Background The established method in primary care to distinguish skin cancer from benign lesions is clinical examination, with or without dermoscopy. The experience among primary care physicians in assessing skin tumours varies, as does the accessibility to teledermoscopy. To enhance diagnostic performance, improved methods for skin tumour assessment are warranted. The aim of this study was to investigate the diagnostic performance of a non-invasive method that combines near-infrared spectroscopy with skin impedance measurement (NIRIMP) to detect skin cancer in primary care.Material and Methods NIRIMP measurements were collected prospectively from patients seeking primary care for skin lesion examination. The measurements were compared to the true lesion diagnosis using several machine learning methods, to determine the best machine learning methods to use and to determine the diagnostic performance of NIRIMP in distinguishing skin cancer from benign lesions.Results Eighty participants with 109 lesions were included. Among these, 50 skin cancers or in situ cancers were detected: eight melanomas/in situ melanomas, four in situ squamous cell carcinomas, and 38 basal cell carcinomas. The ability of NIRIMP to distinguish any skin cancer/in situ cancer, as illustrated by the area under the receiver operating characteristics curve (AUC), was 0.776 and for melanomas/in situ melanomas alone the AUC was 0.911. When detecting any skin cancer, the AUC was slightly higher for NIR alone (0.826) compared to NIRIMP (0.776), whereas for IMP alone it was slightly lower (0.693).Conclusions Near infrared spectroscopy appears to be a promising bioengineering technique to detect skin cancer in primary care settings, of potential benefit for future skin lesion assessment. However, there was no compelling evidence supporting the benefit of adding skin impedance to improve diagnostic performance.

Background Use of artificial intelligence (AI), or machine learning, to assess dermoscopic images of skin lesions to detect melanoma has, in several retrospective studies, shown high levels of diagnostic accuracy on par with - or even outperforming - experienced dermatologists. However, the enthusiasm around these algorithms has not yet been matched by prospective clinical trials performed in authentic clinical settings. In several European countries, including Sweden, the initial clinical assessment of suspected skin cancer is principally conducted in the primary healthcare setting by primary care physicians, with or without access to teledermoscopic support from dermatology clinics.Objectives To determine the diagnostic performance of an AI-based clinical decision support tool for cutaneous melanoma detection, operated by a smartphone application (app), when used prospectively by primary care physicians to assess skin lesions of concern due to some degree of melanoma suspicion.Methods This prospective multicentre clinical trial was conducted at 36 primary care centres in Sweden. Physicians used the smartphone app on skin lesions of concern by photographing them dermoscopically, which resulted in a dichotomous decision support text regarding evidence for melanoma. Regardless of the app outcome, all lesions underwent standard diagnostic procedures (surgical excision or referral to a dermatologist). After investigations were complete, lesion diagnoses were collected from the patients' medical records and compared with the app's outcome and other lesion data.Results In total, 253 lesions of concern in 228 patients were included, of which 21 proved to be melanomas, with 11 thin invasive melanomas and 10 melanomas in situ. The app's accuracy in identifying melanomas was reflected in an area under the receiver operating characteristic (AUROC) curve of 0.960 [95% confidence interval (CI) 0.928-0.980], corresponding to a maximum sensitivity and specificity of 95.2% and 84.5%, respectively. For invasive melanomas alone, the AUROC was 0.988 (95% CI 0.965-0.997), corresponding to a maximum sensitivity and specificity of 100% and 92.6%, respectively.Conclusions The clinical decision support tool evaluated in this investigation showed high diagnostic accuracy when used prospectively in primary care patients, which could add significant clinical value for primary care physicians assessing skin lesions for melanoma. We investigated the diagnostic performance of an AI-based decision support in the form of a mobile app to detect melanoma when used by primary care physicians. The app proved to have high levels of diagnostic accuracy in distinguishing melanomas from other skin lesions. We conclude that it appears to be a potentially valuable diagnostic aid for the primary care physician in the assessment of skin lesions of concern.

Objective: skin examination to detect cutaneous melanomas is commonly performed in primarycare. in recent years, clinical decision support systems (CDSS) based on artificial intelligence (AI) have been introduced within several diagnostic fields.

Setting: this study employs a variety of qualitative and quantitative methodologies to investigatethe feasibility of an ai-based CDSS to detect cutaneous melanoma in primary care.

Subjects and Design: Fifteen primary care physicians (PCPs) underwent near-live simulationsusing the cDss on a simulated patient, and subsequent individual semi-structured interviewswere explored with a hybrid thematic analysis approach. additionally, twenty-five PCPs performeda reader study (diagnostic assessment on the basis of image interpretation) of 18 dermoscopicimages, both with and without help from AI, investigating the value of adding ai support to a PCPs decision. Perceived instrument usability was rated on the system Usability scale (SUS).

Results: From the interviews, the importance of trust in the CDSS emerged as a central concern.scientific evidence supporting sufficient diagnostic accuracy of the CDSS was expressed as animportant factor that could increase trust. access to ai decision support when evaluatingdermoscopic images proved valuable as it formally increased the physician’s diagnostic accuracy.a mean SUS score of 84.8, corresponding to ‘good’ usability, was measured.

Conclusion: AI-based CDSS might play an important future role in cutaneous melanomadiagnostics, provided sufficient evidence of diagnostic accuracy and usability supporting itstrustworthiness among the users.

KEY POINTS

• Effective primary care is important for discovering cutaneous melanoma, the deadliest and anincreasingly prevalent form of skin cancer.
• ‘Trust’, ‘usability and user experience’, and ‘the clinical context’ are the qualitative themes thatemerged from the qualitative analysis. these areas need to be considered for the successfuladoption of ai assisted decision support tools by PCPs.
• The AI CDSS tool was rated by the PCPs at grade B (average 84.8) on the system Usabilityscale (SUS), which is equivalent to ‘good’ usability.
• a reader study, (diagnostic assessment on the basis of image interpretation) with 25 PCPs rating dermoscopic images, showed increased value of adding an AI decision support to theirclinical assessment.

Introduction: Skin cancer is currently the most common cancer type worldwide, and numbers are rapidly increasing. To improve primary prevention, individualised prevention strategies may be of interest as this enhances the chance of long-term behavioural change. The Sun Exposure and Protection Index (SEPI), previously validated in multiple languages, is a tool that could help identify individuals with risky behaviour and tailor interventions to the persons propensity to change. The aim of the present study was to investigate the reliability and validity of a Dutch version of the SEPI for both usage in daily clinical practice and research. Methods: Patients were included at primary care settings and dermatology outpatient settings in a 1:1 ratio. Participants were asked to fill out the SEPI together with some baseline characteristics and the previously validated FACE-Q Skin Cancer - Sun Protection module. Construct validity was tested by comparing SEPI part I and the FACE-Q module using Spearmans Rho. Internal consistency was assessed with Cronbachs Alpha for both SEPI parts separately. To assess test-retest reliability, the SEPI was again filled out three weeks later, and scores were compared with Cohens weighted Kappa. Results: Of the 171 participants completing the first questionnaire, 147 (86.0%) participants also completed the follow-up questionnaire. Comparison between the corresponding SEPI part I and FACE-Q module questions showed good correlations regarding sun exposure habits (correlation coefficients ranging from 0.61 to 0.85). Internal consistency of SEPI part I was 0.63 and SEPI part II was 0.65. The test-retest analysis indicated reproducibility over time (weighted Kappa ranging from 0.38 to 0.76). Conclusion: In conclusion, the Dutch version of the SEPI is shown to be a valid and reliable tool for both usage in daily clinical practice and research to evaluate individual UV exposure and measure a persons propensity to limit it.

Objective Studies on advance care planning in nursing homes are rare, and despite their demonstrated favourable effects on end-of-life care, advance care plans are often lacking. Therefore, we wished to explore: (i) the prevalence of advance care plans in a Swedish nursing home setting using two different definitions, (ii) the content of advance care plans, (iii) adherence to the content of care plans and (iv) possible associations between the presence of advance care planning and background characteristics, physician attendance and end-of-life care. Design Retrospective chart review. Setting Twenty-two nursing homes in Sweden. Subjects A total of 367 deceased patients (included between 1 June 2018 and 23 May 2020) who had lived in nursing homes. Main outcome measures Electronic health record data on the prevalence of advance care plans with two different definitions and variables regarding background characteristics, physician attendance and end-of-life care, were collected. Results Of the study population, 97% had a limited care plan (ACP I) documented. When using the comprehensive definition (ACP II), also including patients preferences and involvement of family members in advance care planning, the prevalence was 77%. Patients with dementia more often had care plans, and a higher physician attendance was associated with presence of advance care plans. Prescription of palliative drugs and information to family members of the patients deterioration and impending death were more common in patients with care plans compared to those where such plans were missing. There was adherence to the care plan content. Conclusion In contrast to previous research, this study showed a high prevalence of advance care plans in nursing home patients. Patients with care plans more frequently received prescriptions of palliative drugs and their family members were informed to a greater extent about the patients deterioration and impending death compared to those without care plans. These aspects are often seen as vital components of good palliative care.

Hälso- och sjukvården i Sverige är en del av administrationssamhället. Det innebär att alltmer tid används till att göra det vi kallar administrativt arbete, som att redovisa, rapportera, kommunicera, mäta, granska och föra statistik.

Personalen inom hälso- och sjukvården ägnar allt mindre av sin tid åt patienterna, människorna, och alltmer tid åt systemen och de krav som systemen ställer. Sammantaget leder detta till att vi får ut mindre vård för de pengar som satsas, eftersom de går åt till administrativt arbete.

I den här boken diskuteras, utifrån studier av arbetstid och arbetsmiljö på vårdcentraler, hur den administrativa förändringen ser ut inom hälso- och sjukvården, vilka förklaringar som kan finnas till utvecklingen och vilka konsekvenserna är. Därav bokens titel: Papper, pengar och patienter: Primärvården i administrationssamhället.

Actinic keratosis is the most common actinic lesion in fair-skinned populations. It is accepted as an indicator of actinic skin damage and as an occasional precursor of squamous cell carcinoma. The aim of this study was to investigate, in a cohort of patients with a diagnosis of actinic keratosis, the relative risk of developing skin cancer during a follow-up period of 10 years. This registry-based cohort study compared a cohort of 2,893 individuals in south-eastern Sweden, who were diagnosed with actinic keratosis during the period 2000 to 2004, with a matched-control cohort of 14,668 individuals without actinic keratosis during the same inclusion period. The subjects were followed for 10 years to identify skin cancer development in both cohorts. Hazard ratios with 95% confidence intervals (95% CI) were used as risk measures. Individuals in the actinic keratosis cohort had a markedly higher risk for all skin cancer forms compared with the control cohort (hazard ratio (HR) 5.1, 95% CI 4.7-5.6). The relative risk was highest for developing squamous cell carcinoma (SCC) (HR 7.7, 95% CI 6.7-8.8) and somewhat lower for basal cell carcinoma (BCC) (HR 4.4, 95% CI 4.1-5.0) and malignant melanoma (MM) (HR 2.7 (2.1-3.6). Patients with a diagnosis of actinic keratosis were found to be at increased risk of developing SCC, BCC and MM in the 10 years following diagnosis of actinic keratosis. In conclusion, a diagnosis of actinic keratosis, even in the absence of documentation of other features of chronic sun exposure, is a marker of increased risk of skin cancer, which should be addressed with individually directed preventive advice.

Background Differentiating between pneumonia and acute bronchitis is often difficult in primary care. There is no consensus regarding clinical decision rules for pneumonia, and guidelines differ between countries. Use of diagnostic tests and change of management over time is not known.

Aim To calculate the proportion of diagnostic tests in the management of lower respiratory tract infections (LRTIs) in a low antibiotic prescribing country, and to evaluate if the use and prescription pattern has changed over time.

Design & setting A register-based study on data from electronic health records from January 2006 to December 2014 in the Kronoberg county of south east Sweden.

Method Data regarding use of C-reactive protein (CRP), chest x-rays (CXRs), microbiological tests, and antibiotic prescriptions were assessed for patients aged 18–79 years, with the diagnosis pneumonia, acute bronchitis, or cough.

Results A total of 54 229 sickness episodes were analysed. Use of CRP increased during the study period from 61.3% to 77.5% for patients with pneumonia (P<0.001), and from 53.4% to 65.7% for patients with acute bronchitis (P<0.001). Use of CXR increased for patients with acute bronchitis from 3.1% to 5.1% (P<0.001). Use of microbiological tests increased for patients with pneumonia, from 1.8% to 5.1% (P<0.001). The antibiotic prescription rate decreased from 18.6 to 8.2 per 1000 inhabitants per year for patients with acute bronchitis, but did not change for patients with pneumonia.

Conclusion Use of CRP and microbiological tests in the diagnostics of LRTIs increased despite the fact that the incidence of pneumonia and acute bronchitis was stable.

Introduction: “mobile health” consists in using electronic devices to support health.

Objectives: observe photoprotection, skin self-examination and compare the impact of multimedia presentation to Whatsapp messages on these habits in primary attention.

Methodology: experimental study, envolving 300 users. First moment: SEPI (Sun Exposure and Protection Index) and SSEAS (Self Skin-Examination Attitudes Scale) were applied and a presentation was performed. Second moment (8 weeks):150 users received photoprotection and self-examination messages. Third moment:300 re-answered questionnaires. Differences were analysed using t test andlinear regression.

Results: 39.66% used sunscreen always/frequently and, in intervention, ascended to 47.91% (p=0.0014) without change in control. Self-examination was a priority for 48.67% and increased to 73.91% in control (p=0.0179) and 69.8% (p=0.0001) in intervention, without difference.

Conclusion: photoprotection remained low and self-examination became priority for twothirds (without difference between groups).

Objectives The aim of this study was to explore if consequent use of chest X-ray (CXR), when the physician is not sure of the diagnosis of pneumonia after clinical examination and CRP-testing, favors a more restrictive prescribing of antibiotics. Design This was an intervention study conducted between September 2015 and December 2017. Setting Two intervention primary health care centers (PHCCs) and three control PHCCs in the southeast of Sweden. Intervention All patients were referred for CXR when the physician s suspicion of pneumonia was unsure, or quite sure after CRP-testing. Control units managed patients according to their usual routine after clinical examination and CRP-testing. Subjects A total of 104 patients were included in the intervention group and 81 patients in the control group. The inclusion criteria of the study were clinically suspected pneumonia in patients &gt;= 18 years, with respiratory symptoms for more than 24 h. Main outcome measure:Antibiotic prescribing rate. Results In the intervention group, 85% were referred for CXR and 69% were prescribed antibiotics, as compared to 26% and 77% in the control group. The difference in antibiotic prescribing rate was not statistically significant, unadjusted OR 0.68 [0.35-1.3] and adjusted OR 1.1 [CI 0.43-3.0]. A total of 24% of patients with negative CXR were prescribed antibiotics. Conclusion This study could not prove that use of CXR when the physician was not sure of the diagnosis of pneumonia results in lowered antibiotic prescribing rate in primary care. In cases of negative findings on CXR the physicians do not seem to rely on the outcome when it comes to antibiotic prescribing.