The Covid-19 pandemic strained most of the world’s health care organizations to, and sometimes beyond, their limits. To anticipate, coordinate, mobilize, and prioritize hospital resources, Sweden’s health care regions established regional medical command and control teams according to the medical major incident structure. This command structure was initially developed based on an all-hazards approach focused primarily on sudden mass casualty incidents with a relatively short time frame. Covid-19 management was active for several months with a most intense operations period during the spring of 2020. This study aimed at identifying competence needs by employing a co-creative approach with members of the staff involved in the pandemic management.

Data was collected and analyzed using a modified Delphi consensus method. The respondents were subject matter experts serving in the regional medical command and control teams during the COVID-19 pandemic. One workshop was held to gather opinions, which were included as statements in a consensus survey and answered by the participants after the first workshop. A second workshop was held to discuss statements that did not reach initial consensus in the survey and establish final consensus.

The consensus agreed statements were sorted into five themes, which constituted the collective agreement of medical command and control core abilities. The five core competence themes were: Situation report, Team organization, Co-operation, Competence management, and Analysis. The consensus agreed statements highlighted competencies needed for creating situation reports, organizing medical command and control teams, effective cross-organization co-operation, decision-making, and medical intelligence analysis.

The core competencies of medical command and control identified in the present study can be used to further affirm current learning objectives and to formulate future learning objectives for education and exercises. The evaluation approach could potentially be used as a post-incident review to fine-tune an organization’s training plan.

A resilient health care system is expected to withstand disruptive events and consistently deliver high quality care by continually adapting, learning, and improving. To achieve these expectations, medical command and control teams are responsible for making relevant strategic decisions, reallocating resources, and initiating cooperation. Early during Covid-19, medical command and control teams were faced with an unforeseen increase in number of patients, as well as unknown disease mechanisms and treatment regimes. Timely and adequate decision-making to become a resilient healthcare system and maintain high quality care was necessary. The aim of the present study was to describe the challenges and strategies in a medical command and control team during the early phase of the Covid-19 pandemic.

A semi-structured retrospective in-depth interview study with phenomenological approach and inductive design was used. Thirteen experienced decision makers serving in a regional medical command and control team were interviewed using the Critical Decision Method. The interviews were analyzed using manifest conventional content analyses.

The respondents described twelve separate episodes during the Covid-19 management. The analysis resulted in five themes: organization, adaptation, common operational picture, assumptions, and analysis. Organization described how organizational challenges affected the decision-making process. Adaptation described the strategies to overcome the obstructive organizational factors. Common operational picture described how challenges in lack of available information affected decision-making and strategies used in creating situational awareness. Assumptions offered descriptions of strategies used to make decisions. Analysis emphasized descriptions and strategies affecting the decision-making process.

This study enables a better understanding of how medical command and control teams can be organized and structured, while also highlighting challenges in maintaining high-quality care during unexpected events. The findings obtained in the present study provide further knowledge about disaster resilience and can be utilized in educational and training settings for medical command and control.

Neurodevelopmental disorders (NDs) are associated with experiences of victimization, but mechanisms remain unclear. We explored sex differences and the role of familial factors and externalizing problems in the association between several NDs and violent victimization in adolescence and young adulthood.

Individuals born in Sweden 1985–1997, residing in Sweden at their 15th birthday, were followed until date of violent victimization causing a hospital visit or death, death due to other causes, emigration, or December 31, 2013, whichever came first. The exposures were diagnoses of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), intellectual disability (ID) and other NDs. We used three different Cox regression models: a crude model, a model adjusted for familial confounding using sibling-comparisons, and a model additionally adjusted for externalizing problems.

Among 1 344 944 individuals followed, on average, for 5 years, 74 487 were diagnosed with NDs and 37 765 had a hospital visit or died due to violence. ADHD was associated with an increased risk of violent victimization in males [hazard ratio (HR) 2.56; 95% confidence interval (CI) 2.43–2.70) and females (HR 5.39; 95% CI 4.97–5.85). ASD and ID were associated with an increased risk of violent victimization in females only. After adjusting for familial factors and externalizing problems, only ADHD was associated with violent victimization among males (HR 1.27; 95% CI 1.06–1.51) and females (HR 1.69; 95% CI 1.21–2.36).

Females with NDs and males with ADHD are at greater risk of being victim of severe violence during adolescence and young adulthood. Relevant mechanisms include shared familial liability and externalizing problems. ADHD may be independently associated with violent victimization.

Although attention-deficit hyperactivity disorder (ADHD) is classified as a neurodevelopmental disorder in the latest diagnostic manuals, it shows phenotypic and genetic associations of similar magnitudes across neurodevelopmental, externalising and internalising disorders.

To investigate if ADHD is aetiologically more closely related to neurodevelopmental than externalising or internalising disorder clusters, after accounting for a general psychopathology factor.

Full and maternal half-sibling pairs (N = 774 416), born between 1980 and 1995, were identified from the Swedish Medical Birth and Multi-Generation Registers, and ICD diagnoses were obtained from the Swedish National Patient Register. A higher-order confirmatory factor analytic model was fitted to examine associations between ADHD and a general psychopathology factor, as well as a neurodevelopmental, externalising and internalising subfactor. Quantitative genetic modelling was performed to estimate the extent to which genetic, shared and non-shared environmental effects influenced the associations with ADHD.

ADHD was significantly and strongly associated with all three factors (r = 0.67–0.75). However, after controlling for a general psychopathology factor, only the association between ADHD and the neurodevelopmental-specific factor remained moderately strong (r = 0.43, 95% CI = 0.42–0.45) and was almost entirely influenced by genetic effects. In contrast, the association between ADHD and the externalising-specific factor was smaller (r = 0.25, 95% CI = 0.24–0.27), and largely influenced by non-shared environmental effects. There remained no internalising-specific factor after accounting for a general factor.

Findings suggest that ADHD comorbidity is largely explained by genetically influenced general psychopathology, but the strong link between ADHD and other neurodevelopmental disorders is also substantially driven by unique genetic influences.

Resilience is often described as a desirable holistic approach to disaster preparedness. However, the term has a wide variety of meanings and is hard to operationalize and implement in disaster management. A goal for the EU H2020 project DARWIN was to operationalize resilience for incident management teams.

To test the resilience operationalization by analyzing command team behaviors in a major incident exercise and trace observations to resilience theory.

A regional medical command and control team (n=11) was observed when performing in a functional simulation exercise of a mass casualty incident (300 injured, 1800 uninjured) following the collision of a cruise ship and an oil tanker close to the Swedish coast. Audio and video recordings of behaviors and communications were reviewed for resilient behaviors based on the DARWIN guidelines using the “resilience markers for small teams” framework (Furniss et al., 2011).

A total of 121 observed instances of resilient behaviors were found in the material. In 95 cases (79%) the observed behaviors followed a priori hypothesized connections between resilient strategies and general markers. Certain marker-strategy combinations occurred frequently, such as 18 observations where the strategy “understand crucial assumptions” occurred together with the marker “adapting to expected and unexpected events.”

Resilience has the potential to contribute to a more holistic disaster management approach. The findings that the observations, in general, correspond to the expected relationship between theoretical concretization and contextualization supports the DARWIN effort to operationalize resilience theory. This is a prerequisite for developing observational protocols for training and further studies of resilient behaviors in disaster management teams.

Traits of attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are strongly associated in children and adolescents, largely due to genetic factors. Less is known about the phenotypic and aetiological overlap between ADHD and ASD traits in adults.

We studied 6866 individuals aged 20–28 years from the Swedish Study of Young Adult Twins. Inattention (IA) and hyperactivity/impulsivity (HI) were assessed using the WHO Adult ADHD Self-Report Scale-V1.1. Repetitive and restricted behaviours (RRB) and social interaction and communication (SIC) were assessed using the Autism-Tics, ADHD, and other Comorbidities inventory. We used structural equation modelling to decompose covariance between these ADHD and ASD trait dimensions into genetic and shared/non-shared environmental components.

At the phenotypic level, IA was similarly correlated with RRB (r = 0.33; 95% Confidence Interval (CI) 0.31–0.36) and with SIC (r = 0.32; 95% CI 0.29–0.34), whereas HI was more strongly associated with RRB (r = 0.38; 95% CI 0.35–0.40) than with SIC (r = 0.24; 95% CI 0.21–0.26). Genetic and non-shared environmental effects accounted for similar proportions of the phenotypic correlations, whereas shared environmental effects were of minimal importance. The highest genetic correlation was between HI and RRB (r = 0.56; 95% 0.46–0.65), and the lowest was between HI and SIC (r = 0.33; 95% CI 0.23–0.43).

We found evidence for dimension-specific phenotypic and aetiological overlap between ADHD and ASD traits in adults. Future studies investigating mechanisms underlying comorbidity between ADHD and ASD may benefit from exploring several symptom-dimensions, rather than considering only broad diagnostic categories.