Bakgrund: Prevalensen för att en kvinna ska drabbas av antenatal depression är 20 % och för postpartumdepression är 8-15%. Det vanligaste instrumentet som används för att screena för depression under och efter graviditet är Edinburgh Postnatal Depression Scale. Att vara deprimerad innebär lidande för gravida och nyblivna mödrar men också ett lidande för familj och vänner. De vanligaste symtomen för depression är nedstämdhet, initiativlöshet, ständig oro och ångest, nedsatt intresse och skam med mera. Det är viktigt för barnmorskan att ha god kunskap om depression under och efter graviditet, då det är barnmorskan som har den kontinuerliga kontakten med kvinnan under och efter graviditeten.  Syfte: att beskriva barnmorskors kunskap om depression under och efter graviditet samt att beskriva vilken utbildning barnmorskor får. Metod: En litteraturstudie där 21 artiklar med kvantitativ och kvalitativ ansats har inkluderats. Resultat:De kategorier och subkategorier som har framkommit efter en schematisk översikt genom manifest innehållsanalys är barnmorskors upplevelser och erfarenheter, upplevelser av arbetsmiljön och organisation samt barnmorskors kompetens och utveckling. Om en barnmorska har en god attityd till och förståelse för kvinnor som har depression under och efter graviditet bidrar det till positiv inställning till att arbeta med dessa kvinnor. Barnmorskorna i artiklarna upplevde att det största hindret för att identifiera kvinnor med depression under och efter graviditet var tidsbrist samt att organisationen behöver bättre kontinuitet för kvinnor med depression under och efter graviditet. Barnmorskor som får god kompetens och utvecklingsmöjligheter bidrar till god kunskap. God kunskap bidrar i sin tur till att barnmorskor känner sig mer trygga i sin roll i identifieringen av kvinnor med depression under och efter graviditet. Slutsats:Barnmorskor behöver mer kunskap om ämnet depression under och efter graviditet. Om en gravid eller nyförlöst mamma mår dåligt av sitt moderskap och inte får den hjälp hon behöver skulle det i slutändan bidra till långvarig behandling och vård. Ur ett samhällsekonomiskt perspektiv vore det en brist för samhället om det inte görs rätt från början. / Background:Prevalence for a woman to suffer from antenatal depression is 20% and postpartum depression is 8-15%. The most common instrument used for screening for depression during and after pregnancy is the Edinburgh Postnatal Depression Scale. Being depressed means suffering for pregnant and new mothers but also suffering for family and friends. The most common symptoms of depression are downhearted, lack of initiative, constant concern and anxiety, impaired interest and shame and more. It is important for the midwife to have good knowledge of depression during and after pregnancy since it is the midwife who has continuous contact with the woman during and after pregnancy. Aim: to describe midwives knowledge about depression during and after pregnancy and which education midwives get. Method: A litterature study of 21 articels inlcuding qualitative and quantitative approaches.   Results: The categories and subcategories that have emerged from a schematic overview through manifest content analysis are midwives' experiences, experiences of the work environment and organization and along with midwifery skills and development. If a midwife has a good attitude and understanding of women who have depression during and after pregnancy it contributes positively to working with these women. Midwives in the articles experienced the greatest obstacle to identifying women with depression during and after pregnancy to be lack of time and the need for better continuity for women with depression during and after pregnancy. Midwives who learn good skills and have development opportunities contribute to good knowledge. Good knowledge, in turn, contributes to the fact that midwives feel more secure with their role in identifying women with depression during and after pregnancy. Conclusion:Midwives need more knowledge about the topic of depression during and after pregnancy. If a pregnant or new mother feels bad about her motherhood and does not get the help she needs it would ultimately contribute to prolonged treatment and care. From the socio-economic perspective, it would be a shortcoming for society if it is not done right from the start.

Background: A health damage that has been specifically related to nursing is pressure ulcers. Pressure ulcers are a complication caused by disease, care and treatment and can result in great suffering for the patient. Pressure ulcers can affect people both physically and psychosocially and is experienced, by most patients, as a serious and unnecessary complication of care. Today there are hundreds of identified risk factors for pressure ulcers described that can be divided into patient and care-related risk factors. A successful pressure ulcer prevention and treatment is to reduce or eliminate the underlying causes for the development of pressure ulcers, prevent deterioration and to treat existing ulcers. To prevent the occurrence of pressure ulcers and heal them, nurses’ knowledge and skills become important.   Aim: The aim was to describe the nurses´ knowledge and attitude towards pressure ulcer prevention and treatment and how it affects the practice.   Methods: The study was conducted as a literature study and was based on Willman, Stoltz och Bahtsevani (2011) methodology for reviewing scientific articles. 12 articles were chosen, three of which were qualitative, eight quantitative and one quantitative and qualitative. The analyze was conducted by Fribergs (2012) analysis regarding qualitative and quantitative research.   Results: The result are presented under the four headings: Differences in nurses’ knowledge, Either you love pressure ulcers or you hate them, Lack of access to training, despite its positive impact, The attitude has a greater impact on the practice than knowledge.   Discussions: The results were discussed based on the concept of health care environment, where the focus was directed towards a psychosocial component. Areas addressed include lack of access to education on pressure ulcers and what it can lead to, how the nurses’ negative attitude affect the practice and finally discussed the need to further examine of how nurses' attitudes can be improved and how they can be inspired to a greater interest in their work with pressure ulcers.   Keywords: Pressure ulcer, Nurse, Prevention, Treatment, Knowledge, Attitude, Practice, Patient safety, Health care environment

Sammanfattning  Bakgrund Tidigare forskning visar att det finns ett samband mellan olika språkliga förmågor och läs- och skrivutvecklingen, varav morfologisk medvetenhet är en av dessa förmågor. Att bedöma morfologisk medvetenhet kan alltså vara ett sätt att identifiera barn som är i risk för läs- och skrivsvårigheter. I dagsläget finns inte ett heltäckande svenskt morfologiskt bedömningsmaterial. Syfte Studiens syfte var att undersöka samband mellan olika test av förmågor som är viktiga för den tidiga läs- och skrivutvecklingen, vilket innefattar avkodning, stavning, ordförståelse och morfologisk medvetenhet hos elever i årskurs 2. Studien undersökte även den interna och externa validiteten hos ett nyutvecklat morfologitest kallat ”Bygga ord” och utvärderade detta test kvalitativt.  Metod Deltagarna bestod av 33 elever i årskurs 2 från två skolor i norra Sverige. Testningarna skedde på skolan under skoltid, både i helklass och individuellt. Samtliga elever fick genomföra tre avkodningstest, två morfologiska test, ett stavningstest och ett ordförståelsetest. Resultat Signifikanta samband påvisades mellan resultaten från testning av förmågorna morfologisk medvetenhet, avkodning, stavning och ordförståelse. Resultaten visade att det nyutvecklade morfologiska testet hade god intern och extern validitet. Den kvalitativa analysen av testet visade att några instruktioner kan behöva förtydligas, vissa deltest upplevdes som svåra, tidsåtgången varierade mellan deltesten, samt att kategorin ”Böjning” upplevdes som enklast.  Slutsatser Resultaten styrker tidigare fynd att morfologisk medvetenhet har en inverkan på utvecklingen av läs- och skrivförmågor. Dock kan inga slutsatser dras gällande kausalitet för de påvisade sambanden. Det nyutvecklade morfologiska testet mäter den förmåga det avser att mäta (morfologisk medvetenhet) och den kvalitativa analysen av testet visar att bedömningsmaterialet i sin helhet fungerar väl, men några revideringar rekommenderas.

Background: Type 2 diabetes is a common chronic disease worldwide. An important part of the treatment is monitoring and treating the elevated levels of blood glucose. But there is also a need for monitoringother risk factors that confer an increased risk for vascular complications. This thesis is based on four studies that explore different aspectsof monitoring blood glucose and obesity in patients with type 2 diabetes in primary care. Methods: To examine the cost and effect on glycaemic control of patients performing self-monitoring of blood glucose (SMBG) an observationalstudy was performed in the county of Östergötland and Jönköping 2003-2004. The study included all known patients with type 2 diabetes at 18 primary health care centres (PHCC), excluding patients in nursery homes. A structured observational intervention study of 98 patients with type 2 diabetes living at 17 nursery homes were done with monitoringof hypoglycaemic episodes followed by a controlled withdrawal of diabetes medication in patients with HbA1c ≤ 6.0 %. Baseline data from the cohort study; Cardiovascularrisk in type 2 diabetes – a prospectivestudy in primary care (CARDIPP), was analysed for correlation analyses between anthropometric status and early cardiovascular organ damage, measured by pulse wave velocity (PWV) and left ventricular mass index (LVMI). Results: When comparing users of SMBG to non-users, there was no association between improvedglycaemic control and use of SMBG. A plasma glucose profile for three consecutive days of the patients at nursery homes, indentified 31 episodes of plasma glucose levels≤ 4.4 mmol/l. A withdrawal of insulin and oral antiglycaemic medicine was performed, which after 3 months follow up was successful in 24 (75 %) of the patients. The mean annual cost per PHCC for visits to general practitioner and nurse, insulin, SMBG and oral antiglycaemic agents was586 € (SD 435) per patient. There was no correlationbetween costs and glycaemic control at PHCC level. In the CARDIPP study, both increased sagittalabdominal diameter and increased waist circumference were, independently of sex, age, blood pressure and HbA1c, associated to increasedPWV and LVMI. Conclusions: Use of SMBG in primary care confers a substantialpart of the treatment costs, but is not associated with improved glycaemic control. Systematic use of SMBG for patients not treated with insulin should not be recommended. At nursery homes, patients with type 2 diabetes are at risk for harmful hypoglycaemia and may benefit from a more frequent control of plasma glucose and a less strict glycaemic control. Increased abdominal obesity measured with either sagittal abdominal diameter or waist circumference is associated with early cardiovascularorgan damage. In addition to analyses of blood glucose, blood pressure and lipids, the monitoring of abdominal obesity is a feasible risk factor assessment tool, that provides further information about cardiovascular risk that goes beyond that of traditional risk factors.

Many depressed patients attend primary health care, and minority-group patients often see general practitioners for depressive symptoms. The diagnosis and classification criteria of depression and guidelines for management are based on symptoms. However,expressions of depression can vary with culture and gender but the diagnostic tools and guidelines are not adapted to gendered or cultural context and have shown to be poorly applicable in clinical practice. The purpose of this thesis was to analyse how socio-cultural factorswith focus on gender and ethnicity and their intersections- could influence the concept of depression from the perspectives of the patient and patient descriptions, of medical experts as well as general practitioners. By viewing these different perspectives I have tried to illustrate how depressive symptoms are expressed and interpreted in different gendered socio-cultural contexts and how they become a disease entity. Furthermore, I want, in particular, to illustrate a variety of difficulties that GPs may face during the process of care when meeting and treating men and women from different countries showing symptoms which may indicate depression. Study I. The aim of the study was to explore the reasons for and patterns of attendance among Roma women in primary health care and to shed light on health problems of the Roma. Four Roma women were interviewed in-depth. The data were audiotaped and analysed according to Grounded Theory. The resuIts showed that the daily life of women was characterized by marked hierarchical order and rules formed by gender, age and the collective culture. Young women had most rules to follow and if the rules were broken it was easy to end up outside the collective and display depressive symptoms or pain. The gendered, collective culture could both construct and/or form the concept of illness among the Roma women. Study II. The aim of the study was to highlight the gendered representations of lay persons´ experiences of depression by drawing on personal stories of depression that appeared in Swedish newspapers. The data were then subjected to a Qualitative Content Analysis. The mediated accounts of depression both upheld and challenged traditional gender stereotypes. The women’s stories were more detailed, relational, emotionally oriented, and embodied. The portrayal of men was less emotional and expressive, reflecting hegemonic patterns of masculinity. The media representations of gendered healthrelated beliefs and behaviours may influence the way patients, physicians and other health care professionals understand and communicate about issues of mental health and depression. Study III. The aim of the study was to explore how authors of medical articles wrote about different symptoms and expressions of depression in men and woman from various ethnic groups as well as to analyse the meaning of gender and ethnicity for expressions of depression. Through a search in the medical database PubMed 30 scientific articles were identified and included in the analysis. The result and the discussion section of each article was analysed with Qualitative Content Analysis. The analysis showed that culture and gender formed the expressions of depression, how depression was interpreted and the diagnosis of depression. The analysis of the articles identified a western point of view, which could lead to “cultural or gender gaps” and which could also influence the diagnosis of depression. Study IV. The aim of the study was to make a qualitative analysis of medical research articles in order to get a broader view of explanations of depression in men and women in various ethnic groups. Through a search in the medical database PubMed 60 scientific articles were identified and included in the analysis. The result and the discussion section of each article was analysed with Qualitative Content Analysis. The explanations for depression in our study have a strong emphasis on socio-cultural causes with focus on depressed persons from non-western minority groups. Even so, discussion about cultural or gendered explanations for depression was almost missing. We interpreted that the view of minority groups in the articles could be described as a view of “others”. The view of “othering” increases risks for cultural and gender gaps, such as biased scientific knowledge, medicalization of social problems, cultural stereotypes, risk for misdiagnosis of men´s depression, and affects the quality and care of depressed patients. Studv V. The aim of the study was to explore and analyse how GPs think and deliberate when seeing and treating patients from foreign countries who display potential depressive symptoms. The data were collected in focus group and individual interviews with GPs in northern Sweden and analysed by Qualitative Content Analysis. The study showed that patients’ early life events of importance were often unknown which blurred the accuracy. Reactions to trauma, cultural frictions and conflicts between the new and old gender norms made the diagnostic process difficult. The patient-doctor encounter comprised misconceptions, and social roles in meetings were sometimes confused. GPs based their judgement mainly on clinical intuition. Tools for management and adequate action were diffuse. There is a need for tools for multicultural, general practice care. It is also essential to be aware of the GPs’ own conceptions to avoid stereotypes and not to under-or overestimate the occurrence of depressive symptoms. Conclusion: The concept of depression is always situated. The gendered socio-cultural norms, beliefs and behaviours can both construct the concept of illness and influence patients’ experiences and expressions of depression as well as form the patient-doctor encounter. The knowledge of medical “experts” is based on a dominating, western view of knowledge, which defines diagnosis and classification criteria of depression as well as guidelines for management. GPs are struggling for clarity between the medical and the clinical practice. The multicultural appearances of depressive symptoms are a challenge for GPs but it is a challenge for society to improve the life circumstances which can lead to a depressed mood and suffering.

SAMMANFATTNING Syfte och frågeställningar: Syftet med studien var att komma närmare i begrepp, diagnos och behandling gällande fenomenen stressrelaterad ohälsa till utmattningssyndrom (UMS). Ielitidrotten finns stressrelaterad ohälsa som överträningssyndrom (OTS). OTS kan också leda till utmattning. Det finns olika stadier av stressrelaterad ohälsa/OTS innan ett UMS utvecklas. Intervjustudien tar upp frågeställningar som rör fenomenen för att få en uppfattning och förklaring bland experter, kliniker och behandlare i Sverige. Frågeställningarna belyser behandlingsvägen för patienter som söker hjälp för stressrelaterad ohälsa. Frågeställningarna vill vidare belysa forskningsläget i de behandlingsmetoder vi använder i de olika faserna av stressrelaterad ohälsa både inom idrottsvärlden och i primärvården i Sverige. Metod: Metoden som valdes var en kvalitativ semistrukturerad intervjustudie som berörde frågeställningarna och syftet. 6 stycken experter varav 3 diagnosförskrivare (1 diagnosförskrivare och 2 experter inom idrottsområdet) och 3 stycken väl valda behandlare varav 2 inom idrottsområdet valdes in. Teman identifierades och frågorna bearbetades. Intervjuerna spelades in och transkriberades ordagrant. Analysen bearbetades med systematisk textkondensering. Resultat:  6 koder hittades. 1. ”Förmågan att förstå processen” handlar om acceptans.2. ”Sortering i stressrelaterad ohälsa” handlar om att sortera inom fenomenet för att visa på hur stort området är. 3.”Förebyggande arbete är behandlingen ”visar på den viktiga aspekten på allt vi kan göra innan och att få en tidig start är det som är kostnadseffektivt i det långa loppet. 4.”Vägen till läkning” beskriver hur vägen ser ut idag för de som drabbas. Behandlingen är individuell återhämtning med inslag av aktiviteter. Specifika åtgärder med individuell plan i ohälsosamma beteenden kräver bearbetning. 5. ”Hur ska vi tackla framtidens utmaningar?” koden beskriver hur samhället bör förändring i att inte individen värderas enbart av sin prestation. Kunskap och lärande om kropp, stress och återhämtning måste startas i låg ålder. 6. ”Återhämtning” ordet behöver få större slagkraft i alla behandlingar som rör stressrelaterad ohälsa. Slutsats: Begreppen är stora, framför allt stressrelaterad ohälsa. Arbete krävs med den medicinska diagnosen UMS för att den ska bli vedertagen både i Sverige och internationellt. Förståelsen om varför och hur en utmattningsprocess kan starta hos individer och behovet av individuell återhämtning och bearbetning måste komma ut tidigare till alla i samhället. Vi bör alltid sträva att stoppa sjukdomsförloppet i stressrelaterad ohälsa i tid. OTS är ett vanligt negativt beteende hos individer som lider av psykisk ohälsa i den stressrelaterade ohälsan. Kopplingen med den mot utmattningsprocessen och UMS bör fortsätta utvecklas. Den kunskapen vi har hittills borde redan nu anammas av vårdpersonal. / ABSTRACT Aim: The aim of this study was to get a more precise definition, diagnosis and treatment of the phenomenon stress related illness and the process to exhaustion. Stress related illness covers the term overtraining syndrome (OTS) which is a common problem in elite sports. Experts, clinics and health workers in Sweden have been interviewed. By recognizing early signals, stress related illness may be dealt with an earlier treatment which leads to a better prognosis. Stress related illness and OTS can be a long-lasting process before exhaustion comes. Sports and work give the same stress to our bodies and minds. Different treatments of the clients were investigated in this study. Method: The method chosen was a quality study with semi structural interviews that investigate these phenomenon’s. Five experts (three in clinics who regularly sets diagnosis) and five health workers (two in clinics who regularly sets diagnosis) were interviewed. Terms were developed after the aim and the interviews were recorded. Systematic text condensation (STC) was used for the analysis. Results: Six codes were found after the analysis. 1.” The capacity of understanding the process”. The patient must admit his problem in order to be able to treat it. 2.” Defining stress related illnesses”. A finer grade of definitions will aid psychologists and doctors to set a certain diagnosis. 3.” The preemptive work is the treatment”. The best treatment is to find it at an early stage. 4.” The road to recovery” visualizes the entire course, from the first symptoms, to treatment and finally recovery. 5.” Challenges of the future”. The highest virtues in our society today are efficiency and performance. In itself those are great and should be revered, but as all things in extreme they can be dangerous. Education is vital if we want to avoid these problems in the future. 6.” Recovery”. When examining and diagnosing stress related illnesses, attention to recovery should always be your first and foremost concern. Conclusions: The definition of stress related illness is still too broad and covers a large field. Cases regarding these kind of illnesses differs and is highly individual. Exhaustion may occur quickly or not at all. The goal should be to coordinate with the rest of Europe to get a joint medical diagnosis. As it is now, definitions and treatments vary even inside of Sweden. If the knowledge regarding stress would be more widespread, exhaustion could be avoided. One should strive to identify the symptoms at an early stage to prevent them becoming severe. OTS should be picked up by health workers in their daily work and not only as a term in elite sports.

Litteraturöversiktens teoretiska referensram utgår från Patricia Benners teori om kompentensstadium. Detta ramverk nyttjas för att beskriva vikten av klinisk erfarenhet under sjuksköterskors professionsutveckling. Klinisk erfarenhet anses vara grundläggande för sjuksköterskors utveckling i yrkesrollen (Benner, 1993). Bakgrund: Att åldras är en naturlig del av livet. Många människor vårdas palliativt vilket resulterar i att sjuksköterskor kräver kunskap och kompetens inom området. Sjuksköterskor som arbetar inom den palliativa vården uttrycker ofta att de vill göra gott för patienten samt anhöriga. Syfte: Syftet med denna litteraturöversikt var att belysa sjuksköterskors erfarenhet av att arbeta inom den palliativa vården. Metod: Studien är en litteraturöversikt med kvalitativ forskning i form av vetenskapliga artiklar. Datasökningarna utfördes i databaserna Cinahl, MEDLINE, PsycINFO och PubMed. Artiklarna granskades med hjälp av Statens beredning för medicinsk och social utvärdering (SBU) granskningsmall. Resultat: Visade för- och nackdelar med att arbeta inom den palliativa vården. Viktiga faktorer hos sjuksköterskor var ansvar, samarbete, känslor och tid samt resurser. En god palliativ vård grundades i sjuksköterskors tillgänglighet och närhet. Slutsats: Resultatet har visat att ett utbildningsbehov framträdde vilket pekar på att grundläggande utbildning inte är tillräcklig inom den palliativa vården. God kommunikationsförmåga, utbildning samt kunskap inom området kan vara alternativ som underlättar för sjuksköterskor.

<p><b>Objectives</b>. To study medication utilization and adherence to prescribed therapy in a female population in central Sweden. To study usage of hormone replacement therapy (HRT) in this population and to assess how HRT users compare to non-users regarding symptom reporting, general health and other variables. To evaluate symptom prevalence adjusted for potential symptom affecting variables. </p><p><b>Material and methods</b>. A cross-sectional postal questionnaire study was performed in 1995 in seven counties in central Sweden. A questionnaire was sent to a random sample of 4,200 women aged 35-64, of whom 2,991 responded (71.2%). The questionnaire contained questions on psycho-socio-economic background, quality of life, self-reported health, height and weight, climacteric symptom prevalence, and menopausal status and symptoms. It also comprised questions on medication prescribed during the past year. </p><p><b>Results</b>. 40% used prescribed medication and 12% took four drugs or more. Age, educational level, self-rated health, and BMI remained significantly correlated to drug use in multivariate analysis. Adherence ranged from 15%-98% depending on age, a scheduled check-up, perceived importance of medication, concern about medication, taking cardiovascular and respiratory disease drugs. The highest adherence was found for hormonal medication the lowest for musculoskeletal medication. </p><p>HRT was used by 15% of the women. 13 % used other symptom relieving therapy. HRT users reported higher score of vasomotor symptoms, except for sweating during the daytime. </p><p>Prevalence of general symptoms did not necessarily increase with age. Especially symptoms related to stress-tension-depression decreased with age. Four different symptom prevalence patterns were found. </p><p><b>Conclusions</b>. Age, health status, educational level and body mass index (BMI) appear to affect drug use. Adherence to therapy is highest among elderly women who regard their medication as important and have a scheduled check-up. HRT relieves some vasomotor symptoms but does not affect other symptoms or self-rated health. Prevalence of symptoms related to Stress-tension-depression appears to decrease with age.</p>

Syftet med avhandlingen var att beskriva diagnostiken och utvärdera handläggningen i primärvård av patienter med subacromial smärta. Avhandlingen omfattar fyra studier. I den första studien användes ett frågeformulär och resultaten beskriver hur distriktsläkare och distriktssjukgymnaster i ett svenskt län diagnosticerar och handlägger primärvårdspatienter med subacromial smärta. Den andra studien beskriver distriktsläkares och distriktssjukgymnasters tilltro till effekten av olika behandlingsmetoder för dessa patienter. Med utgångspunkt från de tilltrodda behandlingsmetoderna genomfördes en systematisk litteraturöversikt. Den tredje studien utvärderar intra- och interbedömar reliabilitet för ett styrketest som ingår i ett utvärderingsinstrument ‘the Constant-Murley shoulder assessment’. Den avslutande studien är en randomiserad klinisk studie som utvärderar och jämför effekten av två behandlingsstrategier, akupunktur och ultraljud, båda i kombination med hemträning. Distriktsläkare och distriktssjukgymnaster visade sig använda en likartad diagnostik. Det troligaste valet av behandling för distriktsläkare var antiinflammatoriska läkemedel och kortisoninjektion i den subacromiala bursan och för distriktssjukgymnaster rörelseträning samt ergonomiska åtgärder. Dock var de flesta behandlingsalternativen troliga val, vilket tolkas som en osäkerhet om behandlingarnas effekt. Med utgångspunkt från de behandlingsmetoder som distriktsläkare och distriktssjukgymnaster tilltrodde som effektiva för patienter med subacromial smärta, genomfördes en systematisk kritisk litteraturöversikt. Fyrtio studier inkluderades och deras evidensnivå utvärderades. Endast kortisoninjektion i den subacromiala bursan visade sig ha definitiva bevis för effekt. Akupunktur visade sig ha troliga bevis för effekt och ultraljudsbehandling konkluderades som ineffektivt för patienter med subacromial smärta. Det förelåg en låg grad av samstämmighet mellan tilltro och tillgängliga vetenskapliga bevis. En digital dynamometer kan ersätta den konventionella fjädervågen i det standardiserade styrketestet. En nästan perfekt överensstämmelse vad gäller både intra- och interbedömarreliabilitet vid test av unga skulderfriska personer, oberoende av om en ”håll emot-” eller ”dragteknik” användes eller om medel- eller maxvärden användes vid beräkningen av överensstämmelse. I den randomiserade kliniska studien inkluderades 85 patienter. Tre utvärderingsinstrument, kombinerade i resultatanalysen, utvärderade förändringen under en uppföljningsperiod på 12 månader tillsammans med patienternas subjektiva skattning av resultatet. Resultaten visade att akupunktur i kombination med hemträning är att föredra. Båda behandlingsgrupperna förbättrades signifikant och fortsatte förbättras över tid oberoende av behandling. De flesta patienter uppnådde ett tillfredställande behandlingsresultat efter 12 månader. Åtminstone tre fjärdedelar i varje behandlingsgrupp skattade sig mycket förbättrade eller helt återställda. Detta tolkas som en behandlingseffekt i kombination med naturalförloppet. Avhandlingen har beskrivit handläggningen i primärvård av patienter med subacromial smärta och har bidragit med vetenskapliga bevis för distriktsläkare att behandla med kortisoninjektion i subacromiala bursan och för distriktssjukgymnaster att behandla med akupunktur kombinerat med hemträning. / The aim of the thesis was to describe the diagnostic approach and evaluate primary care management of patients with subacromial pain. The thesis includes four different studies, a questionnaire study describing attitudes among general practitioners and physiotherapists in a Swedish county toward the diagnostic approach and management of primary care patients with subacromial pain; a combination of a systematic review and general practitioners and physiotherapists beliefs in interventions for patients with subacromial pain; a study of intra- and inter-observer reliability for the strength test in the Constant-Murley shoulder assessment; and a randomised clinical trial to evaluate and compare the efficacy of two treatment strategies for patients with subacromial pain, acupuncture combined with home exercises and continuous ultrasound combined with home exercises. In the questionnaire study we described that general practitioners and physiotherapists have a uniform diagnostic approach. The most probable choice of treatment was non-steroidal anti-inflammatory drugs and corticosteroid injection into the subacromial bursa for general practitioners and movement exercises together with ergonomics/adjustments at work for physiotherapists, but most treatments were probable choices, reflecting an uncertainty about their effectiveness. The treatments trusted by general practitioners and physiotherapists were systematically reviewed. Forty studies were included and the level of evidence was summarised. Only corticosteroid injections into the subacromial bursa, had definitive evidence for efficacy. Acupuncture had tentative evidence for efficacy and therapeutic ultrasound was concluded as ineffective for patients with subacromial pain. The association between trusted treatments and available scientific evidence was weak. A digital dynamometer can replace the conventional spring-balance in the standardised strength test. An almost perfect agreement was found for intra- and inter-observer reliability in young shoulder-healthy persons, regardless of whether a 'resisted-force' or a 'pull-force' was used or if calculated with mean or maximum values. Eighty-five patients were included in the randomised clinical trial. Three shoulder scores, combined in the analysis, measure change during a 12 months follow-up together with a ‘patient self-evaluation’ of the experienced result. The results favoured acupuncture combined with home exercises. Both groups improved significantly and continued to improve over time independent of treatment and most of the patients reached a satisfactory result at 12 months. At least three fourths of the patients, in each treatment group, reported large improvements or felt completely recovered. This is interpreted as a combination of treatment effect and the natural course. This thesis has described the primary care management of patients with subacromial pain and provided scientific evidence for general practitioners to use corticosteroid injection and for physiotherapists to use acupuncture combined with home exercises, when treating these patients. / On the day of the defence date the status on article III was Accepted and article IV was Submitted.

Aim: The aim of this project was to study the age and sex specific occurrence of atopic and non-atopic asthma and other atopic manifestations in a nationwide sample of Swedish pre-school children. Methods: All 70 allergen avoidance day-care centres (AADC) with 84 sections and 140 matched ordinary day-care centres with 440 sections in 62 municipalities across Sweden were sampled. In 2000 the staff at each section responded to a questionnaire on indoor and outdoor environment at the section. In 2002 parents of 5,886 children attending the AADCs and ODCs responded to a postal questionnaire regarding symptoms indicating prevalent asthma, allergic rhinitis, eczema, and food, furred pet and pollen allergy and other data in their children. In 2007, parents of 4255 children responded to an almost identical follow-up questionnaire. Results: The AADCs had far more strict rules than ODCs on furred pets and smoking at home and on perfume use, and the indoor environment was better, owing to better cleaning. The age specific asthma prevalence was curvilinear with a peak at age 3 of 11.4% among boys and 9.8% among girls. In addition the prevalence increased by municipality population density, a proxy for degree of urbanisation. There was a highly significant co-occurrence between all asthma-atopic manifestations, but there was no evidence of ordered sequence of manifestation onset. The asthma incidence was highly dependent on presence or absence of co-occurrence variables. Given the variable mix in the present study population, the annual asthma incidence ranged from 0.6% to 1.2%. Conclusions: AADCs had more strict rules and a better indoor environment than ODCs. The asthma prevalence was affected by age, sex and degree of urbanisation. There was close co-occurrence between all asthma and atopic manifestations but no evidence of ordered sequence of onsets. The annual asthma incidence was strongly dependent of co-occurrence conditions.