Comparisons of recycled manure solids and wood shavings/sawdust as bedding material-Implications for animal welfare, herd health, milk quality, and bedding costs in Swedish dairy herds

Increasing shortages and costs of common bedding materials have led dairy farmers in Sweden to consider using recycled manure solids (RMS), which are readily available and low cost, as an alternative bedding material. The main risks are effects on udder health and milk quality, but RMS could also affect animal welfare and claw health. The advantages and disadvantages of using RMS bedding have not been fully investigated, and findings in other countries cannot be directly applied to Swedish conditions and climate. This observational cross-sectional study investigated the use of RMS as bedding, regarding associations with certain aspects of animal welfare, herd health, milk quality, and bedding costs in Swedish dairy herds. Thirty-four dairy farms using RMS or wood shavings/sawdust (each n = 17) were compared. Each farm was visited 2 times during the housing period from 2020 to 2021, once from October to December and once from March to May. Dairy barns were observed, animal welfare was assessed, and freestall dimensions were measured. Farm owners were interviewed about housing system characteristics, herd performance, and herd management. Data on milk production and herd health were obtained from the Swedish official milk recording scheme for the indoor period from October to March. The prevalence of claw disorders and abnormal claw conformation were collected from the national claw health database for the period from October to May. On each farm visit, composite samples of unused bedding outside the barn and used bedding material from the freestalls, respectively, were taken for total bacterial count and DM analysis. Samples of bulk tank milk for determination of total bacterial count were taken in connection to the visits. In addition, samples of unused and used bedding material and manure from alleys for analysis of 3 Treponema species associated with digital dermatitis (DD) were gathered and analyzed. Total bacterial count was significantly higher in unused (8.50 log10 cfu/g) and used RMS bedding (9.75 log10 cfu/g) than in wood shavings/sawdust (used 4.74; unused 8.63 log10 cfu/g), but there were no significant differences in bulk milk total bacterial count (median 4.07 vs. 3.89 log10 cfu/mL) or SCC (median 243,800 vs. 229,200 cells/mL). The aspects of animal welfare assessed did not differ significantly between the 2 bedding systems, whereas the prevalence of total claw disorders (25.9% vs. 38.0% of trimmed cows), dermatitis (6.9% vs. 16.2% of trimmed cows) and sole ulcers (2.0% vs. 4.0% of trimmed cows) were significantly lower in the RMS herds. Treponema spp. were not detected in unused RMS material, but all RMS herds had presence of DD recorded at foot trimming. An economic assessment based on the interview results and price level from winter 2021 revealed that the costs of RMS bedding varied with amount of RMS produced. Thus, RMS is a potential alternative bedding material for dairy cows in Sweden and can be a profitable option for large dairy herds. However, the high level of total bacteria in the material requires attention to bedding and milking routines as well as regular monitoring of herd health.

Ventricular-arterial coupling (VAC) in a population-based cohort of middle-aged individuals: The STANISLAS cohort

BACKGROUND AND AIMS

Data exploring normal values of different ventricular-arterial coupling (VAC) parameters and their association with anthropometric and cardiovascular (CV) factors are scarce. We aim to report values of two different methods of VAC assessment according to age and sex and explore their association with CV factors within a large population-based cohort of middle-aged individuals.

METHODS

For 1333 (mean age 48 ± 14) individuals participating in the 4th visit of the STANISLAS cohort, VAC was assessed by two methods [1]: arterial elastance (Ea)/end-systolic elastance (Ees) and [2] Pulse wave velocity (PWV)/Global longitudinal strain (GLS).

RESULTS

The mean values of Ea/Ees and PWV/GLS were 1.06 ± 0.20 and 0.42 ± 0.12, respectively. The two methods of VAC assessment were poorly correlated (Pearson's correlation coefficient r = 0.14 (0.08; 0.19)). Increased PWV/GLS was associated with older age and a higher degree of cardiovascular risk factors (i.e., BMI, blood pressure, LDL, diabetes, hypertension) in the whole population as well as in the parent generation. In contrast, higher Ea/Ees were associated with decreasing age, and lower prevalence of risk factors in the whole cohort but neutrally associated with risk factors in the parent generation.

CONCLUSIONS

Higher PWV/GLS is significantly associated with CV factors regardless of age. In contrast, worse Ea/Ees is associated with a better CV risk profile when considering individuals aged 30 to 70 but neutrally associated with CV factors when considering only older patients. These results may suggest that PWV/GLS should preferably be used to explore VAC. In addition, age-individualized threshold of Ea/Ees should be used.

Population fluctuations and synanthropy explain transmission risk in rodent-borne zoonoses

Population fluctuations are widespread across the animal kingdom, especially in the order Rodentia, which includes many globally important reservoir species for zoonotic pathogens. The implications of these fluctuations for zoonotic spillover remain poorly understood. Here, we report a global empirical analysis of data describing the linkages between habitat use, population fluctuations and zoonotic reservoir status in rodents. Our quantitative synthesis is based on data collated from papers and databases. We show that the magnitude of population fluctuations combined with species' synanthropy and degree of human exploitation together distinguish most rodent reservoirs at a global scale, a result that was consistent across all pathogen types and pathogen transmission modes. Our spatial analyses identified hotspots of high transmission risk, including regions where reservoir species dominate the rodent community. Beyond rodents, these generalities inform our understanding of how natural and anthropogenic factors interact to increase the risk of zoonotic spillover in a rapidly changing world.

Health literacy of organisations – a cornerstone for fair health outcome

 

Unhealthy food habits are included in the factors behind several severe health conditions. Their unequal distribution in the population has a complex background. Putting the problem “How can we make our resources more reachable?” instead of “How can we reach these groups?” changes focus from individual to organisational health literacy which opens windows of opportunity. A public health unit with commission to contribute to close health gaps identified a need to systematically develop its own health literacy. Critical examining was conducted by the quan/qual tool Health equlibrium methodology. Reflections on accessability and acceptability of resources offered by the unit were documented and used for methodolocigal development. Aims were to develop professional judgment on how to contribute to fair health outcome and to improve support for healthy habits. Data used were collected 2019-2021.What hinders people from healthier food habits? How can we adjust our practice? Documentation included organised breakfast-talks, food-talk with cultural interpreters, lectures with sports-club health ambassadors, health groups with people of different maternal language, meetings with parents at open pre-school, staff in health promotion commissions and elderly. Problems identified were high costs on healthy food and on travels to vending points, traditional large sugar-intake, marketing of unhealthy food to children, failure to understand information from Swedish Food Agency (except the Keyhole food labelling which was much appreciated). A model for shop-walks with cultural interpreters, more accessible versions of leaflet-materials and dialogue-meetings about food in different settings were developed. Reflections on the unit's communication lead to change of settings for meetings and refined ways to talk about parenthood, women's role and aspects of ethnicity. Systematic self-reflection strenghtens organisational health literacy and may contribute to fair health outcomes

Key messages

Clinical routines for diabetes screening and treatment in cardiac rehabilitation improves detection and treatment of diabetes mellitus in patients with myocardial infarction

Background

Patients with myocardial infarction (MI) have a high prevalence of diabetes mellitus (DM). Prognosis in patients with MI and DM is substantially worse than for those without DM. An unacceptably high proportion of patients with DM remain both undiagnosed and undertreated despite follow-up at cardiac rehabilitation (CR) centres.

Purpose

Using nationwide survey and registry data to investigate associations of clinical routines for DM screening and treatment at CR centres in Sweden with detection and treatment of DM at one-year post-MI.

Methods

Data on CR clinical routines were derived from the Perfect-CR survey, evaluating structures and follow-up processes at CR centres in Sweden (n=78). The response rate was 100% and missing data was minimal. Clinical routines for DM screening and treatment during CR (exposures) included the following: 1) laboratory assessments of fasting glucose and/or HbA1c as a part of initial patient assessment by a nurse, 2) routine use of oral glucose tolerance test (OGTT), 3) joint case rounds with diabetologists, and 4) whether diabetes medication is adjusted by cardiologists. Patient baseline and outcome data was derived from the national quality registry SWEDEHEART (n=7549). Primary outcome was DM incidence at one-year post-MI. Secondary outcome was the proportion of patients receiving diabetes medication other than insulin (secondary outcome). The association between exposures (for each clinical routine and cumulatively [0–4 work routines]) and outcomes was estimated using unadjusted and adjusted logistic regression, adjusting for relevant covariates.

Results

Number (%) of CR centres applying each of the clinical routines is shown in Table 1. The most common routine applied was fasting glucose and/or HbA1c being routinely evaluated at initial patient assessment (n=48 (62%)), while the least common was CR centres having joint case rounds with diabetologists (n=7 (9%)). Twenty (26%) CR centres did not apply any of the clinical routines while 7 (9%) centres applied 3 or 4 routines. Unadjusted and adjusted odds ratios (OR) with 95% confidence intervals (CI) for incident DM are shown in Figure 1. Compared to not applying any routines, 1) applying one or more routines was positively associated higher DM incidence at one-year post-MI (p for trend in unadjusted and adjusted models <0.001. Figure 1), and 2) at centres where all four working routines were applied, the odds for patients being treated with diabetes medication was significantly higher (crude OR 2.37 [1.80–3.13], adjusted OR 1.78 [1.19–2.66]).

Conclusion

Applying structured clinical routines for DM screening and treatment within CR can improve detection and treatment of DM in patients with MI

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The current study was supported by The Swedish Research Council for Health, Working Life and Welfare (FORTE, grant number 2019-00365); The Swedish Heart and Lung Association (grant number 20190431); The Swedish Heart and Lung Patient Organization; The Swedish Cardiology Society; The faculty of Medicine, Lund University, Sweden; Astra Zeneca; and Amgen.

Cerebral saturation is associated with physical activity and post-discharge mortality in heart failure patients

Background

The cross-sectional relationship between heart failure (HF) and cerebral oxygenation has been studied in the past but the prognostic significance of this relationship has been limited. Here, we aimed to assess the role of cerebral tissue oxygen saturation (SctO2) as a risk factor for HF mortality and rehospitalization as well as evaluate the association between SctO2 with physical activity in a Swedish prospective HF cohort.

Methods

Ninety-five patients hospitalized for HF (mean age 70 years; 21% women) were examined with near-infrared spectroscopy (NIRS) and screened for physical activity derived from questionnaires in the Swedish national public health survey. The median follow-up time to death and re-hospitalization was 1377 (interquartile range, 245–2392) and 293 (14–2363) days, respectively. Associations between SctO2 at rest, post-discharge mortality and re-hospitalization were analyzed using multivariable Cox regression analysis adjusted for age, sex, body-mass index, smoking, prevalence of atrial fibrillation, prevalence of diabetes and systolic blood pressure. The associations between SctO2 and self-reported physical activity were explored by using logistic regression analysis adjusted for the aforementioned risk factors.

Results

A total of 25 patients (26%) reported to be engaged in physical activity less than one hour throughout the week. In the fully adjusted Cox regression model, low SctO2 at rest was associated with post-discharge mortality (HR, 0.77; CI, 0.66–0.91; p=0.002). However, low SctO2 was not associated with post-discharge rehospitalization risk (HR, 0.94; CI, 0.88–1.01; p=0.092). In the fully adjusted logistic regression models, low SctO2 at rest was associated with decreased physical activity (<1h per week), (OR 1.22; CI, 1.05–1.42; p=0.01).

Conclusion

We have demonstrated that low cerebral tissue oxygen saturation at rest is associated with post-discharge mortality in patients hospitalized for HF, independently of traditional risk factors. In addition, low cerebral tissue oxygen saturation at rest is associated with low physical activity. These findings highlight the role of cerebral saturation as a risk factor for cardiovascular prognosis, as well as underline the potential importance of taking cerebral perfusion into account when treating for heart failure.

Funding Acknowledgement

Type of funding sources: None.

Selenoprotein-P deficiency is associated with higher risk of incident heart failure

Background

Selenium deficiency has been associated with all-cause and cardiovascular mortality, incident cardiovascular disease (coronary artery disease, myocardial infarction and stroke), and with poor prognosis in patients with acute heart failure (HF). Furthermore, high selenium levels were recently shown to be associated with reduced mortality and reduced incidence of HF in non-smokers.

Purpose

To examine if selenoprotein-P (SELENOP), a main carrier protein of selenium, is associated with incident HF.

Methods

SELENOP concentrations were measured in 5060 randomly selected subjects from the population-based prospective cohort study “the Malmö Preventive Project” (n=18240) using a validated ELISA approach. After exclusion of subjects with prevalent HF (n=230), complete data on all co-variates was available in 4803 subjects (1400 women (29.1%), mean age 69.6±6.2 years, 885 (19.7%) current smokers). SELENOP was continously related to risk of incident HF using Cox regression models adjusted for age, sex, body mass index, systolic blood pressure, anti-hypertensive treatment, smoking status, diabetes status, low-density lipoprotein cholesterol levels, and prevalent coronary events. Further, subjects within the lowest SELENOP quintile were compared to subjects in the remaining four quintiles in an adjusted model.

Results

Each 1 SD increment in SELENOP levels was associated with lower risk of incident HF (n=436) during a median follow-up period of 14.7 years (interquartile range 10.9–15.7 years, hazard ratio (HR) 0.92, 95% confidence interval (95% CI) 0.84–0.99; p=0.049 in a model adjusted for cardiovascular risk factors. Multivariate quintile analyses revealed that the subjects in the lowest SELENOP quintile were at the highest risk of incident HF in an adjusted model (HR 1.46; 95% CI: 1.17–1.83 for incident HF; p for trend 0.039) illustrated in a Kaplan-Meier survival analysis (Figure 1). No interaction effect was seen for sex or smoking.

Conclusion

Low SELENOP levels are associated with a higher risk of incident HF supporting recent studies, which further emphasizes the need for randomly controlled trials to examine if supplementation with selenium improves prognosis.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swedish Medical Research CouncilSwedish Society of Medicine

Biomarkers associated with prevalent hypertension and higher blood pressure in a population-based cohort: a proteomic approach

Background

Globally, hypertension represents an enormous health issue as it is a major, yet modifiable risk factor for developing cardiovascular disease. Recently, chitinase-3-like protein 1 (CHI3L1) was shown to be positively associated with the incidence of hypertension among prehypertensive subjects, and variants of CHI3L1 gene were associated with both CHI3L1-levels and hypertension.

Purpose

To explore associations between prevalent hypertension and blood pressure, and 92 proteins with involvement in inflammation and cardiovascular disease.

Methods

Plasma samples from 1713 individuals from a Swedish population-based cohort (mean age 67.3±6.0 years; 28.9% women) were analysed with a proximity extension assay panel, consisting of 92 proteins. Prior to all analyses, subjects with prevalent cardiovascular disease, defined as having a history of prevalent coronary or stroke event, were excluded (n=189). Univariate logistic regression models were carried out exploring associations between each of the 92 proteins and prevalent hypertension, defined as systolic blood pressure ≥140 mmHg and/or a diastolic blood pressure ≥90 mmHg, or use of antihypertensive treatment (n=1168, 76.4%). Bonferroni-corrected significant associations between proteins and hypertension were further analysed using stepwise selection of covariates, namely age, body mass index, diabetes status, and cystatin C, in logistic regression models. Proteins with significant adjusted associations with prevalent hypertension were further analysed for associations with systolic and diastolic blood pressure individually in stepwise linear regression models. Complete data on all variables were available in 1527 subjects.

Results

Sixteen proteins were significantly associated with prevalent hypertension in univariate analyses. After adjustment, three proteins remained significantly associated with prevalent hypertension (i.e., CHI3L1, low-density lipoprotein receptor (LDL receptor) and tissue plasminogen activator (tPA); Table 1). In analyses of associations with systolic blood pressure, CHI3L1 and LDL receptor showed significant associations. In analyses of associations with diastolic blood pressure, CHI3L1, LDL receptor and tPA showed significant associations (Table 1).

Conclusions

Higher CHI3L1, tPA and LDL receptor levels were positively associated with prevalent hypertension after multivariable adjustment, among 1527 elderly subjects without established cardiovascular disease. Furthermore, higher CHI3L and LDL receptor levels were positively associated with mean systolic, as well as mean diastolic blood pressure in multivariable analyses.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Swedish Medical Research Council and The Swedish Heart and Lung Foundation

Left ventricular kinetic energy across heart failure subgroups and subclinical diastolic dysfunction

Background

Diastolic dysfunction is a common finding in heart failure with preserved ejection fraction (HFpEF) and is considered a key mechanism for limiting exercise performance. Meanwhile, subclinical diastolic dysfunction (SDD) without heart failure is a growing concern and may be common in the general population [1,5[. The kinetic energy (KE) of intracardiac blood flow reflects the work spent on accelerating blood [3] and may provide a novel window into diastolic filling dynamics [2,4]. Our aim was therefore to quantify left ventricular KE in HFpEF patients and compare with healthy controls, subjects with SDD, and heart failure patients with moderately reduced (HFmrEF) or reduced ejection fraction (HFrEF).

Methods

We studied 12 healthy controls, 22 healthy subjects with 1–2 echocardiographic criteria of diastolic dysfunction (SDD), 16 HFpEF, 9 HFmrEF, and 16 HFrEF patients. All subjects underwent CMR imaging at 1.5T with acquisition of anatomical cines and 4D flow from a box covering the heart. The LV was delineated over the cardiac cycle and KE inside the segmentation calculated as 0.5 × m × v2, where v is the instantaneous velocity vector magnitude and m is blood mass. Group comparisons of peak and average values were performed using Kruskal-Wallis test with Dunn's uncorrected post hoc test. Significance was assigned at p<0.05. Median values are given.

Results

Groups were similar with regard to sex, blood pressure, and body surface area. HFpEF (median 72 years) and HFrEF patients (67 years) were significantly older than subjects with SDD (62 years, p=0.001). Examples of KE are shown in Fig. 1. Systolic peak and average KE did not differ between groups (p=0.81 and p=0.54 respectively, Fig. 2). Diastolic peak KE was higher in all groups of heart failure compared to controls (p<0.03 for all) and diastolic average KE was higher in HFmrEF and HFrEF compared to controls (p<0.02). The standard deviation for SDD was wider than in controls (1.6 mJ vs 0.8 mJ for systolic peaks, 2.7 mJ vs 1.1 mJ for diastolic peaks) and more closely resembled the HFpEF group (2.1 mJ in systole, 2.3 mJ in diastole).

Conclusions

Systolic kinetic energy expenditures are on average similar between controls, subjects with subclinical diastolic dysfunction, and heart failure patients, indicating that cardiac pumping involves approximately the same amount of systolic acceleration for a given afterload. Conversely, diastolic KE was found more dispersed both in heart failure and in asymptomatic individuals with subclinical diastolic dysfunction. Higher peak values of KE were seen in diastole for all types of heart failure including HFpEF, indicating more work is spent filling the ventricle. Measurements of KE in diastole could potentially be a new tool for assessment of heart failure, including early stages of disease development in some individuals with subclinical diastolic dysfunction.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swedish Heart Lung FoundationRegion of Scania, Sweden

Puumala Orthohantavirus Infection Does Not Affect the Trapping Success of Its Reservoir Host

Pathogens might affect behavior of infected reservoir hosts and hence their trappability, which could bias population estimates of pathogen prevalence. In this study, we used snap-trapping data on Puumala orthohantavirus (PUUV)-infected (n = 1619) and noninfected (n = 6940) bank voles (Myodes glareolus) from five vole cycles, normally representing increase, peak, and decline phase, to evaluate if infection status affected trapping success. If PUUV infection, as previously suggested, increases activity and/or mobility, we would expect a higher proportion of infected than noninfected specimens in the first trapping night. However, the proportion of PUUV-infected voles did not differ across the three trapping nights. We conclude that PUUV infection did not affect trapping success, confirming snap trapping as an appropriate trapping method for studies on PUUV prevalence and likely other orthohantaviruses.

Climate change accelerates winter transmission of a zoonotic pathogen

Many zoonotic diseases are weather sensitive, raising concern how their distribution and outbreaks will be affected by climate change. At northern high latitudes, the effect of global warming on especially winter conditions is strong. By using long term monitoring data (1980-1986 and 2003-2013) from Northern Europe on temperature, precipitation, an endemic zoonotic pathogen (Puumala orthohantavirus, PUUV) and its reservoir host (the bank vole, Myodes glareolus), we show that early winters have become increasingly wet, with a knock-on effect on pathogen transmission in its reservoir host population. Further, our study is the first to show a climate change effect on an endemic northern zoonosis, that is not induced by increased host abundance or distribution, demonstrating that climate change can also alter transmission intensity within host populations. Our results suggest that rainy early winters accelerate PUUV transmission in bank voles in winter, likely increasing the human zoonotic risk in the North.

Geographical Distribution and Genetic Diversity of Bank Vole Hepaciviruses in Europe

The development of new diagnostic methods resulted in the discovery of novel hepaciviruses in wild populations of the bank vole (Myodes glareolus, syn. Clethrionomys glareolus). The naturally infected voles demonstrate signs of hepatitis similar to those induced by hepatitis C virus (HCV) in humans. The aim of the present research was to investigate the geographical distribution of bank vole-associated hepaciviruses (BvHVs) and their genetic diversity in Europe. Real-time reverse transcription polymerase chain reaction (RT-qPCR) screening revealed BvHV RNA in 442 out of 1838 (24.0%) bank voles from nine European countries and in one of seven northern red-backed voles (Myodes rutilus, syn. Clethrionomys rutilus). BvHV RNA was not found in any other small mammal species (n = 23) tested here. Phylogenetic and isolation-by-distance analyses confirmed the occurrence of both BvHV species (Hepacivirus F and Hepacivirus J) and their sympatric occurrence at several trapping sites in two countries. The broad geographical distribution of BvHVs across Europe was associated with their presence in bank voles of different evolutionary lineages. The extensive geographical distribution and high levels of genetic diversity of BvHVs, as well as the high population fluctuations of bank voles and occasional commensalism in some parts of Europe warrant future studies on the zoonotic potential of BvHVs.

AB0318 RISK FOR CONCOMITANT AUTOIMMUNITY IN PATIENTS WITH ANTIPHOSPHOLIPID SYNDROME; A SWEDISH COHORT STUDY

Background:

In patients with the antiphospholipid syndrome (APS), concomitant systemic autoimmune rheumatic diseases (SARD) are common and often associated with more disease associated damage.

Less is known about the prevalence of non-rheumatic autoimmune diseases (NRAID) in patients with APS.

Objectives:

To evaluate the incidence and prevalence of concomitant autoimmune diseases (AID) in a cohort of APS patients. The risk of AID was also evaluated with respect to the antiphospholipid antibodies (aPL) profiles.

Methods:

This retrospective cohort study comprises consecutive patients identified with APS through review of electronic medical records at Karolinska University Hospital, Sweden between 2014 and 2020. Exclusion criteria were misdiagnosis and age <18. Descriptive statistics was used for baseline data and multivariable Cox proportional hazard regression analysis to investigate the risk factors to develop new onset AID. Ethical approval was obtained from the Swedish Ethical Review Authority (2020-02333).

Results:

Of 271 included patients, 66% were women and the median age at diagnosis of APS was 43 years (IQR 31–55). At inclusion, 130 (48%) patients presented with other AID; 101 (37%) of them had a concomitant SARD while 54 (19%) had a NRAID. Systemic lupus erythematosus (SLE) was the most frequent in 30% of patients, followed by autoimmune thyroid disease (ATD) in 10% of patients.

In addition, 35 (13%) APS-patients developed AID during the study period, corresponding to an incidence rate of 28.4 (95% CI; 19.3-40.3) per 1.000 person-years with mean time at risk of 4 (±2) years. Twenty-one (8%) patients developed a SARD and further 14 (5%) were diagnosed with a NRAID.

The cumulative incidence for AID was significantly higher in patients with high titers of IgG aPL. Patients that developed SARD had significantly higher median titers of a-β2GPI IgG isotype, p=0.05. In the NRAID group, median a-β2GPI and aCL IgG isotypes were significantly increased, p=0.02 and p=0.04, respectively. The hazard ratio to develop diagnosis of AID was significantly increased in patients with high titers of the IgG isotype aPL (HR 2.4 95% CI; 1.1-5.3). Obstetric APS manifestations were associated with a significantly increased hazard ratio of 2.8 (95% CI; 1.1-7.7) to develop SARD, and also trendwise for AID, as a compound variable.

During the study period, 52 patients had at least one new APS manifestation, as defined by the Sydney criteria (1). In comparison to patients without new manifestations, these patients had significantly higher median titers of aPL of the IgG isotype, and concomitant AID at first visit (p=0.01, p=0.02, respectively).

Conclusion:

APS patients are at high risk to develop other AID, and APS patients with concomitant AID had an increased risk to develop new clinical APS manifestations. These findings might be helpful when considering risk stratification and alternate treatment options in this patient group.

References:

[1]Miyakis S, Lockshin MD, Atsumi T et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006; 4: 295–306.

Acknowledgements:

I have no acknowledgements to declare.

Disclosure of Interests:

None declared

Proteomic and Metabolomic Characterization of Metabolically Healthy Obesity: A Descriptive Study from a Swedish Cohort

METHOD

Associations between different biomarkers (proteomics, lipidomics, and metabolomics) coupled to either MHO or metabolically unhealthy obese (MUO) individuals were analyzed through principal component analysis (PCA). Subjects were identified from a subsample of 416 obese individuals, selected from the Malmö Diet and Cancer study-Cardiovascular arm (MDCS-CV, n = 3,443). They were further divided into MHO (n = 143) and MUO (n = 273) defined by a history of hospitalization, or not, at baseline inclusion, and nonobese subjects (NOC, n = 3,027). Two distinctive principle components (PL2, PP5) were discovered with a significant difference and thus further investigated through their main loadings.

RESULTS

MHO individuals had a more metabolically favorable lipid and glucose profile than MUO subjects, that is, lower levels of traditional blood glucose and triglycerides, as well as a trend of lower metabolically unfavorable lipid biomarkers. PL2 (lipidomics, p=0.02) showed stronger associations of triacylglycerides with MUO, whereas phospholipids correlated with MHO. PP5 (proteomics, p=0.01) included interleukin-1 receptor antagonist (IL-1ra) and leptin with positive relations to MUO and galanin that correlated positively to MHO. The group differences in metabolite profiles were to a large extent explained by factors included in the metabolic syndrome.

CONCLUSION

Compared to MUO individuals, corresponding MHO individuals present with a more favorable lipid metabolic profile, accompanied by a downregulation of potentially harmful proteomic biomarkers. This unique and extensive biomarker profiling presents novel data on potentially differentiating traits between these two obese phenotypes.

Intraventricular hemodynamic forces do not differentiate between healthy controls and heart failure patients with preserved ejection fraction

Background

Hemodynamic force analysis has been proposed as a noninvasive marker of cardiac function. In a recent study, longitudinal (apical-to-basal) hemodynamic forces were derived from anatomical MRI images and found decreased in heart failure with preserved ejection fraction (HFpEF) patients compared to controls, indicating a potential use for prognostication and testing of therapeutic response. This issue has not been investigated using the reference method of measurement.

Purpose

To investigate whether intraventricular hemodynamic forces computed using gold-standard cardiac magnetic resonance flow maps can reproducibly differentiate between healthy controls and HFpEF patients.

Methods

4D flow data were acquired in 59 subjects through cardiac magnetic resonance imaging using a 1.5T scanner (Siemens Healthcare, Erlangen, Germany). Hemodynamic forces within the LV were computed across the cardiac cycle using the Navier-Stokes equation to find the global pressure gradient, which was then integrated over the LV volume to produce the instantaneous hemodynamic force (unit: Newton) and subsequently normalized to ventricular volume, resulting in a force-volume index (N/l). Average longitudinal forces (root mean square, FRMS) were quantified over the entire cardiac cycle, with and without volume normalization.

Results

We studied 33 healthy subjects, 14 patients with HFpEF, 6 patients with HFmEF and 6 patients with HFrEF. Groups were similar with regards to sex, cardiac output, heart rate, systolic and diastolic blood pressure, and body surface area.

Volume-normalized FRMS did not differ between controls and HFpEF (0.86±0.19 vs. 0.75±0.19 N/l, p=0.08) while lower values were found in HFmEF (0.60±0.19 N/l, p=0.004) and HFrEF (0.38±0.15 N/l, p&lt;0.0001) compared to controls (Figure 1A). There was a significant positive correlation between EF and FRMS, both for the entire population (R2 = 0.54, Figure 1B) and for patients (R2 = 0.67, p&lt;0.0001 for both). Importantly, non-normalized FRMS did not differ between controls (Figure 1C, 0.10±0.03 N) and HFpEF (0.09±0.03 N, p=0.25), HFmEF (0.11±0.02 N, p=0.18) or HFrEF (0.09±0.02 N, p=0.67). Moreover, no correlation was seen between non-normalized FRMS and EF (Figure 1D).

Conclusions

Hemodynamic forces computed from reference standard 4D flow CMR data do not differentiate between healthy controls and HFpEF patients regardless of whether volume normalization is used or not. Our findings do not support a role for hemodynamic forces in HFpEF assessment.

Figure 1. (A) Volume-normalized hemodynamic forces over the entire cardiac cycle (lines: average values, shaded area: ±1SD for HFpEF), and (B) variation of volume-normalized average force, FRMS, with left ventricular ejection fraction (LVEF). (C), (D): When indexing to LV volume was not performed, the differences between groups was attenuated, and no correlation was seen between EF and FRMS.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swedish Heart and Lung Foundation, Region of Scania

Dietary guidelines made useful in migrant networks

Globally, many deaths and DALY:s are attributed to unhealthy diets. Short education, low income and migration are risk factors. Healthy food cost more and is less available while unhealthy food is cheaper and heavily advertised. Health guides (HG) speak Swedish and at least one more language and have networks among migrants. Their work draw on the Right to health framework - availability, accessibility, acceptability and quality for all (AAAQ). HG transfer viewpoints from their groups to health care and contribute to culturally accessible and acceptable information and support.

Public Health Unit of a local hospital initiated a project with the aim to develop a method to make information about healthy food accessible for a wider range of people. How to make food based dietary guidelines useful for recent migrants? How to avoid that official guidelines, when transferred by laymen, become distorted by personal experiences rather than being enriched by them? Systematic collection of viewpoints from inhabitants, helped of HG, implied that “shop walks” have potential to increase health equity. During a shop walk the guide shows healthy alternatives and transfers knowledge on different options. The intervention was developed during 2019. The first shop walks were conducted in February 2020.

Dietary guidelines were made useful by a process including cooperation between HG, nutritionally skilled staff and the communication department. A detailed manuscript and a participant folder were developed together with a mandatory education including theory and practice. 14 HG speaking six languages were included. During the first three weeks six shop walks were conducted. Qualitative evaluation implies that shop walks are functional arenas for strengthening AAAQ.

By structured shop walks HG can contribute to making dietary guidelines relevant for recent migrants. AAAQ is supported by participation of stakeholders in the population in collaboration with professional expertise.

Key messages

If food based dietary guidelines are to be made useful outside the majority population, methods that allow those most concerned to participate in planning, execution and evaluation should be used. Availability, accessibility, acceptability and quality - The Right to health framework – should be used when developing public health interventions that aim at health equity.

Cultural mediators are needed to fulfill Right to health for all

The Right to health framework supports available, accessible and acceptable health care of high quality for all (AAAQ). Health of migrants often worsen in the new country. AAAQ may be hindered by poverty, discrimination, health cares' shortcomings and misunderstandings, respectively. Advocating for marginalised groups' Right to health include action. Interventions based on shared influence, participation and control need to be launched. Cultural mediators (CM), i.e. persons that are knowledgeable in both cultures and with networks in migrant groups help overcome lingual problems, lack of trust and uneven power relations. This resource needs to be further examined.

How can a CM strengthen AAAQ in a public health setting? Women with Somalian origin living in an underserved neighborhood in Sweden contacted the Public Health Unit of a local hospital, asking for support for a health focused group-activity. Weight loss after delivery was a primary concern. Women gathered monthly 2018-19. The objective was to support healthy life style habits drawing on issues raised by the women. The intervention was conducted by group talks, led by the CM and a public health planner. Methods were based on Social Cognitive Theory focusing on self-efficacy.

The CM recruited women, helped them to find the venue, encouraged them to trust the public health planner and broadened perspectives to include female genital mutilation, children's food, how to seek care and workforce issues. Trust developed over time. 70 women participated. Reported gains were raised awareness of ones' rights, increased self-efficacy in relation to food, physical activity and how to support children to a healthy life style. Support for a healthy lifestyle was made more available, accessible and acceptable by the cooperation with the CM, as was the quality of the support.

A CM bridges distances regarding spoken language, trust and cultural understanding. S/he puts forward perspectives and needs from the group in question

Key messages

The Right to health framework highlights areas that need to be in focus when advocating for health equity. Health care workers in settings with many migrants should strive to include cultural mediators in planning, execution and evaluation of interventions.

Using documentation to develop grounded advocacy for equity focused public health work

Health inequity is a global concern. The Public Health Unit (PHU) of a local hospital conducts activities in partnership with many actors, aiming at decreasing the health gap. This commission highlights the need to advocate for shared participation, influence and control and for methods that make health care available, accessible and acceptable for all. A platform for such advocacy includes analysis of interventions based on evidence-informed strategies.

How may PHU:s activities (2019) have contributed to health equity? Analyses build on documentation in the Health Equilibrium Methodology system which draw on Social Cognitive Theory, critical reflection and quantitative measurements.

PHU participated in 81 meetings on the strategic level. Common values and trust, more stable in long-term partnership, facilitated development of population-focused activities that could support marginalised groups. On the population level the Unit participated in 170 activities. Examples were bicycle courses, family centred talks with dietician, tobacco talks with youths and groups for mothers of Somalian origin. Common strategies were to support self-efficacy by confirming and communicating knowledge, to use reciprocal determination by drawing attention to environmental factors, to affect outcome expectations by highlighting links between lifestyle and health and to facilitate healthy habits by making guidelines accessible. Critical reflection highlighted barriers for making use of general advice. Data indicate that professional reflection is needed to implement shared participation, influence and control and that trust-building is dependent on stable presence.

Professional reflection, systematically documented and taken into account is needed to fully use health care potential to ensure Right to health for all.

Trust takes time to build but creates possibilities for inhabitants to raise health issues from their perspective, enabling meaningful support

Key messages

To take the full potential of public health work into account actors should use systematic documentation focusing on processes, avoiding to reduce evaluation to numerical reports. Health care professionals that aim at closing the health gap need to distance themselves from their personal perspectives by using systematic critical reflection of their practice.

Comparison of quality of urinary bladder filling in CT urography with different doses of furosemide in the work-up of patients with macroscopic hematuria

INTRODUCTION

The protocol for preparation of computed tomography urography (CTU) examinations at our hospital was changed in 2013 to improve the quality of urinary bladder filling in the excretory phase. The aim of this study was to evaluate the quality of urinary bladder filling on CTU after different doses of furosemide were administered to patients with macroscopic hematuria.

METHODS

The cohort was 215 patients who underwent elective CTU due to macroscopic hematuria between 2014 and 2018. 5 mg furosemide were administrated to 100 patients, 2.5 mg to 100 patients and 0 mg to 15 patients. Contrast medium layered bladders were excluded, leaving 193 patients: 92, 89 and 12 in each group. Urinary bladder volume was calculated in corticomedullary (CMP) and excretory phase (EP). Bladder distension was classified as satisfactory or not. Attenuation of bladder content in EP was noted.

RESULTS

Average volume in EP was 370 ± 224 ml (28-1052) after 5 mg furosemide, 274 ± 120 ml (43-628) after 2.5 mg and 180 ± 104 ml (53-351) after 0 mg. 85% of the bladders were satisfactory distended after 5 mg, 80% after 2.5 mg and 58% after 0 mg. Average attenuation was 266 ± 89 HU (103-524) after 5 mg, 362 ± 156 HU (118-948) after 2.5 mg and 761 ± 331 HU (347-1206) after 0 mg. The differences in volume and attenuation were significant.

CONCLUSION

5 mg furosemide is preferred rather than 2.5 mg in preparation for CTU examinations of patients with macroscopic hematuria. There was no difference between the doses concerning rate of satisfactory bladder distension, but the higher dose resulted in larger bladder volume and more suitable attenuation of bladder content.

IMPLICATIONS FOR PRACTICE

Development of CTU-image quality could improve bladder cancer diagnostics.

Geographical Distribution of Ljungan Virus in Small Mammals in Europe

Ljungan virus (LV), which belongs to the Parechovirus genus in the Picornaviridae family, was first isolated from bank voles (Myodes glareolus) in Sweden in 1998 and proposed as a zoonotic agent. To improve knowledge of the host association and geographical distribution of LV, tissues from 1685 animals belonging to multiple rodent and insectivore species from 12 European countries were screened for LV-RNA using reverse transcriptase (RT)-PCR. In addition, we investigated how the prevalence of LV-RNA in bank voles is associated with various intrinsic and extrinsic factors. We show that LV is widespread geographically, having been detected in at least one host species in nine European countries. Twelve out of 21 species screened were LV-RNA PCR positive, including, for the first time, the red vole (Myodes rutilus) and the root or tundra vole (Alexandromys formerly Microtus oeconomus), as well as in insectivores, including the bicolored white-toothed shrew (Crocidura leucodon) and the Valais shrew (Sorex antinorii). Results indicated that bank voles are the main rodent host for this virus (overall RT-PCR prevalence: 15.2%). Linear modeling of intrinsic and extrinsic factors that could impact LV prevalence showed a concave-down relationship between body mass and LV occurrence, so that subadults had the highest LV positivity, but LV in older animals was less prevalent. Also, LV prevalence was higher in autumn and lower in spring, and the amount of precipitation recorded during the 6 months preceding the trapping date was negatively correlated with the presence of the virus. Phylogenetic analysis on the 185 base pair species-specific sequence of the 5' untranslated region identified high genetic diversity (46.5%) between 80 haplotypes, although no geographical or host-specific patterns of diversity were detected.

High circulating levels of midregional proenkephalin A predict vascular dementia: a population-based prospective study

Midregional Pro-enkephalin A (MR-PENK A) and N-terminal Protachykinin A (NT-PTA) have been associated with vascular dementia. However, the longitudinal relationship between these biomarkers and incident dementia has not been fully investigated. In the population-based Malmö Preventive Project, circulating levels of MR-PENK A and NT-PTA were determined in a random sample of 5,323 study participants (mean age: 69 ± 6 years) who were followed-up over a period of 4.6 ± 1.6 years. The study sample included 369 patients (7%) who were diagnosed in the same period with dementia. We analyzed relationship of MR-PENK A and NT-PTA with the risk of developing dementia by using multivariable-adjusted Cox regression models adjusted for traditional risk factors. Increased plasma levels of MR-PENK A were associated with higher risk of incident vascular dementia whereas no associations were found with all-cause or Alzheimer dementia. The risk of vascular dementia was mainly conferred by the highest quartile of MR-PENK as compared with lower quartiles. Elevated levels of NT-PTA yielded significant association with all-cause dementia or dementia subtypes. Elevated plasma concentration of MR-PENK A independently predicts vascular dementia in the general population. MR-PENK A may be used as an additional tool for identifying vascular subtype in ambiguous dementia cases.

Selective Predation by Owls on Infected Bank Voles (Myodes glareolus) as a Possible Sentinel of Tularemia Outbreaks

Tularemia is a widely spread zoonotic disease in the northern hemisphere, caused by the bacterium Francisella tularensis. In humans, tularemia is an acute febrile illness with incidence peaks in late summer to early autumn of outbreak years, but there is no early warning system in place that can reduce the impact of disease by providing timely risk information. In this study, we revisit previously unpublished data on F. tularensis in water, sediment, soil, and small mammals from 1984 in northern Sweden. In addition, we used human case data from the national surveillance system for tularemia in the same year. In the environmental and small mammal material, bank vole (Myodes glareolus) samples from urine and bladder were the only samples that tested positive for F. tularensis. The prevalence of F. tularensis among trapped bank voles was 13.5%, although all six bank voles that were retrieved from owl nest boxes in early May tested positive. Forty-two human tularemia cases were reported from August to December in 1984. Based on these results, we encourage investigating the potential role of tularemia-infected bank voles retrieved from owl nest boxes in spring as an early warning for outbreaks of tularemia among humans in summer and autumn of the same year.

Effect of spatial scale and latitude on diversity-disease relationships

Natural ecosystems provide humans with different types of ecosystem services, often linked to biodiversity. The dilution effect (DE) predicts a negative relationship between biodiversity and risk of infectious diseases of humans, other animals, and plants. We hypothesized that a stronger DE would be observed in studies conducted at smaller spatial scales, where biotic drivers may predominate, compared to studies at larger spatial scales where abiotic drivers may more strongly affect disease patterns. In addition, we hypothesized a stronger DE in studies from temperate regions at mid latitudes than in those from subtropical and tropical regions, due to more diffuse species interactions at low latitudes. To explore these hypotheses, we conducted a meta‐analysis of observational studies of diversity–disease relationships for animals across spatial scales and geographic regions. Negative diversity–disease relationships were significant at small (combined site and local), intermediate (combined landscape and regional), and large (combined continental and global) scales and the effect did not differ depending on size of the study areas. For the geographic region analysis, a strongly negative diversity–disease relationship was found in the temperate region while no effect was found in the subtropical and tropical regions. However, no overall effect of absolute latitude on the strength of the dilution effect was detected. Our results suggest that a negative diversity–disease relationship occurs across scales and latitudes and is especially strong in the temperate region. These findings may help guide future management efforts in lowering disease risk.

Health promoting ideas and actions generated by community engagement in an underserved Swedish area

Background

For an intervention to contribute to decreased health gaps, people living in underserved areas must participate in the research-to-action process during the development of the intervention.

Methods for increased engagement and participation have been developed within the community-based participatory research (CBPR) paradigm. Group Level Assessment (GLA) is a qualitative, participatory methodology that is designed for a large group to generate and evaluate relevant needs and priorities within a lens of action for positive social change. Influence of researchers is tuned down in favour of partnership and impact from the community. Ideally, the process results in participant-driven data and relevant action plans. The aim was to apply GLA to generate reflections on the situation in the community, aligning towards action for change.

Methods

We applied GLA together with people living in Gårdsten, an underserved Swedish suburb where obesity, caries and other illnesses are prevalent. Residents were recruited by posters and post cards at a community center and by snowball sampling. In total, 47 residents attended at least one of eight GLA sessions held over a five-month time period. The majority were women. Outcomes were reflections, suggestions and actions for change.

Results

Themes were: resident pride of the area, the importance of communication and of places to meet, a feeling of being abandoned by society, and a desire for more collaboration between schools and parents. Immediate results were a language café and inquiries from the community about information regarding teeth, food and health. When the results were presented for stakeholders in a report and an exhibition, new collaborations were founded and old were refreshed.

Conclusions

GLA helped residents identify what they thought valuable and relevant concerning health issues and supported them in taking actions to achieve change.

Key messages

Participatory processes that directly engage community residents can result in fruitful discussions and actions. Methodologies like GLA that support such processes may contribute to closing the health gap.