Childhood atopic disorders in relation to placental changes-A systematic review and meta-analysis

Fetal programming may arise from prenatal exposure and increase the risk of diseases later in life, potentially mediated by the placenta. The objective of this systematic review was to summarize and critically evaluate publications describing associations between human placental changes and risk of atopic disorders during childhood. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The inclusion criteria were original research articles or case reports written in English describing a human placental change in relation to disease occurring in offspring during childhood. The MEDLINE and EMBASE databases were searched for eligible studies. Risk of bias (RoB) was assessed using the ROBINS-I tool. The results were pooled both in a narrative way and by a meta-analysis. Nineteen studies were included (n = 12,997 participants). All studies had an overall serious RoB, and publication bias could not be completely ruled out. However, five studies showed that histological chorioamnionitis in preterm-born children was associated with asthma-related problems (pooled odds ratio = 3.25 (95% confidence interval = 2.22-4.75)). In term-born children, a large placenta (≥750 g) increased the risk of being prescribed anti-asthma medications during the first year of life. Placental histone acetylation, DNA methylation, and gene expression differences were found to be associated with different atopic disorders in term-born children. There is some evidence supporting the idea that the placenta can mediate an increased risk of atopic disorders in children. However, further studies are needed to validate the findings, properly control for confounders, and examine potential mechanisms.

In the eye of the ophthalmologist: the corneal microbiome in microbial keratitis

PURPOSE

To describe the bacterial findings by a targeted sequencing approach from corneal samples of patients with microbial keratitis and factors influencing culture outcome of indirectly inoculated corneal specimen.

METHODS

Prospective inclusion of patients fulfilling predefined criteria of microbial keratitis. Samples from the corneal lesion were collected and dispensed in liquid transport medium, from which both culture and targeted amplification and sequencing of the V3-V4 region of the 16S rRNA gene were carried out. Additional standard corneal culture from the corneal lesions was also performed. Factors influencing culture outcome of indirectly inoculated corneal samples were identified by a multivariate regression model incorporating quantitative data from sequencing.

RESULTS

Among the 94 included patients with microbial keratitis, contact lens wear (n = 69; 73%) was the most common risk factor. Contact lens wearers displayed significant differences in the bacterial community composition of the corneal lesion compared to no lens wearers, with higher abundance of Staphylococcus spp., Corynebacterium spp., and Stenotrophomonas maltophilia. Targeted sequencing detected a potential corneal pathogen in the highest proportional abundance among 9 of the 24 (38%) culture-negative patients with microbial keratitis. Age, bacterial density in the sample, and prior antibiotic treatment significantly influenced culture outcome of indirectly inoculated corneal samples.

CONCLUSION

Targeted sequencing may provide insights on pathogens in both culture negative episodes of microbial keratitis and among subgroups of patients with microbial keratitis as well as factors influencing culture outcome of indirectly inoculated corneal samples.

Informal caregivers' experiences of support from a tailored primary healthcare unit for older adults - A focus group study

BACKGROUND

Informal caregivers are an essential part of health and social care systems worldwide. As such, they may need professional support.

AIM

The aim of this study was to describe informal caregivers' experiences and need for support from a tailored primary health care (PHC) unit.

METHODS

This is a qualitative descriptive study using data collected from five semi-structured focus group discussions with a purposeful sample of 16 informal caregivers of older relatives. Respondents were recruited from a tailored PHC unit for people aged 75 years or older in a region in central Sweden. The data were analysed by qualitative content analysis with an abductive approach, based on the principles of the patient- and family-centred care framework.

RESULTS

The overarching theme was 'Striving for partnership'. The findings indicate that informal caregivers to some extent felt supported by the healthcare professionals. However, the caregivers expressed a need to be further acknowledged by the professionals in order to participate in the care of their older relatives in the way they wanted. Moreover, insufficient information regarding the older adult's health condition and care provided by the professionals had a negative impact on the caregiver's participation in care.

CONCLUSIONS

Informal caregivers have unmet needs for support and strive for a partnership with the PHC professionals. PHC professionals should be more attentive and invite informal caregivers to participate in the care of the older adult in order to meet their support needs and build an equal partnership. The patient- and family-centred care framework may be of guidance when providing care for older adults in a PHC context.

The effect of an endovascular Heaney maneuver to achieve total hepatic isolation on survival, hemodynamic stability, retrohepatic bleeding, and collateral flow in a porcine model

PURPOSE

Combining resuscitative endovascular balloon occlusion of the aorta (REBOA) and the inferior vena cava (REBOVC) with open surgery is a new hybrid approach for treating retrohepatic vena caval injuries. We compared endovascular total hepatic isolation with supraceliac REBOA ± suprahepatic REBOVC and no occlusion in experimental retrohepatic vena cava bleeding regarding survival, bleeding volume, hemodynamic stability, and arterial collateral blood flow.

METHODS

Twenty-five anesthetized pigs (n = 6-7/group) were randomized to REBOA; REBOA + REBOVC; REBOA + infra and suprahepatic REBOVC + portal vein occlusion (endovascular Heaney maneuver, four-balloon-occlusion, 4BO) or no occlusion. After balloon inflation, free bleeding was initiated from an open sheath in the retrohepatic vena cava. Bleeding volume, right internal thoracic artery (RITA) blood flow, hemodynamics, and arterial blood variables were measured until death or up to 90 min.

RESULTS

The REBOA group had a longer median survival time (63 min) compared with the 4BO (24 min, P = 0.02) and no occlusion (30 min, P = 0.02) groups, not versus the REBOA + REBOVC group (49 min, P > 0.05). The first 15 min accumulated bleeding was comparable in all groups (P > 0.05); Thereafter, bleeding volume was higher in the REBOA group versus the 4BO group (P < 0.05), not versus the other groups. RITA blood flow and MAP were higher in the REBOA group versus the other groups after 10 min of bleeding (P < 0.05).

CONCLUSIONS

Endovascular Heaney maneuver was not beneficial for survival or hemodynamic stability in this porcine model, whereas supraceliac REBOA was. Anatomical differences in thoracoabdominal collaterals between pigs and humans must be considered when interpreting these results.

Household air pollution and pneumococcal density related to nasopharyngeal inflammation in mothers and children in Ethiopia: A cross-sectional study

BACKGROUND

Three billion people in low- and middle-income countries are exposed to household air pollution as they use biomass fuel for cooking. We investigated the associations between solid fuel use and nasopharyngeal (NP) inflammation, as well as the associations between high pneumococcal density and NP inflammation, in mothers and children in rural and urban Ethiopia.

MATERIALS AND METHODS

Sixty pairs of mothers (median age, 30 years; range, 19-45 years) with a child (median age, 9 months; range, 1-24 months) were included from rural Butajira (n = 30) and urban Addis Ababa (n = 30) in Ethiopia. The cohort was randomly selected from a previous study of 545 mother/child pairs included 2016. Questionnaire-based data were collected which included fuel type used (solid: wood, charcoal, dung or crop waste; cleaner: electricity, liquefied petroleum gas). Nasopharyngeal (NP) samples were collected from all mothers and children and analyzed for the levels of 18 cytokines using a Luminex immunoassay. Pneumococcal DNA densities were measured by a real-time multiplex PCR and a high pneumococcal density was defined as a cyclic threshold (Ct) value ≤ 30.

RESULTS

Mothers from rural areas had higher median CXCL8 levels in NP secretions than those from urban areas (8000 versus 1900 pg/mL; p < 0.01), while rural children had slightly higher IL-10 levels than those from the urban area (26 vs 13 pg/mL; p = 0.04). No associations between fuel type and cytokine levels were found. However, a high pneumococcal density was associated with higher levels of cytokines in both mothers (CCL4, CXCL8, IL-1β, IL-6 and VEGF-A) and children (CCL4, CXCL8, IL-1β, IL-6 and IL-18).

CONCLUSIONS

No significant associations were found between solid fuel use and NP inflammation in Ethiopian mothers and children, but the inflammatory activity was higher in individuals living in the rural compared to the urban area. In addition, high cytokine levels were associated with high pneumococcal density in both mothers and children, indicating a significant impact of NP pathogens on inflammatory mediator levels in upper airways.

Antipsychotics in the maintenance phase for psychotic depression

OBJECTIVE

This study aimed to associate antidepressants with versus without antipsychotics with readmission and suicide in patients with psychotic unipolar depression.

METHODS

Swedish national registers were used to identify inpatients with psychotic unipolar depression, treated 2007-2016. The participants collected antidepressants with or without antipsychotics from a pharmacy within 14 days after discharge and were followed up for 2 years. The primary outcome was hospital readmission due to any psychiatric disorder, suicide attempt, or completed suicide. Cox regression was used to analyze the data, which were adjusted for sex, age, prior admissions, comorbidity, electroconvulsive therapy, and other pharmacological treatments.

RESULTS

We identified 4391 patients, of which 2972 were in the antidepressant + antipsychotic combination therapy group, and 1419 were in the antidepressant monotherapy group. After 2 years, 42.3% and 36.6% of patients were readmitted or committed suicide in the combination therapy and monotherapy group, respectively. Monotherapy was significantly associated with a lower risk of reaching the outcome in the main analysis (hazard ratio = 0.86; 95% confidence interval: 0.77-0.95). The results went in the same direction in all sensitivity analyses.

CONCLUSION

Our findings do not indicate any advantage of adding antipsychotics as adjunctive to antidepressants as maintenance treatment. Considering the wide use, known side effects, and the current lack of evidence supporting the benefit, further studies on the effect of antipsychotics in the maintenance phase of psychotic unipolar depression are urgently warranted.

Machine learning slice-wise whole-lung CT emphysema score correlates with airway obstruction

OBJECTIVES

Quantitative CT imaging is an important emphysema biomarker, especially in smoking cohorts, but does not always correlate to radiologists' visual CT assessments. The objectives were to develop and validate a neural network-based slice-wise whole-lung emphysema score (SWES) for chest CT, to validate SWES on unseen CT data, and to compare SWES with a conventional quantitative CT method.

MATERIALS AND METHODS

Separate cohorts were used for algorithm development and validation. For validation, thin-slice CT stacks from 474 participants in the prospective cross-sectional Swedish CArdioPulmonary bioImage Study (SCAPIS) were included, 395 randomly selected and 79 from an emphysema cohort. Spirometry (FEV1/FVC) and radiologists' visual emphysema scores (sum-visual) obtained at inclusion in SCAPIS were used as reference tests. SWES was compared with a commercially available quantitative emphysema scoring method (LAV950) using Pearson's correlation coefficients and receiver operating characteristics (ROC) analysis.

RESULTS

SWES correlated more strongly with the visual scores than LAV950 (r = 0.78 vs. r = 0.41, p < 0.001). The area under the ROC curve for the prediction of airway obstruction was larger for SWES than for LAV950 (0.76 vs. 0.61, p = 0.007). SWES correlated more strongly with FEV1/FVC than either LAV950 or sum-visual in the full cohort (r =  - 0.69 vs. r =  - 0.49/r =  - 0.64, p < 0.001/p = 0.007), in the emphysema cohort (r =  - 0.77 vs. r =  - 0.69/r =  - 0.65, p = 0.03/p = 0.002), and in the random sample (r =  - 0.39 vs. r =  - 0.26/r =  - 0.25, p = 0.001/p = 0.007).

CONCLUSION

The slice-wise whole-lung emphysema score (SWES) correlates better than LAV950 with radiologists' visual emphysema scores and correlates better with airway obstruction than do LAV950 and radiologists' visual scores.

CLINICAL RELEVANCE STATEMENT

The slice-wise whole-lung emphysema score provides quantitative emphysema information for CT imaging that avoids the disadvantages of threshold-based scores and is correlated more strongly with reference tests than LAV950 and reader visual scores.

KEY POINTS

• A slice-wise whole-lung emphysema score (SWES) was developed to quantify emphysema in chest CT images. • SWES identified visual emphysema and spirometric airflow limitation significantly better than threshold-based score (LAV950). • SWES improved emphysema quantification in CT images, which is especially useful in large-scale research.

Analysis of fracture-related infections from Swedish insurance claims between 2011 and 2021

Fracture-related infections (FRI) pose a serious complication with an incidence of 1-2%. This study aimed to analyze compensation claims submitted to The Swedish National Patient Insurance Company (LÖF) because of FRI after closed/open reduction and internal fixation (C/ORIF) in the four most common fracture sites (proximal humerus, distal radius, hip, ankle). Patients registered in the LÖF database with a suspected FRI between 2011 and 2021 were identified by matching International Classification of Diseases and procedural codes indicative of a combination of fractures to the proximal humerus, distal radius, hip and ankle, C/ORIF and infection. Medical records were reviewed for fracture sites, pathogens and complications. Data from the Swedish Fracture Register (SFR) were extracted to estimate the proportion of reported claims to the presumed number of FRI. Of 122 FRI identified in the LÖF database, 34 were after C/ORIF in the proximal humerus, 12 in the distal radius, 28 in the hip and 48 in the ankle. LÖF compensated 111 patients (91%). Median time from C/ORIF to an FRI was 3 weeks (interquartile range 2-6), and 95% of all FRI occurred within 1 year after C/ORIF. Staphylococcus aureus was the most common pathogen in patients with a distal radius, hip and ankle FRI. In contrast, Cutibacterium spp. were the most common aetiology in FRI of the proximal humerus. The total number of fractures treated with C/ORIF in the four fracture sites registered in the SFR during 2021 was 18,711. Most of the FRI patients were diagnosed within the first year after C/ORIF, and 91% of the patients received compensation. Given an expected FRI incidence of 1-2%, our estimates with extrapolated data from the SFR indicate that < 10% of affected patients applied for compensation.

CT-Based Micromotion Analysis After Locking Plate Fixation of AO Type C Distal Radius Fractures

Background

Volar locking plate fixation (VLPF) is the most common method for operative fixation of distal radius fractures (DRF). The dorsal ulnar corner (DUC) can be difficult to stabilize as the fragment is small and not exposed when using the volar approach. The purpose of this study was to study fracture fragment migration after VLPF of AO type C DRF, using a volume registration technique of paired CT scans with special focus on the DUC fragment.

Materials and Methods

This pilot study included ten patients with AO type C DRF, all operated with VLPF. The primary outcome was radiographic outcome. Postoperative and 1-year scans were compared and analyzed. Fragment migration was assessed with CT-based micromotion analysis (CTMA), a software technique used for volume registration of paired CT scans.

Results

All plates were stable over time. Two patients showed signs of screw movement (0.2-0.35 mm and 0.35- > 1 mm respectively). Postoperative reduction was maintained, and there was no fragment migration at the 1-year follow-up except for one case with increased dorsal tilt. The DUC fragment was found in 8/10 cases, fixated in 7/8 cases, and not dislocated in any case at the 1-year follow-up.

Conclusion

The CTMA results indicate that variable-angle VLPF after AO type C DRF can yield and maintain a highly stable reduction of the fracture fragments. The DUC fragment remained stable regardless of the number of screws through the fragment. CT volume registration can be a valuable tool in the detailed assessment of fracture fragment migration following volar plate fixation of DRFs.

How can we identify subglottic stenosis in patients with suspected obstructive disease?

PURPOSE

Subglottic stenosis, a rare condition of the upper airway, is frequently misdiagnosed as obstructive lung disease. The aim of this study was to investigate whether subglottic stenosis could be identified and distinguished from asthma and chronic obstructive pulmonary disease (COPD) using spirometry or the dyspnea index (DI).

METHODS

The study population included 43 patients with asthma, 31 patients with COPD and 50 patients with subglottic stenosis planned to undergo endoscopic intervention. All patients completed the DI and underwent dynamic spirometry registering both inspiratory and expiratory volumes and flows, including the expiratory disproportion index (EDI), the ratio of forced expiratory volume in 1 s to peak expiratory flow. One-way analysis of variance assessed the discrepancy of the variables among the study groups, and receiver operating curve (ROC) analysis determined the measurement with the best discriminatory power providing a cutoff value, maximizing both sensitivity and specificity.

RESULTS

The only statistically significant variables differing between all three groups were the EDI and the DI. The EDI showed an excellent area under the ROC curve (0.99, p < 0.001) with a cutoff value of 0.39 (98% sensitivity, 96% specificity), followed by DI (0.87, p < 0.001) with a cutoff score of > 25 (83% sensitivity and 78% specificity).

CONCLUSION

In patients with dyspnea of unknown cause, an increase in EDI should arouse a suspicion of extrathoracic airway obstruction, advocating for further evaluation with laryngotracheoscopy.

Reliability of the DSS-Swe Questionnaire

BACKGROUND

Symptomatic postbariatric hypoglycemia (PBH) is a known complication that can occur a few years after Roux-en-Y gastric bypass (RYGB). There is currently no established rating scale for PBH-associated symptoms developed for use in Swedish populations. The aim of the study was to translate an already existing questionnaire into Swedish and to test its reliability.

METHODS

The study included forward and backward translations of the original Dumping Severity Scale (DSS) questionnaire with 8 items regarding symptoms of early dumping and 6 items regarding hypoglycemia, with each item graded on a 4-point Likert scale. The reliability of the Swedish translated questionnaire (DSS-Swe) was estimated using internal consistency and test-retest methods.

RESULTS

A total of 200 patients were included in the study. Good internal consistency was demonstrated regarding the items related to early dumping symptoms, with a Cronbach's alpha coefficient of 0.82, and very good agreement in terms of test-retest reliability, with an overall intraclass correlation coefficient (ICC) of 0.91 (95% CI 0.88-0.93). The items related to hypoglycemia yielded a good Cronbach's alpha coefficient of 0.76 and an ICC of 0.89 (95% CI 0.85-0.91).

CONCLUSION

The DSS-Swe questionnaire shows good reliability regarding both internal consistency and test-retest performance for use in Swedish populations.

Safety of and response to electroconvulsive therapy during pregnancy: Results from population-based nationwide registries

INTRODUCTION

Psychiatric disorders are common during pregnancy, affecting up to 16% of pregnant women. Severe depression and anxiety have significant negative effects on the health of both the mother and the developing fetus. Electroconvulsive therapy (ECT) is considered a treatment option for pregnant women with severe psychiatric disorders when other treatments have been ineffective or pose risks to the fetus. Knowledge of the safety and efficacy of ECT during pregnancy, however, remains limited.

METHODS

Data were obtained from nationwide registries of pregnant women in Sweden who received ECT for a severe psychiatric disorder from January 2008 to December 2021. ECT-related outcomes in pregnant women were compared by propensity score matching with a group of non-pregnant women who also received ECT. Pregnancy-related outcomes were compared with two additional control groups: one consisting of the same group of women who did not receive ECT during another pregnancy and the other composed of pregnant women admitted to inpatient psychiatric care but who did not receive ECT, matched based on propensity score.

RESULTS

Ninety-five pregnant women received ECT during the study period, accounting for 97 pregnancies. The response rate to ECT in pregnant women (n = 54) was similar to the matched control group of non-pregnant women (74% vs. 65%; OR 1.61; 95% CI 0.79-3.27). Rates of adverse events related to ECT were similar to those in the control group. There were no pre-term births or severe adverse outcomes related to the pregnancy, that were close in time to ECT. Therefore, no adverse outcomes related to pregnancy and childbirth could be directly attributed to ECT. The likelihood of premature birth and a 5-min Apgar score <7 in the newborn were both significantly higher in the ECT group, compared with the matched non-ECT group (OR 2.33, 95% CI 1.15-4.73, p = 0.008, and OR 3.68, 95% CI 1.58-8.55, p < 0.001, respectively). By contrast, no significant differences were observed when women in the pregnant ECT group were compared with the same group lacking ECT during another pregnancy.

CONCLUSIONS

ECT was associated with a positive treatment response in pregnant women with severe psychiatric disorders. The response rate to ECT was similar in pregnant and non-pregnant women. Nevertheless, the risks of premature birth and of a slightly poorer condition in newborns were higher in women who did than did not receive ECT, emphasizing the need for increased attention to severe psychiatric disorders during pregnancy.

Intra-aortic and Intra-caval Balloon Pump Devices in Experimental Non-traumatic Cardiac Arrest and Cardiopulmonary Resuscitation

Intra-aortic balloon pump (IABP) use during CPR has been scarcely studied. Intra-caval balloon pump (ICBP) may decrease backward venous flow during CPR. Mechanical chest compressions (MCC) were initiated after 10 min of cardiac arrest in anesthetized pigs. After 5 min of MCC, IABP (n = 6) or ICBP (n = 6) was initiated. The MCC device and the IABP/ICBP had slightly different frequencies, inducing a progressive peak pressure phase shift. IABP inflation 0.15 s before MCC significantly increased mean arterial pressure (MAP) and carotid blood flow (CBF) compared to inflation 0.10 s after MCC and to MCC only. Coronary perfusion pressure significantly increased with IABP inflation 0.25 s before MCC compared to inflation at MCC. ICBP inflation before MCC significantly increased MAP and CBF compared to inflation after MCC but not compared to MCC only. This shows the potential of IABP in CPR when optimally synchronized with MCC. The effect of timing of intra-aortic balloon pump (IABP) inflation during mechanical chest compressions (MCC) on hemodynamics. Data from12 anesthetized pigs.

Clozapine but not lithium reverses aberrant tyrosine uptake in patients with bipolar disorder

RATIONALE

Availability of the dopamine and noradrenaline precursor tyrosine is critical for normal functioning, and deficit in tyrosine transport across cell membrane and the blood-brain barrier has been reported in bipolar disorder and schizophrenia. Clozapine and lithium are two psychoactive agents used to treat psychosis, mood disorders and suicidal behavior, but their mechanism of action remains largely unknown.

OBJECTIVE

To characterize immediate and delayed differences in tyrosine uptake between healthy controls (HC) and bipolar patients (BP) and see if these differences could be normalized by either clozapine, lithium or both. A second objective was to see if clozapine and lithium have additive, antagonistic or synergistic effects in this.

METHOD

Fibroblasts from five HC and five BP were incubated for 5 min or 6 h with clozapine, lithium, or combination of both. Radioactive labelled tyrosine was used to quantify tyrosine membrane transport.

RESULTS

There was significantly reduced tyrosine uptake at baseline in BP compared to HC, a deficit that grew with increasing incubation time. Clozapine selectively increased tyrosine uptake in BP and abolished the deficit seen under baseline conditions, while lithium had no such effect. Combination treatment with clozapine and lithium was less effective than when clozapine was used alone.

CONCLUSIONS

There was significant deficit in tyrosine transport in BP compared to HC that was reversed by clozapine but not lithium. Clozapine was more effective when used alone than when added together with lithium. Potential clinical implications of this will be discussed.

"InMotion"-Mixed physical exercise program with creative movement as an intervention for adults with schizophrenia: study protocol for a randomized controlled trial

Background

Schizophrenia is among the world's top 10 causes of long-term disability with symptoms that lead to major problems in social and occupational functioning, and in self-care. Therefore, it is important to investigate the efficacy of complementary treatment options for conventionally used antipsychotic medication, such as physical training, and psychosocial interventions.

Objective

To combine aerobic and strength training with cognitive, emotional and social stimulation in one intervention for people with schizophrenia and test the feasibility and effects of this intervention.

Methods

The study is a mixed-method randomized controlled trial to evaluate the effects of a 12-week intervention for adults with schizophrenia. The treatment group (30 participants) will receive the intervention in addition to standard care and the control group (30 participants) only standard care. The intervention consists of 24 biweekly sessions with a duration of 60 min. The pre-test (weeks from 4 to 2 prior to the intervention) and post-test (week 12) include clinical measure (PANSS), quality of life, social performance, movement quantity, brain function and eye tracking measures. In addition, a treatment subgroup of 12-15 participants and their family member or other next of kin will complete a qualitative interview as a part of their post-test. Two follow-up tests, including clinical, quality of life, brain function and eye tracking will be made at 6 and 12 months from the completion of the intervention to both study groups. The primary outcome is change in negative symptoms. Secondary outcome measures include general and positive symptoms, quality of life, social performance, movement quantity, brain function and eye tracking. Explorative outcome includes patient and family member or other next of kin interview.

Results

Pilot data was collected by June 2023 and the main data collection will begin in September 2023. The final follow-up is anticipated to be completed by 2026.

Conclusion

The InMotion study will provide new knowledge on the feasibility, efficacy, and experiences of a novel intervention for adults with schizophrenia. The hypothesis is that regular participation in the intervention will reduce clinical symptoms, normalize physiological measures such as brain activation, and contribute to new active habits for the participants.

Trial registration

ClinicalTrials.gov, identifier NCT05673941.

Fecal incontinence and associated pelvic floor dysfunction during and one year after the first pregnancy

INTRODUCTION

Obstetric anal sphincter injury is an important risk factor for postpartum fecal incontinence but few studies have reported fecal incontinence occurring, even during pregnancy. The first objective of this study was to examine the prevalence of fecal incontinence, obstructed defecation and vaginal bulging early and late in pregnancy and postpartum. The second objective was to assess the association between symptoms in pregnancy, delivery characteristics, and bowel and vaginal bulging symptoms at 1 year postpartum.

MATERIAL AND METHODS

This prospective cohort study was conducted between October 2014 and October 2017, including 898 nulliparous women enrolled with the maternity healthcare service in Örebro County, Sweden. The women responded to questionnaires regarding pelvic floor dysfunction in early and late pregnancy and at 8 weeks and 1 year postpartum. The data were analyzed using random effect logistic models estimating odds ratios (ORs) and generalized linear models estimating relative risks, with 95% confidence intervals (CIs).

RESULTS

At 1 year postpartum, the prevalence of fecal incontinence, obstructed defecation and vaginal bulging was 6% (40/694), 28% (197/699) and 8% (56/695), respectively. Among women with vaginal delivery, the risk of fecal incontinence and vaginal bulging increased significantly both in late pregnancy, with ORs of 3.4 (95% CI 1.5-7.7) and 3.6 (95% CI 1.6-8.1), respectively, and at 1 year postpartum, with ORs of 5.0 (95% CI 2.1-11.5) and 8.3 (95% CI 3.8-18.1), respectively, compared with early pregnancy. Among all women, factors associated with increased prevalence of fecal incontinence 1 year postpartum were fecal incontinence during pregnancy (adjusted relative risk [aRR] 7.4; 95% CI 4.1-13.3), obstructed defecation during pregnancy (aRR 2.0; 95% CI 1.1-3.9) and concurrent obstructed defecation (aRR 2.4; 95% CI 1.3-4.5).

CONCLUSIONS

This prospective study shows an increased risk of fecal incontinence by late pregnancy, suggesting that the pregnancy itself may be involved in the development of postpartum fecal incontinence. Obstructed defecation during pregnancy and postpartum was found to be associated with increased risk of fecal incontinence postpartum, indicating that postpartum fecal incontinence may be a result of incomplete bowel emptying.

A porcine study of ultrasound-guided versus fluoroscopy-guided placement of endovascular balloons in the inferior vena cava (REBOVC) and the aorta (REBOA)

Objectives

In fluoroscopy-free settings, alternative safe and quick methods for placing resuscitative endovascular balloon occlusion of the aorta (REBOA) and resuscitative endovascular balloon occlusion of the inferior vena cava (REBOVC) are needed. Ultrasound is being increasingly used to guide the placement of REBOA in the absence of fluoroscopy. Our hypothesis was that ultrasound could be used to adequately visualize the suprahepatic vena cava and guide REBOVC positioning, without significant time-delay, when compared with fluoroscopic guidance, and compared with the corresponding REBOA placement.

Methods

Nine anesthetized pigs were used to compare ultrasound-guided placement of supraceliac REBOA and suprahepatic REBOVC with corresponding fluoroscopic guidance, in terms of correct placement and speed. Accuracy was controlled by fluoroscopy. Four intervention groups: (1) fluoroscopy REBOA, (2) fluoroscopy REBOVC, (3) ultrasound REBOA and (4) ultrasound REBOVC. The aim was to carry out the four interventions in all animals. Randomization was performed to either fluoroscopic or ultrasound guidance being used first. The time required to position the balloons in the supraceliac aorta or in the suprahepatic inferior vena cava was recorded and compared between the four intervention groups.

Results

Ultrasound-guided REBOA and REBOVC placement was completed in eight animals, respectively. All eight had correctly positioned REBOA and REBOVC on fluoroscopic verification. Fluoroscopy-guided REBOA placement was slightly faster (median 14 s, IQR 13-17 s) than ultrasound-guided REBOA (median 22 s, IQR 21-25 s, p=0.024). The corresponding comparisons of the REBOVC groups were not statistically significant, with fluoroscopy-guided REBOVC taking 19 s, median (IQR 11-22 s) and ultrasound-guided REBOVC taking 28 s, median (IQR 20-34 s, p=0.19).

Conclusion

Ultrasound adequately and quickly guide the placement of supraceliac REBOA and suprahepatic REBOVC in a porcine laboratory model, however, safety issues must be considered before use in trauma patients.

Level of evidence

Prospective, experimental, animal study. Basic science study.

Psychometric evaluation of the WHODAS 2.0 and prevalence of disability in a Swedish general population

BACKGROUND

The World Health Organization Disability Assessment Schedule (WHODAS 2.0) is a generic questionnaire that captures health and disability-related functioning information corresponding to six major life domains: Cognition, Mobility, Self-care, Getting along, Life activities, and Participation. The WHODAS 2.0 is used in a wide range of international clinical and research settings. A psychometric evaluation of WHODAS 2.0, Swedish version, in the general population is lacking, together with national reference data to enable interpretation and comparison. This study aims to evaluate the psychometric properties of the Swedish 36-item version of WHODAS 2.0 and describe the prevalence of disability in a Swedish general population.

METHODS

A cross-sectional survey was performed. Internal consistency reliability was assessed with Cronbach's alpha. The construct validity was evaluated with item-total correlation, Pearson's correlation between the WHODAS 2.0 domains and the RAND-36 subscales, analysis of known groups by one-way ANOVA, and analysis of the factor structure by confirmatory factor analysis.

RESULTS

Three thousand four hundred and eighty two adults aged 19-103 years (response rate 43%) participated. Significantly higher degrees of disability were reported by the oldest age group (≥ 80 years), adults with a low level of education, and those on sick leave. Cronbach's alpha was from 0.84 to 0.95 for the domain scores and 0.97 for the total score. The item-scale convergent validity was satisfactory, and the item-scale discriminant validity was acceptable except for the item about sexual activity. The data partially supported the factor structure, with borderline fit indices.

CONCLUSION

The psychometric properties of the self-administered Swedish 36-item version of the WHODAS 2.0 are comparable to those of other language versions of the instrument. Data of the prevalence of disability in Swedish general population enables normative comparisons of WHODAS 2.0 scores of individuals and groups within clinical practice. The instrument has certain limitations that could be improved on in a future revision. The test-retest reliability and responsiveness of the Swedish version of WHODAS 2.0 for different somatic patient populations remain to be evaluated.

Previous pre-eclampsia, gestational diabetes mellitus and the risk of cardiovascular disease: A nested case-control study in Sweden

OBJECTIVE

Pre-eclampsia and gestational diabetes mellitus (GDM) are two common pregnancy complications that affect birth outcomes and are associated with a long-term risk of cardiovascular disease (CVD). The aims of this study were to investigate if the pre-eclampsia association with CVD is independent of GDM and modified by body mass index (BMI) or GDM.

DESIGN

Case-control study.

SETTING

Sweden.

POPULATION

Cases were women with a first CVD event between 1991 and 2008 and a previous pregnancy who were matched with controls without CVD (1:5) by year of birth, age and region of birth.

METHODS

Conditional logistic regression was used to evaluate the associations of GDM, pre-eclampsia and maternal BMI with CVD adjusted for potential confounders and effect modifications with interaction tests.

MAIN OUTCOME MEASURES

CVD.

RESULTS

There were 2639 cases and 13 310 controls with complete data. Pre-eclampsia and GDM were independent risk factors for CVD (adjusted odds ratio [aOR] 2.59, 95% CI 2.12-3.17 and aOR 1.47, 95% CI 1.04-2.09, respectively). After stratifying by maternal BMI, the adjusted association of pre-eclampsia with CVD did not differ notably between BMI groups: normal weight (aOR 2.65, 95% CI 1.90-3.69), overweight (aOR 2.67, 95% CI 1.52-4.68) and obesity (aOR 3.03, 95% CI 0.74-12.4). Similar findings were seen when stratifying on GDM/non-GDM.

CONCLUSIONS

Pre-eclampsia and GDM are independent risk factors for later CVD and having both during pregnancy is a major risk factor for later CVD. The association between pre-eclampsia and CVD is not modified by BMI. Effective CVD preventive programs for high-risk women are urgently needed in order to improve women's long-term health.

NO-Donation Increases Visceral Circulation in a Porcine Model of Abdominal Hypertension

Intraabdominal hypertension (IAH) is negative for outcome after intensive care. Little research has focused on medical intervention to improve visceral circulation during IAH. A nitric oxide (NO)-donor was compared with placebo in 25 pigs; each pig was randomized into three groups: PDNO (NO-donor), Control (placebo), or Sham. IAH was induced by CO2 insufflation to 30 mmHg. Sham group had surgical preparation only. Blood gases, invasive venous and arterial blood pressure, intestinal microcirculation and superior mesenteric blood flow were measured. The PDNO group had significantly increased intestinal microcirculation compared with Controls during IAH (last hour, P = 0.009). The mean arterial pressure and abdominal perfusion pressures (APP) were decreased, and the cardiac index were increased in the PDNO group. Also, systemic and pulmonary vascular resistances were lower in the PDNO group compared with Controls. These experimental findings indicate that NO should be further explored with potential application to improve intestinal microcirculation in IAH patients.

Posttraumatic Arthritis After Combined Plating of Distal Radius Fractures AO Type C: A 7-Year Follow-up of 97 Cases

BACKGROUND

Volar locking plate fixation is the most common method of operative fixation of distal radius fractures (DRFs). For more complex cases, combined plating is an option for stabilizing intra-articular fragments. The prevalence of posttraumatic arthritis (PA) after an intra-articular DRF, and its relation to patient-reported outcome measures (PROMs), remains unclear. The purpose of this study was to study the prevalence of PA and its correlation to clinical outcome measures.

METHODS

We evaluated 97 consecutive patients with intra-articular DRF, operated with combined plating, 7 years postoperatively. The primary outcome measure was the prevalence of radiographic PA. Secondary outcome measures included visual analog scale (VAS) pain score, hand grip strength, wrist range of motion (ROM), Patient-Rated Wrist Evaluation (PRWE) score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Radiographic examination was performed between 1 and 7 years postoperatively.

RESULTS

The prevalence of PA was 29% at the 7-year follow-up. No correlation was found between PA and ROM, hand grip strength, PRWE, QuickDASH, VAS pain scores, or radiographic reduction. Median wrist ROM and grip strength were significantly inferior compared with the uninjured side. Hardware removal was performed in 51.5% of cases. There were 2 cases of tendon ruptures.

CONCLUSIONS

Combined plating can yield a good clinical outcome 7 years postoperatively and a low prevalence of PA. The presence of PA did not correlate to clinical outcome measures or to the accuracy of anatomical reduction 1 year postoperatively. The frequency of tendon ruptures was acceptable, but the high frequency of hardware removal is a concern.

The General Self-Efficacy Scale in a population planned for bariatric surgery in Sweden: a psychometric evaluation study

OBJECTIVES

This study psychometrically evaluated General Self-Efficacy (GSE) Scale in patients planned for bariatric surgery in Sweden.

DESIGN

A cross-sectional psychometric study. The psychometric evaluation was guided by the COnsensus-based Standards for the selection of health status Measurement Instruments checklist for health-related reported-patient outcomes.

SETTING

Three bariatric centres in Sweden.

PARTICIPANTS

Adult patients≥18 years old scheduled for primary bariatric surgery (with sleeve gastrectomy or Roux-en-Y gastric bypass).

PRIMARY AND SECONDARY MEASURES

Psychometric properties of the GSE.

RESULTS

In total, 704 patients were included in the analysis. Mean values for GSE items were 2.9-3.4 and the mean GSE sum score was 31.4 (SD 4.7). There were no floor or ceiling effects. Cronbach's alpha was 0.89. Men reported a higher mean GSE than did women, that is, 31.2 (SD 4.8) for women versus 32.1 (SD 4.3) for men, p=0.03. Correlation coefficients were weak or negligible: GSE and mental component summary score of 36-Item Short Form Health Survey (SF-36)/RAND 36, r=0.18 (p<0.00); GSE and physical component summary score of SF-36/RAND 36, r=0.07 (p=0.138); GSE and obesity-related problem scale r=-0.15 (p=0.001) and GSE and level of education, r=0.04 (p=0.35). Confirmatory factor analysis indicated a one-factor construct with a satisfactory goodness of fit, that is, Comparative Fit Index=0.927, root mean square error of approximation=0.092 and standardised root mean square residual=0.045. The factor GSE explained almost half or over half of the variance of each item (0.45-0.75, p-values<0.001).

CONCLUSIONS

The GSE scale is a valid and reliable scale that can be used to assess general self-efficacy in patients undergoing bariatric surgery.

Global microRNA and protein expression in human term placenta

Introduction

Description of the global expression of microRNAs (miRNAs) and proteins in healthy human term placentas may increase our knowledge of molecular biological pathways that are important for normal fetal growth and development in term pregnancy. The aim of this study was to explore the global expression of miRNAs and proteins, and to point out functions of importance in healthy term placentas.

Materials and methods

Placental samples (n = 19) were identified in a local biobank. All samples were from uncomplicated term pregnancies with vaginal births and healthy, normal weight newborns. Next-generation sequencing and nano-scale liquid chromatographic tandem mass spectrometry were used to analyse miRNA and protein expression, respectively.

Results

A total of 895 mature miRNAs and 6,523 proteins were detected in the placentas, of which 123 miRNAs and 346 proteins were highly abundant. The miRNAs were in high degree mapped to chromosomes 19, 14, and X. Analysis of the highly abundant miRNAs and proteins showed several significantly predicted functions in common, including immune and inflammatory response, lipid metabolism and development of the nervous system.

Discussion

The predicted function inflammatory response may reflect normal vaginal delivery, while lipid metabolism and neurodevelopment may be important processes for the term fetus. The data presented in this study, with complete miRNA and protein findings, will enhance the knowledge base for future research in the field of placental function and pathology.

Do reasons for undergoing bariatric surgery influence weight loss and health-related quality of life?-A Swedish mixed method study

Background

A wish for improved health or avoidance of ill health is often given as reason for wanting to undergo bariatric surgery. How such reasons relate to postoperative outcome is unclear.

Objective

The aim was to explore Swedish patients’ reasons for undergoing bariatric surgery. Also, we wanted to analyze if there were sex and age differences and associations with weight loss and health-related quality of life (HRQoL).

Settings

This was a single-center study conducted at a university hospital.

Method

Data on 688 patients (528 women and 160 men) including a free text response was analyzed inductively and deductively using predefined statements and was merged with data from the Scandinavian Obesity Surgery Registry. All data was analyzed using descriptive and analytic statistics.

Result

The most common reason for undergoing bariatric surgery was pain in different body parts. A wish for an improved medical condition was reported by most patients (59%, n = 408), followed by physical limitations making daily life difficult (42%, n = 288). Men and women reported similar reasons. Younger patients were more distressed about physical appearance (p = 0.001) and older patients wanted to improve their medical condition (p = 0.013). Health-related quality of life improved irrespective of reasons for undergoing surgery.

Conclusion

The most reported reasons for undergoing bariatric surgery were a wish for improved medical condition and to make daily life easier. Factors associated with the decision for surgery showed that there were few sex differences, but age seemed to be a factor. The HRQoL trajectory showed improvement regardless of reasons for undergoing surgery.

Intravenous anti-P. aeruginosa IgY-antibodies do not decrease pulmonary bacterial concentrations in a porcine model of ventilator-associated pneumonia

Ventilator associated pneumonia (VAP) caused by P. aeruginosa is a cause of morbidity and mortality in critically ill patients. The spread of pathogens with anti-microbial resistance mandates the investigation of novel therapies. Specific polyclonal anti-P. aeruginosa IgY-antibodies (Pa-IgY) might be effective for VAP caused by P. aeruginosa. The objective of this study was to investigate if intravenous Pa-IgY decreases the lower airway concentration of P. aeruginosa in VAP. We used a double blind randomized placebo controlled porcine model of VAP caused by P. aeruginosa. Eighteen pigs were randomized to either receive intravenous Pa-IgY or placebo. Repeated registration of physiological parameters and sampling was performed for 27 h. Concentration of P. aeruginosa in BAL-cultures was similar in both groups with 104.97 ± 102.09 CFU/mL in the intervention group vs 104.37 ± 102.62 CFU/mL in the control group at the end of the experiment. The intervention group had higher heart rate, cardiac index, oxygen delivery and arterial oxygen tension/fraction of inspired oxygen-ratio, but lower plasma lactate and blood hemoglobin levels than the control group. In summary, in an anesthetized and mechanically ventilated porcine model of VAP, Pa-IgY at the dose used did not decrease concentrations of P. aeruginosa in the lower airways.

Clonidine as analgesia during retinopathy of prematurity screening in preterm infants (cloROP): protocol for a randomised controlled trial

INTRODUCTION

Preterm infants are at risk of negative consequences from stress and pain at the same time as they often are in need of intensive care that includes painful interventions. One of the frequent painful procedures preterm infants undergo is eye examination screening to detect early signs of ROP (retinopathy of prematurity). These examinations are both stressful and painful, and despite a multitude of research studies, no conclusive pain-relieving treatment has been demonstrated. The main aim of this trial is to investigate the analgesic effect of clonidine during ROP eye examinations.

METHODS AND ANALYSIS

The planned study is a multicentre randomised controlled trial with a crossover design. Infants will be recruited from two different neonatal intensive care units (NICUs) in Sweden. Infants born before gestation week 30 (and therefore eligible for ROP screening) and cared for in either of the NICUs will be eligible for inclusion in the study. The primary outcome will be Premature Infant Pain Profile-Revised score within 30 s after starting the examination. Secondary outcomes will be changes in the galvanic skin response parameters (area small peaks, area huge peaks, peaks per second and average rise time) within 30 s after starting the eye examination, together with the number and evaluation of adverse events reported within 72 hours after the examination and the examining physician's assessment of how easy the infant was to examine.

ETHICS AND DISSEMINATION

Approval from the Swedish Ethical Review Authority and the Swedish Medical Products Agency has been obtained for the study. Parents of eligible infants will be getting both verbal and written information about the study including that participation is voluntary. Data will be collected and treated in accordance with the European general data protection regulations. The results will be reported on group level and published in a scientific journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT04902859).EudraCT (2021-003005-21).

A Study Protocol for Persons With Neurological Diseases: Linking Rehabilitation Goals to the International Classification of Functioning, Disability and Health With a Focus on Assistive Technology for Cognition and Its Effects

Persons with neurological diseases often have some degree of cognitive impairment. They are in need of assistive technology for cognition (ATC) to compensate for cognitive impairments that affect their daily functioning. Goal setting in relation to cognitive deficits using ATC are common in clinical practice, and therapists often set several rehabilitation goals together with a patient. However, these rehabilitation goals are usually phrased differently, which limit the comparison of ATC and rehabilitation goals. It is thus valuable to link the goals to some standardized terminologies, such as the International Classification of Functioning, Disability and Health (ICF). Furthermore, goal achievement is seldom used to evaluate long-term effects of ATC in persons with neurological diseases and limited attention has been paid to the factors that predict goal achievement in using the ATC as cognitive support in persons with neurological diseases. The aim of the project is 3-fold. Firstly, we will use the ICF to link rehabilitation goals regarding the use of ATC in adults with neurological diseases. Secondly, we will evaluate effects of the ATC using goal achievement over a 5-year period. Thirdly, we will explore the variables that predict goal achievement in relation to the effects of ATC.

Sustained elevation of soluble B- and T- lymphocyte attenuator predicts long-term mortality in patients with bacteremia and sepsis

Soluble B and T lymphocyte attenuator (sBTLA) has been shown to be associated with severity and outcome, in critically ill septic patients. We aimed to assess the dynamic expression of sBTLA, as a prognostic biomarker of long-term mortality in patients with bloodstream infection (BSI) and sepsis, and to evaluate its association with biomarkers indicative of inflammation and immune dysregulation. Secondarily, sBTLA was evaluated in association with severity and bacterial etiology. Patients with BSI (n = 108) were prospectively included, and serially sampled from admission to day 28. Blood and plasma donors (n = 31), sampled twice 28 days apart, served as controls. sBTLA concentration in plasma was determined with enzyme-linked immunosorbent assay. Associations between sBTLA on day 1-2 and 7, and mortality at 90 days and 1 year, were determined with unadjusted, and adjusted Cox regression. Differences related to severity was assessed with linear regression. Mixed model was used to assess sBTLA dynamics over time, and sBTLA associations with bacterial etiology and other biomarkers. sBTLA on day 1-2 and 7 was associated with mortality, in particular failure to normalize sBTLA by day 7 was associated with an increased risk of death before day 90, adjusted HR 17 (95% CI 1.8-160), and one year, adjusted HR 15 (95% CI 2.8-76). sBTLA was positively associated with CRP, and negatively with lymphocyte count. sBTLA on day 1-2 was not linearly associated with baseline SOFA score increase. High SOFA (≥4) was however associated with higher mean sBTLA than SOFA ≤3. sBTLA was not associated with bacterial etiology. We show that sustained elevation of sBTLA one week after hospital admission is associated with late mortality in patients with BSI and sepsis, and that sBTLA concentration is associated with CRP and decreased lymphocyte count. This suggests that sBTLA might be an indicator of sustained immune-dysregulation, and a prognostic tool in sepsis.

Delayed puberty in boys in central Sweden: an observational study on diagnosing and management in clinical practice

OBJECTIVES

To compare the usefulness of the classical definition of delayed puberty (DP) in boys with puberty nomograms and to describe the management of DP in boys in a hospital-based setting.

STUDY DESIGN

Observational retrospective multicentre study with a short-term follow-up.

SETTING AND PARTICIPANTS

Boys diagnosed with DP during 2013-2015 at paediatric departments in four counties in central Sweden. The medical records of 165 boys were reviewed.

PRIMARY AND SECONDARY OUTCOME MEASURES

Number of boys with DP after re-evaluation of the diagnosis according to the classical definition in comparison with puberty nomograms. Description of investigations performed and treatment provided to boys with DP.

RESULTS

In total, 45 and 58 boys were found to have DP according to the classical definition and the nomograms, respectively. Biochemical and/or radiological testing was performed in 91% of the 58 boys, but an underlying disease was only found in 9% of them. Approximately 79% of the boys received testosterone treatment, either as injections of testosterone enanthate or as testosterone undecanoate.

CONCLUSIONS

Puberty nomograms may be helpful instruments when diagnosing pubertal disorders in boys as they are not limited to an age close to 14 years and also identify boys with pubertal arrest. The majority of boys with DP undergo biochemical or radiological examinations, but underlying diseases are unusual emphasising the need for structural clinical practice guidelines for this patient group.

Older meningioma patients: a retrospective population-based study of risk factors for morbidity and mortality after neurosurgery

BACKGROUND

Meningioma is the most common primary CNS tumour. Most meningiomas are benign, and most patients are 65 years or older. Surgery is usually the primary treatment option. Most prior studies on early surgical outcomes in older patients with meningioma are small, and there is a lack of larger population-based studies to guide clinical decision-making. We aimed to explore the risks for perioperative mortality and morbidity in older patients with meningioma and to investigate changes in surgical incidence over time.

METHODS

In this retrospective population-based study on patients in Sweden, 65 years or older with surgery 1999-2017 for meningioma, we used data from the Swedish Brain Tumour Registry. We analysed factors contributing to perioperative mortality and morbidity and used official demographic data to calculate yearly incidence of surgical procedures for meningioma.

RESULTS

The final study cohort included 1676 patients with a 3.1% perioperative mortality and a 37.6% perioperative morbidity. In multivariate analysis, higher age showed a statistically significant association with higher perioperative mortality, whereas larger tumour size and having preoperative symptoms were associated with higher perioperative morbidity. A numerical increased rate of surgical interventions after 2012 was observed, without evidence of worsening short-term surgical outcomes.

CONCLUSIONS

Higher mortality with increased age and higher morbidity risk in larger and/or symptomatic tumours imply a possible benefit from considering surgery in selected older patients with a growing meningioma before the development of tumour-related symptoms. This study further underlines the need for a standardized method of reporting and classifying complications from neurosurgery.

An Internet Based Intervention for Adults With Autism Spectrum Disorder-A Qualitative Study of Participants Experiences

Background: Adults with autism spectrum disorder face several barriers to accessing evidence-based care, including difficulties in communicating needs, social anxiety or in traveling to a health care unit. In recent years, several forms of internet-based treatments have shown to be effective for a variety of psychiatric conditions. Internet-based treatment alternatives allow convenient and flexible formats, and therefore have the potential to increase access to health care for individuals with autism spectrum disorder. However, knowledge about how internet-based treatment features may suit the needs of individuals with autism is limited. The aim of this study was to explore the participant experiences of an internet-based intervention for adults with autism spectrum disorder. The primary focus of the investigation was on autism-specific needs in relation to the features unique to the online format. Methods: In this qualitative study, semi-structured telephone interviews were conducted with 14 participants who had completed a text-based internet-based intervention for adults with autism spectrum disorder. We used an inductive approach and analyzed the data using qualitative content analysis. Results: Five main categories were identified: (1) implications of the online format, (2) the fixed non-individualized model, (3) therapist interaction, (4) interacting with other participants, and (5) making use of the treatment content. Overall, participants appreciated the availability and that they could work on their treatment independent of time or location. Among those participating in group-based chat-sessions with the other participants, it was considered a generally positive experience. Furthermore, most participants felt safe and relaxed in relation to the therapist and appreciated the text-based format. However, several participants felt that the format and content of the treatment was not sufficiently adapted to their individual life situation. Conclusion: In conclusion, this internet-based treatment constitutes an accessible and energy-saving treatment alternative for adults with autism. Further, integrating group-based components seems feasible in an otherwise individual internet-based treatment for individuals with autism. However, group-based components do require a clear purpose and rationale. Future studies should develop and evaluate treatment adaptations tailored to individual needs.

Remission, relapse, and risk of major cardiovascular events after metabolic surgery in persons with hypertension: A Swedish nationwide registry-based cohort study

BACKGROUND

Several studies have shown that metabolic surgery is associated with remission of diabetes and hypertension. In terms of diabetes, factors such as duration, insulin use, weight loss, and age have been shown to contribute to the likelihood of remission. Such factors have not been determined for hypertension. The aim of this study was to evaluate factors associated with the remission and relapse of hypertension after metabolic surgery, as well as the risk for major adverse cardiovascular event (MACE) and mortality in patients with and without remission.

METHODS AND FINDINGS

All adults who underwent metabolic surgery between January 2007 and June 2016 were identified in the nationwide Scandinavian Obesity Surgery Registry (SOReg). Through cross-linkage with the Swedish Prescribed Drug Register, Patient Register, and Statistics Sweden, individual data on prescriptions, inpatient and outpatient diagnoses, and mortality were retrieved. Of the 15,984 patients with pharmacologically treated hypertension, 6,286 (39.3%) were in remission at 2 years. High weight loss and male sex were associated with higher chance of remission, while duration, number of antihypertensive drugs, age, body mass index (BMI), cardiovascular disease, and dyslipidemia were associated with lower chance. After adjustment for age, sex, BMI, comorbidities, and education, the cumulative probabilities of MACEs (2.8% versus 5.7%, adjusted odds ratio (OR) 0.60, 95% confidence interval (CI) 0.47 to 0.77, p < 0.001) and all-cause mortality (4.0% versus 8.0%, adjusted OR 0.71, 95% CI 0.57 to 0.88, p = 0.002) were lower for patients being in remission at 2 years compared with patients not in remission, despite relapse of hypertension in 2,089 patients (cumulative probability 56.3%) during 10-year follow-up. The main limitations of the study were missing information on nonpharmacological treatment for hypertension and the observational study design.

CONCLUSIONS

In this study, we observed an association between high postoperative weight loss and male sex with better chance of remission, while we observed a lower chance of remission depending on disease severity and presence of other metabolic comorbidities. Patients who achieved remission had a halved risk of MACE and death compared with those who did not. The results suggest that in patients with severe obesity and hypertension, metabolic surgery should not be delayed.

Evaluation of the "Let's Get Organized" group intervention to improve time management: protocol for a multi-centre randomised controlled trial

BACKGROUND

Time management skills are essential for living in modern society. People with mental or neurodevelopmental disorders typically have cognitive limitations, including affected time management, which might lead to poor occupational balance, low self-efficacy, and poor parental sense of competence. "Let's Get Organized" (LGO) is a recently developed manual-based group intervention to train time management skills. The aim of this trial is to evaluate the efficiency of the Swedish version of LGO (LGO-S) compared to treatment as usual (individual occupational therapy) to improve time management for adults with impaired time management skills due to mental or neurodevelopmental disorders. Furthermore, to evaluate if the intervention is a cost-effective way to improve the quality of life and time management skills of these individuals, we will conduct a health economic evaluation.

METHODS

The trial will have a multi-centre, open, parallel randomised controlled design. A total of 104 adults with cognitive limitations due to mental or neurodevelopmental disorders will be recruited from open psychiatric or habilitation care units. Outcomes will be measured before and after a 10-week intervention, with a follow-up 3 months after completing the intervention. The primary outcome will be self-assessed time management skills. Secondary outcomes will be e.g. self-assessed skills in organisation and planning, regulation of emotions, satisfaction with daily occupations, occupational balance, self-efficacy, and quality-adjusted life years.

DISCUSSION

A recent feasibility study has shown promising results for LGO-S, and a randomised trial will provide robust evidence for the possible efficacy of LGO-S in comparison to treatment as usual.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03654248 . Registered on 20 August 2018.

Factors determining chance of type 2 diabetes remission after Roux-en-Y gastric bypass surgery: a nationwide cohort study in 8057 Swedish patients

INTRODUCTION

Bariatric and metabolic surgery is an effective treatment option for type 2 diabetes (T2D). Increased knowledge regarding factors associated with diabetes remission is essential in individual decision making and could guide postoperative care. Therefore, we aimed to explore factors known to affect the chance of achieving diabetes remission after bariatric and metabolic surgery and to further investigate the impact of socioeconomic factors.

RESEARCH DESIGN AND METHODS

In this nationwide study, we assessed all patients with T2D who underwent Roux-en-Y gastric bypass (RYGB) surgery between 2007 and 2015 in the Scandinavian Obesity Surgery Registry. Remission was defined as absence of antidiabetic medication for T2D 2 years after surgery. Multivariable logistic regression was used to evaluate factors associated with diabetes remission, with missing data handled by multiple imputations.

RESULTS

A total of 8057 patients were included. Mean age±SD was 47.4±10.1 years, mean body mass index 42.2±5.7 kg/m², mean hemoglobin A1c 59.0±17.33, and 61.7% (n=4970) were women. Two years after surgery, 6211 (77.1%) patients achieved T2D remission. Preoperative insulin treatment (OR 0.26, 95% CI 0.22 to 0.30), first-generation immigrant (OR 0.66, 95% CI 0.57 to 0.77), duration of T2D (OR 0.89, 95% CI 0.88 to 0.90), dyslipidemia (OR 0.71, 95% CI 0.62 to 0.81), age (OR 0.97, 95% CI 0.96 to 0.97), and high glycosylated hemoglobin A1c (HbA1c) (OR 0.99, 95% CI 0.98 to 0.99) were all associated with lower T2D remission rate. In contrast, residence in a medium-sized (OR 1.39, 95% CI 1.20 to 1.61) or small (OR 1.46, 95% CI 1.25 to 1.71) town and percentage of total weight loss (OR 1.04, 95% CI 1.03 to 1.04) were associated with higher remission rates.

CONCLUSION

Among patients with T2D undergoing RYGB surgery, increasing age, HbA1c, and diabetes duration decreased the chance of reaching diabetes remission without cut-offs, while postoperative weight loss demonstrated a positive linear association. In addition, being a first-generation immigrant and living in a large city were socioeconomic factors having a negative association.

Differentiation of distal ureteral stones and pelvic phleboliths using a convolutional neural network

The objectives were to develop and validate a Convolutional Neural Network (CNN) using local features for differentiating distal ureteral stones from pelvic phleboliths, compare the CNN method with a semi-quantitative method and with radiologists' assessments and to evaluate whether the assessment of a calcification and its local surroundings is sufficient for discriminating ureteral stones from pelvic phleboliths in non-contrast-enhanced CT (NECT). We retrospectively included 341 consecutive patients with acute renal colic and a ureteral stone on NECT showing either a distal ureteral stone, a phlebolith or both. A 2.5-dimensional CNN (2.5D-CNN) model was used, where perpendicular axial, coronal and sagittal images through each calcification were used as input data for the CNN. The CNN was trained on 384 calcifications, and evaluated on an unseen dataset of 50 stones and 50 phleboliths. The CNN was compared to the assessment by seven radiologists who reviewed a local 5 × 5 × 5 cm image stack surrounding each calcification, and to a semi-quantitative method using cut-off values based on the attenuation and volume of the calcifications. The CNN differentiated stones and phleboliths with a sensitivity, specificity and accuracy of 94%, 90% and 92% and an AUC of 0.95. This was similar to a majority vote accuracy of 93% and significantly higher (p = 0.03) than the mean radiologist accuracy of 86%. The semi-quantitative method accuracy was 49%. In conclusion, the CNN differentiated ureteral stones from phleboliths with higher accuracy than the mean of seven radiologists' assessments using local features. However, more than local features are needed to reach optimal discrimination.

Multi-Reader-Multi-Split Annotation of Emphysema in Computed Tomography

Emphysema is visible on computed tomography (CT) as low-density lesions representing the destruction of the pulmonary alveoli. To train a machine learning model on the emphysema extent in CT images, labeled image data is needed. The provision of these labels requires trained readers, who are a limited resource. The purpose of the study was to test the reading time, inter-observer reliability and validity of the multi-reader-multi-split method for acquiring CT image labels from radiologists. The approximately 500 slices of each stack of lung CT images were split into 1-cm chunks, with 17 thin axial slices per chunk. The chunks were randomly distributed to 26 readers, radiologists and radiology residents. Each chunk was given a quick score concerning emphysema type and severity in the left and right lung separately. A cohort of 102 subjects, with varying degrees of visible emphysema in the lung CT images, was selected from the SCAPIS pilot, performed in 2012 in Gothenburg, Sweden. In total, the readers created 9050 labels for 2881 chunks. Image labels were compared with regional annotations already provided at the SCAPIS pilot inclusion. The median reading time per chunk was 15 s. The inter-observer Krippendorff's alpha was 0.40 and 0.53 for emphysema type and score, respectively, and higher in the apical part than in the basal part of the lungs. The multi-split emphysema scores were generally consistent with regional annotations. In conclusion, the multi-reader-multi-split method provided reasonably valid image labels, with an estimation of the inter-observer reliability.

Sarcoidosis and silica dust exposure among men in Sweden: a case-control study

OBJECTIVE

To determine whether occupational exposure to silica dust is associated with an increased risk of developing sarcoidosis.

DESIGN

Case-control study of all individuals between 20 and 65 years of age diagnosed with sarcoidosis (D86) in Sweden between 2007 and 2016. Controls were matched to cases (2:1) based on age, sex and county at the time of diagnosis. A Job Exposure Matrix was used to estimate the occupational silica exposure of all cases and controls.

SETTING

Medical and occupational data from the National Outpatient Register were used to implement a case-control analysis, while the two controls used for each case were selected from the National Register of the Total Population. Information about occupation and time of employment were collected from the Swedish Occupational Register.

PARTICIPANTS

All men and women aged 20-65 years old who were diagnosed sarcoidosis (D86) from 2007 to 2016 were included and assigned two controls.

MAIN OUTCOMES

Silica dust exposure correlates with an increased risk of developing sarcoidosis in men.

RESULTS

The prevalence of silica exposure at work was statistically significantly higher among male cases than controls (OR 1.27, 95% CI 1.13 to 1.43). For men of an age of 35 years or younger the correlation seems to be stronger (OR 1.48, 95% CI 1.1 to 1.87) than in older men (OR 1.21, 95% CI 1.05 to 1.39). For men older than 35 with exposure to silica the prevalence of sarcoidosis increased with the exposure time, with an OR of 1.44 (95% CI 1.04 to 2.00) for exposure of more than 10 years.

CONCLUSIONS

Occupational exposure to silica dust seems to increase the risk of sarcoidosis among men between 20 and 65 years of age. The risk is higher among exposed men 35 years or younger and older men with longer exposure (>6 years).

Association between metabolic surgery and cardiovascular outcome in patients with hypertension: A nationwide matched cohort study

BACKGROUND

Hypertension, together with obesity, is a leading cause of mortality and disability. Whilst metabolic surgery offers remission of several metabolic comorbidities, the effect for patients with hypertension remains controversial. The objective of the present study was to evaluate the effect of metabolic surgery on cardiovascular events and mortality on patients with morbid obesity (body mass index [BMI] ≥ 35 kg/m2) and hypertension.

METHODS AND FINDINGS

We conducted a matched cohort study of 11,863 patients with morbid obesity and pharmacologically treated hypertension operated on with metabolic surgery and a matched non-operated-on control group of 26,199 subjects with hypertension (matched by age, sex, and area of residence) of varied matching ratios from 1:1 to 1:9, using data from the Scandinavian Obesity Surgery Register (SOReg), the Swedish National Patient Registers (NPR) for in-hospital and outpatient care, the Swedish Prescribed Drug Register, and Statistics Sweden. The main outcome was major adverse cardiovascular event (MACE), defined as first occurrence of acute coronary syndrome (ACS) event, cerebrovascular event, fatal cardiovascular event, or unattended sudden cardiac death. The mean age in the study group was 52.1 ± 7.46 years, with 65.8% being women (n = 7,810), and mean BMI was 41.9 ± 5.43 kg/m2. MACEs occurred in 379 operated-on patients (3.2%) and 1,125 subjects in the control group (4.5%). After adjustment for duration of hypertension, comorbidities, and education, a reduction in risk was seen in the metabolic surgery group (adjusted hazard ratio [HR] 0.73, 95% confidence intervals [CIs] 0.64-0.84, P < 0.001). The surgery group had lower risk for ACS events (adjusted HR 0.52, 95% CI 0.41-0.66, P < 0.001) and a tendency towards lower risk for cerebrovascular events (adjusted HR 0.81, 95% CI 0.63-1.01, P = 0.060) compared with controls. The main limitations with the study were the lack of information on BMI and history of smoking in the control group and the nonrandomised study design.

CONCLUSION

Metabolic surgery on patients with morbid obesity and pharmacologically treated hypertension was associated with lower risk for MACEs and all-cause mortality compared with age- and sex-matched controls with hypertension from the general population.

Risks of developing ulcerative colitis and Crohn's disease in relation to silica dust exposure in Sweden: a case-control study

OBJECTIVE

To determine whether occupational exposure to silica dust causes an increased risk of developing Crohn's disease (CD) and ulcerative colitis (UC).

DESIGN

Case-control study of CD (K50) and UC (K51) from 2007 through 2016. Controls were matched to cases (2:1) based on age, sex and county at the time of diagnosis. A job exposure matrix was used to estimate the occupational silica exposure of all cases and controls.

SETTING

Medical and occupational data from the National Outpatient Register were used to implement a case-control analysis, while the two controls used for each case were selected from the National Register of the Total Population.

PARTICIPANTS

All men and women aged 20-65 years old who were diagnosed with CD (K50) and UC (K51) during the years of study were included and assigned two controls, resulting in 58 136 cases and 116 272 controls.

MAIN OUTCOMES

Silica dust exposure correlates with an increased risk of developing UC in men and CD in women.

RESULTS

The prevalence of UC was significantly higher in the group exposed to silica dust (OR 1.13, 95% CI 1.06 to 1.21) than in controls, particularly in individuals with over 5 years exposure. When stratified by sex, a significantly increased OR was detected for men (OR 1.33, 95% CI 1.05 to 1.22). This trend was also consistent with longer exposure times. The prevalence of UC was not increased in exposed women. The prevalence of CD was significantly increased among exposed women (OR 1.29, 95% CI 1.01 to 1.65), but not for exposed men.

CONCLUSIONS

Silica dust exposure correlates with an increased risk of developing UC, especially in men, and the risk seems to increase with the duration and degree of exposure. Conversely, silica dust exposure correlates positively with the risk of developing CD in women.

Plasma concentrations of secretory leukocyte protease inhibitor (SLPI) differ depending on etiology and severity in community-onset bloodstream infection

The severity of bloodstream infections (BSI) depends on pathogen, source, and host factors. Secretory leukocyte protease inhibitor (SLPI) counteracts tissue damage, balances inflammation, and is increased in pneumonia and sepsis. We aimed to evaluate whether SLPI production differs depending on etiology, disease severity, and sex in BSI and to correlate SLPI with markers of inflammation and immunosuppression. Of the adult patients with BSI, 109 were included and sampled repeatedly, from hospital admission through day 28. Controls (blood donors) were sampled twice. SLPI in plasma was measured with enzyme-linked immunosorbent assay (ELISA) technique. Streptococcus pneumoniae and Staphylococcus aureus etiology were associated with higher SLPI than Escherichia coli on days 1–2 and 3. On day 1–2, subjects with sepsis had higher SLPI concentrations than those with non-septic BSI. Pneumonia was associated with higher SLPI than a non-pulmonary source of infection. SLPI co-varied with inflammatory markers. SLPI concentrations did not differ with regard to sex in the full cohort, but men with pneumonia had higher SLPI than women on day 1–2. S. pneumoniae and S. aureus BSI were associated with higher SLPI, when compared to E. coli. Severity and pneumonia, as well as male sex in the pneumonia sub-cohort, were factors independently associated with higher SLPI.