Fecal calcium levels of bird nestlings as a potential indicator of species-specific metal sensitivity

Sensitivity of bird species to environmental metal pollution varies but there is currently no general framework to predict species-specific sensitivity. Such information would be valuable from a conservation point-of-view. Calcium (Ca) has antagonistic effects on metal toxicity and studies with some common model species show that low dietary and circulating calcium (Ca) levels indicate higher sensitivity to harmful effects of toxic metals. Here we measured fecal Ca and five other macroelement (potassium K, magnesium Mg, sodium Na, phosphorus P, sulphur S) concentrations as proxies for dietary levels in 66 bird species to better understand their interspecific variation and potential use as an indicator of metal sensitivity in a wider range of species (the main analyses include 39 species). We found marked interspecific differences in fecal Ca concentration, which correlated positively with Mg and negatively with Na, P and S levels. Lowest Ca concentrations were found in insectivorous species and especially aerial foragers, such as swifts (Apodidae) and swallows (Hirundinidae). Instead, ground foraging species like starlings (Sturnidae), sparrows (Passeridae), cranes (Gruidae) and larks (Alaudidae) showed relatively high fecal Ca levels. Independent of phylogeny, insectivorous diet and aerial foraging seem to indicate low Ca levels and potential sensitivity to toxic metals. Our results, together with information published on fecal Ca levels and toxic metal impacts, suggest that fecal Ca levels are a promising new tool to evaluate potential metal-sensitivity of birds, and we encourage gathering such information in other bird species. Information on the effects of metals on breeding parameters in a wider range of bird species would also help in ranking species by their sensitivity to metal pollution.

Development of and adherence to an ERAS® and prehabilitation protocol for patients undergoing pancreatic surgery: An observational study

BACKGROUND AND OBJECTIVE

There are still gaps in knowledge concerning the adherence to different multimodal pathways in pancreatic surgery. The aim of this trial was to explore and evaluate an Enhanced Recovery After Surgery (ERAS®) and prehabilitation protocol in patients undergoing open pancreatic surgery.

METHODS

Three groups of patients were included: two prospective series of 75 patients undergoing open pancreatic surgery following an ERAS® protocol with or without prehabilitation, and one group of 55 historical controls. Variables regarding adherence to, and effects of the protocols, were collected from the local database and the patients' hospital records. Patients' adherence to advice given pre-operatively was followed up using a study-specific questionnaire.

RESULTS

The patients reported high adherence to remembered advice given. The health care professionals' adherence to the various parts of the concepts varied. ERAS® implementation resulted in more frequent gut motility stimulation (p < 0.001) and shorter duration of epidural anesthesia, site drains, and urinary catheter (p = 0.001). With prehabilitation, more patients were screened concerning nutritional status and prescribed preoperative training (p < 001). There was a significant change in weight before surgery, a shorter time to first flatus and a shorter length of stay after implementation of the concepts (p < 0.05). Complications were rare in all three groups and there were no significant differences between the groups.

CONCLUSION

The implementation of an ERAS® and a prehabilitation protocol increased adherence to the protocols by both patients and healthcare professionals. An implementation of an ERAS® protocol with and without prehabilitation decreases length of stay and may decrease preoperative weight loss and time to bowel movement.

Working on connective professionalism: What cross-sector strategists in Swedish public organizations do to develop connectivity in addressing ‘wicked’ policy problems

In light of current debates on ‘protective’ and ‘connective’ professionalism, this article explores a new type of occupational position that is emerging within the Swedish public sector: the cross-sector strategist. The growing presence of this intermediary occupational position is seen as attempts to formalize and institutionalize the imprecise roles and governance of ‘wicked’ policy problems, and the job of these strategists is focused on supporting other jurisdictions to meet and act. By pursuing connective strategies in the form of triggering, selling, bridging, brokering, and forming accountabilities, cross-sector strategists seek to establish embedded workspaces where strategic action and decisions can be produced jointly and across jurisdictional boundaries. The study illustrates how calls for changes in professional action towards connectivity are now part of the formal organizational structure of public sector organizations, confirming the incapability of professional actors to connect in the absence of intermediary support functions. In the concluding discussion, we consider the relevance of ‘connective professionalism’ as a descriptive theoretical device applied to work settings understood as increasingly complex and interdependent, with calls for inter-professional collaboration and intensifying engagement in preventing problems rather than simply treating them.

Nurturing innovative culture in a healthcare organisation - Lessons from a Swedish case study

PURPOSE

Healthcare organisations are often described as less innovative than other organisations, since organisational culture works against innovations. In this paper, the authors ask whether it has to be that way or whether is possible to nurture an innovative culture in a healthcare organisation. The aim of this paper is to describe and analyse nurturing an innovative culture within a healthcare organisation and how culture can support innovations in such a healthcare organisation.

DESIGN/METHODOLOGY/APPROACH

Based on a qualitative case study of a healthcare unit that changed, within a few years, from having no innovations to repeatedly generating innovations, the authors describe important aspects of how innovative culture can be nurtured in healthcare. Data were analysed using inductive and deductive analysis steps.

FINDINGS

The study shows that it is possible to nurture an innovative culture in a healthcare organisation. Relationships and competences beyond healthcare, empowering structures and signalling the importance of innovation work with resources all proved to be important. All are aspects that a manager can influence. In this case, the manager's role in nurturing innovative culture was very important.

PRACTICAL IMPLICATIONS

This study highlights that an innovative culture can be nurtured in healthcare organisations and that managers can play a key role in such a process.

ORIGINALITY/VALUE

The paper describes and analyses an innovative culture in a healthcare unit and identifies important conditions and strategies for nurturing innovative culture in healthcare organisations.

If It Is Complex, Let It Be Complex - Dealing With Institutional Complexity in Hospitals Comment on "Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?"

Waitzberg and colleagues identified strategies that managers and physicians in hospitals apply to reconcile dilemmas between clinical and economic considerations. Contributions that actually acknowledge the institutional complexity of hospitals and describe how to deal with it are rare. This comment explains the reason behind the institutional complexity in healthcare organizations and argues that institutional complexity is a good foundation for a well-functioning and sustainable healthcare, as long as we are able to deal with this complexity. This point underscores the importance of their contribution. However, even if the identified strategies on how to reconcile and balance different, competing demands are important, they are not easy to apply in practice. First, the strategies require frequent and high-quality interaction between different actors adhering to different institutional logics. Second, even when the strategies are applied successfully, it is difficult to make them sustainable since they rest on a fragile balance between competing logics. However, these are important avenues for future research for researchers who want to follow the route of Waitzberg and colleagues.

Clinicians' psychological empowerment to engage in management as part of their daily work

PURPOSE

The purpose of the article is to analyze how physicians and nurses, as the two major health care professions, experience psychological empowerment for managerial work.

DESIGN/METHODOLOGY/APPROACH

The study was designed as a qualitative interview study at four primary care centers (PCCs) in Sweden. In total, 47 interviews were conducted, mainly with physicians and nurses. The first inductive analysis led us to the concept of psychological empowerment, which was used in the next deductive step of the analysis.

FINDINGS

The study showed that both professions experienced self-determination for managerial work, but that nurses were more dependent on structural empowerment. Nurses experienced that they had competence for managerial work, whereas physicians were more ignorant of such competence. Nurses used managerial work to create impact on the conditions for their clinical work, whereas physicians experienced impact independently. Both nurses and physicians experienced managerial work as meaningful, but less meaningful than nurses and physicians' clinical work.

PRACTICAL IMPLICATIONS

For an effective health care system, structural changes in terms of positions, roles, and responsibilities can be an important route for especially nurses' psychological empowerment.

ORIGINALITY/VALUE

The qualitative method provided a complementary understanding of psychological empowerment on how psychological empowerment interacted with other factors. One such aspect was nurses' higher dependence on structural empowerment, but the most important aspect was that both physicians and nurses experienced that managerial work was less meaningful than clinical work. This implies that psychological empowerment for managerial work may only make a difference if psychological empowerment does not compete with physicians' and nurses' clinical work.

PACADI: translation and adaptation of a Swedish-language version of the pancreatic cancer disease impact score

Objective

The Norwegian pancreatic cancer disease impact score (PACADI) is a digitalized analogue questionnaire that assesses different disease-specific symptoms. There is a need of translations of it into other languages. Therefore, the aim of this article is to describe the translation process of a Swedish version of PACADI and present its validity to EORCT QLQ PAN26. The self-administered questionnaire PACADI was translated according to guidelines and assessed by an expert panel of health care personnel. The test of its validity was performed with the disease-specific questionnaire for EORCT QLQ PAN26. Both questionnaires were completed by 66 subjects with pancreatic cancer, either before, at discharge or three months after surgery.

Result

The results between the groups indicate that patients suffer from different symptoms at different times. The correlations between the different symptoms of the two questionnaires were fair to good. In conclusion, PACADI and QLQ PAN 26 have a good correlation and PACADI can be used in clinical practise.

Dyspnea and perfusion defects (V/Q scan) are common after an acute pulmonary embolus whereas chronic thromboembolic pulmonary hypertension (CTEPH) is a rare sequele

Introduction

Acute pulmonary embolism (PE), a common disease with substantial morbidity and mortality. Many previous studies have focused on the short-term consequences after an acute PE, but less attention has been directed to the long-term effects of a PE. The most feared complication is chronic thromboembolic pulmonary hypertension (CTEPH), with reported incidence rates ranging from 0.6 to 4.8%. Even though CTEPH is a rare complication after PE, dyspnea and functional impairment are common complaints, and a syndrome named PPES (post-PE-syndrome) has been suggested. The aim of this study was to follow a large national-wide cohort of post-PE-patients and to gather information regarding long-term symptoms and to determine the prevalence of CTEPH.

Patients and methods

We identified all patients diagnosed with acute PE in 2005 (ICD-10-SE: I26.0 and I26.9) that were registered in the Swedish National Patient Register (NPR), which has nearly 100% coverage.

In 2007, all surviving individuals were invited to participate by letter. They were asked to complete a questionnaire regarding symptoms and risk factors for long-term sequele including CTEPH.

Individuals who reported dyspnea or had known risk factors for CTEPH were invited to a follow-up with blood tests (NT-pro-BNP) and pulmonary scintigraphy. If any perfusion defects were detected, an echocardiography was performed. If signs of pulmonary hypertension, a referral was done to the regional PAH-center.

Results

In 2005, 5793 unique patients were admitted with a PE diagnosis in Sweden. Of those, 3510 were still alive in 2007, and 3226 individuals were contacted and asked to complete the questionnaire. Altogether 2105 (65%) individuals returned the questionnaire, and 53% reported dyspnea and 15% were asymptomatic but had risk factors for CTEPH. Altogether 944 individuals were referred for further follow-up including a recommendation to perform a V/Q-scan. Altogether 530 V/Q-scans were performed and 44% showed perfusion defects, whereof 85% had an echocardiography. Twenty-seven % of them registered a systolic right ventricular pressure of at least 30 mmHg. Referrals resulted in 6 cases with proved CTEPH. In parallel, 10 patients with CTEPH diagnosed before 2005 were detected, and 8 patients were diagnosed after 2005 and outside the study.Altogether 24 patients with CTEPH were thus identified and the cumulative incidence of CTEPH ranged between 0.7 and 1.2%.

Conclusion

Dyspnea is common after an acute PE and over 40% of them have perfusion defects on a V/Q scan, suggesting the presence of a post PE-syndrome (PPES). The incidence of CTEPH is however low. More research is needed to better define PPES.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Actelion PharamceuticalsSwedish Heart and Lung Foundation

Using systems thinking to increase understanding of the innovation system of healthcare organisations

PURPOSE

This paper applies systems thinking modelling to enhance the dynamic understanding of how to nurture an innovative culture in healthcare organisations to develop the innovation system in practice and speed up the innovative work. The model aims to provide a holistic view of a studied healthcare organisation's innovation processes, ranging from managerial values to its manifestation in improved results.

DESIGN/METHODOLOGY/APPROACH

The study is based on empirical material from a healthcare unit that, within a few years, changed from having no innovations to repeatedly generating innovations. The study uses the modelling language of causal loop diagrams (CLDs) in the system dynamics methodology to identify the key important aspects found in the empirical material.

FINDINGS

The proposed model, based on the stories of the interviewees, explores the dynamics of inertia when nurturing an innovative culture, identifying delays attributed to the internal change processes and system relationships. These findings underscored the need for perseverance when developing an innovative culture in the entrepreneurial phases.

PRACTICAL IMPLICATIONS

The approach of using systems thinking to make empirical healthcare research results more tangible through the visual notations of CLDs and mental simulations is believed to support exploring complex phenomena to induce and nurture both individual and organisational learning.

ORIGINALITY/VALUE

The results from this approach provide deepened analysis and provoke the systems view to explain how the nurturing of the culture can accelerate the innovation processes, which helps practitioners and researchers to further expand their understanding of their healthcare contexts.

Neuropsychiatric Symptoms in Dementia: Considering a Clinical Role for Electroencephalography

OBJECTIVE

Degenerative dementia is characterized by progressive cognitive decline and neuropsychiatric symptoms. People with Alzheimer's disease (AD), the most common cause of dementia, show synaptic loss and disruption of functional brain networks along with neuritic plaques and neurofibrillary tangles. Electroencephalography (EEG) directly reflects synaptic activity, and among patients with AD it is associated with slowing of background activity. The purpose of this study was to identify associations between neuropsychiatric symptoms and EEG in patients with dementia and to determine whether EEG parameters could be used for clinical assessment of pharmacological treatment of neuropsychiatric symptoms in dementia (NPSD) with galantamine or risperidone.

METHODS

Seventy-two patients with EEG recordings and a score ≥10 on the Neuropsychiatric Inventory (NPI) were included. Clinical assessments included administration of the NPI, the Mini-Mental State Examination (MMSE), and the Cohen-Mansfield Agitation Inventory (CMAI). Patients underwent EEG examinations at baseline and after 12 weeks of treatment with galantamine or risperidone. EEG frequency analysis was performed. Correlations between EEG and assessment scale scores were statistically examined, as were EEG changes from baseline to the week 12 visit and the relationship with NPI, CMAI, and MMSE scores.

RESULTS

Significant correlations were found between NPI agitation and delta EEG frequencies at baseline and week 12. No other consistent and significant relationships were observed between NPSD and EEG at baseline, after NPSD treatment, or in the change in EEG from baseline to follow-up.

CONCLUSIONS

The limited informative findings in this study suggest that there exists a complex relationship between NPSD and EEG; hence, it is difficult to evaluate and use EEG for clinical assessment of pharmacological NPSD treatment.

Family members as hybrid owner-managers in family-owned newspaper companies: handling multiple institutional logics

Purpose

This article aims to increase the understanding of the role of individual actors and arenas in dealing with multiple institutional logics in family firms.

Design/methodology/approach

This study follows a case-study approach of two family-owned newspaper companies. Based on interviews and secondary sources, the empirical material was analysed focussing on three institutional logics, that is, family logic, management logic and journalistic logic.

Findings

First, the authors show how and in which arenas competing logics are balanced in family-owned newspaper companies. Second, the authors highlight that family owners are central actors in the process of balancing different institutional logics. Further, they analyse how family members can become hybrid owner-managers, meaning that they have access to all institutional logics and become central actors in the balancing process.

Originality/value

The authors reveal how multiple institutional logics are balanced in family firms by including formal actors and arenas as additional lenses. Therefore, owning family members, especially hybrid owner-managers, are the best-suited individual actors to balance competing logics. Hybrid owner-managers are members of the owner families who are also skilled in one or several professions.

The degradation map process - a tool for obtaining a lean stability strategy in drug development

Stability is fundamental when exploring a drug candidate's potential as a drug product. During the pharmaceutical industry drug development process information regarding stability and degradation are captured in different departments, e.g. from discovery to operations, and will be included in the overall control strategy. With a profound understanding of a drug candidate's degradation chemistry, a science and risk based approach in progressing a lean stability strategy is possible. This case study present a clear and visible concept to facilitate a lean stability strategy by the use of degradation maps and describes a process for how these can be used during drug development. The understanding of possible and/or observed degradation pathways will guide the design of the drug product and stability studies in development. A degradation map displays degradation pathways with short comments on the reaction/mechanism involved. The degradation map process starts with a theoretical degradation map. The map is updated as the drug project progresses, preferably after forced degradation experiments, after compatibility studies and finally when the late stage formulation is set. The degradation map should be used to capture information of intrinsic chemical properties of the active pharmaceutical ingredient (API) and can thereby be used to mitigate stability issues. The map is foremost a cross-functionally available tool collecting and visualizing stability information throughout the development process, and as such a valuable tool to efficiently develop a lean stability strategy.

Can machine learning augment clinician adjudication of events in cardiovascular trials? A case study of major adverse cardiovascular events (MACE) across CVRM trials

Background and introduction

Accurate identification of clinical outcome events is critical to obtaining reliable results in cardiovascular outcomes trials (CVOTs). Current processes for event adjudication are expensive and hampered by delays. As part of a larger project to more reliably identify outcomes, we evaluated the use of machine learning to automate event adjudication using data from the SOCRATES trial (NCT01994720), a large randomized trial comparing ticagrelor and aspirin in reducing risk of major cardiovascular events after acute ischemic stroke or transient ischemic attack (TIA).

Purpose

We studied whether machine learning algorithms could replicate the outcome of the expert adjudication process for clinical events of ischemic stroke and TIA. Could classification models be trained on historical CVOT data and demonstrate performance comparable to human adjudicators?

Methods

Using data from the SOCRATES trial, multiple machine learning algorithms were tested using grid search and cross validation. Models tested included Support Vector Machines, Random Forest and XGBoost. Performance was assessed on a validation subset of the adjudication data not used for training or testing in model development. Metrics used to evaluate model performance were Receiver Operating Characteristic (ROC), Matthews Correlation Coefficient, Precision and Recall. The contribution of features, attributes of data used by the algorithm as it is trained to classify an event, that contributed to a classification were examined using both Mutual Information and Recursive Feature Elimination.

Results

Classification models were trained on historical CVOT data using adjudicator consensus decision as the ground truth. Best performance was observed on models trained to classify ischemic stroke (ROC 0.95) and TIA (ROC 0.97). Top ranked features that contributed to classification of Ischemic Stroke or TIA corresponded to site investigator decision or variables used to define the event in the trial charter, such as duration of symptoms. Model performance was comparable across the different machine learning algorithms tested with XGBoost demonstrating the best ROC on the validation set for correctly classifying both stroke and TIA.

Conclusions

Our results indicate that machine learning may augment or even replace clinician adjudication in clinical trials, with potential to gain efficiencies, speed up clinical development, and retain reliability. Our current models demonstrate good performance at binary classification of ischemic stroke and TIA within a single CVOT with high consistency and accuracy between automated and clinician adjudication. Further work will focus on harmonizing features between multiple historical clinical trials and training models to classify several different endpoint events across trials. Our aim is to utilize these clinical trial datasets to optimize the delivery of CVOTs in further cardiovascular drug development.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZenca Plc

Patients' perceptions of quality in Swedish primary care - a study of differences between private and public ownership

Purpose

The purpose of the paper is to describe and analyze differences in patients' quality perceptions of private and public primary care centers in Sweden.

Design/methodology/approach

The article explores the differences in quality perceptions between patients of public and private primary care centers based on data from a large patient survey in Sweden. The survey covers seven dimensions, and in this paper the measure Overall impression was used for the comparison. With more than 80,000 valid responses, the survey covers all primary care centers in Sweden which allowed for a detailed analysis of differences in quality perceptions among patients from the different categories of owners.

Findings

The article contributes with a detailed description of different types of private owners: not-for-profit and for profit, as well as corporate groups and independent care centers. The results show a higher quality perception for independent centers compared to both public and corporate groups.

Research limitations/implications

The small number of not-for-profit centers (21 out of 1,117 centers) does not allow for clear conclusions for this group. The results, however, indicate an even higher patient quality perception for not-for-profit centers. The study focus on describing differences in quality perceptions between the owner categories. Future research can contribute with explanations to why independent care centers receive higher patient satisfaction.

Social implications

The results from the study have policy implications both in a Swedish as well as international perspective. The differentiation between different types of private owners made in this paper opens up for interesting discussions on privatization of healthcare and how it affects patient satisfaction.

Originality/value

The main contribution of the paper is the detailed comparison of different categories of private owners and the public owners.

Providing healthcare through “value shops”: impact on professional fulfilment for physicians and nurses

Purpose

The purpose of this paper is to empirically explore and demonstrate the ability of healthcare professionals to attain professional fulfilment when providing healthcare inspired by “value shops”.

Design/methodology/approach

A qualitative case study incorporating interviews and observations was conducted.

Findings

The empirical data suggest that the professional fulfilment of both physicians and nurses is facilitated when care is organized through “value shops”. Both groups of professionals state that they are able to return to their “professional core”.

Originality/value

The beneficial outcomes of organizing healthcare inspired by the “value shop” have previously been explored in terms of efficiency and quality. However, the professional fulfilment of healthcare professionals when providing such care has not been explicitly addressed. Professional fulfilment is vital in order to safeguard high-quality care, as well as healthcare professionals' involvement and engagement in implementing quality improvements. This paper highlights the fact that care provision inspired by the “value shop” may facilitate professional fulfilment, which further strengthens the potential positive outcomes of the “value shop” when utilized in a healthcare setting.

Histological stroke clot analysis after thrombectomy: Technical aspects and recommendations

The recent advent of endovascular procedures has created the unique opportunity to collect and analyze thrombi removed from cerebral arteries, instigating a novel subfield in stroke research. Insights into thrombus characteristics and composition could play an important role in ongoing efforts to improve acute ischemic stroke therapy. An increasing number of centers are collecting stroke thrombi. This paper aims at providing guiding information on thrombus handling, procedures, and analysis in order to facilitate and standardize this emerging research field.

EEG time signature in Alzheimer´s disease: Functional brain networks falling apart

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EEG microstate topographies differ between controls and memory clinic patients.

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Microstate parameters differ in a gradient-like manner in SCD, MCI and AD patients.

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Changes in topography of microstate class C correlate with CSF Aβ42 levels.

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Changes in topography of microstate class B correlate with CSF p-tau levels.

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EEG microstates detect early disruption of neurocognitive networks in AD.

Spontaneous mental activity is characterized by dynamic alterations of discrete and stabile brain states called functional microstates that are thought to represent distinct steps of human information processing. Electroencephalography (EEG) directly reflects functioning of brain synapses with a uniquely high temporal resolution, necessary for investigation of brain network dynamics. Since synaptic dysfunction is an early event and best correlate of cognitive status and decline in patients along Alzheimer's disease (AD) continuum, EEG microstates might serve as valuable early markers of AD. The present study investigated differences in EEG microstate topographies and parameters (duration, occurrence and contribution) between a large cohort of healthy elderly (n = 308) and memory clinic patients: subjective cognitive decline (SCD, n = 210); mild cognitive impairment (MCI, n = 230) and AD (n = 197) and how they correlate to conventional cerebrospinal fluid (CSF) markers of AD. Four most representative microstate maps assigned as classes A, B (asymmetrical), C and D (symmetrical) were computed from the resting state EEGs since it has been shown previously that this is sufficient to explain most of the resting state EEG data. Statistically different topography of microstate maps were found between the controls and the patient groups for microstate classes A, C and D. Changes in the topography of microstate class C were associated with the CSF Aβ42 levels, whereas changes in the topography of class B were linked with the CSF p-tau levels. Gradient-like increase in the contribution of asymmetrical (A and B) and gradient-like decrease in the contribution of symmetrical (C and D) maps were observed with the more severe stage of cognitive impairment. Our study demonstrated extensive relationship of resting state EEG microstates topographies and parameters with the stage of cognitive impairment and AD biomarkers. Resting state EEG microstates might therefore serve as functional markers of early disruption of neurocognitive networks in patients along AD continuum.

Correction to: The unexplained success of stentplasty vasospasm treatment : Insights using Mechanistic Mathematical Modeling

Correction to: Clin Neuroradiol 2019 https://doi.org/10.1007/s00062-019-00776-2 The original version of this article unfortunately contained a mistake. The Acknowledgements were missing. The correct information is given ….

The unexplained success of stentplasty vasospasm treatment : Insights using Mechanistic Mathematical Modeling

BACKGROUND

Cerebral vasospasm (CVS) following subarachnoid hemorrhage occurs in up to 70% of patients. Recently, stents have been used to successfully treat CVS. This implies that the force required to expand spastic vessels and resolve vasospasm is lower than previously thought.

OBJECTIVE

We develop a mechanistic model of the spastic arterial wall to provide insight into CVS and predict the forces required to treat it.

MATERIAL AND METHODS

The arterial wall is modelled as a cylindrical membrane using a constrained mixture theory that accounts for the mechanical roles of elastin, collagen and vascular smooth muscle cells (VSMC). We model the pressure diameter curve prior to CVS and predict how it changes following CVS. We propose a stretch-based damage criterion for VSMC and evaluate if several commercially available stents are able to resolve vasospasm.

RESULTS

The model predicts that dilatation of VSMCs beyond a threshold of mechanical failure is sufficient to resolve CVS without damage to the underlying extracellular matrix. Consistent with recent clinical observations, our model predicts that existing stents have the potential to provide sufficient outward force to successfully treat CVS and that success will be dependent on an appropriate match between stent and vessel.

CONCLUSION

Mathematical models of CVS can provide insights into biological mechanisms and explore treatment approaches. Improved understanding of the underlying mechanistic processes governing CVS and its mechanical treatment may assist in the development of dedicated stents.

Swedish consensus reached on recording, interpretation and reporting of neonatal continuous simplified electroencephalography that is supported by amplitude-integrated trend analysis

Continuous monitoring of electroencephalography (EEG), with a focus on amplitude-integrated EEG (aEEG), has been used in neonatal intensive care for decades. A number of systems have been suggested for describing and quantifying aEEG patterns. Extensive full-montage EEG monitoring is used in specialised intensive care units. The American Clinical Neurophysiology Society published recommendations for defining and reporting EEG findings in critically ill adults and infants. Swedish neonatologists and clinical neurophysiologists collaborated to optimise simplified neonatal continuous aEEG and EEG recordings based on these American documents.

CONCLUSION

This paper describes the Swedish consensus document produced by those meetings.

Healthcare quality improvement work: a professional employee perspective

Purpose The purpose of this paper is to describe and analyze conditions that influence how employees engage in healthcare quality improvement (QI) work. Design/methodology/approach Qualitative case study based on interviews ( n=27) and observations ( n=10). Findings The main conditions that influence how employees engage in healthcare QI work are professions, work structures and working relationships. These conditions can both prevent and facilitate healthcare QI. Professions and work structures may cement existing institutional logics and thus prevent employees from engaging in healthcare QI work. However, attempts to align QI with professional logics, together with work structures that empower employees, can make these conditions increase employee engagement, which can be accomplished through positive working relationships that foster institutional work, which bridge different competing institutional logics, making it possible to overcome barriers that professions and work structures may constitute. Practical implications Understanding the conditions that influence how employees engage in healthcare QI work will make initiatives more likely to succeed. Originality/value Healthcare QI has mainly been studied from an implementer perspective, and employees have either been neglected or seen as passive resisters. Weak employee perspectives make healthcare QI research incomplete. In our research, healthcare QI work is studied closely at the actor level to understand healthcare QI from an employee perspective.

Serious life events and the risk of latent autoimmune diabetes in adults (LADA) and Type 2 diabetes

AIM

It has been suggested that experiencing serious life events may promote Type 1 diabetes in children. Studies in adults are lacking, as are studies on the interaction of life events with genetic factors. We aimed to investigate life events and the risk of latent autoimmune diabetes in adults (LADA) and Type 2 diabetes while taking into account HLA genotype.

METHODS

Analysis was based on 425 incident cases of LADA, 1417 incident cases of Type 2 diabetes and 1702 population-based controls recruited in Sweden between 2010 and 2016. Self-reported information on life events including conflicts, divorce, illness/accidents, death and financial problems experienced during the 5 years preceding diagnosis/index year was used. Odds ratios (ORs) and 95% confidence intervals (95% CI) were calculated by logistic regression and adjusted for age, sex, BMI, family history of diabetes, smoking, physical activity and education.

RESULTS

Overall there was no association between experience of any life event and either LADA (OR 0.86, 95% CI 0.68-1.08) or Type 2 diabetes (OR 1.00, 95% CI 0.83-1.21). The results were similar for individual events as well as in separate analysis of men and women. Similar results were seen in more autoimmune LADA (glutamic acid decarboxylase antibodies > median) [OR (any life event) 0.88, 95% CI 0.64-1.21] and in LADA carriers of the high-risk HLADR4-DQ8 genotype (OR 0.89, 95% CI 0.61-1.29).

CONCLUSIONS

Our findings indicate that experience of a serious life event, including the death of a family member, divorce or financial problems, is not associated with an increased risk of LADA, overall or in genetically susceptible individuals.

How long do centenarians survive? Life expectancy and maximum lifespan

OBJECTIVES

The purpose of this study was to explore the pattern of mortality above the age of 100 years. In particular, we aimed to examine whether Scandinavian data support the theory that mortality reaches a plateau at particularly old ages. Whether the maximum length of life increases with time was also investigated.

METHODS

The analyses were based on individual level data on all Swedish and Danish centenarians born from 1870 to 1901; in total 3006 men and 10 963 women were included. Birth cohort-specific probabilities of dying were calculated. Exact ages were used for calculations of maximum length of life. Whether maximum age changed over time was analysed taking into account increases in cohort size.

RESULTS

The results confirm that there has not been any improvement in mortality amongst centenarians in the past 30 years and that the current rise in life expectancy is driven by reductions in mortality below the age of 100 years. The death risks seem to reach a plateau of around 50% at the age 103 years for men and 107 years for women. Despite the rising life expectancy, the maximum age does not appear to increase, in particular after accounting for the increasing number of individuals of advanced age.

CONCLUSION

Mortality amongst centenarians is not changing despite improvements at younger ages. An extension of the maximum lifespan and a sizeable extension of life expectancy both require reductions in mortality above the age of 100 years.

Family history of type 1 and type 2 diabetes and risk of latent autoimmune diabetes in adults (LADA)

BACKGROUND

A family history of diabetes (FHD) is a strong predictor of diabetes risk, yet has rarely been investigated in latent autoimmune diabetes in adults (LADA). This study therefore investigated the risk of LADA and type 2 diabetes (T2D) in relation to FHD, taking into account the type of diabetes in relatives.

METHODS

Data from a population-based study were used, including incident cases of LADA [glutamic acid decarboxylase antibody (GADA)-positive, n=378] and T2D (GADA-negative, n=1199), and their matched controls (n=1484). First-degree relatives with disease onset at age<40 years and taking insulin treatment were classified as type 1 diabetes (T1D) or, if otherwise, as T2D. Odds ratios (ORs) were adjusted for age, gender, BMI, education and smoking. Cases were genotyped for high- and low-risk HLA genotypes.

RESULTS

Both FHD-T1D (OR: 5.8; 95% CI: 3.2-10.3) and FHD-T2D (OR: 1.9; 95% CI: 1.5-2.5) were associated with an increased risk of LADA, whereas the risk of T2D was associated with FHD-T2D (OR: 2.7; 95% CI: 2.2-3.3), but not FHD-T1D. In LADA patients, FHD-T1D vs FHD-T2D was associated with higher GADA but lower C-peptide levels, lower prevalence of low-risk HLA genotypes (5.0% vs 28.6%, respectively; P=0.038) and a tendency for higher prevalence of high-risk genotypes (90.0% vs 69.1%, respectively; P=0.0576).

CONCLUSION

The risk of LADA is substantially increased with FHD-T1D but also, albeit significantly less so, with FHD-T2D. This supports the idea of LADA as a mix of both T1D and T2D, but suggests that the genes related to T1D have greater impact. LADA patients with FHD-T1D had more T1D-like features, emphasizing the heterogeneity of LADA.

Smokeless tobacco (snus) is associated with an increased risk of type 2 diabetes: results from five pooled cohorts

BACKGROUND

Smoking and nicotine exposure increase insulin resistance and the risk of type 2 diabetes. Swedish smokeless tobacco (snus) is high in nicotine, and its use is prevalent in Scandinavian countries, but few studies have investigated snus use in relation to diabetes risk.

OBJECTIVE

To explore the association between snus use and risk of type 2 diabetes using pooled data from five cohorts.

METHODS

Analyses were based on prospective studies conducted between 1990 and 2013 including 54 531 never-smoking men and 2441 incident cases of type 2 diabetes identified through screening, self-reporting and hospital and prescription registries. Hazard ratios (HRs) and 95% confidence intervals (CIs) were assessed and adjusted for age, body mass index, educational level, alcohol consumption and physical activity.

RESULTS

Compared to never users, the HR of type 2 diabetes was 1.15 (95% CI: 1.00-1.32) in current users of snus. In individuals consuming 5-6 boxes per week, the HR was 1.42 (95% CI: 1.07-1.87); in those consuming ≥7 boxes per week, the HR was 1.68 (95% CI: 1.17-2.41). Each additional box of snus consumed per week yielded an HR of 1.08 (95% CI: 1.01-1.16).

CONCLUSION

Our findings indicate that high consumption of snus is a risk factor for type 2 diabetes. The risk was similar to that in smokers, implying that smokers will not reduce their risk of type 2 diabetes by changing to snus use. The results also support the notion that nicotine increases the risk of type 2 diabetes.

Use of Swedish smokeless tobacco (snus) and the risk of Type 2 diabetes and latent autoimmune diabetes of adulthood (LADA)

AIMS

It has been suggested that moist snuff (snus), a smokeless tobacco product that is high in nicotine and widespread in Scandinavia, increases the risk of Type 2 diabetes. Previous studies are however few, contradictory and, with regard to autoimmune diabetes, lacking. Our aim was to study the association between snus use and the risk of Type 2 diabetes and latent autoimmune diabetes of adulthood (LADA).

METHOD

Analyses were based on incident cases (Type 2 diabetes, n = 724; LADA, n = 200) and population-based controls (n = 699) from a Swedish case-control study. Additional analyses were performed on cross-sectional data from the Norwegian HUNT study (n = 21 473) with 829 prevalent cases of Type 2 diabetes. Odds ratios (OR) were estimated adjusted for age, BMI family history of diabetes and smoking. Only men were included.

RESULTS

No association between snus use and Type 2 diabetes or LADA was seen in the Swedish data. For Type 2 diabetes, the OR for > 10 box-years was 1.00 [95% confidence interval (CI), 0.47 to 2.11] and for LADA 1.01 (95% CI, 0.45 to 2.29). Similarly, in HUNT, the OR for Type 2 diabetes in ever-users was estimated at 0.91 (95% CI, 0.75 to 1.10) and in heavy users at 0.92 (95% CI, 0.46 to 1.83).

CONCLUSION

The risk of Type 2 diabetes and LADA is unrelated to the use of snus, despite its high nicotine content. This opens the possibility of the increased risk of Type 2 diabetes seen in smokers may not be attributed to nicotine, but to other substances in tobacco smoke.

Preformulation investigation and challenges; salt formation, salt disproportionation and hepatic recirculation

A compound, which is a selective peroxisome proliferator activated receptor (PPAR) agonist, was investigated. The aim of the presented studies was to evaluate the potential of the further development of the compound. Fundamental physicochemical properties and stability of the compound were characterized in solution by liquid chromatography and NMR and in solid-state by various techniques. The drug itself is a lipophilic acid with tendency to form aggregates in solution. The neutral form was only obtained in amorphous form with a glass-transition temperature of approximately 0°C. The intrinsic solubility at room temperature was determined to 0.03mg/mL. Chemical stability studies of the compound in aqueous solutions showed good stability for at least two weeks at room temperature, except at pH1, where a slight degradation was already observed after one day. The chemical stability in the amorphous solid-state was investigated during a period of three months. At 25°C/60% relative humidity (RH) and 40°C/75% RH no significant degradation was observed. At 80°C, however, some degradation was observed after four weeks and approximately 3% after three months. In an accelerated photostability study, degradation of approximately 4% was observed. Attempts to identify a crystalline form of the neutral compound were unsuccessful, however, salt formation with tert-butylamine, resulted in crystalline material. Results from stability tests of the presented crystalline salt form indicated improved chemical stability at conditions whereas the amorphous neutral form degraded. However, the salt form of the drug dissociated under certain conditions. The drug was administered both per oral and intravenously, as amorphous nanoparticles, to conscious dogs. Plasma profiles showed curves with secondary absorption peaks, indicating hepatic recirculation following both administration routes. A similar behavior was observed in rats after oral administration of a pH-adjusted solution. The observed double peaks in plasma exposure and the dissociation tendency of the salt form, were properties that contributed to make further development of the candidate drug challenging. Options for development of solid dosage forms of both amorphous and crystalline material of the compound are discussed.

Optimization, validation, and identification of two reliable antibodies for immunodetection of WNT5A

WNT5A is a secreted, noncanonical WNT signaling protein that has been reported to promote progression of several types of cancer, including oral squamous cell carcinoma. Many WNT5A antibodies are available commercially for immunohistochemistry (IHC) and western blot analysis. Validation of the primary antibodies, however, is often neglected. We characterized antibodies for detecting WNT5A by IHC and western blot analysis. We evaluated one polyclonal and three monoclonal commercially available WNT5A antibodies. After optimization of the IHC assay, all four antibodies showed cytoplasmic WNT5A expression in tissue samples; in contrast, only one antibody detected WNT5A in western blots. A pre-absorption test with recombinant WNT5A showed that AF645 and 3A4 antibodies specifically detected WNT5A in different assays. We suggest that the monoclonal 3A4 antibody is the most appropriate for use with IHC, while the polyclonal AF645 antibody is the best for western blot analysis.

H.E.S.S. Limits on Linelike Dark Matter Signatures in the 100 GeV to 2 TeV Energy Range Close to the Galactic Center

A search for dark matter linelike signals iss performed in the vicinity of the Galactic Center by the H.E.S.S. experiment on observational data taken in 2014. An unbinned likelihood analysis iss developed to improve the sensitivity to linelike signals. The upgraded analysis along with newer data extend the energy coverage of the previous measurement down to 100 GeV. The 18 h of data collected with the H.E.S.S. array allow one to rule out at 95% C.L. the presence of a 130 GeV line (at l=-1.5°, b=0° and for a dark matter profile centered at this location) previously reported in Fermi-LAT data. This new analysis overlaps significantly in energy with previous Fermi-LAT and H.E.S.S.

RESULTS

No significant excess associated with dark matter annihilations was found in the energy range of 100 GeV to 2 TeV and upper limits on the gamma-ray flux and the velocity weighted annihilation cross section are derived adopting an Einasto dark matter halo profile. Expected limits for present and future large statistics H.E.S.S. observations are also given.

Effect of Interferon on T1 Relaxation Times of Liver Metastases from Endocrine Gastrointestinal Tumours

Eight patients with liver metastases from endocrine gastrointestinal tumours were examined with magnetic resonance imaging of the liver before and during treatment with interferon. T1, T2 and tumour size were measured and compared with tumour marker levels and symptomatic improvement or deterioration. Before therapy all tumours showed a long T1 and T2, in comparison to normal liver and fat, and during therapy they all showed a decrease in T1. As no change in liver T1 and fat T1 occurred, the decreased tumour T1 is considered to be a therapy effect. This cannot be fully explained but is possibly due to a reduction in tumour growth rate during interferon treatment. There was no certain correlation between tumour T1 and tumour marker levels or symptomatic changes.

Ultrasound Monitored Laser-Induced Local Hyperthermia in the Liver

Ultrasound (US) was used to monitor the size of tissue necrosis generated by Nd-YAG laser-induced local interstitial hyperthermia and tissue coagulation in 8 normal pig livers. Four treatments were done in each liver with 4 different energy settings. The size of the tissue necrosis measured on specimens was compared to the size measured on US. The laser energy caused a round tissue necrosis with some charring in the centre surrounded by a zone of white necrosis and a thin border of hyperaemia. A good correlation was found between the true and US-measured size of the necrosis diameters. It therefore seems possible to safely guide and monitor local laser hyperthermia in the liver with real-time US. The water-cooled quartz fibre used in this study has, however, some limitations.

Angiography, Computed Tomography, Magnetic Resonance Imaging and Ultrasonography in Detection of Liver Metastases from Endocrine Gastrointestinal Tumours

Twenty-five patients with endocrine tumours (13 with endocrine pancreatic tumours and 12 with carcinoids) were examined with angiography, computed tomography, magnetic resonance imaging and ultrasonography. Seventeen patients had liver metastases and were followed between 3 and 66 months with serial examinations during treatment with chemotherapeutic agents and interferon. The efficiency of the various techniques to detect metastases was investigated. Analysis of changes in tumour size during treatment was made to see if treatment effects could be monitored with radiologic examinations. Ultrasonography was the best non-invasive method for detection of metastases and is recommended as standard method for imaging in this group of patients. Angiography was even better showing extremely small metastases, less than 5 mm, and is recommended in selected cases. With one exception, no significant change in tumour size was noted in spite of clear laboratory and clinical signs of therapy effect indicating that tumour size determination is not useful for therapy monitoring in this type of disease.

Field-Echo Pulse Sequences Used under Suspended Respiration for Detection of Liver Metastases

To obtain a fast MRI sequence for detection of liver metastases under suspended respiration, two healthy volunteers were examined with the field echo sequence FLASH, using a large number of repetition times, echo times, flip angles and matrix sizes. The spleen was used to simulate liver metastases and contrast-to-noise ratios between liver and spleen were calculated and the sequence with the highest ratio was considered optimal. The different FLASH sequences were also compared with spin echo sequences using short repetition and echo times. A FLASH sequence with a repetition time of 140 ms, an echo time of 14 ms, a flip angle of 80 to 100 degrees and a matrix size of 128×256 was considered the most suitable for detecting liver metastases. This sequence, together with other FLASH and spin echo sequences, were used for examination of five patients with liver metastases from endocrine gastrointestinal tumours.

Contrast Enhancement of Pathologic Lymph Nodes Demonstrated by Computed Tomography

Enlarged mediastinal, retroperitoneal and pelvic lymph nodes are often difficult to differentiate from vascular structures. Contrast medium is therefore used to help to discriminate arteries and veins from lymph nodes. This study was undertaken to investigate the degree to which pathologic lymph nodes become enhanced after an intravenous bolus injection of contrast medium. Computed tomography was performed in 25 patients with enlargement of retroperitoneal lymph nodes due to primary lymphoproliferative disease or metastases. A dynamic sequence of a well delineated lymph node was obtained over a period of two minutes. Contrast enhancement was seen in all lymph nodes, but of varying degree. The enhancement was correlated to that observed in the inferior vena cava. Most examined lymph nodes showed slight or moderate enhancement, but in five instances strong enhancement, more than 75 per cent of that of the vena cava, was found. These nodes could possibly have been misinterpreted as blood vessels.

Ultrasound Guided Needle Biopsy of Brain Tumors Using an Automatic Sampling Instrument

All ultrasound (US) guided needle biopsies of brain tumors performed during an 8-year period were reviewed. Tissue samples were obtained in 112 of 115 biopsy procedures, and a histologic diagnosis was established in 99 cases (88.4%). The rate of major complications was 8.0%. The mortality is similar as in reports on stereotactic and CT-guided biopsy procedures while the morbidity is higher in our material. There are no large series available on US guided intracranial biopsy with adequate reports of complications. A modified biopsy technique is introduced here using a cutting needle and an automatic sampling instrument. The modified technique, which has been used in all cases since 1985, yielded diagnostic material in 91.5%. This method consistently provides a tissue core which is essential for a confident histopathologic diagnosis.

Ultrasound Guided Tumour Biopsy in the Anterior Mediastinum

To evaluate percutaneous ultrasound (US) guided tumour biopsy of the anterior mediastinum all patients scheduled for open mediastinal biopsy were considered for percutaneous biopsy during a 2-year period. US guided biopsy was chosen when CT had shown the tumour to be in contact with the thoracic wall. US guided biopsy was performed in 23 patients on 28 occasions. The procedure was technically successful in all cases and no complications occurred. In 27 of 28 cases the biopsy diagnosis was identical to the final diagnosis. In one patient with a malignant lymphoma a false diagnosis of connective tissue remnant was reached. US guided tumour biopsy of the anterior mediastinum is a safe, cost-effective and reliable method and a good alternative to the traditional biopsy techniques via mediastinoscopy or thoracotomy.