Anna Sjöström

Background: Carotid ultrasound is traditionally confined to specialist settings because examination quality and diagnostic reliability are highly dependent on the operator’s technical skill and experience. Recent advances in AI-assisted ultrasound may enable task shifting to primary care staff and support the integration of personalized visual risk communication into routine preventive care. Visualization of subclinical atherosclerosis has been shown to strengthen cardiovascular risk communication and support preventive engagement. However, limited evidence exists on how such technology can be practically integrated into routine primary care workflows and what conditions are required to support use by nonexpert operators. Objective: This study aimed to describe an iterative user-centered design process enabling nonexpert use of AI-assisted carotid ultrasound for visualizing subclinical atherosclerosis in primary care cardiovascular disease prevention. Methods: We conducted a user-centered, iterative study within the Västerbotten Intervention Programme in northern Sweden. Fourteen nurse assistants from 4 primary care centers representing urban, rural, and remote rural settings tested an AI-assisted carotid ultrasound prototype with real-time guidance and artery segmentation in their primary care work environment, while 15 nurse assistants participated in semistructured interviews. Structured system-interaction observations were conducted during prototype testing. Interview data were analyzed using inductive thematic analysis informed by Braun and Clarke’s approach, while data from structured system-interaction observations were analyzed pragmatically to identify usability and workflow issues relevant to the iterative development process. Results: The thematic analysis of interview data identified 4 themes describing nurse assistants’ experiences and conditions for implementation: technology that fits the everyday primary care work; system guidance as a prerequisite for effective use; practical, peer-supported learning for confidence in clinical use; and confidence in the patient encounter. Observations identified recurring usability challenges related to ergonomics, probe handling, interface navigation, image acquisition, and time pressure. These findings led to iterative refinements, including redesigned interface navigation, simplified data entry, added audio feedback, enhanced probe support, and revised training materials. Conclusions: This user-centered study identified key practical, organizational, and educational conditions for integrating AI-assisted carotid ultrasound into routine preventive care by nonexpert staff in primary care. The findings suggest that successful implementation will depend not only on technical capability but also on ergonomic and workflow fit, intuitive system guidance, peer-supported learning, and confidence in patient communication. These findings provide a foundation for future validation and implementation studies.

BACKGROUND Carotid ultrasound is traditionally confined to specialist settings because examination quality and diagnostic reliability are highly dependent on the operator’s technical skill and experience. Recent advances in AI-assisted ultrasound may enable task shifting to primary care staff and support the integration of personalized visual risk communication into routine preventive care. Visualization of subclinical atherosclerosis has been shown to strengthen cardiovascular risk communication and support preventive engagement. However, limited evidence exists on how such technology can be practically integrated into routine primary care workflows and what conditions are required to support use by nonexpert operators. OBJECTIVE This study aimed to describe an iterative user-centered design process enabling nonexpert use of AI-assisted carotid ultrasound for visualizing subclinical atherosclerosis in primary care cardiovascular disease prevention. METHODS We conducted a user-centered, iterative study within the Västerbotten Intervention Programme in northern Sweden. Fourteen nurse assistants from 4 primary care centers representing urban, rural, and remote rural settings tested an AI-assisted carotid ultrasound prototype with real-time guidance and artery segmentation in their primary care work environment, while 15 nurse assistants participated in semistructured interviews. Structured system-interaction observations were conducted during prototype testing. Interview data were analyzed using inductive thematic analysis informed by Braun and Clarke’s approach, while data from structured system-interaction observations were analyzed pragmatically to identify usability and workflow issues relevant to the iterative development process. RESULTS The thematic analysis of interview data identified 4 themes describing nurse assistants’ experiences and conditions for implementation: technology that fits the everyday primary care work; system guidance as a prerequisite for effective use; practical, peer-supported learning for confidence in clinical use; and confidence in the patient encounter. Observations identified recurring usability challenges related to ergonomics, probe handling, interface navigation, image acquisition, and time pressure. These findings led to iterative refinements, including redesigned interface navigation, simplified data entry, added audio feedback, enhanced probe support, and revised training materials. CONCLUSIONS This user-centered study identified key practical, organizational, and educational conditions for integrating AI-assisted carotid ultrasound into routine preventive care by nonexpert staff in primary care. The findings suggest that successful implementation will depend not only on technical capability but also on ergonomic and workflow fit, intuitive system guidance, peer-supported learning, and confidence in patient communication. These findings provide a foundation for future validation and implementation studies.

Background: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally and in Sweden. Effective primary prevention requires not only clinical risk assessment but also person-centred communication to promote a healthy lifestyle. Nurses play a key role in structured preventive dialogues, such as those in the Västerbotten Intervention Programme (VIP), one of the world’s largest prevention programmes. However, little is known about how nurses experience and navigate risk communication in real-world primary care. This study aimed to explore nurses’ experiences with cardiovascular risk communication and lifestyle counselling during preventive dialogues in primary care. Methods: Semistructured interviews were conducted with 11 nurses delivering VIP health dialogues across primary care centres in Västerbotten County between December 2024 and April 2025. The interviews were audio-recorded and transcribed verbatim. Data were analysed via qualitative content analysis, identifying meaning units, codes, categories, and an overarching theme. Reporting followed COREQ. Results: The analysis generated two main categories. The first, Meeting the person professionally while taking a step back , captured how nurses described exploring each patient’s unique situation, needs, motivations, and attitudes. The second, Continuously adapting approaches in self-management support , captured nurses’ accounts of using flexible strategies, such as gradual goal setting, visual tools, and practical daily habit suggestions, to support patients in understanding and working with lifestyle change. Together, these categories formed the overarching theme Shifting between leading and following , illustrating how nurses experienced balancing individualised adaptation with professional guidance while navigating structural and contextual challenges. Conclusions: Nurses described translating cardiovascular risk into person-centred, relational dialogue by flexibly combining structure, responsiveness, and motivational strategies. Understanding preventive dialogues as interactive, person-centred processes, supported by the sensitive use of visualisation tools, may inform the continued development of cardiovascular prevention in primary care and warrants further evaluation.

Cystatin C was identified as a marker of glomerular filtration rate (GFR) in 1979, and the parallel analysis of cystatin C and creatinine led to the identification of shrunken pore syndrome (SPS) - a new kidney disorder - in 2015. Since then, it has been shown that cystatin C in many aspects is superior to creatinine as a marker of GFR and cardiovascular risk. SPS, an entity within the selective glomerular hypofiltration syndromes (SGHS), has been demonstrated to be associated with a strong increase in morbidity and mortality in several populations. Despite the seriousness of SPS and SGHS, and the availability of potential treatments, many patients with these conditions remain undiagnosed, due to the limitations of the international Kidney Disease Improving Global Outcomes Organization (KDIGO) guidelines. Given the significant clinical advantages of cystatin C in diagnosing and treating kidney disorders, there is a need to expand the KDIGO guidelines to include cystatin C measurements alongside creatinine at least in the initial patient evaluation but also in follow-up evaluations. This would improve the early detection and management of patients with kidney diseases, ultimately enhancing patient outcomes. The present discourse summarizes the development of this understanding from the original observations in 1979 and 2015 to the latest findings.

Background: Digitalization has profoundly transformed health care delivery, especially within primary health care, as a crucial avenue for providing accessible, cost-effective care. While eHealth services are frequently highlighted for improving health care availability and promoting equality, it is essential to recognize that digitalization can inadvertently exclude individuals who lack the prerequisites to use eHealth services, that is, those with low eHealth literacy. Previous research has identified lower eHealth literacy among older individuals, those with lower educational levels, and those who use the internet less frequently. However, in a Swedish context, only a few studies have investigated eHealth literacy. Objective: This study investigated eHealth literacy and its association with health-related internet use and sociodemographic characteristics among primary health care visitors. Methods: This cross-sectional study used a quantitative, descriptive approach. Swedish-speaking patients visiting a primary health care center participated by answering the multidimensional eHealth Literacy Questionnaire (eHLQ) and questions regarding sociodemographic characteristics and internet usage. The study compared mean scores using the Mann-Whitney U test and the Kruskal-Wallis test. A logistic regression analysis also explored the associations between eHealth literacy and significant independent variables identified in the univariate analyses. Results: As a group, the 172 participants rated highest in understanding and engagement with their health (median eHLQ score 3, IQR 2.8‐3.4), as well as in feeling secure about the confidentiality of eHealth services (median eHLQ score 3, IQR 2‐3), while they rated lower in motivation to use eHealth (median eHLQ score 2.6, IQR 2‐3), the suitability of eHealth services to their personal needs (median eHLQ score 2.75, IQR 2‐3), and their perceived ability to understand and use health-related internet information (median eHLQ score 2.6, IQR 2‐3). The logistic regression analysis identified that lower eHealth literacy was associated with older age, particularly in domains related to finding, understanding, and using health-related internet information (odds ratio [OR] 1.02, 95% CI 1‐1.05; P=.03); digital technology use (OR 1.05, 95% CI 1.02‐1.08; P<.001); and accessing well-functioning eHealth services (OR 1.02, 95% CI 1‐1.05; P=.03). Additionally, in the logistic regression analysis, perceiving health-related internet information as not useful was linked to lower literacy in all eHLQ domains except one. Conclusions: Our findings regarding the primary challenges within our sample underscore the importance of developing and tailoring eHealth services to accommodate users’ individual needs better, enhancing motivation for eHealth use, and continuing efforts to improve overall health literacy. These measures, which both eHealth developers and health care professionals should consider, are crucial for addressing the digital divide and expanding access to eHealth services for as many people as possible.

BACKGROUND Digitalization has profoundly transformed healthcare delivery, especially within primary healthcare, as a crucial avenue for providing accessible and cost-effective care. While eHealth services are frequently highlighted for improving healthcare availability and promoting equality, it is essential to recognize that digitalization can inadvertently exclude individuals who lack the prerequisites to utilize eHealth services. Previous research has identified lower eHealth literacy among older individuals, those with lower educational levels, and those who use the Internet less frequently. However, in a Swedish context, only a few studies have investigated eHealth literacy. OBJECTIVE This study investigated eHealth literacy and its association with health-related Internet use and sociodemographic characteristics among primary healthcare visitors. METHODS This cross-sectional study employed a quantitative, descriptive approach. 172 Swedish-speaking patients visiting a primary healthcare center participated by answering the eHealth Literacy Questionnaire (eHLQ). The study compared mean scores using the Mann-Whitney U-test and Kruskal-Wallis-test. A logistic regression analysis also explored the associations between low eHealth literacy and significant independent variables identified in the univariate analyses. RESULTS The results showed that higher age and perceptions of health-related Internet information as not useful or important were the primary factors associated with lower eHealth literacy. The eHealth literacy domains in which participants scored highest—understanding of and engagement with health, and a sense of security and control—were not directly linked to utilizing and interacting with the eHealth system. Instead, the most challenging domains were related to motivation to use eHealth and aligning eHealth services with individual needs. CONCLUSIONS Healthcare professionals are crucial in addressing patients' attitudes and motivation towards eHealth use. Person-centered support can guide patients toward services that meet their individual needs, by recommending personalized websites and other eHealth services. To ensure that eHealth services effectively align with users' requirements, it is essential for eHealth developers and healthcare authorities to actively involve both patients and healthcare professionals in the development process.

Background: With the increasing digitalization in health care, an effective instrument is necessary to assess health care consumers’ digital competencies—their “eHealth literacy.” The 7-scale eHealth Literacy Questionnaire (eHLQ), based on the theoretically robust eHealth Literacy Framework, has shown strong psychometric properties in Denmark and Australia. Objective: The aim of this study was to translate, culturally adapt, and evaluate the psychometric properties of the Swedish version of the eHLQ. Methods: We followed the Translation Integrity Procedure guidelines to translate and culturally adapt the questionnaire to Swedish using forward and backward translations, review by an expert panel, and cognitive interviewing. The psychometric properties of the Swedish eHLQ were investigated by evaluating its internal consistency (Cronbach α) and a priori–defined factor structure (confirmatory factor analysis). Results: A total of 236 primary health care patients and parents of hospitalized children were included in the validation analysis. The mean age was 48.5 years, and 129 (55%) were women. All 7 eHLQ scales showed good internal consistency, with the Cronbach α ranging from .82 to .92. Single-factor and 7-factor confirmatory factor analysis showed satisfactory model-fit values. With one exception, all items demonstrated satisfactory loadings on their respective factors. Conclusions: The Swedish eHLQ demonstrated strong psychometric properties. It has the potential as a useful tool for a variety of purposes, including population surveys, intervention evaluations, and eHealth service implementations.

Estimation of kidney function is often part of daily clinical practice, mostly done by using the endogenous glomerular filtration rate (GFR)‐markers creatinine or cystatin C. A recommendation to use both markers in parallel in 2010 has resulted in new knowledge concerning the pathophysiology of kidney disorders by the identification of a new set of kidney disorders, selective glomerular hypofiltration syndromes. These syndromes, connected to strong increases in mortality and morbidity, are characterized by a selective reduction in the glomerular filtration of 5–30 kDa molecules, such as cystatin C, compared to the filtration of small molecules <1 kDa dominating the glomerular filtrate, for example water, urea and creatinine. At least two types of such disorders, shrunken or elongated pore syndrome, are possible according to the pore model for glomerular filtration. Selective glomerular hypofiltration syndromes are prevalent in investigated populations, and patients with these syndromes often display normal measured GFR or creatinine‐based GFR‐estimates. The syndromes are characterized by proteomic changes promoting the development of atherosclerosis, indicating antibodies and specific receptor‐blocking substances as possible new treatment modalities. Presently, the KDIGO guidelines for diagnosing kidney disorders do not recommend cystatin C as a general marker of kidney function and will therefore not allow the identification of a considerable number of patients with selective glomerular hypofiltration syndromes. Furthermore, as cystatin C is uninfluenced by muscle mass, diet or variations in tubular secretion and cystatin C‐based GFR‐estimation equations do not require controversial race or sex terms, it is obvious that cystatin C should be a part of future KDIGO guidelines.

BACKGROUND With the increasing digitalization in health care, an effective instrument is necessary to assess health care consumers’ digital competencies—their “eHealth literacy.” The 7-scale eHealth Literacy Questionnaire (eHLQ), based on the theoretically robust eHealth Literacy Framework, has shown strong psychometric properties in Denmark and Australia. OBJECTIVE The aim of this study was to translate, culturally adapt, and evaluate the psychometric properties of the Swedish version of the eHLQ. METHODS We followed the Translation Integrity Procedure guidelines to translate and culturally adapt the questionnaire to Swedish using forward and backward translations, review by an expert panel, and cognitive interviewing. The psychometric properties of the Swedish eHLQ were investigated by evaluating its internal consistency (Cronbach α) and a priori–defined factor structure (confirmatory factor analysis). RESULTS A total of 236 primary health care patients and parents of hospitalized children were included in the validation analysis. The mean age was 48.5 years, and 129 (55%) were women. All 7 eHLQ scales showed good internal consistency, with the Cronbach α ranging from .82 to .92. Single-factor and 7-factor confirmatory factor analysis showed satisfactory model-fit values. With one exception, all items demonstrated satisfactory loadings on their respective factors. CONCLUSIONS The Swedish eHLQ demonstrated strong psychometric properties. It has the potential as a useful tool for a variety of purposes, including population surveys, intervention evaluations, and eHealth service implementations. CLINICALTRIAL

During the COVID-19 pandemic, the Internet has been a major source of information for people to keep updated with news and guidelines. However, concerns have been raised about the ‘infodemic’, which includes the overabundance of online information and the spread of misleading information. Adequate eHealth literacy skills among world citizens have therefore been emphasized as vital during the pandemic. Persons with type 2 diabetes have been at increased risk of severe outcomes of COVID-19 disease. This study aimed to explore online COVID-19 information acquisition experiences among persons with type 2 diabetes and varying eHealth literacy. Fifty-eight participants filled out the eHealth Literacy Scale (eHEALS), along with a qualitative questionnaire with free-text questions. Additionally, 10 participants were interviewed. Thematic analysis was applied to identify patterns in participants’ experiences. Two domains were identified: perceived challenges with online information about COVID-19, and coping strategies to manage challenges. The perceived challenges were: being exposed to information overload, dealing with conflicting information, and being strongly emotionally affected. The related coping strategies were: protecting oneself, trusting authorities, taking command, and using common sense. These strategies often involved triangulation of the information obtained, including participants consulting their common sense, various sources, or family and friends. This paper highlights the crucial role of authorities in delivering online information, that according to health literacy principles, is easy to access, understand, and use. Furthermore, our results reinforce the importance of diabetes nurses, as well as healthcare professionals in general, in encouraging patients to share their Internet findings, promote information from reliable sources, and deliver tailored information that suits individual needs. Because our results underline the importance of social support in eHealth literacy and the assessment of online health information, the inclusion of family and friends needs to be increasingly considered in diabetes care. Due to the small homogenous sample, the results of this study cannot be generalized. However, the reader can assess the transferability to other situations and settings based on our contextual descriptions.