Modeling geographic vaccination strategies for COVID-19 in Norway

Vaccination was a key intervention in controlling the COVID-19 pandemic globally. In early 2021, Norway faced significant regional variations in COVID-19 incidence and prevalence, with large differences in population density, necessitating efficient vaccine allocation to reduce infections and severe outcomes. This study explored alternative vaccination strategies to minimize health outcomes (infections, hospitalizations, ICU admissions, deaths) by varying regions prioritized, extra doses prioritized, and implementation start time. Using two models (individual-based and meta-population), we simulated COVID-19 transmission during the primary vaccination period in Norway, covering the first 7 months of 2021. We investigated alternative strategies to allocate more vaccine doses to regions with a higher force of infection. We also examined the robustness of our results and highlighted potential structural differences between the two models. Our findings suggest that early vaccine prioritization could reduce COVID-19 related health outcomes by 8% to 20% compared to a baseline strategy without geographic prioritization. For minimizing infections, hospitalizations, or ICU admissions, the best strategy was to initially allocate all available vaccine doses to fewer high-risk municipalities, comprising approximately one-fourth of the population. For minimizing deaths, a moderate level of geographic prioritization, with approximately one-third of the population receiving doubled doses, gave the best outcomes by balancing the trade-off between vaccinating younger people in high-risk areas and older people in low-risk areas. The actual strategy implemented in Norway was a two-step moderate level aimed at maintaining the balance and ensuring ethical considerations and public trust. However, it did not offer significant advantages over the baseline strategy without geographic prioritization. Earlier implementation of geographic prioritization could have more effectively addressed the main wave of infections, substantially reducing the national burden of the pandemic.

Metacognitions in patients with chronic obstructive pulmonary disease: a psychometric study of the metacognitions questionnaire-30

The metacognitions questionnaire-30 (MCQ-30) was developed for the assessment of metacognitive beliefs and processes that are central components of the metacognitive model of emotional disorders. Anxiety and depression commonly occur in patients with chronic obstructive pulmonary disease (COPD). Testing such a model for anxiety and depression in patients with COPD is warranted. However, the psychometric properties of the MCQ-30 in COPD patients are unknown. Therefore, in this study we aimed to examine these properties in COPD patients. The MCQ-30 was administered to 203 COPD patients referred to a rehabilitation unit in respiratory medicine. Confirmatory factor analysis (CFA) was used to test the five-factor as well as the bi-factor models of MCQ-30. Exploratory factor analyses were also performed. Both models did not meet the criteria for an acceptable fit on Comparative Fit Index (CFI) of 0.810 and 0.858 vs. criterion of ≥0.9, but the Root Mean Square Error of Approximation (RMSEA) criterion ≤0.08 was acceptable for both models with RMSEA = 0.074 and 0.066, respectively. The factors were mostly moderately correlated (0.41-0.58) with acceptable reliability coefficients (0.73-0.87). The exploratory factor analysis identified three of the five factors originally described in the five-factor model of the MCQ-30. These data show that the factor structure of the MCQ-30 appears to differ from that of the original instrument in COPD patients and further studies are needed to confirm its validity and reliability in this patient group.

Antibiotic Consumption in a Cohort of Hospitalized Adults with Viral Respiratory Tract Infection

Development of antibiotic resistance, a threat to global health, is driven by inappropriate antibiotic usage. Respiratory tract infections (RTIs) are frequently treated empirically with antibiotics, despite the fact that a majority of the infections are caused by viruses. The purpose of this study was to determine the prevalence of antibiotic treatment in hospitalized adults with viral RTIs, and to investigate factors influencing the antibiotic decision-making. We conducted a retrospective observational study of patients ≥ 18 years, hospitalized in 2015-2018 with viral RTIs. Microbiological data were taken from the laboratory information system and information on antibiotic treatment drawn from the hospital records. To investigate decisions for prescribing antibiotic treatment, we evaluated relevant factors such as laboratory and radiological results, in addition to clinical signs. In 951 cases without secondary bacterial RTIs (median age 73 years, 53% female), 720 (76%) were prescribed antibiotic treatment, most frequently beta-lactamase-sensitive penicillins, but cephalosporins were prescribed as first-line in 16% of the cases. The median length of treatment (LOT) in the patients treated with antibiotics was seven days. Patients treated with antibiotics had an average of two days longer hospital stay compared to patients with no such treatment, but no difference in mortality was found. Our study revealed that there is still a role for antimicrobial stewardship to further improve antibiotic use in patients admitted for viral RTIs in a country with relatively low antibiotic consumption.

A real-time regional model for COVID-19: Probabilistic situational awareness and forecasting

The COVID-19 pandemic is challenging nations with devastating health and economic consequences. The spread of the disease has revealed major geographical heterogeneity because of regionally varying individual behaviour and mobility patterns, unequal meteorological conditions, diverse viral variants, and locally implemented non-pharmaceutical interventions and vaccination roll-out. To support national and regional authorities in surveilling and controlling the pandemic in real-time as it unfolds, we here develop a new regional mathematical and statistical model. The model, which has been in use in Norway during the first two years of the pandemic, is informed by real-time mobility estimates from mobile phone data and laboratory-confirmed case and hospitalisation incidence. To estimate regional and time-varying transmissibility, case detection probabilities, and missed imported cases, we developed a novel sequential Approximate Bayesian Computation method allowing inference in useful time, despite the high parametric dimension. We test our approach on Norway and find that three-week-ahead predictions are precise and well-calibrated, enabling policy-relevant situational awareness at a local scale. By comparing the reproduction numbers before and after lockdowns, we identify spatially heterogeneous patterns in their effect on the transmissibility, with a stronger effect in the most populated regions compared to the national reduction estimated to be 85% (95% CI 78%-89%). Our approach is the first regional changepoint stochastic metapopulation model capable of real time spatially refined surveillance and forecasting during emergencies.

Molecular epidemiology and antibiotic resistance profiles of invasive Haemophilus influenzae from Norway 2017–2021

Invasive Haemophilus influenzae (Hi) disease has decreased in countries that included Hi type b (Hib) vaccination in their childhood immunization programs in the 1990s. Non-typeable (NT) and non-b strains are now the leading causes of invasive Hi disease in Europe, with most cases reported in young children and the elderly. Concerningly, no vaccines toward such strains are available and beta-lactam resistance is increasing. We describe the epidemiology of invasive Hi disease reported to the Norwegian Surveillance System for Communicable Diseases (MSIS) (2017–2021, n = 407). Whole-genome sequencing (WGS) was performed on 245 isolates. We investigated the molecular epidemiology (core genome phylogeny) and the presence of antibiotic resistance markers (including chromosomal mutations associated with beta-lactam or quinolone resistance). For isolates characterized with both WGS and phenotypic antibiotic susceptibility testing (AST) (n = 113) we assessed correlation between resistance markers and susceptibility categorization by calculation of sensitivity, specificity, and predictive values. Incidence rates of invasive Hi disease in Norway ranged from 0.7 to 2.3 per 100,000 inhabitants/year (mean 1.5 per 100,000) and declined during the COVID-19 pandemic. The bacterial population consisted of two major phylogenetic groups with subclustering by serotype and multi-locus sequence type (ST). NTHi accounted for 71.8% (176). The distribution of STs was in line with previous European reports. We identified 13 clusters, including four encapsulated and three previously described international NTHi clones with blaTEM–1 (ST103) or altered PBP3 (rPBP3) (ST14/IIA and ST367/IIA). Resistance markers were detected in 25.3% (62/245) of the isolates, with blaTEM–1 (31, 50.0%) and rPBP3 (28, 45.2%) being the most frequent. All isolates categorized as resistant to aminopenicillins, tetracycline or chloramphenicol possessed relevant resistance markers, and the absence of relevant substitutions in PBP3 and GyrA/ParC predicted susceptibility to cefotaxime, ceftriaxone, meropenem and quinolones. Among the 132 WGS-only isolates, one isolate had PBP3 substitutions associated with resistance to third-generation cephalosporins, and one isolate had GyrA/ParC alterations associated with quinolone resistance. The detection of international virulent and resistant NTHi clones underlines the need for a global molecular surveillance system. WGS is a useful supplement to AST and should be performed on all invasive isolates.

Clinical Outcome of Viral Respiratory Tract Infections in Hospitalized Adults in Norway: High Degree of Inflammation and Need of Emergency Care for Cases With Respiratory Syncytial Virus

Background

The clinical features and outcomes of viral respiratory tract infections (RTIs) in adults have not been thoroughly studied, especially the respiratory syncytial virus (RSV) disease burden. It has become apparent that outbreaks of RSV in the elderly are associated with increased hospitalization rates. However, little data exists on the severity of such viral RTIs in adults, particularly the need for hospitalization, respiratory support and intensive care.

Methods

We conducted a retrospective observational single-center study at Østfold Hospital Trust, Norway, during three winter seasons 2015–2018. Patients ≥18 years with either influenza A, influenza B, RSV A/B, human metapneumovirus, parainfluenza virus 1–4 or adenovirus detected in respiratory specimens were included, if they were hospitalized 14 days prior or following the detection date, with signs of RTI. Hospital records on treatment and outcome were investigated, as well as mortality of all causes up to 30 days from discharge.

Results

Of the 1222 infection events that were included, influenza A was the most frequent virus detected (39%), while 179 infection events (14.6%) were due to RSV. Influenza B counted for 24% of the infection events, human metapneumovirus 13%, parainfluenza virus 9% and adenovirus 1%. Patients admitted with RSV more often suffered from COPD and congestive heart failure than patients with influenza A. In addition, RSV patients were overrepresented in the urgent response NEWS score (National Early Warning Score) category ≥5. RSV patients also showed signs of more severe inflammation, with WBC ≥11.1 × 10⁹/L and CRP >100 mg/L, and they were more often treated with antibiotic agents during their hospital stay. However, we found no differences in the need for ICU admission or mortality.

Conclusion

Patients with RSV had more often high values for markers of inflammation and elevated NEWS score when compared to patients hospitalized with other common respiratory viruses. Taken into account that they suffered more frequently from comorbidities like COPD, these patients needed hospitalization more urgently. These findings highlight the need for further investigations on RSV disease in adults and the elderly.

Mucosal Gene Transcript Signatures in Treatment Naïve Inflammatory Bowel Disease: A Comparative Analysis of Disease to Symptomatic and Healthy Controls in the European IBD-Character Cohort

Background

Studies of the mucosal transcriptomic landscape have given new insight into the pathogenesis of inflammatory bowel disease (IBD). Recently, the predictive biomarker potential of gene expression signatures has been explored. To further investigate the mucosal gene expression in IBD, we recruited a cohort of treatment naïve patients and compared them to both symptomatic and healthy controls.

Methods

Altogether, 323 subjects were included: Crohn’s disease (N = 75), ulcerative colitis (N = 87) and IBD unclassified (N = 3). Additionally, there were two control groups: symptomatic controls (N = 131) and healthy controls (N = 27). Mucosal biopsies were collected during ileocolonoscopy and gene expression in inflamed and non-inflamed mucosa was explored. Gene expression profiling was performed using Agilent G3 Human Gene Expression 860K v3 One-Color microarray. We recorded information about treatment escalation to anti-TNF agents or surgery, and anti-TNF response, to explore predictive opportunities of the mucosal transcriptome.

Results

Gene expression profiles in symptomatic controls in whom IBD had been excluded resembled that of IBD patients and diverged from that of healthy controls. In non-inflamed Crohn’s disease and ulcerative colitis, gene set enrichment analysis revealed dysregulation of pathways involved in basic cellular biological processes. Mitochondria-associated pathways were dysregulated both in non-inflamed and inflamed Crohn’s disease and ulcerative colitis (>2.6 normalized enrichment scores <−1.8). Gene expression signatures of Crohn’s disease and ulcerative colitis did not predict time for treatment escalation (p = 0.175). No significant association was found between gene expression signatures and anti-TNF response.

Conclusion

Non-inflamed samples are probably superior to inflamed samples when exploring gene expression signatures in IBD and might reveal underlying mechanisms central for disease initiation. The gene expression signatures of the control groups were related to if they were symptomatic or not, which may have important implications for future study designs.

Increased transmissibility of the alpha SARS-CoV-2 variant: evidence from contact tracing data in Oslo, January to February 2021

BACKGROUND

Information about the contagiousness of new SARS-CoV-2 variants, including the alpha lineage, and how they spread in various locations is essential. Country-specific estimates are needed because local interventions influence transmissibility.

METHODS

We analysed contact tracing data from Oslo municipality, reported from January through February 2021, when the alpha lineage became predominant in Norway and estimated the relative transmissibility of the alpha lineage with the use of Poisson regression.

RESULTS

Within households, we found an increase in the secondary attack rate by 60% (95% CI 20-114%) among cases infected with the alpha lineage compared to other variants; including all close contacts, the relative increase in the secondary attack rate was 24% (95% CI -6%-43%). There was a significantly higher risk of infecting household members in index cases aged 40-59 years who were infected with the alpha lineage; we found no association between transmission and household size. Overall, including all close contacts, we found that the reproduction number among cases with the alpha lineage was increased by 24% (95% CI 0%-52%), corresponding to an absolute increase of 0.19, compared to the group of index cases infected with other variants.

CONCLUSION

Our study suggests that households are the primary locations for rapid transmission of the new lineage alpha.

Hypophosphatemia after high-dose intravenous iron treatment in patients with inflammatory bowel disease: Mechanisms and possible clinical impact

BACKGROUND

High-dose intravenous iron is an effective treatment option for iron deficiency (ID) or ID anaemia (IDA) in inflammatory bowel disease (IBD). However, treatment with ferric carboxymaltose (FCM) has been associated with the development of hypophosphatemia.

AIM

To investigate mechanisms behind the development of hypophosphatemia after intravenous iron treatment, and disclose symptoms and clinical manifestations related to hypophosphatemia short-term.

METHODS

A prospective observational study of adult IBD patients with ID or IDA was conducted between February 1, 2017 and July 1, 2018 at two separate university hospitals in the southeast region of Norway. Patients received one dose of 1000 mg of either FCM or ferric derisomaltose (FDI) and were followed for an observation period of at least 7 wk. Blood and urine samples were collected for relevant analyses at baseline, week 2 and at week 6. Clinical symptoms were assessed at the same timepoints using a respiratory function test, a visual analogue scale, and a health-related quality of life questionnaire.

RESULTS

A total of 106 patients was available for analysis in this study. The FCM treatment group consisted of 52 patients and hypophosphatemia was present in 72.5% of the patients at week 2, and in 21.6% at week 6. In comparison, the FDI treatment group consisted of 54 patients and 11.3% of the patients had hypophosphatemia at week 2, and 3.7% at week 6. The difference in incidence was highly significant at both week 2 and 6 (P < 0.001 and P < 0.013, respectively). We observed a significantly higher mean concentration of intact fibroblast growth factor 23 (P < 0.001), a significant rise in mean urine fractional excretion of phosphate (P = 0.004), a significant decrease of 1,25-dihydroxyvitamin D (P < 0.001) and of ionised calcium levels (P < 0.012) in the FCM-treated patients compared with patients who received FDI. No clinical symptoms could with certainty be related to hypophosphatemia, since neither the respiratory function test, SF-36 (36-item short form health survey) or the visual analogue scale scores resulted in significant differences between patients who developed hypophosphatemia or not.

CONCLUSION

Fibroblast growth factor 23 has a key role in FCM induced hypophosphatemia, probably by inducing loss of phosphate in the urine. Short-term clinical impact of hypophosphatemia was not demonstrated.

Patient affect, physician liking for the patient, physician behavior, and patient reported outcomes: A modeling approach

OBJECTIVE

To determine associations between patient affect and physician liking of the patient, and their associations with physician behavior and patient-reported outcomes.

METHODS

Structural equation modeling based on coding of 497 videotaped hospital encounters, with questionnaires assessing pre-visit patient affect, post-visit patient affect and encounter evaluations, and physician liking of the patient, involving 71 physicians.

RESULTS

In first visits, patient reported outcomes were strongly correlated with physician behavior and less so with physician liking, while in later visits, patient reported outcomes were directly related to physician liking and not mediated by physician behavior. Physician liking predicted physician behavior, more for female physicians in first visits. Patient negative affect before the visit was negatively associated with male physicians' liking. When acquainted, both patient positive and negative affect were associated with physician liking.

CONCLUSION

Physician liking of the patient plays a dynamic role in a consultation, is influenced by patient pre-encounter affect, and influences physician behavior. The dynamics are different in first and later visits, and influenced by physician gender.

PRACTICE IMPLICATIONS

Physicians should be aware how patient affect influences their behavior, and administrators should take any prior relationship between patient and physician into account when evaluating patient reported outcomes.

Incidence of hypophosphatemia in patients with inflammatory bowel disease treated with ferric carboxymaltose or iron isomaltoside

BACKGROUND

Iron deficiency and iron deficiency anaemia are common complications in inflammatory bowel disease (IBD). In patients with moderate-to-severe anaemia, oral iron intolerance or ineffectiveness of oral iron, ferric carboxymaltose and iron isomaltoside are widely used. Hypophosphatemia is a side effect of both preparations.

AIMS

To investigate the occurrence of hypophosphatemia in IBD patients with iron deficiency/iron deficiency anaemia treated with high-dose intravenous iron.

METHODS

A prospective observational study of adult IBD patients with iron deficiency/iron deficiency anaemia was conducted at two study sites where patients received 1000 mg of ferric carboxymaltose or iron isomaltoside. At baseline, weeks 2 and 6, blood and faecal samples were collected. The primary endpoint was to determine the incidence of moderate-to-severe hypophosphatemia. Secondary endpoints included the total incidence of hypophosphatemia, possible risk factors for hypophosphatemia, and response to single-dose intravenous iron.

RESULTS

One hundred and thirty patients were included. In the per-protocol set, 52 patients received ferric carboxymaltose and 54 patients received iron isomaltoside. Ferric carboxymaltose treatment had a significantly higher incidence of moderate-to-severe hypophosphatemia compared with iron isomaltoside at week 2 (56.9% vs 5.7%, P < 0.001) and a higher incidence at week 6 (13.7% vs 1.9%, P = 0.054).The overall incidence of hypophosphatemia was significantly higher with ferric carboxymaltose compared with iron isomaltoside treatment at weeks 2 (72.5% vs 11.3%, P < 0.001) and 6 (21.6% vs 3.7%, P = 0.013).

CONCLUSIONS

In IBD patients with iron deficiency/iron deficiency anaemia, ferric carboxymaltose was associated with higher incidence, severity and persistence of hypophosphatemia compared with iron isomaltoside. The presence of moderate-to-severe hypophosphatemia beyond 6 weeks is a clinical concern that requires further investigation.

Interventional study to improve adherence to phosphate binder treatment in dialysis patients

Background

Adherence to phosphate binder treatment is important to prevent high serum phosphate level in chronic dialysis patients. We therefore wanted to investigate patient knowledge, beliefs about and adherence to phosphate binders among these patients and assess whether one-to-one pharmacist-led education and counselling enhance adherence and lead to changes in serum phosphate levels.

Methods

A descriptive, interventional, single arm, pre-post study was performed at a hospital in Norway, including chronic dialysis patients aged 18 years or more using phosphate binders. The primary end-point was change in the proportion of patients with serum phosphate below 1.80 mmol/L and the secondary end-points included change in the patient’s knowledge, beliefs and adherence after the intervention measured by completion of questionnaires ‘Patient Knowledge’, Medication Adherence Report Scale (MARS− 5) and Beliefs about Medicines Questionnaire (BMQ). Data was collected both prior to and after one-to-one pharmacist-led education and counselling about their phosphate binders. Other medicines used by the patient was also registered.

Results

A total of 69 patients were enrolled in the study. After intervention, the probability of serum phosphate being below the target threshold 1.80 mmol/L (5.58 mg/dL) increased, although no significant change in mean serum phosphate levels was seen. On the other hand, the knowledge regarding phosphate binder treatment and the patients’ beliefs about the necessity of the treatment increased, while the concerns decreased (BMQ). This effect did not lead to increase in self-reported adherence measured by MARS-5. However the scores were high before the intervention.

Conclusions

Short term one-to-one individualized pharmacist-led education and counselling about phosphate binders increased the probability of serum phosphate concentrations being below the target threshold level 1.80 mmol/L (5.58 mg/dL), although not statistically significant. However, it did not decrease the mean serum phosphate level or increase the patients’ self-reported adherence. The patients increased their knowledge about the phosphate binder and their understanding of adherence, and were less concerned about the side effects of the medication.

Trial registration

ISRCTN52852596, registered 11 April 2019. The trial was registered retrospectively.

Abstract OT1-01-01: The NEO-LET-EXE-trial: An intra-patient cross-over trial to explore the "lack of cross-resistance" between steroidal and non-steroidal aromatase inhibitors

Background. The aromatase inhibitor letrozole and the aromatase inactivator exemestane currently belong to the most widely used antihormonal drugs for breast cancer worldwide. Both compounds are strongly suppressing estradiol levels in postmenopausal patients with breast cancer. However, in the metastatic setting, these drugs may be used after another, causing new responses in selected patients following switching to the alternative drug after progressing on the first choice. This well-known “lack of cross resistance” has been recognized for some time and is documented by several trials. However, the precise explanation for this clinical observation is still unknown. The solution may potentially lead us to a novel strategy to treat hormone-sensitive breast cancer.

Trial design. NEO-LET-EXE is a neoadjuvant, randomized, open-label, intra-patient cross-over trial .

Eligibility criteria. Postmenopausal patients suffering from estrogen receptor (ER) positive (&gt;50%), HER-2 negative, locally advanced breast cancer, suitable for neoadjuvant/presurgical antihormonal therapy, may be enrolled. Age: 18+ (no upper limit).

Specific aims. To explain the phenomenon of a lack of cross-resistance between steroidal and non-steroidal aromatase inhibitors in vivo. Sequential tumor biopsies and blood samples, obtained at baseline and following 2 months of therapy with each drug given in sequence, will be used to perform a comprehensive exploration of the consequences of each drug therapy. The influence on plasma and tissue steroids (estrogens, androgens, etc.) will be compared. In addition, whole genome sequencing, whole exome sequencing, epigenetics, proteomics and plasma analysis (cytokines, tumor DNA fragments, etc.) will be performed.

Statistical methods. Data will be analyzed using mixed effects models.

Present accrural and target accrural. 49 out of planned 100 patients have been enrolled so far. The last patient is expected to enter the trial in Q4 2019.

Citation Format: Bahrami N, Sauer T, Loeng M, Gravdehaug B, Engebretsen SS, Aljabri B, Bemanian V, Lindstrøm JC, Lüders T, Kristensen VN, Geisler J. The NEO-LET-EXE-trial: An intra-patient cross-over trial to explore the "lack of cross-resistance" between steroidal and non-steroidal aromatase inhibitors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-01-01.

Vitamin D supplementation and neurofilament light chain in multiple sclerosis

OBJECTIVES

The effect of vitamin D supplementation on the disease course of multiple sclerosis (MS) is not established. Neurofilament light chain (NFL) is a sensitive marker of axonal degeneration. The aim of this study was to establish whether high-dose vitamin D supplementation reduces serum levels of NFL.

MATERIALS AND METHODS

We have performed a 96 weeks placebo-controlled randomized study of weekly supplementation with 20 000 IU vitamin D3 in 71 patients with relapsing remitting MS (RRMS). Serum levels of NFL were measured at baseline, week 48 and week 96 with a single molecule (Simoa) assay in 69 of these patients.

RESULTS

Serum levels of 25-hydroxyvitamin D more than doubled in the vitamin D group. Compared to placebo, vitamin D supplementation had no overall effect on the change in serum levels of NFL from baseline (P = 0.93 at week 48 and P = 0.56 at week 96). In the subgroup of patients not receiving disease-modifying therapy, NFL decreased by 30.9% to week 48% and 32.6% to week 96 from baseline in the vitamin D group as compared to the placebo group (P = 0.06 for both time points).

CONCLUSION

With a possible exception for patients not treated with disease-modifying drugs, weekly supplementation with 20 000 IU vitamin D3 did not affect NFL levels in these RRMS patients.

The prevalence and transcriptional activity of the mucosal microbiota of ulcerative colitis patients

Active microbes likely have larger impact on gut health status compared to inactive or dormant microbes. We investigate the composition of active and total mucosal microbiota of treatment-naïve ulcerative colitis (UC) patients to determine the microbial picture at the start-up phase of disease, using both a 16S rRNA transcript and gene amplicon sequencing. DNA and RNA were isolated from the same mucosal colonic biopsies. Our aim was to identify active microbial members of the microbiota in early stages of disease and reveal which members are present, but do not act as major players. We demonstrated differences in active and total microbiota of UC patients when comparing inflamed to non-inflamed tissue. Several taxa, among them the Proteobacteria phyla and families therein, revealed lower transcriptional activity despite a high presence. The Bifidobacteriaceae family of the Actinobacteria phylum showed lower abundance in the active microbiota, although no difference in presence was detected. The most abundant microbiota members of the inflamed tissue in UC patients were not the most active. Knowledge of active members of microbiota in UC patients could enhance our understanding of disease etiology. The active microbial community composition did not deviate from the total when comparing UC patients to non-IBD controls.

Somatic EP300-G211S mutations are associated with overall somatic mutational patterns and breast cancer specific survival in triple-negative breast cancer

PURPOSE

We have compared the mutational profiles of human breast cancer tumor samples belonging to all major subgroups with special emphasis on triple-negative breast cancer (TNBC). Our major goal was to identify specific mutations that could be potentially used for clinical decision making in TNBC patients.

PATIENTS AND METHODS

Primary tumor specimens from 149 Norwegian breast cancer patients were available. We analyzed the tissue samples for somatic mutations in 44 relevant breast cancer genes by targeted next-generation sequencing. As a second confirmatory technique, we performed pyrosequencing on selected samples.

RESULTS

We observed a distinct subgroup of TNBC patients, characterized by an almost completely lack of pathogenic somatic mutations. A point mutation in the adenoviral E1A binding protein p300 (EP300-G211S) was significantly correlated to this TNBC subgroup. The EP300-G211S mutation was exclusively found in the TNBC patients and its presence reduced the chance for other pathological somatic mutations in typical breast cancer genes investigated in our gene panel by 94.9% (P < 0.005). Interestingly, the EP300-G211S mutation also predicted a lower risk for relapses and decreased breast cancer-specific mortality during long-term follow-up of the patients.

CONCLUSION

Next-generation sequencing revealed specific mutations in EP300 to be associated with the mutational patterns in typical breast cancer genes and long-term outcome of triple-negative breast cancer patients.

Hospitals implementing changes in law to protect children of ill parents: a cross-sectional study

BACKGROUND

Norway is one of the first countries to require all health professionals to play a part in prevention for children of parents with all kinds of illnesses (mental illness, drug addiction, or severe physical illness or injury) in order to mitigate their increased risk of psychosocial problems. Hospitals are required to have child responsible personnel (CRP) to promote and coordinate support given by health professionals to patients who are parents and to their children.

METHODS

This study examined the extent to which the new law had been implemented as intended in Norwegian hospitals, using Fixsen's Active Implementation Framework. A stratified random sample of managers and child responsible personnel (n = 167) from five Hospitals filled in an adapted version of the Implementation Components Questionnaire (ICQ) about the implementation of policy changes. Additional information was collected from 21 hospital coordinators (H-CRP) from 16 other hospitals.

RESULTS

Significant differences were found between the five hospitals, with lowest score from the smallest hopitals. Additional analysis, comparing the 21 hospitals, as reported by the H-CRP, suggests a clear pattern of smaller hospitals having less innovative resources to implement the policy changes. Leadership, resources and system intervention (strategies to work with other systems) were key predictors of a more successful implementation process.

CONCLUSIONS

Legal changes are helpful, but quality improvements are needed to secure equal chances of protection and support for children of ill parents.

TRIAL REGISTRATION

The study is approved by the Regional Committee on Medical and Health Research Etics South-East (reg.no. 2012/1176 ) and by the Privacy Ombudsmann.

Sex ratio in multiple sclerosis mortality over 65 years; an age-period-cohort analysis in Norway

Increasing female: male ratio in multiple sclerosis (MS) has been assigned to cohort effects, with females in more recent birth cohorts possibly being more exposed or vulnerable to environmental risk factors than males. We collected MS mortality data in Norway from 1951 to 2015 from The Norwegian Cause of Death registry. Age-Period-Cohort analysis was conducted using log-linear Poisson models, including sex interaction terms. MS was registered as the underlying, contributing or direct cause in 6060 deaths. MS associated mortality remained stable with a slight preponderance among males until after 1980, and have since increased preferentially among females. Throughout the study period the mean annual increase was 1.25% for females and 0.3% for males (p < 0.0001). Age-period-cohort analysis revealed limited evidence of cohort effects for the gender differences; the best fitting model only included gender-age and gender-period interaction terms. The period effect evened out for males in the last three decades but increased for females, especially among the oldest age-groups. In conclusion, the increased female: male mortality ratio in MS associated mortality is driven mainly by increased mortality among females in the three last decades, particularly in the older age groups. It is best explained by disproportional period effects, providing evidence of time-varying external factors including improved access to diagnosis among females.

Recovery concept in a Norwegian setting to be examined by the assertive community treatment model and mixed methods

Recovery is a crucial concept in the mental health field. The research of recovery is split into the categories of personal, social and clinical recovery. The purpose of this study was to explore the fragmented concept of recovery in light of assertive community treatment (ACT) in Norway. The study has a mixed methods design with a pragmatic approach. The Questionnaire about the Process of Recovery and open-ended questions posed to 70 participants from 12 ACT teams in Norway, gathered by the "Users interview users" method, are combined with interviews or focus groups with eight of these participants. Surprisingly those under a community treatment order (CTO) report the highest degree of personal recovery. The qualitative material shows that the service users interpreted the concept of recovery differently than researchers and professionals. The ACT service users highlighted three important elements: flexible treatment, medication and access to a car. They emphasized the necessity for basic needs to be met in order to experience a meaningful recovery process, and these basic needs may be of even greater importance to those under CTOs. Their experiences should imply a greater emphasis on securing basic needs such as secure housing, sounder finances and access to the normal benefits offered by society.

Assessing amyotrophic lateral sclerosis prevalence in Norway from 2009 to 2015 from compulsory nationwide health registers

OBJECTIVE

In Norway, diagnoses from specialist health care visits, drug prescriptions, and causes of deaths are registered in compulsory health registers. We aimed to determine amyotrophic lateral sclerosis (ALS) prevalence from 2009 to 2015 by combining these registers.

METHODS

We validated the Norwegian Patient Registry (NPR) through hospital files, and linked it with the Norwegian Cause of Death Registry and the Norwegian Prescription Database. Poisson regression models were fitted for estimating gender ratios, time trends and possible interactions. Similar models were used for mortality data subtracted from the dataset.

RESULTS

Eleven percent of patients with at least one ALS-related entry in NPR did not have ALS. ALS prevalence could nevertheless be reliably estimated through ascertaining cases identified in two separate registers, or with at least two entries in NPR with first entry within four years prior to prevalence date. ALS prevalence remained stable, and was 7.6/100,000 (95% CI 6.9-8.4) at 31st December 2015. Mean male:female ratio was higher for prevalence (1.8; 95% CI 1.6-2.0) than for mortality (1.5; 95% CI 1.2-1.8) (p = 0.04). There were also significant regional differences in prevalence (p < 0.01) but not in mortality.

CONCLUSIONS

Norwegian compulsory health registers provide reliable tools for ALS surveillance, and suggest gender and regional differences in survival after diagnosis.

Prevalence of Posttraumatic Stress Disorder in Persons with Chronic Pain: A Meta-analysis

OBJECTIVE

To summarize evidence for the prevalence of posttraumatic stress disorder (PTSD) among persons with chronic pain (CP).

METHODS

We searched databases for studies published between January 1995 and December 2016, reporting the prevalence of PTSD in persons with CP. Two reviewers independently extracted data and assessed the risk of bias. We calculated the pooled prevalence using a random-effects model and performed subgroup analyses according to pain location, the population and assessment method.

RESULTS

Twenty-one studies were included and the PTSD prevalence varied from 0-57%, with a pooled mean prevalence of 9.7%, 95% CI (5.2-17.1). In subgroup analysis, the PTSD prevalence was 20.5%, 95% CI (9.5-39.0) among persons with chronic widespread pain, 11.2%, 95% CI (5.7-22.8) among persons with headache, and 0.3%, 95% CI (0.0-2.4) among persons with back pain. The prevalence in clinical populations was 11.7%, 95% CI (6.0-21.5) and in non-clinical populations 5.1%, 95% CI (0.01-17.2). In studies of self-reported PTSD symptoms, PTSD prevalence was 20.4%, 95% CI (10.6-35.5), and in studies where structured clinical interviews had been used to assess PTSD its prevalence was 4.5%, 95% (CI 2.1-9.3). The risk of bias was medium for most studies and the heterogeneity was high (I2 = 98.6).

CONCLUSION

PTSD is overall more prevalent in clinical cohorts of persons with CP and particularly in those with widespread pain, but may not always be more prevalent in non-clinical samples of persons with CP, compared to the general population. There is a large heterogeneity in prevalence across studies. Future research should identify sources of heterogeneity and the mechanisms underlying the comorbidity of the two conditions.

High dose vitamin D supplementation does not affect biochemical bone markers in multiple sclerosis - a randomized controlled trial

Background

People with multiple sclerosis have high risk of osteoporosis and fractures. A poor vitamin D status is a risk factor for MS, and vitamin D supplementation has been recommended both to prevent MS progression and to maintain bone health.

Methods

We assessed the effect of 20,000 IU vitamin D₃ weekly compared to placebo on biochemical markers of bone metabolism in 68 persons with relapsing remitting multiple sclerosis.

Results

Serum levels of 25-hydroxyvitamin D more than doubled in the vitamin D group, and parathyroid hormone decreased in the vitamin D group compared to the placebo group at week 48 and week 96. There was however no effect on bone formation as measured by procollagen type I N propeptide (PINP), or on bone resorption as measured by C-terminal cross-linking telopeptide of type I collagen (CTX1). Neither PINP nor CTX1 predicted bone loss from baseline to week 96.

Conclusions

These findings corroborate the previously reported lack of effect of weekly high dose vitamin D supplementation on bone mass density in the same patients, and suggest that such vitamin D supplementation does not prevent bone loss in persons with MS who are not vitamin D deficient.

Trial registration

The trial was registered at ClinicalTrials.gov on April 4 2008, registration number NCT00785473.

Exploring similarities and differences in hospital adverse event rates between Norway and Sweden using Global Trigger Tool

OBJECTIVES

In this paper, we explore similarities and differences in hospital adverse event (AE) rates between Norway and Sweden by reviewing medical records with the Global Trigger Tool (GTT).

DESIGN

All acute care hospitals in both countries performed medical record reviews, except one in Norway. Records were randomly selected from all eligible admissions in 2013. Eligible admissions were patients 18 years of age or older, undergoing care with an in-hospital stay of at least 24 hours, excluding psychiatric and care and rehabilitation. Reviews were done according to GTT methodology.

SETTING

Similar contexts for healthcare and similar socioeconomic and demographic characteristics have inspired the Nordic countries to exchange experiences from measuring and monitoring quality and patient safety in healthcare. The co-operation has promoted the use of GTT to monitor national and local rates of AEs in hospital care.

PARTICIPANTS

10 986 medical records were reviewed in Norway and 19 141 medical records in Sweden.

RESULTS

No significant difference between overall AE rates was found between the two countries. The rate was 13.0% (95% CI 11.7% to 14.3%) in Norway and 14.4% (95% CI 12.6% to 16.3%) in Sweden. There were significantly higher AE rates of surgical complications in Norwegian hospitals compared with Swedish hospitals. Swedish hospitals had significantly higher rates of pressure ulcers, falls and 'other' AEs. Among more severe AEs, Norwegian hospitals had significantly higher rates of surgical complications than Swedish hospitals. Swedish hospitals had significantly higher rates of postpartum AEs.

CONCLUSIONS

The level of patient safety in acute care hospitals, as assessed by GTT, was essentially the same in both countries. The differences between the countries in the rates of several types of AEs provide new incentives for Norwegian and Swedish governing bodies to address patient safety issues.

Abstract P3-05-08: Steroid receptors and steroidogenic enzymes in human breast cancer: Associations with breast cancer subtypes and clinical outcome

Introduction: The majority of breast cancer (BC) cases are believed to be highly steroid dependent. Therefore exploitation of currently untapped steroid pathways could potentially contribute to our search for novel targeted breast cancer therapies. Given the growing understanding of the importance of both intratumoral steroid metabolism and impact of alternate steroid receptors in BC biology, we evaluated selected steroidogenic pathways in a cohort of 140 BC cases from Akershus University Hospital, Norway. In this study we immunolocalized both the androgen receptor (AR) and glucocorticoid receptor (GR) in addition to steroid sulfatase (STS) and 17β hydroxysteroid dehydrogenase 2 (17βHSD2). We also evaluated immunoreactivity of Ki-67 and CYP19/aromatase. We correlated these factors with the occurrence of distant metastasis or local relapse, and survival adjusted by age at surgery. We also examined whether any of these pathways were enriched in the classical breast cancer subtypes (Luminal A, Luminal B, HER-2 positive, triple-negative BC). Logistic and Cox regression analysis was employed to examine interactions between the above factors.

Results: In an analysis looking at possible interactions between recurrence and the factors above, the status of intratumoral STS was significantly inversely associated with distant metastasis (OR=0.17, p&lt;0.001) and local relapses (OR=0.17, p&lt;0.001), while that of 17βHSD2 trended towards correlation with the presence of metastasis (OR=3.47, p=0.055) and relapse (OR=3.14, p=0.07). Interestingly, ER and PR were not correlated with metastasis or relapse, but HER2 status positively correlated with distant metastasis during follow-up (OR=2.15, p=0.02) and trended to be associated with local relapses as well (OR=1.99, p=0.054). When evaluated according to the established breast cancer subtypes the only significant changes detected between subgroups were for AR and STS. AR was positive in a lesser proportion of the cases in the TNBC subgrouping (p=0.01), while STS was depleted in the luminal B and enriched in the HER2 subtypes (p=0.027). In an analysis of survival, STS was the only factor examined that was significantly associated with survival outcomes of the patients. Positive intratumoral STS status was significantly associated with improved survival (HR=0.27, p&lt;0.001). The inverse of this was also noticed for 17βHSD2 but the correlation did not reach statistical significance (HR=2.1, p=0.16).

Discussion and Conclusions: The results of our present study suggest that the intratumoral metabolism of estrogens through STS is associated with significantly lower incidence of relapse and/or distant metastasis and correspondingly a better prognosis. The inverse is also true when evaluating the trends noted with the expression of 17βHSD2 adding consistency to our finding above. The enrichment of STS in the HER2 overexpressing subtype of breast cancer is intriguing, especially given the possible role of HER-2 positivity in endocrine resistance. All in all, our results suggest that extended endocrine information about the intratumoral steroid metabolism of a given tumour may have so far unused prognostic potential and impact on clinical decision making.

Citation Format: McNamara KM, Guestini F, Sauer T, Lindstrøm JC, Sasano H, Geisler J. Steroid receptors and steroidogenic enzymes in human breast cancer: Associations with breast cancer subtypes and clinical outcome [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-05-08.

How to implement Illness Management and Recovery (IMR) in mental health service settings: evaluation of the implementation strategy

Background

The purpose of this study was to evaluate the implementation strategy used in the first-phase of implementation of the Illness Management and Recovery (IMR) programme, an intervention for adults with severe mental illnesses, in nine mental health service settings in Norway.

Methods

A total of 9 clinical leaders, 31 clinicians, and 44 consumers at 9 service settings participated in the implementation of IMR. Implementation was conducted by an external team of researchers and an experienced trainer. Data were gathered on fidelity to the intervention and implementation strategy, feasibility, and consumer outcomes.

Results

Although the majority of clinicians scored within the acceptable range of high intervention fidelity, their participation in the implementation strategy appeared to moderate anticipated future use of IMR. No service settings reached high intervention fidelity scores for organizational quality improvement after 12 months of implementation. IMR implementation seemed feasible, albeit with some challenges. Consumer outcomes indicated significant improvements in illness self-management, severity of problems, functioning, and hope. There were nonsignificant positive changes in symptoms and quality of life.

Conclusions

The implementation strategy appeared adequate to build clinician competence over time, enabling clinicians to provide treatment that increased functioning and hope for consumers. Additional efficient strategies should be incorporated to facilitate organizational change and thus secure the sustainability of the implemented practice.

Trial registration ClinicalTrials.gov NCT02077829. Registered 25 February 2014

Are Users Satisfied with Assertive Community Treatment in Spite of Personal Restrictions?

The purpose of this explorative study was to examine satisfaction among 70 users of 12 Norwegian Assertive Community Treatment teams. The study was carried out among a group of 70 service users, and reveals generally high levels of satisfaction with the service, with satisfaction also being high in comparison to other ACT satisfaction studies. Users under a Community Treatment Order were more satisfied, while users with an alcohol use disorder were less satisfied. Younger service users were less positive than older users. There was no difference in satisfaction between the genders. This study's positive result may reflect the ACT model's focus on user involvement, recovery and building relationships, and the fact that this service has a more holistic approach than previous services that users have experienced.

Psychometric properties of the Norwegian version of the Evidence-Based Practice Attitude Scale (EBPAS): to measure implementation readiness

BACKGROUND

Attitudes can be a precursor to the decision of whether or not to try a new practice. In order to tailor the implementation of evidence-based practices (EBPs) in mental health settings, we must first consider practitioner attitudes towards EBP adoption. To assess these attitudes, the Evidence-Based Practice Attitude Scale (EBPAS) was developed. The purpose of this study was to investigate the psychometric properties of the Norwegian version of the EBPAS, and to examine differences in attitudes towards implementing EBPs among mental health practitioners.

METHODS

The EBPAS was translated into Norwegian and administered to 294 practitioners from seven primary and 22 specialized mental care units within a defined geographical area of Norway.

RESULTS

The EBPAS showed good psychometric properties. The less clinical experience the practitioner had, the more positive their attitude toward EBPs. Primary care practitioners reported more positive attitudes towards implementing EBPs that were required of them than specialized care practitioners.

CONCLUSIONS

The Norwegian version of the EBPAS is a promising tool for measuring implementation readiness in mental health services, and can be used in clinical practice to tailor implementation efforts.

TRIAL REGISTRATION

The study was approved by the regional committees for medical and health research ethics [ REK 2013/2035 ] on 25(th) of May, 2014.

Monitoring adverse events in Norwegian hospitals from 2010 to 2013

OBJECTIVES

To describe how adverse event (AE) rates were monitored and estimated nationally across all Norwegian hospitals from 2010 to 2013, and how they developed during the monitoring period. Monitoring was based on medical record review with Global Trigger Tool (GTT).

SETTING

All publicly and privately owned hospitals were mandated to review randomly selected medical records to monitor AE rates. The initiative was part of the Norwegian patient safety campaign, launched by the Norwegian Ministry of Health and Care Services. It started in January 2011 and lasted until December 2013. 2010 was the baseline for the review. One of the main aims of the campaign was to reduce patient harm.

METHOD

To standardise the medical record reviews in all hospitals, GTT was chosen as a standard method. GTT teams from all hospitals reviewed 40,851 medical records randomly selected from 2,249,957 discharges from 2010 to 2013. Data were plotted in time series for local measurement and national AE rates were estimated, plotted and monitored.

RESULTS

AE rates were estimated and published nationally from 2010 to 2013. Estimated AE rates in severity categories E-I decreased significantly from 16.1% in 2011 to 13.0% in 2013 (-3.1% (95% CI -5.2% to -1.1%)).

CONCLUSIONS

Monitoring estimated AE rates emerges as a potential element in national systems for patient safety. Estimated AE rates in the category of least severity decreased significantly during the first 2 years of the monitoring.