Exploring the Role of Complexity in Health Care Technology Bottom-Up Innovations: Multiple-Case Study Using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability Complexity Assessment Tool.

BACKGROUND: New digital technology presents new challenges to health care on multiple levels. There are calls for further research that considers the complex factors related to digital innovations in complex health care settings to bridge the gap when moving from linear, logistic research to embracing and testing the concept of complexity. The nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework was developed to help study complexity in digital innovations. OBJECTIVE: This study aims to investigate the role of complexity in the development and deployment of innovations by retrospectively assessing challenges to 4 digital health care innovations initiated from the bottom up. METHODS: A multicase retrospective, deductive, and explorative analysis using the NASSS complexity assessment tool LONG was conducted. In total, 4 bottom-up innovations developed in Region Västra Götaland in Sweden were explored and compared to identify unique and shared complexity-related challenges. RESULTS: The analysis resulted in joint insights and individual learning. Overall, the complexity was mostly found outside the actual innovation; more specifically, it related to the organization's readiness to integrate new innovations, how to manage and maintain innovations, and how to finance them. The NASSS framework sheds light on various perspectives that can either facilitate or hinder the adoption, scale-up, and spread of technological innovations. In the domain of condition or diagnosis, a well-informed understanding of the complexity related to the condition or illness (diabetes, cancer, bipolar disorders, and schizophrenia disorders) is of great importance for the innovation. The value proposition needs to be clearly described early to enable an understanding of costs and outcomes. The questions in the NASSS complexity assessment tool LONG were sometimes difficult to comprehend, not only from a language perspective but also due to a lack of understanding of the surrounding organization's system and its setting. CONCLUSIONS: Even when bottom-up innovations arise within the same support organization, the complexity can vary based on the developmental phase and the unique characteristics of each project. Identifying, defining, and understanding complexity may not solve the issues but substantially improves the prospects for successful deployment. Successful innovation within complex organizations necessitates an adaptive leadership and structures to surmount cultural resistance and organizational impediments. A rigid, linear, and stepwise approach risks disregarding interconnected variables and dependencies, leading to suboptimal outcomes. Success lies in embracing the complexity with its uncertainty, nurturing creativity, and adopting a nonlinear methodology that accommodates the iterative nature of innovation processes within complex organizations.

Interrater reliability of the violence risk assessment checklist for youth: a case vignette study.

BACKGROUND: Facilities providing health- and social services for youth are commonly faced with the need for assessment and management of violent behavior. These providers often experience shortage of resources, compromising the feasibility of conducting comprehensive violence risk assessments. The Violence Risk Assessment Checklist for Youth aged 12-18 (V-RISK-Y) is a 12-item violence risk screening instrument developed to rapidly identify youth at high risk for violent behavior in situations requiring expedient evaluation of violence risk. The V-RISK-Y instrument was piloted in acute psychiatric units for youth, yielding positive results of predictive validity. The aim of the present study was to assess the interrater reliability of V-RISK-Y in child and adolescent psychiatric units and acute child protective services institutions. METHODS: A case vignette study design was utilized to assess interrater reliability of V-RISK-Y. Staff at youth facilities (N = 163) in Norway and Sweden scored V-RISK-Y for three vignettes, and interrater reliability was assessed with the intraclass correlation coefficient (ICC). RESULTS: Results indicate good interrater reliability for the sum score and Low-Moderate-High risk level appraisal across staff from the different facilities and professions. For single items, interrater reliability ranged from poor to excellent. CONCLUSIONS: This study is an important step in establishing the psychometric properties of V-RISK-Y. Findings support the structured professional judgment tradition the instrument is based on, with high agreement on the overall risk assessment. This study had a case vignette design, and the next step is to assess the reliability and validity of V-RISK-Y in naturalistic settings.

Inequity in access to digital public primary healthcare in Sweden: a cross-sectional study of the effects of urbanicity and socioeconomic status on utilization.

BACKGROUND: Social and geographical inequity in access to primary healthcare is an ongoing concern in Sweden. Digital care can potentially decrease geographical inequity. This study aimed to evaluate how urbanicity affects the utilization of a public digital primary healthcare service - PHC Online. METHODS: We performed an ecological cross-sectional study of 4,482 PHC Online visits grouped by 83 public primary healthcare centers. Multiple linear regression analysis was performed with PHC Online visits per 1,000 registered patients as the dependent variable and urbanicity (municipalities grouped by number of inhabitants), socioeconomic status (Care Need Index), and morbidity (Adjusted Clinical Groups) per primary healthcare center as independent variables. RESULTS: Utilization of PHC Online was more common among those of a younger age (median 32 years) and among women (65%). Urbanicity did not affect utilization. Lower socioeconomic status and higher morbidity had negative effects on utilization (B -3.289, p = 0.001, B -7.728, p = 0.045). CONCLUSIONS: Geographical differences based on urbanicity do not seem to affect the utilization of PHC Online. Further studies are needed to clarify a possible association to geographical barriers in access to primary healthcare, specifically accounting for factors associated with urbanicity and distance to physical clinics, and how age and sex affect such an association. Lower utilization of PHC Online in low socioeconomic status and high morbidity populations raises questions on the effect of digital primary care on equitable access to primary healthcare.

Socio-demographic inequalities influence differences in the chemical exposome among Swedish adolescents.

Relatively little is known about the relationship between socio-demographic factors and the chemical exposome in adolescent populations. This knowledge gap hampers global efforts to meet certain UN sustainability goals. The present work addresses this problem in Swedish adolescents by discerning patterns within the chemical exposome and identify demographic groups susceptible to heightened exposures. Enlisting the Riksmaten Adolescents 2016-17 (RMA) study population (N = 1082) in human-biomonitoring, and using proportional odds ordinal logistic regression models, we examined the associations between concentrations of a diverse array of substances (N = 63) with the determinants: gender, age, participant/maternal birth country income per capita level, parental education levels, and geographic place of living (longitude/latitude). Participant/maternal birth country exhibited a significant association with the concentrations of 46 substances, followed by gender (N = 41), and longitude (N = 37). Notably, individuals born in high-income countries by high-income country mothers demonstrated substantially higher estimated adjusted means (EAM) concentrations of polychlorinated biphenyls (PCBs), brominated flame retardants (BFRs) and per- and polyfluoroalkyl substances (PFASs) compared to those born in low-income countries by low-income country mothers. A reverse trend was observed for cobalt (Co), cadmium (Cd), lead (Pb), aluminium (Al), chlorinated pesticides, and phthalate metabolites. Males exhibited higher EAM concentrations of chromium (Cr), mercury (Hg), Pb, PCBs, chlorinated pesticides, BFRs and PFASs than females. In contrast, females displayed higher EAM concentrations of Mn, Co, Cd and metabolites of phthalates and phosphorous flame retardants, and phenolic substances. Geographical disparities, indicative of north-to-south or west-to-east substance concentrations gradients, were identified in Sweden. Only a limited number of lifestyle, physiological and dietary factors were identified as possible drivers of demographic inequalities for specific substances. This research underscores birth country, gender, and geographical disparities as contributors to exposure differences among Swedish adolescents. Identifying underlying drivers is crucial to addressing societal inequalities associated with chemical exposure and aligning with UN sustainability goals.

A web-based pesticide risk assessment tool for drinking water protection zones in Sweden.

To protect human health, wildlife and the aquatic environment, "safe uses" of pesticides are determined at the EU level while product authorization and terms of use are established at the national level. In Sweden, extra precaution is taken to protect drinking water, and permits are therefore required for pesticide use within abstraction zones. This paper presents MACRO-DB, a tool for assessing pesticide contamination risks of groundwater and surface water, used by authorities to support their decision-making for issuing such permits. MACRO-DB is a meta-model based on 583,200 simulations of the physically-based MACRO model used for assessing pesticide leaching risks at EU and national level. MACRO-DB is simple to use and runs on widely available input data. In a qualitative comparative assessment for two counties in Sweden, MACRO-DB outputs were in general agreement with groundwater monitoring data and matched or were more protective than the national risk assessment procedure for groundwater.

Remote neuropsychological assessment of patients with neurological disorders and injuries-a study protocol for a cross-sectional case-control validation study.

INTRODUCTION: There are great potential benefits of being able to conduct neuropsychological assessments remotely, especially for hard-to-reach or less mobile patient groups. Such tools need to be equivalent to standard tests done in the clinic and also easy to use in a variety of clinical populations. METHODS AND ANALYSIS: This study protocol describes a cross-sectional study aimed at validating the newly developed digitalized neuropsychological test battery Mindmore Remote in patients with neurological disorders and injuries. Diagnoses comprise traumatic brain injury, stroke, Parkinson's disease, multiple sclerosis, brain tumour and epilepsy. 50 patients in each patient group will be included. In addition, 50 healthy controls will be recruited. All participants will undergo both testing with Mindmore Remote at home and traditional neuropsychological assessment face-to-face in a randomised order. The primary outcome is the association between tests from the Mindmore Remote battery and their equivalent traditional neuropsychological tests. Further, bias between methods and differences between groups will also be investigated. ETHICS AND DISSEMINATION: The study protocol has been approved by the Swedish Ethical Review Authority (2022-06230-01) and adheres to the declaration of Helsinki. All participants will be given oral and written information about the study and sign informed consent forms before entering the study. All participants are informed that they can terminate their participation in the study at any given time, without giving any explanation, and participating in the study or not will not affect their care at the clinic. Neither authors nor personnel involved in the research project are affiliated with Mindmore AB. The results from the study will be published in peer-reviewed scientific journals and presented at national and international conferences on the topic. TRIAL REGISTRATION NUMBER: NCT05819008.

Income disparities in loss in life expectancy after colon and rectal cancers: a Swedish register-based study.

BACKGROUND: Differences in the prognosis after colorectal cancer (CRC) by socioeconomic position (SEP) have been reported previously; however, most studies focused on survival differences at a particular time since diagnosis. We quantified the lifetime impact of CRC and its variation by SEP, using individualised income to conceptualise SEP. METHODS: Data included all adults with a first-time diagnosis of colon or rectal cancers in Sweden between 2008 and 2021. The analysis was done separately for colon and rectal cancers using flexible parametric models. For each cancer and income group, we estimated the life expectancy in the absence of cancer, the life expectancy in the presence of cancer and the loss in life expectancy (LLE). RESULTS: We found large income disparities in life expectancy after a cancer diagnosis, with larger differences among the youngest patients. Higher income resulted in more years lost following a cancer diagnosis. For example, 40-year-old females with colon cancer lost 17.64 years if in the highest-income group and 13.68 years if in the lowest-income group. Rectal cancer resulted in higher LLE compared with colon cancer. Males lost a larger proportion of their lives. All patients, including the oldest, lost more than 30% of their remaining life expectancy. Based on the number of colon and rectal cancer diagnoses in 2021, colon cancer results in almost double the number of years lost compared with rectal cancer (24 669 and 12 105 years, respectively). CONCLUSION: While our results should be interpreted in line with what individualised income represents, they highlight the need to address inequalities.

Impact of an oral care subsidization reform on intersectional inequities in self-rated oral health in Sweden.

BACKGROUND: Oral health in Sweden is good at the population level, but seemingly with persisting or increasing inequities over the last decades. In 2008, a major Swedish reform introduced universal partial subsidies to promote preventive care and reduce the treatment cost for patients with extensive care needs. This study aimed to apply an intersectional approach to assess the impact of the 2008 subsidization reform on inequities in self-rated oral health among adults in Sweden over the period 2004-2018. METHODS: Data from 14 national surveys conducted over 2004-2018 were divided into three study periods: pre-reform (2004-2007), early post-reform (2008-2012) and late post-reform (2013-2018). The final study population was 118,650 individuals aged 24-84 years. Inequities in self-rated oral health were examined by intersectional analysis of individual heterogeneity and discriminatory accuracy across 48 intersectional strata defined by gender, age, educational level, income, and immigrant status. RESULTS: Overall, the prevalence of poor self-rated oral health decreased gradually after the reform. Gender-, education- and income-related inequities increased after the reform, but no discernible change was seen for age- or immigration-related inequities. The majority of intersectional strata experienced patterns of persistently or delayed increased inequities following the reform. CONCLUSIONS: Increased inequities in self-rated oral health were found in most intersectional strata following the reform, despite the seemingly positive oral health trends at the population level. Applying an intersectional approach might be particularly relevant for welfare states with overall good oral health outcomes but unsuccessful efforts to reduce inequities.

Change in avoidable hospitalizations for low-income elders following quasi-market reform in primary care - Evidence from a natural experiment in Sweden.

Quasi-market reforms have been increasingly implemented in tax-funded health care, but their effects in terms of equity, quality and socioeconomic differentials in quality remain sparsely studied. We create a natural experiment setup exploiting the differential timing of a set of quasi-market reforms - including patient choice, free establishment of providers and changes in provider remuneration -, implemented in primary care in the two largest Swedish regions (Stockholm and Västra Götaland) in 2008-2009. Using a database with individual level data from 2005 to 2009, we construct a difference-in-difference-in-differences model that compares pre to post reform changes in avoidable hospitalizations (AHs) for low-income elders and a matched comparison group, in the region exposed to, versus unexposed to, reform (total N âˆ¼ 200 000). The results show that for low-income elders - a group dominated by older women - reform led to higher AH rates, i.e., worse primary health care quality, than what would have been the case in absence of reform. Specifically, low-income elders exposed to reform missed out on improvements in AHs seen simultaneously in the unexposed region. At the same time, the reform had on average no effect for comparable, non-low-income, peers. The fact that this pattern was specific for avoidable hospitalizations - judged as amenable to interventions in primary care -, but not present for total hospitalizations, supports that it was driven by reform implementation rather than other factors. The study contributes with high-quality empirical evidence to a policy relevant but sparsely researched area and highlights the necessity to consider differential effects of organizational changes across socioeconomic groups.

Socioeconomic position indicators and risk of alcohol-related medical conditions: A national cohort study from Sweden.

BACKGROUND: Alcohol consumption contributes to excess morbidity and mortality in part through the development of alcohol-related medical conditions (AMCs, including alcoholic cardiomyopathy, hepatitis, cirrhosis, etc.). The current study aimed to clarify the extent to which risk for these outcomes differs as a function of socioeconomic position (SEP), as discrepancies could lead to exacerbated health disparities. METHODS AND FINDINGS: We used longitudinal Swedish national registries to estimate the individual and joint associations between 2 SEP indicators, educational attainment and income level, and risk of AMC based on International Classification of Diseases codes, while controlling for other sociodemographic covariates and psychiatric illness. We conducted Cox proportional hazards models in sex-stratified analyses (N = 1,162,679 females and N = 1,196,659 males), beginning observation at age 40 with follow-up through December 2018, death, or emigration. By the end of follow-up, 4,253 (0.37%) females and 11,183 (0.93%) males had received an AMC registration, corresponding to overall AMC incidence rates among females and males of 2.01 and 5.20, respectively. In sex-stratified models adjusted for birth year, marital status, region of origin, internalizing and externalizing disorder registrations, and alcohol use disorder (AUD) registration, lower educational attainment was associated with higher risk of AMC in both females (hazard ratios [HRs] = 1.40 to 2.46 for low- and mid-level educational attainment across 0 to 15 years of observation) and males (HRs = 1.13 to 1.48). Likewise, risk of AMC was increased for those with lower income levels (females: HRs = 1.10 to 5.86; males: HRs = 1.07 to 6.41). In secondary analyses, we further adjusted for aggregate familial risk of AUD by including family genetic risk scores for AUD (FGRSAUD), estimated using medical, pharmacy, and criminal registries in extended families, as covariates. While FGRSAUD were associated with risk of AMC in adjusted models (HR = 1.17 for females and HR = 1.21 for males), estimates for education and income level remained largely unchanged. Furthermore, FGRSAUD interacted with income level, but not education level, such that those at higher familial liability to AUD were more susceptible to the adverse effect of low income. Limitations of these analyses include the possibility of false negatives for psychiatric illness registrations, changes in income after age 40 that were not accounted for due to modeling restrictions, restriction to residents of a high-income country, and the inability to account for individual-level alcohol consumption using registry data. CONCLUSIONS: Using comprehensive national registry data, these analyses demonstrate that individuals with lower levels of education and/or income are at higher risk of developing AMC. These associations persist even when accounting for a range of sociodemographic, psychiatric, and familial risk factors. Differences in risk could contribute to further health disparities, potentially warranting increased screening and prevention efforts in clinical and public health settings.

Vertical policy coordination of COVID-19 testing in Sweden: an analysis of policy-specific demands and institutional barriers.

PURPOSE: The build-up of large-scale COVID-19 testing required an unprecedented effort of coordination within decentralized healthcare systems around the world. The aim of the study was to elucidate the challenges of vertical policy coordination between non-political actors at the national and regional levels regarding this policy issue, using Sweden as our case. DESIGN/METHODOLOGY/APPROACH: Interviews with key actors at the national and regional levels were analyzed using an adapted version of a conceptualization by Adam et al. (2019), depicting barriers to vertical policy coordination. FINDINGS: Our results show that the main issues in the Swedish context were related to parallel sovereignty and a vagueness regarding responsibilities and mandates as well as complex governmental structures and that this was exacerbated by the unfamiliarity and uncertainty of the policy issue. We conclude that understanding the interaction between the comprehensiveness and complexity of the policy issue and the institutional context is crucial to achieving effective vertical policy coordination. ORIGINALITY/VALUE: Many studies have focused on countries' overall pandemic responses, but in order to improve the outcome of future pandemics, it is also important to learn from more specific response measures.

Cost effectiveness of pembrolizumab plus lenvatinib compared with chemotherapy for treating previously treated advanced endometrial cancer in Sweden.

OBJECTIVE: Pembrolizumab plus lenvatinib was recently approved for the treatment of advanced or recurrent endometrial carcinoma in women with disease progression on or following prior treatment with a platinum­containing therapy in any setting, and who are not candidates for curative surgery or radiation (KEYNOTE-775/Study-309; NCT03517449). The objective was to assess the cost effectiveness of pembrolizumab plus lenvatinib compared with chemotherapy from a Swedish healthcare perspective. MATERIALS AND METHODS: A lifetime partitioned-survival model with three health states (progression free, progressed disease, death) was constructed. Chemotherapy was represented by paclitaxel or doxorubicin. Overall survival, progression-free survival, time on treatment, and utility data were obtained from KEYNOTE-775 (database lock: March 1, 2022). Costs (in 2020 Swedish Krona [SEK]) included drug acquisition and administration, health state, end of life, adverse event management, subsequent treatment, and societal (scenario analysis). Outcomes were calculated as quality-adjusted life-years (QALY) and life-years. Model results were presented as incremental cost-effectiveness ratios for all-comers, patients with proficient mismatch repair tumors, and deficient mismatch repair tumors. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS: Pembrolizumab plus lenvatinib is a cost-effective treatment when compared with chemotherapy, with estimated deterministic and probabilistic incremental cost-effectiveness ratios of SEK 795,712 and 819,757 per QALY gained. Pembrolizumab plus lenvatinib was associated with a large incremental QALY and life-year gain per person versus chemotherapy over the model time horizon (1.49 and 1.76). LIMITATIONS: Time-to-event data were incomplete and semiparametric and parametric curves were utilized for lifetime extrapolation. Willingness-to-pay thresholds, costs, and utility weights vary by country, which would vary the treatment's cost effectiveness in different countries. CONCLUSIONS: This partitioned survival analysis suggests that pembrolizumab plus lenvatinib is cost effective compared with chemotherapy in Sweden for women with advanced or recurrent endometrial carcinoma following previous systemic therapy. Results were robust to mismatch repair status and to changes in parameters/assumptions.

Trends in mental health problems among Swedish adolescents: Do school-related factors play a role?

AIM: The aim of this study is to investigate the extent to which school-related factors, such as school liking, participation in decision-making, school-related parental support, teachers' support, and school physical environment, explain trends in mental health problems. The problems considered are psychosomatic symptoms (PSS), depressive symptoms (DS), suicidal ideations (SI), and suicide attempts (SA) among Swedish adolescents of varying socioeconomic status (SES) from 2004 to 2020. METHODS: We analyzed data collected through repeated cross-sectional surveys from 19,873 15-year-old students at schools in a county in Sweden. Boys and girls each constituted 50% of the participants. We fitted linear and logistic regression models to investigate associations between the school-related factors and trends in mental health problems. RESULTS: Increased school-related parental support and school liking were cross-sectionally associated with decreased PSS, DS and SI, with school liking also associated with decreased SA. Conducive school physical environment was also found to be cross-sectionally associated with lower PSS and DS scores. Over time, mental health problems have shown a general increase among adolescents in the low SES group and a decrease among those in the high SES group. While school-related factors explained the improvement in mental health in the high SES group, we found such association only between parental support trends in PSS and DS, along with participation and trends in SA over time among adolescents in the low SES group. CONCLUSIONS: The results show that school-related factors play significant roles in influencing adolescent mental health. The influence, however, varied across SES gradients over time. This suggests that working against inequities in school-related factors would help address inequities in mental health.

Cost of Illness of Head and Neck Cancer in Sweden.

OBJECTIVES: Head and neck cancer (HNC) is the sixth most common cancer worldwide. The condition and its treatment often lead to marked morbidities and, for some patients, premature death. Inferentially, HNC imposes a significant economic burden on society. This study aims to provide a comprehensive and detailed estimation of the cost of illness of HNC for Sweden in 2019. METHODS: This is a prevalence-based cost of illness study. Resource utilization and related costs are quantified using national registry data. A societal perspective is applied, including (1) direct costs for healthcare utilization, (2) costs for informal care from family and friends, and (3) costs for productivity loss due to morbidity and premature death. The human capital approach is used when estimating productivity losses. RESULTS: The societal cost of HNC for Sweden in 2019 was estimated at €92 million, of which the direct costs, costs for informal care, and costs for productivity loss represented 34%, 2%, and 64%, respectively. Oral cavity cancer was the costliest HNC, followed by oropharyngeal cancer, whereas nasopharyngeal cancer was the costliest per person. The cost of premature mortality comprised 60% of the total cost of productivity loss. Males accounted for 65% of direct costs and 67% of costs for productivity loss. CONCLUSIONS: The societal cost of HNC is substantial and constitutes a considerable burden to Swedish society. The results of the present study may be used by policymakers for planning and allocation of resources. Furthermore, the information may be used for future cost-effectiveness analyses.

Comparing Survival Extrapolation within All-Cause and Relative Survival Frameworks by Standard Parametric Models and Flexible Parametric Spline Models Using the Swedish Cancer Registry.

BACKGROUND: In health technology assessment, restricted mean survival time and life expectancy are commonly evaluated. Parametric models are typically used for extrapolation. Spline models using a relative survival framework have been shown to estimate life expectancy of cancer patients more reliably; however, more research is needed to assess spline models using an all-cause survival framework and standard parametric models using a relative survival framework. AIM: To assess survival extrapolation using standard parametric models and spline models within relative survival and all-cause survival frameworks. METHODS: From the Swedish Cancer Registry, we identified patients diagnosed with 5 types of cancer (colon, breast, melanoma, prostate, and chronic myeloid leukemia) between 1981 and 1990 with follow-up until 2020. Patients were categorized into 15 cancer cohorts by cancer and age group (18-59, 60-69, and 70-99 y). We right-censored the follow-up at 2, 3, 5, and 10 y and fitted the parametric models within an all-cause and a relative survival framework to extrapolate to 10 y and lifetime in comparison with the observed Kaplan-Meier survival estimates. All cohorts were modeled with 6 standard parametric models (exponential, Weibull, Gompertz, log-logistic, log-normal, and generalized gamma) and 3 spline models (on hazard, odds, and normal scales). RESULTS: For predicting 10-y survival, spline models generally performed better than standard parametric models. However, using an all-cause or a relative survival framework did not show any distinct difference. For lifetime survival, extrapolating from a relative survival framework agreed better with the observed survival, particularly using spline models. CONCLUSIONS: For extrapolation to 10 y, we recommend spline models. For extrapolation to lifetime, we suggest extrapolating in a relative survival framework, especially using spline models. HIGHLIGHTS: For survival extrapolation to 10 y, spline models generally performed better than standard parametric models did. However, using an all-cause or a relative survival framework showed no distinct difference under the same parametric model.Survival extrapolation to lifetime within a relative survival framework agreed well with the observed data, especially using spline models.Extrapolating parametric models within an all-cause survival framework may overestimate survival proportions at lifetime; models for the relative survival approach may underestimate instead.

Whole exome sequencing and polygenic assessment of a Swedish cohort with severe developmental language disorder.

Developmental language disorder (DLD) overlaps clinically, genetically, and pathologically with other neurodevelopmental disorders (NDD), corroborating the concept of the NDD continuum. There is a lack of studies to understand the whole genetic spectrum in individuals with DLD. Previously, we recruited 61 probands with severe DLD from 59 families and examined 59 of them and their families using microarray genotyping with a 6.8% diagnostic yield. Herein, we investigated 53 of those probands using whole exome sequencing (WES). Additionally, we used polygenic risk scores (PRS) to understand the within family enrichment of neurodevelopmental difficulties and examine the associations between the results of language-related tests in the probands and language-related PRS. We identified clinically significant variants in four probands, resulting in a 7.5% (4/53) molecular diagnostic yield. Those variants were in PAK2, MED13, PLCB4, and TNRC6B. We also prioritized additional variants for future studies for their role in DLD, including high-impact variants in PARD3 and DIP2C. PRS did not explain the aggregation of neurodevelopmental difficulties in these families. We did not detect significant associations between the language-related tests and language-related PRS. Our results support using WES as the first-tier genetic test for DLD as it can identify monogenic DLD forms. Large-scale sequencing studies for DLD are needed to identify new genes and investigate the polygenic contribution to the condition.

Two years of neurosurgical intraoperative MRI in Sweden - evaluation of use and costs.

BACKGROUND: The current shortage of radiology staff in healthcare provides a challenge for departments all over the world. This leads to more evaluation of how the radiology resources are used and a demand to use them in the most efficient way. Intraoperative MRI is one of many recent advancements in radiological practice. If radiology staff is performing intraoperative MRI at the operation ward, they may be impeded from performing other examinations at the radiology department, creating costs in terms of exams not being performed. Since this is a kind of cost whose importance is likely to increase, we have studied the practice of intraoperative MRI in Sweden. METHODS: The study includes data from the first four hospitals in Sweden that installed MRI scanners adjacent to the operating theaters. In addition, we included data from Karolinska University Hospital in Solna where intraoperative MRI is carried out at the radiology department. RESULTS: Scanners that were moved into the operation theater and doing no or few other scans were used 11-12% of the days. Stationary scanners adjacent to the operation room were used 35-41% of the days. For scanners situated at the radiology department doing intraoperative scans interspersed among all other scans, the proportion was 92%. CONCLUSION: Our study suggests that performing exams at the radiology department rather than at several locations throughout the hospital may be an efficient approach to tackle the simultaneous trends of increasing demands for imaging and increasing staff shortages at radiology departments.

Can equity in care be achieved for stigmatized patients? Discourses of ideological dilemmas in perioperative care.

BACKGROUND: In the perioperative care of individuals with obesity, it is imperative to consider the presence of risk factors that may predispose them to complications. Providing optimal care in such cases proves to be a multifaceted challenge, significantly distinct from the care required for non-obese patients. However, patients with morbidities regarded as self-inflicted, such as obesity, described feelings of being judged and discriminated in healthcare. At the same time, healthcare personnel express difficulties in acting in an appropriate and non-insulting way. In this study, the aim was to analyse how registered nurse anaesthetists positioned themselves regarding obese patients in perioperative care. METHODS: We used discursive psychology to analyse how registered nurse anaesthetists positioned themselves toward obese patients in perioperative care, while striving to provide equitable care. The empirical material was drawn from interviews with 15 registered nurse anaesthetists working in a hospital in northern Sweden. RESULTS: Obese patients were described as "untypical", and more "resource-demanding" than for the "normal" patient in perioperative care. This created conflicting feelings, and generated frustration directed toward the patients when the care demanded extra work that had not been accounted for in the schedules created by the organization and managers. CONCLUSIONS: Although the intention of these registered nurse anaesthetists was to offer all patients equitable care, the organization did not always provide the necessary resources. This contributed to the registered nurse anaesthetists either consciously or unconsciously blaming patients who deviated from the "norm".

Validation of a web-based self-administered test for cognitive assessment in a Swedish geriatric setting.

Computerized cognitive tests have the potential to cost-effectively detect and monitor cognitive impairments and thereby facilitate treatment for these conditions. However, relatively few of these tests have been validated in a variety of populations. Brain on Track, a self-administered web-based test, has previously been shown to have a good ability to differentiate between healthy individuals and patients with cognitive impairment in Portuguese populations. The objective of this study was to validate the differential ability and evaluate the usability of Brain on Track in a Swedish memory clinic setting. Brain on Track was administered to 30 patients with mild cognitive impairment/mild dementia and 30 healthy controls, all scheduled to perform the test from home after one week and after three months. To evaluate the usability, the patient group was interviewed after completion of the testing phase. Patients scored lower than healthy controls at both the first (median score 42.4 vs 54.1, p<0.001) and the second test (median score 42.3 vs 55.0, p<0.001). The test-retest intra-class correlation was 0.87. A multiple logistic regression model accounting for effects of age, gender and education rendered an ability of Brain on Track to differentiate between the groups with an area under the receiver operation characteristics curve of 0.90 for the first and 0.88 for the second test. In the subjective evaluation, nine patients left positive comments, nine were negative whereas five left mixed comments regarding the test experience. Sixty percent of patients had received help from relatives to log on to the platform. In conclusion, Brain on Track performed well in differentiating healthy controls from patients with cognitive impairment and showed a high test-retest reliability, on par with results from previous studies. However, the substantial proportion of patients needing help to log in could to some extent limit an independent use of the platform.