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Robèrt J, Tsatsaris E, Berinder K, Bonelli L, Burman P, Dahlqvist P, Höybye C, Olsson DS, Ragnarsson O, Vouzouneraki K, Åkerman AK, Ekman B, Edén Engström B. Establishing a valid cohort of patients with acromegaly by combining the National Patient Register with the Swedish Pituitary Register. J Endocrinol Invest 2024; 47:995-1003. [PMID: 37851314 DOI: 10.1007/s40618-023-02217-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE The aim of this study was to establish a valid national cohort of patients diagnosed with acromegaly by combining data from the general National Patient Register (NPR) and the disease-specific Swedish Pituitary Register (SPR). METHODS Patients ≥ 18 years of age at diagnosis of acromegaly reported from 1991 to 2018 who were registered in the NPR and/or SPR were included. The diagnosis of acromegaly was considered correct for patients identified in both registers or confirmed through chart review. Medical records were reviewed in two of Sweden´s six health care regions if the patient was reported only in the NPR. An algorithm for the NPR, with criteria requiring multiple diagnosis registrations and tumour and/or surgery codes, was constructed to reduce the number of patients to review in the remaining four regions. RESULTS A total of 1866 patients were identified. Among these, 938 were reported in both registers. After application of the algorithm and chart review, the diagnosis was confirmed for 83 of the 906 patients found only in the NPR. Among 22 patients only registered in the SPR, a review of medical records confirmed acromegaly in 13. This resulted in a total of 1034 cases with acromegaly during the study period. The incidence rate of acromegaly in Sweden 1991-2018 was calculated to 4.0/million/year in the entire population and 5.1/million/year among subjects ≥ 18 years of age. CONCLUSION The combination of the SPR and NPR established a valid cohort of patients diagnosed with acromegaly and increased the estimated incidence in Sweden.
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Affiliation(s)
- J Robèrt
- Departments of Endocrinology in Linköping and Norrköping, Linköping University, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - E Tsatsaris
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - K Berinder
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - L Bonelli
- Department of Endocrinology, Skåne University Hospital Malmö, Lund University, Malmö, Sweden
| | - P Burman
- Department of Endocrinology, Skåne University Hospital Malmö, Lund University, Malmö, Sweden
| | - P Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - C Höybye
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - D S Olsson
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - O Ragnarsson
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, Göteborg, Sweden
| | - K Vouzouneraki
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - A-K Åkerman
- Department of Internal Medicine, Örebro University Hospital, Örebro, Sweden
- Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - B Ekman
- Departments of Endocrinology in Linköping and Norrköping, Linköping University, Linköping, Sweden.
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
| | - B Edén Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
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Markowitz D, Aamodt WW, Hamedani AG. Social Determinants of Health in Idiopathic Intracranial Hypertension. J Neuroophthalmol 2024:00041327-990000000-00544. [PMID: 38170607 DOI: 10.1097/wno.0000000000002073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) disproportionately affects women from socioeconomically disadvantaged communities, but specific social determinants of health have not been examined. METHODS We used data from the National Institutes of Health's All of Us Research Program, an ongoing nationwide study of more than 300,000 diverse individuals in the United States. Height and weight were measured at baseline, and participants completed questionnaires about demographics, health care access, and quality of life. Women aged 18-50 years with IIH were identified through electronic health record data, excluding those with venous thrombosis, meningitis, hydrocephalus, or central nervous system neoplasms. We used logistic regression to compare questionnaire responses for IIH cases and controls, adjusting for age, race, ethnicity, annual income, and body mass index (BMI). RESULTS We included 416 women with IIH and 107,111 women without IIH. The mean age was 38 years, and 49.3% identified as non-White. After adjusting for age, race/ethnicity, and BMI, women with IIH were more likely to be unemployed (odds ratio [OR] 1.40, 95% confidential interval [CI]: 1.14-1.71) and report delaying care because of difficulty affording copays (OR 1.47, 95% CI: 1.02-2.10) or specialist care (OR 1.52, 95% CI: 1.06-2.18). They also delayed care because of rural residence (OR 2.08, 95% CI: 1.25-3.47) and transportation limitations (OR 2.23, 95% CI: 1.55-3.20). Although women with IIH were more likely to be non-Hispanic Black (OR 1.66, 95% CI: 1.32-2.09), this association lost significance when controlling for BMI and income (OR 1.27, 95% CI: 0.96-1.68). CONCLUSIONS Women with IIH experience adverse social determinants of health beyond those associated with obesity alone.
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Affiliation(s)
- Daniel Markowitz
- Drexel University School of Medicine (DM), Philadelphia, Pennsylvania; Departments of Neurology (WWA, AGH), Ophthalmology (AGH), and Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Stunkel L. Big Data in Neuro-Ophthalmology: International Classification of Diseases Codes. J Neuroophthalmol 2022; 42:1-5. [PMID: 35067628 DOI: 10.1097/wno.0000000000001522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Leanne Stunkel
- John F. Hardesty, MD Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri; and Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
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Predictive Value of International Classification of Diseases Codes for Idiopathic Intracranial Hypertension in a University Health System. J Neuroophthalmol 2022; 42:6-10. [DOI: 10.1097/wno.0000000000001563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Khushzad F, Kumar R, Muminovic I, Moss HE. Predictive Value of International Classification of Diseases Codes for Idiopathic Intracranial Hypertension in a University Health System. J Neuroophthalmol 2021; 41:e679-e683. [PMID: 34788247 PMCID: PMC8600052 DOI: 10.1097/wno.0000000000000992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Misclassification bias is introduced into medical claims-based research because of reliance on diagnostic coding rather than full medical record review. We sought to characterize this bias for idiopathic intracranial hypertension (IIH) and evaluate strategies to reduce it. METHODS A retrospective review of medical records was conducted using a clinical data warehouse containing medical records and administrative data from an academic medical center. Patients with 1 or more instances of International Classification of Diseases (ICD)-9 or -10 codes for IIH (348.2 or G93.2) between 1989 and 2017 and original results of neuroimaging (head CT or MRI), lumbar puncture, and optic nerve examination were included in the study. Diagnosis of IIH was classified as definite, probable, possible, or inaccurate based on review of medical records. The positive predictive value (PPV) for IIH ICD codes was calculated for all subjects, subjects with an IIH code after all testing was completed, subjects with high numbers of IIH ICD codes and codes spanning longer periods, subjects with IIH ICD codes associated with expert encounters (ophthalmology, neurology, or neurosurgery), and subjects with acetazolamide treatment. RESULTS Of 1,005 patients with ICD codes for IIH, 103 patients had complete testing results and were included in the study. PPV of ICD-9/-10 codes for IIH was 0.63. PPV in restricted samples was 0.82 (code by an ophthalmologist n = 57), 0.70 (acetazolamide treatment n = 87), and 0.72 (code after all testing, n = 78). High numbers of code instances and longer duration between the first and last code instance also increased the PPV. CONCLUSIONS An ICD-9 or -10 code for IIH had a PPV of 63% for probable or definite IIH in patients with necessary diagnostic testing performed at a single institution. Coding accuracy was improved in patients with an IIH ICD code assigned by an ophthalmologist. Use of coding algorithms considering treatment providers, number of codes, and treatment is a potential strategy to reduce misclassification bias in medical claims-based research on IIH. However, these are associated with a reduced sample size.
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Affiliation(s)
- Fareshta Khushzad
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | - Riya Kumar
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | - Irma Muminovic
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | - Heather E. Moss
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
- Department of Neurology & Neurological Sciences, Stanford University, Palo Alto, CA, USA
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Sundholm A, Burkill S, Waldenlind E, Bahmanyar S, Nilsson Remahl AIM. A national Swedish case-control study investigating incidence and factors associated with idiopathic intracranial hypertension. Cephalalgia 2021; 41:1427-1436. [PMID: 34407644 PMCID: PMC8619724 DOI: 10.1177/03331024211024166] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To study the incidence of idiopathic intracranial hypertension in Sweden and to explore whether previously proposed risk factors are associated with idiopathic intracranial hypertension by investigating the odds of exposure one year prior to diagnosis in patients compared to controls. METHODS Using Swedish health care registers and validated diagnostic algorithms, idiopathic intracranial hypertension patients diagnosed between 2000-2016 were compared with randomly selected matched controls, five from the general population and five with obesity. RESULTS We identified 902 idiopathic intracranial hypertension patients and 4510 matched individuals in each control group. Mean incidence among inhabitants ≥18 years of age was 0.71 per 100,000; rising from 0.53 in 2000-2005 to 0.95 in 2012-2016. There were increased odds for idiopathic intracranial hypertension patients compared to general population for exposure to: kidney failure (odds ratio =13.2 (4.1-42.0)), arterial hypertension (odds ratio =17.5 (10.5-29.3)), systemic lupus erythematosus (odds ratio =13.8 (4.3-44.7)), tetracyclines, sulphonamides, lithium, and corticosteroids. In obese controls, odds ratios were also significantly increased for these exposures. Hormonal contraceptive use and exposure to pregnancy did not appear to be associated factors for idiopathic intracranial hypertension development. CONCLUSIONS The incidence of idiopathic intracranial hypertension in Sweden is lower relative to reports from other countries but is on the rise. This case-control study confirms several previously reported risk factors associated with idiopathic intracranial hypertension.
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Affiliation(s)
- Anna Sundholm
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Department of Neurology, 59562Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Sarah Burkill
- Saw Swee Hock School of Public Health, 37580National University of Singapore, National University of Singapore, Singapore
| | - Elisabet Waldenlind
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Department of Neurology, 59562Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Shahram Bahmanyar
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden and Centre for Phychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - A Ingela M Nilsson Remahl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Department of Neurology, 59562Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden
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Hamedani AG, Thibault DP, Revere KE, Lee JYK, Grady MS, Willis AW, Liu GT. Trends in the Surgical Treatment of Pseudotumor Cerebri Syndrome in the United States. JAMA Netw Open 2020; 3:e2029669. [PMID: 33320265 PMCID: PMC7739135 DOI: 10.1001/jamanetworkopen.2020.29669] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Optic nerve sheath fenestration (ONSF) and cerebrospinal fluid shunting are sometimes used to treat pseudotumor cerebri syndrome (PTCS), but their use patterns are unknown. OBJECTIVES To investigate the frequency of surgical PTCS treatment in the United States and to compare patients undergoing ONSF with those treated with shunting. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective longitudinal cross-sectional study. Inpatient data were obtained from the National Inpatient Sample (NIS), and outpatient surgical center data were obtained from the National Survey of Ambulatory Surgery (NSAS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Included in the analysis were 10 720 patients aged 18 to 65 years with a diagnosis code for PTCS, excluding venous thrombosis and other causes of intracranial hypertension. Time trends were explored and logistic regression was used to measure differences according to age, race/ethnicity, sex, Elixhauser comorbidity index, and other patient and hospital characteristics. Data analysis was performed from March 31 to October 7, 2020. EXPOSURE Treatment for PTCS, excluding venous thrombosis and other causes of intracranial hypertension. MAIN OUTCOMES AND MEASURES Annual number of PTCS-related admissions, ONSFs, and shunt procedures from 2002-2016. Patient and hospital-level characteristics of patients with PTCS undergoing ONSF or shunting were compared. RESULTS Between 2010 and 2016, 297 ONSFs were performed and 10 423 shunts were placed as treatment for PTCS. The procedures were most commonly performed in individuals aged 26 to 35 years (39.4%), and 9920 (92.4%) of the surgically treated patients were women. ONSF was more common among younger patients (eg, adjusted odds ratio [AOR] for patients ≥46 years vs those 18-25 years, 0.22; 95% CI, 0.08-0.61) and in Black, Hispanic, or other minority populations (AOR, 2.37; 95% CI, 1.31-4.30) and less common in the South (AOR, 0.34; 95% CI, 0.13-0.88) and West (AOR, 0.15; 95% CI, 0.04-0.58) compared with the Northeast. Total PTCS-related hospitalizations increased from 6081 (95% CI, 5137-7025) in 2002 to 18 020 (95% CI, 16 607-19 433) in 2016. Shunting increased from 2002 to 2011 and subsequently plateaued and declined. ONSF was used much less frequently, and use has not increased. No instances of outpatient ONSF or shunting for PTCS were recorded in the NSAS or NHAMCS databases. CONCLUSIONS AND RELEVANCE This study's findings suggest that shunting is more common than ONSF and that the use gap has widened as shunting has increased. However, because overall PTCS-related hospitalizations have increased even more rapidly, the percentage of inpatients with PTCS undergoing surgery has decreased. These trends may reflect changes in medical treatment practices and outcomes or growing limitations in access to ophthalmic surgical expertise.
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Affiliation(s)
- Ali G. Hamedani
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Dylan P. Thibault
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia
| | - Karen E. Revere
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John Y. K. Lee
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - M. Sean Grady
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Allison W. Willis
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Grant T. Liu
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Validity of International Classification of Diseases Codes for Identifying Neuro-Ophthalmic Disease in Large Data Sets: A Systematic Review. J Neuroophthalmol 2020; 40:514-519. [PMID: 33197163 DOI: 10.1097/wno.0000000000000971] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Administrative health claims data have been used for research in neuro-ophthalmology, but the validity of International Classification of Diseases (ICD) codes for identifying neuro-ophthalmic conditions is unclear. EVIDENCE ACQUISITION We performed a systematic literature review to assess the validity of administrative claims data for identifying patients with neuro-ophthalmic disorders. Two reviewers independently reviewed all eligible full-length articles and used a standardized abstraction form to identify ICD code-based definitions for 9 neuro-ophthalmic conditions and their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). A quality assessment of eligible studies was also performed. RESULTS Eleven articles that met criteria for inclusion are as follows: 3 studies of idiopathic intracranial hypertension (PPV 54%-91% and NPV 74%-85%), 2 studies of giant cell arteritis (sensitivity 30%-96% and PPV 94%), 3 studies of optic neuritis (sensitivity 76%-99%, specificity 83%-100%, PPV 25%-100%, and NPV 98%-100%), 1 study of neuromyelitis optica (sensitivity 60%, specificity 100%, PPV 43%-100%, and NPV 98%-100%), 1 study of ocular motor cranial neuropathies (PPV 98%-99%), and 2 studies of myasthenia gravis (sensitivity 53%-97%, specificity 99%-100%, PPV 5%-90%, and NPV 100%). No studies met eligibility criteria for nonarteritic ischemic optic neuropathy, thyroid eye disease, and blepharospasm. Approximately 45.5% provided only one measure of diagnostic accuracy. Complete information about the validation cohorts, inclusion/exclusion criteria, data collection methods, and expertise of those reviewing charts for diagnostic accuracy was missing in 90.9%, 72.7%, 81.8%, and 36.4% of studies, respectively. CONCLUSIONS Few studies have reported the validity of ICD codes for neuro-ophthalmic conditions. The range of diagnostic accuracy for some disorders and study quality varied widely. This should be taken into consideration when interpreting studies of neuro-ophthalmic conditions using administrative claims data.
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Sundholm A, Burkill S, Waldenlind E, Bahmanyar S, Nilsson Remahl AIM. Infectious and inflammatory disorders might increase the risk of developing idiopathic intracranial hypertension - a national case-control study. Cephalalgia 2020; 40:1084-1094. [PMID: 32447976 PMCID: PMC7457460 DOI: 10.1177/0333102420928079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective To investigate whether conditions causing inflammatory activation are associated with increased risk of idiopathic intracranial hypertension. Methods All newly diagnosed idiopathic intracranial hypertension patients (cases) in Sweden between 2000–2016 were identified using pre-determined algorithms (n = 902) and matched with five controls from the general population and five individuals with an obesity diagnosis (n = 4510) for age, sex, region, and vital status. National health registers provided information on infections, inflammatory disorders and dispensed medications. Conditional logistic regression was used to estimate odds ratios and 95% confidence intervals. Results Compared to general population controls, the cases had fourfold increased odds of having an infection (odds ratio = 4.3, 95% confidence interval 3.3–5.6), and threefold increased odds of an inflammatory disorder the year prior to idiopathic intracranial hypertension diagnosis (odds ratio = 3.2, 95% confidence interval 2.4–4.3). Organ specific analyses showed that odds were increased for the study diseases in the respiratory organ, kidney organ and gastrointestinal tract, but not for female genital infections. Similar results were found when comparing idiopathic intracranial hypertension with obese controls though the odds ratios were of lower magnitude. Sub-analyses on exposure to anti-infectious and anti-inflammatory drugs confirmed the increased odds ratios for idiopathic intracranial hypertension patients. Conclusions These findings suggest that major inflammatory activation may be a risk factor in idiopathic intracranial hypertension development.
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Affiliation(s)
- Anna Sundholm
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Sweden
| | - Sarah Burkill
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Elisabet Waldenlind
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Sweden
| | - Shahram Bahmanyar
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet and Centre for Psychiatry Research, Karolinska Institutet, Sweden
| | - A Ingela M Nilsson Remahl
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neurology, Karolinska University Hospital, Sweden
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