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The aims of the study were to identify factors affecting nurses' decision to undergo specialist education and choose a specialty and to describe differences between specialization areas with different types of care.A descriptive cross-sectional design.A survey was conducted among specialist nurse students in three nursing colleges in Sweden (n = 227). Instruments such as Big Five Inventory and RAND-36 and items earlier used by Bexelius and Olsson were included. Survey data were analysed by using descriptive and analytical statistics, and for open-ended question qualitative content analysis was used.Wage benefit during the education was regarded by 47% as an incentive to start studies. Most of the specialist nurse students considered an opportunity for new tasks (75%), new areas of responsibility (75%), intellectual challenges (72%) and higher wages (71%) to be of high importance when choosing a specialty. However, the students in specialization areas with transitory care-rated challenges regarding the practical skills (84%) and the occurrence of acute events (82%) higher.Although higher wages were important to make nurses feel that they will get value from the education, there were also other important aspects, such as opportunity for new tasks, new areas of responsibility and intellectual challenges that influenced nurses' willingness to undergo a specialist education. Our findings provide employers with the useful information to guide and influence nurses' decisions to enter specialist education and their choice of specialist area.

Le roman historique ne nous éclaire pas uniquement sur l’Histoire ; il parle aussi de notre époque. Depuis le XXe siècle, l’analogie entre le passé et le présent s’est considérablement répandue dans la littérature. Les fictions suédoises situées à l’époque viking n’échappent pas à cette tendance. Dans les trois œuvres analysées ici, les romanciers ont certes eu à cœur de reconstituer fidèlement le haut Moyen Âge scandinave à l’aide de lectures et de recherches approfondies. Mais les romans constituent surtout une réflexion autour de phénomènes et de problématiques modernes qui engagent fortement leur auteur. L’époque viking fait donc l’objet d’une relecture idéologique et se transforme en miroir de notre temps. The historical novel doesn’t only shed light on History ; it deals also with our time. Since the twentieth century, analogy in literature between past and present is widespread. Swedish fictions set in the Viking Age are no exception to this trend. In the three works analyzed here, the novelists have certainly been keen to faithfully reconstruct the Nordic Early Middle Ages through readings and extensive research. But, above all, the novels constitute a reflection on modern phenomena and issues which strongly involve their author. Thus, the Viking Age undergoes an ideological reinterpretation and becomes a mirror of our time.

Highlights • An RT process simulation model aided managers with resource planning decisions. • Several scenarios could easily be evaluated without affecting the clinical work. • Starting vacation periods for preparations prior to treatment was most beneficial., Purpose Radiotherapy (RT) resources need to be used wisely to balance workload and patient throughput. There are no known strategies on how to plan resource use around longer vacation periods to avoid patient waiting times. We created a simulation model over the RT workflow to evaluate different scenarios for this purpose. Materials and Methods The simulation model mimics a large modern RT department in Sweden. It was based on real data on patient referral patterns and resource use extracted from clinical systems (3666 treatment courses). Workshops with managers and staff were held to investigate nine different scenarios for the summer vacation period including one scenario to validate the model. Different capacity reductions, vacation period lengths and timing of the vacation periods between the preparatory part of the RT workflow and the treatment part were evaluated. Results For an eight-week period, resource utilization was predicted to be high both before and after the vacation period regardless of timing. However, more patients would be waiting with completed preparations with simultaneous vacation periods than when the preparatory part started one-two weeks prior to the treatment part. With shorter vacation periods, treatment would require overtime during the vacation period with higher levels of patients waiting compared to an eight-week scenario. Conclusions Our proposed strategy aided managers to identify a preferred scenario for the summer vacation period with the preparatory part starting one-two weeks prior to the treatment part for an eight-week vacation period. This can help other RT departments to plan for similar situations.

Highlights • Linacs were fully booked already three weeks before a majority of investigated days. • Non-treatment events were scheduled ≤ 11% for the investigated time period. • Planned booking scenarios deviated from real scenarios for most investigated days. • Largest changes were primarily related to linac downtime/maintenance issues. • Tool visualizing linac utilization may aid staff to achieve an even RT workflow., Background and purpose Resources in radiotherapy (RT) need to be used effectively to meet the current clinical demand. The aim of this data-driven study is to identify temporal trends in the scheduling of patients for RT and to develop a tool for a visual overview of future scheduling levels. Material and methods Scheduling data at an eight-linac modern RT department in Sweden were collected twice daily for planned and observed linac use in 2018–2020. Information was retrieved each day for the present (Day 0) and the forthcoming 100 weekdays with total linac utilization rates (LURs) calculated for two activity categories: treatment and non-treatment. An in-house tool based on the LUR concept, database queries from the oncology information system (OIS)/automatic calculations was developed and evaluated by RT managers and scheduling staff (n = 10). Results Overall median LURs were 87%/89% (planned/observed; p

Background In meeting input data requirements for a system dynamics (SD) model simulating the radiotherapy (RT) process, the number of patient care pathways (RT workflows) needs to be kept low to simplify the model without affecting the overall performance. A large RT department can have more than 100 workflows, which results in a complex model structure if each is to be handled separately. Here we investigated effects on model performance by reducing the number of workflows for a model of the preparatory steps of the RT process. Methods We created a SD model sub-structure capturing the preparatory RT process. Real data for patients treated in 2015-2016 at a modern RT department in Sweden were used. RT workflow similarity was quantified by averaged pairwise utilization rate differences (%) and the size of corresponding correlation coefficients (r). Grouping of RT workflows was determined using two accepted strategies (80/20 Pareto rule; merging all data into one group) and a customized algorithm with r≥0.75:0.05:0.95 as criteria for group inclusion by two strategies (A1 and A2). Number of waiting patients for each grouping strategy were compared to the reference of all workflows handled separately. Results There were 128 RT workflows for 3209 patients during the studied period. The 80/20 Pareto rule resulted in 14/8/21 groups for curative/palliative/disregarding treatment intent. Correspondingly, A1 and A2 resulted in 7-40/≤4-36/7-82 groups depending on r cutoff. Results for the Pareto rule and A2 at r≥85 were comparable to the reference. Conclusions The performance of a simulation model over the RT process will depend on the grouping strategy of patient input data. Either the Pareto rule or the grouping of patients by resource use can be expected to better reflect overall departmental effects to various changes than when merging all data into one group. Our proposed approach to identify groups based on similarity in resource use can potentially be used in any setting with variable incoming flows of objects which go through a multi-step process comparable to RT where the aim is to reduce the complexity of associated model structures without compromising with overall performance.

Background The aim of this study was to adapt the instrument and evaluate the psychometric properties of the Swedish version of the Swallowing Quality of Care questionnaire (S-SWAL-CARE) in patients with oropharyngeal dysphagia. Methods Translation and adaptation of the original SWAL-CARE into Swedish was performed according to established international guidelines. Field testing was performed using 100 patients with oropharyngeal dysphagia due to multiple reasons such as head and neck cancer and neurologic/neuromuscular disease, who had undergone swallowing evaluation within 6 months prior to the study. The patients answered the S-SWAL-CARE, the Quality from the Patient’s Perspective (QPP) and the Swallowing Quality of Life (SWAL-QOL). Test–retest was performed in 20% of the participants. The reliability and validity of the S-SWAL-CARE were assessed by Pearson correlation coefficient and Cronbach’s alpha as well as convergent and discriminative validity, respectively. Results The field testing of the S-SWAL-CARE resulted in sufficient reliability, with Cronbach’s alpha values exceeding 0.90 for all domains. All items correlated strongly to their own domain, with weaker correlations to the other domains, indicating proper scale structure. Results also indicate sufficient convergent and discriminant validity when tested for association to the QPP domains and the SWAL-QOL Total score. The test–retest reliability of the S-SWAL-CARE demonstrated sufficient intraclass correlation coefficient (ICC) for the General advice domain (0.73) and Clinical advice domain (0.82). The ICC for the Patient satisfaction domain was lower (0.44). Conclusion The S-SWAL-CARE can be considered a reliable and valid tool to assess the dysphagia-related quality of care in a mixed Swedish dysphagia patient population.

Highlights • RT staff generally enjoyed their work and was positive to change. • An important key to enjoy work/perform well was willingness to cooperate. • Organizational issues, shortage of time and lack of staff were current concerns. • Contouring was the most critical bottleneck in the RT workflow. • Small departments were less affected by work-related problems., Background The radiotherapy (RT) community faces great challenges to meet the growing cancer incidence, especially regarding workload and recruitment of personnel. Workflow-related issues affect involved professions differently since they have specific expertise and various roles in the workflow. To obtain an objective understanding of the current working situation and identify workflow bottle necks in RT, we conducted a national survey on this topic in 2018. Materials and Methods All 17 (photon-based) RT departments in Sweden were invited to participate in the study, which targeted both managers and employees in RT. Descriptive statistics were calculated for each profession and for small, medium and large departments (2/3–4/≥5 linacs). Results Altogether, 364 filled-in questionnaires were returned (32/332 managers/employees; 94% response rate). Managers reported a general need for more staff (all professions). Small departments reported no problems with waiting times (0/3); whereas 2/3 of medium and large departments did (medium: 5/8, large: 2/3). All professions had a positive attitude towards working in RT (mean = 86%, 0/100%=negative/positive attitude). Organizational issues were ranked highest among reoccurring events that were most frustrating/had most negative effect on the work environment. The most severe workflow-related problems were reported to originate at contouring. Conclusion Future efforts to improve the modern RT workflow need to focus on how to make positive mechanisms at small departments useful in larger settings. Our data also reveal that strong leadership and improved routines at contouring are warranted by all RT professions to reduce frustration related to organizational issues and to increase work effectivity.

Diabetes is characterized by hyperglycaemia and entails many complications, including retinopathy and entrapment neuropathies, such as ulnar nerve entrapment (UNE) and carpal tunnel syndrome (CTS). Hyperglycaemia damages the nerves of the retina, as well as peripheral nerves. There is a correlation between entrapment neuropathies and retinopathy in patients with diabetes, but whether patients with diabetic retinopathy are more prone to develop CTS and UNE is uncertain. Hence, the aim was to investigate if retinopathy can be used as a factor predicting the development of CTS and UNE. Data from 95,437 individuals from the National Diabetes Registry were merged with data from the Skåne Healthcare Registry. The population was analysed regarding prevalence of CTS or UNE and retinopathy status. Population characteristics were analysed using the Chi2-test, Student’s Independent T-test, and the Mann-Whitney U-test. Two logistic regression models were used to analyse the odds ratio (OR) for development of CTS and UNE depending on retinopathy status, adjusted for possible confounders. Both CTS and UNE were more frequent among those with retinopathy, compared to those without (CTS: 697/10,678 (6.5%) vs. 2756/83,151 (3.3%; p

A fundamental problem in radiotherapy is the variation of organ at risk (OAR) volumes. Here we present our initial experience in engaging a large Radiation Oncology (RO) community to agree on national guidelines for OAR delineations. Our project builds on associated standardization initiatives and invites professionals from all radiotherapy departments nationwide. Presently, one guideline (rectum) has successfully been agreed on by a majority vote. Reaching out to all relevant parties in a timely manner and motivating funding agencies to support the work represented early challenges. Population-based data and a scalable methodological approach are major strengths of the proposed strategy.

Objectives To explore an understanding of medical doctors' entire process of specialty choice with a focus on the influence of personal experiences and personality traits on choices made. Methods A qualitative study was performed. Semi-structured individual interviews were conducted with medical doctors undergoing their specialty training in Sweden about their experiences and personalities. The transcribed interviews were analyzed with an inductive content analysis approach. Results A total of 15 medical doctors participated. Three themes were identified using content analysis: To be invited or not, to fit in or not and to contribute or not. Furthermore, the results refute that specialty choice is a long-term, complex process. Conclusions First, the importance of being invited to the specialty choice was stressed by the doctors, especially in their early years when they needed to feel valued and trusted. Secondly, the need to fit in was essential to make a sustainable career choice. Finally, the doctors' expressed a will to contribute to the medical field of their chosen specialty. The interviews showed that specialty choice is a long-term, complex process; therefore, one implication for the healthcare sector would be to target the entire chain of medical education to improve recruitment strategies for those specialties with recruitment difficulties. More studies are needed to understand better how positive and negative encounters within the healthcare sector can influence young doctors' specialty choice.

Several studies have demonstrated that medical students and doctors rank specialties differently in terms of perceived status and prestige. At the same time some of the specialties have problems with recruiting and retaining staff. This study aimed to understand what constitutes status and prestige in the medical field and how it influences medical doctors’ choice of specialty. By using a sociological perspective and applying Bourdieu’s theoretical concepts of field, symbolic capital and perceived status, we analysed young doctors’ journeys towards their chosen specialty. We conducted 15 in-depth semi-structured interviews. The data was analysed using content analysis. The findings suggest that medical specialties carry different social status. In the field of power, surgery is seen as the most prestigious of all specialties. However, in the future it might be a less attractive choice when young doctors tend to view their profession less as an identity and more like a job. For specialties perceived as low status, the challenge is to raise popularity by better describing to young doctors the characteristics and advantages of these specialties.

Objectives: Evaluation of the degree of concordance between an artificial intelligence (AI) program and radiologists in assessing malignant lesions in screening mammograms. Methods: The study population consisted of all consecutive cases of screening-detected histopathologically confirmed breast cancer in females who had undergone mammography at the NU Hospital Group (Region Västra Götaland, Sweden) in 2018 to 2019. Data were retrospectively collected from the AI program (lesion risk score in percent and overall malignancy risk score ranging from 1 to 10) and from medical records (independent assessments by two radiologists). Ethical approval was obtained. Results: Altogether, 120 females with screening-detected histopathologically confirmed breast cancer were included in this study. The AI program assigned the highest overall malignancy risk score 10 to 86% of the mammograms. Five cases (4%) were assigned an overall malignancy risk score ≤5. Lack of consensus between the two radiologists involved in the initial assessment was associated with lower overall malignancy risk scores (p = 0,002). Conclusion: The AI program detected a majority of the cancerous lesions in the mammograms. The investigated version of the program has, however, limited use as an aid for radiologists, due to the pre-calibrated risk distribution and its tendency to miss the same lesions as the radiologists. A potential future use for the program, aimed at reducing radiologists’ workload, might be to preselect and exclude low-risk mammograms. Although, depending on cut-off score, a small percentage of the malignant lesions can be missed using this procedure, which thus requires a thorough risk–benefit analysis. Advances in knowledge: This study conducts an independent evaluation of an AI program’s detection capacity under screening-like conditions which has not previously been done for this program.

Background Interprofessional Education (IPE) is now included in curricula in universities worldwide. It is known that there are differences in attitudes towards IPE among students, but less is known regarding how students’ personalities and learnings styles correspond with those attitudes. The aim of this study was to investigate whether personality traits and learning styles have any impact on medical students’ attitudes towards IPE. Methods Seventy nine medical students in their 9th term (63% females, mean age 29 years) were questioned regarding their attitudes towards IPE according to the Interdisciplinary Education Perception Scale questionnaire, the Kolb’s learning style and Big Five Inventory questionnaires. For all three instruments we used the Swedish translated versions. Results When investigated with a logistic regression, adjusting for age and gender, there were no significant associations between Big Five inventory, Kolb’s learning style and IEPS, except for the Reflective-Pragmatic learning style that was moderately associated with a higher IEPS score. Conclusion There was no clear correlation between personality, learning style and attitude towards IPE as measured by the IEPS among medical students in our study population. Further investigations would benefit from a combination of qualitative and quantitative design.

Health care is a complex system with multiprofessional staff and multiple patient care pathways. Time pressure and minimal margins for error make it challenging to implement new policies or procedures, no matter how desirable. Changes in health care also requires the participation of the staff. System dynamics (SD) simulations can lead to shared systems understanding and allows for the development and testing of new scenarios in silico before implementing solutions. However, research shows that the actual implementation rate of simulations is low. This paper presents a reanalysis of a successful change project in health care combining SD principles with basic action research (AR) premises. The analysis was done by a multidisciplinary research group using qualitative methodology and identifies that a fruitful combination of AR inquiry and SD modelling potentially can improve implementation rates. publishedVersion

Background and purpose: In uterine cervical cancer tumour spread reaching the para-aortic lymph nodes is the most significant independent pre-treatment predictor of progression-free survival. When introducing [18F]fluorodeoxyglucose-positron emission tomography (FDG-PET)/computed tomography (CT) in our clinic for patients with advanced cervical cancer planned for definitive radiochemotherapy, the purpose of this study was to quantify to what extent the added information lead to changes in radiotherapy planning. Material and methods: We included 25 consecutive patients with cervical cancer stages IB2 – IIIB planned for definitive radiochemotherapy between November 2010 and May 2012. The patients were examined both with magnetic resonance imaging (MRI) and FDG-PET/CT before treatment and after four weeks of treatment. Results: In 11/24 (46%) of the patients the FDG-PET/CT before treatment provided additional diagnostic information leading to changes in treatment planning compared to information from MRI. Seven of these eleven patients (64%) were alive and without evidence of disease at four-year follow-up. The MRI detected pelvic tumour spread not seen on the FDG-PET/CT in 2/24 patients. The disease-free four-year survival was 59%. Conclusions: Additional diagnostic information from FDG-PET/CT changed treatment strategy in almost half of the patients and may have increased chances of survival in this limited group of patients with locally advanced uterine cervical cancer. We recommend both modalities for nodal detection. Keywords: Cervical cancer, Nodal spread, Radiochemotherapy, FDG-PET/CT, MRI

PURPOSE/OBJECTIVE(S) Although radiation-induced side-effects affecting mastication functionality have been studied in head and neck cancer (HNC) radiotherapy (RT), dose constraints for the associated structures are rarely included during treatment plan optimization. Previous research has identified several radiation dose relationships with mean dose thresholds around 30-40 Gy for masseter muscles, 40-50 Gy for pterygoid muscles, and 15-60 Gy for temporomandibular joint (TMJ) relating to a 10% trismus risk post RT. The purpose of this work was to use a multi-criteria optimization (MCO) approach to investigate to what extent doses to these structures can be lowered without violating existing clinical treatment goals in inverse planning of HNC RT. MATERIALS/METHODS This exploratory treatment planning study used data from 22 HNC patients treated to 68 Gy without mastication-structure-sparing intent in 2017-2019 at one institute in Sweden. Original volumetric-modulated arc therapy (VMAT) plans were re-activated in the treatment planning system and masseter muscles, pterygoid muscles (medial and lateral), and TMJ were consistently delineated according to a previously reported delineation manual4. Re-planning was done using the MCO function of the treatment planning system with the resulting dose distribution normalized to match the clinical target volume (CTV T) mean dose of the clinical treatment plan. Dose differences between MCO and clinical plans were not allowed to exceed 2 Gy for any original clinical treatment goal unless tolerance doses had been substantially exceeded in the clinical treatment plan. To what extent dose to mastication structures could be lowered without violating existing clinical treatment goals were quantified by group and by patient. RESULTS Altogether, there were 334 clinical treatment goals in the clinical treatment plans (median = 15, range: 7-24 per patient, depending on tumor location), which easily could be met in the corresponding MCO plans. Mean doses to the mastication structures were in most cases below proposed tolerance doses in the clinical plan but could on average be further reduced between 3-5 Gy in the MCO plans (Table). Of the 25/88 patient reductions below 5 Gy (28%), 18/25 (72%) were for the masseter (n = 8) and medial pterygoid (n = 10) muscles. CONCLUSION With modern RT, it seems possible to reduce the dose to mastication structures below proposed trismus dose tolerance thresholds for most HNC patients without violating clinical treatment goals. Focusing on masseter and medial pterygoid muscle doses may prove to give the largest benefit in individual cases.

Purpose/Objective(s) Successful delivery of radiotherapy (RT) relies on correct and consistent definition of organs at risk (OAR). Artificial intelligence (AI) auto-segmentation based on deep learning (DL) is emerging as a means to reduce variability of OARs. Knowledge about how auto-segmentation tools perform on standardized datasets is limited. Our aim is to evaluate the quality of rectal volumes defined by an existing DL auto-contouring algorithm on a standardized dataset for rectal volumes in prostate cancer RT as proposed by the Swedish STRONG guidelines for male pelvis [1][2][3]. [1] Olsson et al. PhIRO 2019:11:88 [2] Gay et al. IJROBP 2012:83:e353 [3] Salembier et al. RO 2018:127:49 Materials/Methods DICOM-RT datasets for 19 patients extracted from a treatment planning system at one institution in Sweden was used. The patients were treated for prostate cancer in 2018-2019 using 15 MV photon beams to total doses of 50-70Gy@2-3Gy/fraction. Rectal volumes were defined on planning CT images clinically (clinical), according to proposed standard (reference), and auto-contoured using the existing version of the MVision software. The degree of variation between volumes was investigated. Statistics included dose volume histogram metrics, the Jaccard index, and the Dice similarity coefficient with comparisons between groups based on hypothesis testing with a two-sided P-value≤0.05 indicating a statistically significant difference. Results The clinical and the MVision DVH points were in general closer to each other than to the points of the reference DVH. Clinical and MVision volumes were also somewhat larger than the reference volume (83cc and 84cc versus 80cc; P > > 0.05). Overall, mean doses were 0.8/0.9Gy lower for clinical/MVision compared with the reference (21.9 ± 5.1/21.8 ± 5.1Gy versus 22.7 ± 5.9Gy; P > > 0.05) whilst maximum doses were similar for all (67.8-67.9 ± 4.3). Both overlap metrics were similar for volume comparisons between MVision and reference and for MVision and clinical but somewhat higher for clinical and reference (Jaccard index/Dice coefficient: 0.74/0.85 versus 0.73/0.83 versus 0.90/0.95, respectively). Differences were primarily found in cranio-caudal direction between any two data sets. Conclusion This is the first systematic comparison of an auto-contouring algorithm's performance on a standardized OAR dataset in RT. Our results need to be confirmed on a larger patient cohort, but indicate that the MVision algorithm did very well since the size of identified differences generally was small both with respect to clinical and to reference volumes. However, to increase the use of AI-algorithms for clinical studies and research, retraining them on standardized reference datasets has the potential to improve performance further.

Dysphagia is a common and severe toxicity after oncological treatment of head and neck cancer (HNC). The study aim was to investigate relationships between patient-reported dysphagia and clinically measured swallowing function in HNC after modern curative radiotherapy with or without chemotherapy to identify possible alarm symptoms for clinically manifest dysphagia. Patients with tumors of the tonsil, base of tongue, hypopharynx, and larynx treated in 2007–2015 were assessed for dysphagia post-treatment by telephone interview and videofluoroscopy (VFS). A study-specific categorized symptom score was used to determine patient-reported dysphagia (DESdC = presence of Drinking, Eating, Swallowing difficulties, and Coughing when eating/drinking (any combination); scores between 0 and 4 with 0 = no symptom); the penetration–aspiration scale (PAS) to determine swallowing function by VFS. Swallowing difficulties were defined as DESdC ≥ 1 and PAS ≥ 2. Relationships between clinically relevant cut-offs for DESdC and PAS were determined by Pearson’s correlation coefficient (Pr). Swallowing difficulties according to DESdC were reported by 89% of the patients and according to PAS by 60% at a median of 7 months post-treatment. Averaged correlations between DESdC score 1/2/3/4 and PAS were 0.16/0.10/0.27/0.18. Almost one in two patients with DESdC score ≥3 had severe swallowing difficulties according to PAS. Correlations between individual DESdC:s were highest for swallowing and eating (Pr = 0.53) and lowest for swallowing and coughing (Pr = 0.11). Our data suggest that if a patient reports having swallowing difficulties, it is likely that he or she also has eating difficulties but not necessarily coughing problems when eating/drinking. However, if all these three symptoms are reported, it is likely that the patient will present with moderate or severe impaired swallowing function according to PAS and thus should be referred for further evaluation and treatment.

Objectives To identify temporal patterns of patient-reported trismus during the first year post-radiotherapy, and to study their associations with maximal interincisal opening distances (MIOs). Design Single institution case series. Setting University hospital ENT clinic. Participants One hundred ninety six subjects who received radiotherapy (RT) for head and neck cancer (HNC) with or without chemotherapy in 2007-2012 to total dose of 64.6/68 Gy in 38/34 fractions, respectively. All subjects were prospectively assessed for mouth-opening ability (Gothenburg Trismus Questionnaire (GTQ), and MIO) pre-RT and at 3, 6, and 12 months after RT. Main outcome measures Correlations between temporally robust GTQ-symptoms and MIO as given by Pearson's correlation coefficients (Pr); temporally robust GTQ-symptom domains as given by factor analysis; rates of trismus with respect to baseline by risk ratios (RRs). Results Four temporally robust domains were identified: Eating (3-7 symptoms), Jaw (3-7), Pain (2-5), and Quality of Life (QoL, 2-5), and included 2-3 persistent symptoms across all post- RT assessments. The median RR for a moderate/severe (>2/>3) cut-off was the highest for Jaw (3.7/3.6) and QoL (3.2/2.9). The median Pr between temporally robust symptoms and MIO post-radiotherapy was 0.25-0.35/0.34-0.43/0.24-0.31/0.34-0.50 for Eating/Jaw/Pain/QoL, respectively. Conclusions Mouth-opening distances in HNC patients post-RT can be understood in terms of associated patient-reported outcomes on trismus-related difficulties. Our data suggest that a reduction in MIO can be expected as patients communicate their mouth-opening status to interfere with private/social life, a clinical warning signal for emerging or worsening trismus as patients are being followed after RT. This article is protected by copyright. All rights reserved.

Highlights • Majority of DARS investigated for radiation-induced late dysphagia in HNC. • Epiglottis (E) and submandibular glands (SG) have previously not been reported as critical for dysphagia. • Reduced epiglottic inversion may explain the importance of E dose. • Interplay between xerostomia and dysphagia may explain the importance of SG dose. • Potential DVH thresholds to reduce dysphagia: E V60 = 60% and contralateral SG V60 = 17%, Background and purpose Dysphagia is a common, severe and dose-limiting toxicity after oncological treatment of head and neck cancer (HNC). This study aims to investigate relationships between radiation doses to structures involved in normal swallowing and patient-reported as well as clinically measured swallowing function in HNC patients after curative (chemo-) radiation therapy (RT) with focus on late effects. Materials and methods Patients (n = 90) with HNC curatively treated with RT ± chemotherapy in 2007–2015 were assessed for dysphagia post-treatment by telephone interview and videofluoroscopy (VFS). A study-specific symptom score was used to determine patient-reported dysphagia. The Penetration-Aspiration Scale (PAS) was applied to determine swallowing function by VFS (PAS ≥ 4/ ≥ 6 = moderate/severe dysphagia). Thirteen anatomical structures involved in normal swallowing were individually delineated on the patients’ original planning CT scans and associated dose-volume histograms (DVHs) retrieved. Relationships between structure doses and late toxicity were investigated through univariable and multivariable logistic regression analysis (UVA/MVA) accounting for effects by relevant clinical factors. Results Median assessment time was 7 months post-RT (range: 5–34 months). Mean dose to the contralateral parotid gland and supraglottic larynx as well as maximum dose to the contralateral anterior digastric muscle predicted patient-reported dysphagia (AUC = 0.64–0.67). Mean dose to the pharyngeal constrictor muscle, the larynx, the supraglottic larynx and the epiglottis, as well as maximum dose to the contralateral submandibular gland predicted moderate and severe dysphagia by VFS (AUC = 0.71–0.80). Conclusion The patients in this cohort were consecutively identified pre-treatment, and were structurally approached and assessed for dysphagia after treatment at a specific time point. In addition to established dysphagia organs-at-risk (OARs), our data suggest that epiglottic and submandibular gland doses are important for swallowing function post-RT. Keeping DVH thresholds below V60 = 60% and V60 = 17%, respectively, may increase chances to reduce occurrence of severe late dysphagia. The results need to be externally validated in future studies.

Vasopressin-dependent trafficking of AQP2 in the renal collecting duct is crucial for the regulation of water homeostasis. This process involves the targeting of AQP2 to the apical membrane during dehydration as well as its removal when hydration levels have been restored. The latter involves AQP2 endocytosis and sorting into multivesicular bodies (MVB), from where it may be recycled, degraded in lysosomes, or released into urine via exosomes. The lysosomal trafficking regulator-interacting protein 5 (LIP5) plays a crucial role in this by coordinating the actions of the endosomal sorting complex required for transport III (ESCRT-III) and vacuolar protein sorting 4 (Vps4) ATPase, resulting in the insertion of AQP2 into MVB inner vesicles. While the interaction between LIP5 and the ESCRT-III complex and Vps4 is well characterized, very little is known about how LIP5 interacts with AQP2 or any other membrane protein cargo. Here, we use a combination of fluorescence spectroscopy and computer modeling to provide a structural model of how LIP5 interacts with human AQP2. We demonstrate that, the AQP2 tetramer binds up to two LIP5 molecules and that the interaction is similar to that seen in the complex between LIP5 and the ESCRT-III component, charged multivesicular body protein 1B (CHMP1B). These studies give the very first structural insights into how LIP5 enables membrane protein insertion into MVB inner vesicles and significantly increase our understanding of the AQP2 trafficking mechanism.

Introduction: About 20% of the working-age population in the average OECD country is suffering from a mental disorder. The prevalence rates are especially high among young adults and women. Young adults need to deal with challenges connected to growing up and entering the labour market, their young age often leaving them with little experience and a low level of preparedness for failure. Moreover, young women and men are confronted with gender norms and expectations that have been found to affect both sick leave and return to work. While managers have been shown to have a significant impact on the well-being of employees, few studies investigate the experiences of both employees and managers in relation to sick leave and return to work among youth. The aim of this study is to investigate perceived causes of sick leave owing to common mental disorders as well as barriers to and resources for return to work for young employees, from the perspectives of both employees and managers. Furthermore, differences and similarities in the patterns of experiences of women and men will be analyzed. Methods and analysis: This study has a qualitative research design. Data will consist of individual interviews with employees aged 19–29 and managers in female- and male-dominated occupations in a Swedish setting. The participants will be recruited using a purposive sampling strategy. The interviews will be analysed in two steps: firstly, a conventional content analysis will be conducted. Secondly, a gender analysis focusing social relations and gender order will be applied to interpret the data by examining differences and similarities in the patterns of experiences of women and men.

Purpose To develop an infrastructure for structured and automated collection of interoperable radiation therapy (RT) data into a national clinical quality registry. Materials and methods The present study was initiated in 2012 with the participation of seven of the 15 hospital departments delivering RT in Sweden. A national RT nomenclature and a database for structured unified storage of RT data at each site (Medical Information Quality Archive, MIQA) have been developed. Aggregated data from the MIQA databases are sent to a national RT registry located on the same IT platform (INCA) as the national clinical cancer registries. Results The suggested naming convention has to date been integrated into the clinical workflow at 12 of 15 sites, and MIQA is installed at six of these. Involvement of the remaining 3/15 RT departments is ongoing, and they are expected to be part of the infrastructure by 2016. RT data collection from ARIA®, Mosaiq®, Eclipse™, and Oncentra® is supported. Manual curation of RT-structure information is needed for approximately 10% of target volumes, but rarely for normal tissue structures, demonstrating a good compliance to the RT nomenclature. Aggregated dose/volume descriptors are calculated based on the information in MIQA and sent to INCA using a dedicated service (MIQA2INCA). Correct linkage of data for each patient to the clinical cancer registries on the INCA platform is assured by the unique Swedish personal identity number. Conclusions An infrastructure for structured and automated prospective collection of syntactically interoperable RT data into a national clinical quality registry for RT data is under implementation. Future developments include adapting MIQA to other treatment modalities (e.g. proton therapy and brachytherapy) and finding strategies to harmonize structure delineations. How the RT registry should comply with domain-specific ontologies such as the Radiation Oncology Ontology (ROO) is under discussion.

Purpose: To identify imaged regions in which dose is associated with radiation-induced trismus after head and neck cancer radiation therapy (HNRT) using a novel image-based data mining (IBDM) framework. Methods and Materials: A cohort of 86 HNRT patients were analyzed for region identification. Trismus was characterized as a continuous variable by the maximum incisor-to-incisor opening distance (MID) at 6 months after radiation therapy. Patient anatomies and dose distributions were spatially normalized to a common frame of reference using deformable image registration. IBDM was used to identify clusters of voxels associated with MID (P ≤.05 based on permutation testing). The result was externally tested on a cohort of 35 patients with head and neck cancer. Internally, we also performed a dose-volume histogram–based analysis by comparing the magnitude of the correlation between MID and the mean dose for the IBDM-identified cluster in comparison with 5 delineated masticatory structures. Results: A single cluster was identified with the IBDM approach (P s = −0.36, –0.35, −0.32; P =.001,.001,.002, respectively). External validation confirmed an association between mean dose to the IBDM cluster and MID (R s = −0.45; P =.007). Conclusions: IBDM bypasses the common assumption that dose patterns within structures are unimportant. Our novel IBDM approach for continuous outcome variables successfully identified a cluster of voxels that are highly associated with trismus, overlapping partially with the ipsilateral masseter. Tests on an external validation cohort showed an even stronger correlation with trismus. These results support use of the region in HNRT treatment planning to potentially reduce trismus.