted (p = 0.021). Conclusion This study shows a significant association between beliefs about medication and BP levels, on hypertensive patients in the Swedish primary care setting, in only one out of four subsections of the BMQ. The intervention did not have a significant effect on changing patients’ beliefs about medication. Further emphasis on patients’ beliefs about medications could be useful in the clinical setting.

Responding to Elder Abuse in GERiAtric care (REAGERA) educational intervention for healthcare providers: a non-randomised stepped wedge trial

IntroductionElder abuse is prevalent and associated with different forms of ill health. Despite this, healthcare providers are often unaware of abusive experiences among older patients and many lack training about...

Uncomplicated urinary tract infection in primary health care: presentation and clinical outcome

Background Uncomplicated urinary tract infection (UTI) causes bothersome symptoms among women and is a leading cause for antibiotic prescribing in primary healthcare (PHC). Methods A prospective observational study in eight different PHC centres in Sweden including 192 women with symptoms of uncomplicated UTI. Questionnaires and symptom diaries were used to retrieve patient data. All urine samples were analysed with urine culture and susceptibility testing. The aim was to describe the clinical presentation of symptoms in uncomplicated UTI in relation to bacterial findings in urine and to describe the course and duration of symptoms in relation to anamnestic factors, bacterial findings and antibiotic treatment. Results Median symptom duration before seeking care was four days (IQR 1–7). Restrictions in daily life related to symptoms of uncomplicated UTI were reported by the majority (74%) of respondents. The median number of days concerning any symptom after consultation was 4.0 days (IQR 2.0–5.0) for patients treated with antibiotics, and 6.5 days (IQR 3.0–10.0) for patients not treated with antibiotics. There was an association between longer symptom duration after consultation and age over 50 years, relative risk (RR) 1.76 (95% CI 1.25–2.49). Antibiotic treatment RR 0.47 (95% CI 0.27–0.81) was associated with reported shorter duration of symptoms. Conclusions Women visiting primary health care with symptoms indicating uncomplicated UTI have symptoms for several days before seeking care and after consulting. A majority of patients feel restricted in their daily activities due to uncomplicated UTI. Older women and women not treated with antibiotics have the longest symptom duration after consultation.

Organisation of primary diabetes care in people with type 2 diabetes in relation to all-cause mortality: A nationwide register-based cohort study

AimsTo examine if personnel resources and organisational features in Swedish primary health-care centres (PHCCs) are associated to all-cause mortality (ACM) in people with type 2 diabetes mellitus (T2DM). MethodsA total of 187,570 people with T2DM registered in the Swedish National Diabetes Register (NDR) during 2013 were included in this nationwide cohort study. Individual NDR data were linked to data from a questionnaire addressing personnel resources and organisational features for 787 (68%) PHCCs as well as to individual data on socio-economic status and comorbidities. Furthermore, data on ACM were obtained and followed up until 30 January 2018. Hierarchical Cox regression analyses were applied. ResultsAfter a median follow-up of 4.2 years, 27,136 (14.5%) participants had died. An association was found between number of whole-time-equivalent (WTE) general practitioner’s (GP’s) devoted to diabetes care/500 people with T2DM and lower risk of early death (hazard ratio 0.919 [95% confidence interval 0.895–0.945] per additional WTE GP; p = 0.002). No other personnel resources or organisational features were significantly associated with ACM. ConclusionsThis nationwide register-based cohort study suggests that the number of WTE GPs devoted to diabetes care have an impact on the risk of early death in people with T2DM.

Penicillin V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci: randomised controlled, open label, non-inferiority study

ObjectiveTo determine whether total exposure to penicillin V can be reduced while maintaining adequate clinical efficacy when treating pharyngotonsillitis caused by group A streptococci.DesignOpen label, randomised controlled non-inferiority study.Setting17 primary...

Influence of contextual factors on quality of primary care in children with asthma.

Asthma is a common chronic disease among children, quality assurance is thus important. Adherence to pre-specified quality indicators of practice guidelines could be used to assess the quality of asthma care. The aim was to estimate which contextual factors that had an influence on the primary health care centres (PHCs) adherence to the quality indicators as stated in the practice guidelines. A pragmatic cross-sectional study was performed comprising 14 PHCs in Sweden. Included contextual factors were socio-demographic characteristics, organizational characteristics, and indicators regarding engagement in asthma care. Documentation on adherence to the quality indicators was retrieved from the medical health care records. Quality indicators included documentation of history of allergy and risk factors, diagnostics and patient support performed, and pharmacological treatment. To score adherence, a composite quality indicator (CQI) was computed for each PHC. A multivariable regression analysis was performed by orthogonal projection to latent structures (OPLS). By this analysis, the relationship between the result variable (CQI) and 26 pre-specified contextual factors was assessed. There was a wide variation of CQI between the PHCs. The OPLS analysis identified that 10 of the contextual factors influenced CQI. The most pronounced influences were found in more time scheduled for asthma care, a lower age-limit for performing spirometry, a lower duty-grade for general practitioners, and a higher activity at asthma educational seminars. We found no influence of socio-demographic contextual factors. We found that some of the contextual factors at the PHCs influenced the quality of performed care. Evidence-based care in paediatric asthma may thus be presumed to be facilitated by allocating time, by improving interprofessional collaboration, and by creating structures and opportunities for commitment to asthma care.

Multimorbidity among Patients with Back Pain: A Study of Records at a Swedish Primary Health Care Centre

Multimorbidity among Patients with Back Pain: A Study of Records at a Swedish Primary Health Care Centre

Possible causes of experiencing problems with sick leave questions in telephone nursing

Background: Registered nurses at primary health care centres in Sweden receive about 20 million telephone calls annually. Questions related to sick leave occur regularly. Previous studies conclude that those calls often are perceived as problematic. The aim of this study was to explore factors associated with problems regarding sick leave questions in telephone nursing.Methods: A questionnaire was distributed to all registered nurses (n = 185) working with telephone nursing in 26 Swedish primary health care centres, of whom 114 (61.6%) responded. Based on the results of a Spearman correlation analysis a logistic regression analysis was performed of significant exposure variables on outcome (perceived problems).Results: Significant exposure variables were: experience of telephone nursing, age, being educated in social insurance medicine, and frequency of telephone calls with sick leave questions. Young age was associated with more problems than old age. Those having education in social insurance medicine reported fewer problems than those who had not, and so did those having few telephone calls with sick leave questions as compared with those who had many.Conclusions: Young age, lack of education in insurance medicine, and high frequency of sick leave questions increased the perceived problem level in telephone nursing.

General practitioners’ accounts of how to facilitate consultations with toddlers – an interview study

Objective: To describe general practitioners’ (GPs’) accounts of how to facilitate consultations with children aged 1–2 years.Design: A qualitative study based on focus group interviews.Setting and subjects: Five focus group interviews were conducted with a total of 25 GPs at Swedish primary health care (PHC) centres. The GPs regularly invited toddlers to consultations.Result: The GPs’ accounts of how to facilitate consultations with toddlers revealed descriptions of making efforts to instil confidence in the situation to enable the consultation. Toddlers in need of health care always visit the GP with adults such as their parents, guardians or other relatives. Therefore, the GP directs efforts towards the adults and the child more or less simultaneously, as they both need to rely on the GP. The GPs describe how they instil confidence in the adults by establishing a mutual understanding that the consultation is necessary to secure the child’s health. Regarding the child, the GP instils confidence by establishing a relationship in order to approach the child and accomplish bodily examinations.Conclusion: The result shows that GPs’ encounters with children in consultations are two-sided. The GP needs to conduct bodily examinations to secure the child’s health and development, but to do so he/she needs to establish purposeful relationships with the adults and the child by instilling confidence. This indicates that establishing relationships in the consultation is significant, and a way to achieve a child-centred consultation.KEY POINTSResearch regarding GPs’ encounters with toddlers in consultation is limited, even though toddlers frequently visit PHC.• GPs make efforts to instil confidence by establishing mutual understanding with parents and a relationship with the child.• Establishing purposeful relationships with both the child and parent is significant in enabling the consultation.• Establishing a relationship with the child overrides conducting the bodily examination, to promote the child’s feeling of ease and allow a child-centred consultation.

Work motivation among healthcare professionals

PurposeThe purpose of this paper is to explore work motivation among professionals at well-functioning primary healthcare centers subject to a national healthcare reform which include financial incentives.Design/methodology/approachFive primary healthcare centers in Sweden were purposively selected for being well-operated and representing public/private and small/large units. In total, 43 interviews were completed with different medical professions and qualitative deductive content analysis was conducted.FindingsWork motivation exists for professionals when their individual goals are aligned with the organizational goals and the design of the reform. The centers’ positive management was due to a unique combination of factors, such as clear direction of goals, a culture of non-hierarchical collaboration, and systematic quality improvement work. The financial incentives need to be translated in terms of quality patient care to provide clear direction for the professionals. Social processes where professionals work together as cohesive groups, and provided space for quality improvement work is pivotal in addressing how alignment is created.Practical implicationsLeaders need to consistently translate and integrate reforms with the professionals’ drives and values. This is done by encouraging participation through teamwork, time for structured reflection, and quality improvement work.Social implicationsThe design of the reforms and leadership are essential preconditions for work motivation.Originality/valueThe study offers a more complete picture of how reforms are managed at primary healthcare centers, as different medical professionals are included. The value also consists of showing how a range of aspects combine for primary healthcare professionals to successfully manage external reforms.

Bariatric Surgery and the Risk of New-Onset Atrial Fibrillation in Swedish Obese Subjects

BackgroundObesity is a risk factor for atrial fibrillation, which in turn is associated with stroke, heart failure, and increased all-cause mortality. ObjectivesThe authors investigated whether weight loss through bariatric surgery may reduce the risk of new-onset atrial fibrillation. MethodsSOS (Swedish Obese Subjects) is a prospective matched cohort study conducted at 25 surgical departments and 480 primary healthcare centers in Sweden. The cohort was recruited between 1987 and 2001. Among 4,021 obese individuals with sinus rhythm and no history of atrial fibrillation, 2,000 underwent bariatric surgery (surgery group), and 2,021 matched obese control subjects received usual care (control group). The outcome, first-time atrial fibrillation, was ascertained by crosschecking the SOS database with the Swedish National Patient Register on inpatient and outpatient diagnosis codes. ResultsDuring a median follow-up of 19 years, first time atrial fibrillation occurred in 247 patients (12.4%) in the surgical group, and in 340 (16.8%) control subjects. The risk of developing atrial fibrillation was 29% lower in the surgery group versus the control group (hazard ratio: 0.71; 95% confidence interval: 0.60 to 0.83; p < 0.001). Younger individuals benefited more from surgical intervention than those who were older (p value for interaction 0.001). Also, those with a high diastolic blood pressure benefitted more from surgery than did those with a low diastolic blood pressure (p for interaction = 0.028). ConclusionsCompared with usual care, weight loss through bariatric surgery reduced the risk of atrial fibrillation among persons being treated for severe obesity. The risk reduction was more apparent in younger people and in those with higher blood pressure.

Resource allocation and organisational features in Swedish primary diabetes care: Changes from 2006 to 2013

AimsTo compare the resource allocation and organisational features in Swedish primary diabetes care for patients with type 2 diabetes mellitus (T2DM) between 2006 and 2013. MethodsUsing a repeated cross-sectional study design, questionnaires covering personnel resources and organisational features for patients with T2DM in 2006 and 2013 were sent to all Swedish primary health care centres (PHCCs) during the following year. In total, 684 (74.3%) PHCCs responded in 2006 and 880 (76.4%) in 2013. ResultsCompared with 2006, the median list size had decreased in 2013 (p<0.001), whereas the median number of listed patients with T2DM had increased (p<0.001). Time devoted to patients with T2DM and diabetes-specific education levels for registered nurses (RNs) had increased, and more PHCCs had in-house psychologists (all p<0.001). The use of follow-up systems and medical check-ups had increased (all p<0.05). Individual counselling was more often based on patients’ needs, while arrangement of group-based education remained low. Patient participation in setting treatment targets mainly remained low. ConclusionsEven though the diabetes-specific educational level among RNs increased, the arrangement of group-based education and patient participation in setting treatment targets remained low. These results are of concern and should be prioritised as key features in the care of patients with T2DM.

Low risk of seroconversion or clinical disease in humans after a bite by an Anaplasma phagocytophilum-infected tick

The risk of contracting human granulocytic anaplasmosis (HGA) after a tick bite is mainly unknown. In this study we investigated the clinical and serological response in 30 humans bitten by ticks positive for Anaplasma phagocytophilum (Group A), 30 humans bitten by Borrelia burgdorferi sensu lato (s.l.)-positive ticks (Group B), and 30 humans bitten by ticks negative for both A. phagocytophilum and B. burgdorferi s.l. (Group C). Ticks, blood samples and questionnaires were collected from tick-bitten humans at 34 primary healthcare centres in Sweden and in the Åland Islands, Finland, at the time of the tick bite and after three months. A total of 2553 ticks detached from humans in 2007–2009 were analyzed by polymerase chain reaction, and 31 (1.2%) were positive for A. phagocytophilum, 556 (21.8%) were positive for B. burgdorferi s.l., and eight (0.3%) were co-infected by A. phagocytophilum and B. burgdorferi s.l. The overall prevalence of Anaplasma IgG antibodies in the included participants (n=90) was 17%, and there was no significant difference between the groups A-C. Only one of the participants (in Group C) showed a four-fold increase of IgG antibodies against A. phagocytophilum at the three-month follow-up, but reported no symptoms. The frequency of reported symptoms did not differ between groups A-C, and was unrelated to the findings of A. phagocytophilum and B. burgdorferi s.l. in the detached ticks. We conclude that the risk for HGA or asymptomatic seroconversion after a tick bite in Sweden or in the Åland Islands is low, even if the tick is infected by A. phagocytophilum.

Depression, stroke and gender: evidence of a stronger association in men

Background/aimsDepression is associated with an increased risk for stroke. The aim of this study was to examine whether demographic and socioeconomic factors modify this association.MethodsThis follow-up study comprised 137 305...