Appendectomy during pregnancy: rates, safety, and outcomes over a five-year period. A hospital-based follow-up study

INTRODUCTION

Appendicitis is the most common acute abdominal complication during pregnancy. If appendix perforation occurs there is an increasing risk of preterm delivery and other pregnancy complications.

OBJECTIVE

To assess the outcome of pregnancy after appendectomy, the mode of surgery used, appendectomy rates, and complications.

METHODS

A prospective cohort study of pregnant women with, or without, appendectomy at South Stockholm General Hospital, December 2015 to February 2021 in a setting where pregnant women are prioritized for surgery and laparoscopic surgery was standard of care in first half of pregnancy. Data on preoperative imaging, surgical method, intraoperative findings, microscopic findings, hospital stay, pregnancy, and 30-day complications were prospectively recorded in a local appendectomy register. A non-pregnant control group was gathered comprising women of fertile age in the same study interval.

RESULTS

During the study period 50 pregnant women, of whom 44 gave birth, underwent appendectomy of 38 199 women giving birth. There were no differences between women with or without appendectomy in proportion of preterm delivery (4.5% vs. 5.6%), small-for-gestational age (2.3% vs. 6.2%), or Cesarean delivery (18.2% vs. 20.4%). The rate of appendix perforation was 19% in non-pregnant control group compared to 12% among pregnancy. There was no case of perforated appendix in the second half of pregnancy. However, women with gestational age > 20 weeks more frequently had an unaffected appendix compared to those operated ≤ 20 gestational weeks (4/11 vs. 2/39, p = .005). Laparoscopic surgery was used in 97% of non-pregnant control group, 92% of appendectomies ≤ 20 weeks gestation, and in 27% >20 weeks. As compared to first half, the appendectomy rate was three times lower during the second half of pregnancy. Pregnant women had priority for surgery < 6 h compared to < 24 h among non-pregnant women, this resulted in a shorter time-to-surgery among pregnant women (p < .001).

CONCLUSION

Routine laparoscopic surgery and time priority for pregnant surgery is associated with a low risk of perforation, preterm birth and other complications. However, a low threshold for surgery may increase the risk of a negative exploration.

Clinicopathologic factors associated with malignant transformation of oral leukoplakias: a retrospective cohort study

It is clinically challenging to identify oral leukoplakias that have a high risk of undergoing malignant transformation. The aim of this retrospective study was to elucidate the associations between malignant transformation of oral leukoplakias and various clinicopathologic factors. Patients with a diagnosis of clinical oral leukoplakia, verified through histopathologic examination and with access to digital images of the lesion, were retrospectively included for the period 2003-2013. Using the clinical images, all lesions were re-evaluated regarding diagnosis and clinical subtype. Of the 234 included patients, with a median follow-up of 9 years, 27 (11.5%) developed oral squamous cell carcinoma. Among the clinicopathologic factors investigated, non-homogeneous oral leukoplakia (OL), OL with dysplasia, and OL localized to the tongue showed statistically significant increased rates of malignant transformation in the multivariate Cox regression analysis. Non-homogeneous OL showed a 15.2-times higher transformation rate than homogenous OL (P<0.001). Dysplastic leukoplakias developed into carcinomas 2.4-times more often than did non-dysplastic leukoplakias (P=0.048). OL located on the tongue showed a 2.8-times higher malignant transformation rate than OLs at other oral locations (P=0.018), when other locations were combined into one group. Non-homogeneous OL, OL with dysplasia, and OL localized to the tongue have higher transformation rates.

Occupational exposure to whole body vibrations and birth outcomes - A nationwide cohort study of Swedish women

BACKGROUND

More women in reproductive ages are entering occupations where exposure to whole body vibrations (WBV) is common (e.g. in transportation and construction). Previous studies based on self-assessed exposure suggest increased risks of adverse birth outcomes, but it is unclear at what exposure levels and if the current exposure guidelines are appropriate during pregnancy.

OBJECTIVES

To investigate whether occupational WBV-exposure increases the risk of preterm birth, low birth weight, and/or small-for-gestational age, in a large, nationwide, prospective, cohort study.

DESIGN

The Fetal Air Pollution Exposure cohort (FAIR) was formed by merging data from multiple, national registers, and the present study includes singletons born 1994-2014 to working women in Sweden (n = 1,091,080 births). WBV-exposure was assessed quantitatively using a job-exposure matrix based on measurements, and calculated odds ratios were adjusted for potential confounders such as smoking and BMI, and other occupational exposures like noise, combustion particles, and physically and psychologically strenuous work. Data on absence from work (full-/part time, sick leave, parental leave, etc.) was also used.

RESULTS

Exposure to WBV during pregnancy, among women with low absence from work (n = 476,419), was associated with an increased risk of preterm birth, below the occupational exposure limit (1.15 m/s²). Compared to unexposed mothers, the OR was 1.38 (95% CI: 1.05, 1.83) for exposure ≥0.5 m/s², corresponding to an increase from 47/1000 cases to 65/1000 cases. No increased risk was found for small-for-gestational age.

CONCLUSIONS

Exposure to WBV was associated with an increased risk of preterm birth. The results suggest that the current permissible exposure and action levels for WBV-exposure do not adequately protect pregnant women with continuous exposure.

OP0101-HPR QUALITY OF LIFE IN PEOPLE WITH SYSTEMIC SCLEROSIS WITH DIFFERENT DEGREES OF LUNG DISEASE - A CROSS-SECTIONAL STUDY

Background:

There are few studies evaluating different aspects of quality of life including depressive symptoms and physical capacity and physical activity in patients with systemic sclerosis (SSc) with different degrees of lung disease.

Objectives:

The aim of this study was to evaluate differences in self-reported disability, physical capacity and activity, depressive symptoms and quality of life, between patients with SSc with no-mild lung disease and those with moderate-endstage lung disease.

Methods:

In this cross-sectional study, 279 patients with SSc fulfilling the 2013 ACR/EULAR criteria for SSc (84% limited and 16% diffuse SSc) were included. Medsger disease severity scale was used to subgroup the patients into no-mild (n=156) or moderate- endstage lung disease (n=115). Disability was measured with Health Assessment Questionnaire-Disability Index (HAQ-DI); physical capacity (ability to walk, jog/run); and physical activity (different intensities) was measured with three single questions; depressive symptoms with Hospital Anxiety and Depression-scale (HADs); and quality of life was measured with TheShort Form(36) Health Survey (SF-36).

Results:

Patients with moderate-endstage lung disease reported higher scores on HAQ-DI (p<0.001) and lower scores on SF-36 physical component (p<0.0001) than patients with no-mild lung disease. Patients with moderate-endstage lung disease reported lower physical capacity (p<0.0001), less physical activity on low to moderate intensity the past 6 months (p<0.016) and less exercise on moderate to high intensity the past year (p=0.022) compared to those with no-mild lung disease. There was no difference between the two subgroups when it comes to the mental component in SF-36 (p=0.2), however patients with moderate-endstage lung disease had lower scores on the subscales vitality ((p=0.003), social function (p=0.002) and emotional role function (p=0.005) as well as higher scores on the HADs depressive symptoms scale (p=0.024), than the patients with no-mild lung disease.

Conclusion:

Patients with SSc with moderate-endstage lung disease report more disability, lower physical capacity and activity, are more depressed and the physical aspects of quality of life is lower, as well as vitality, social function and emotional role function, compared to patients with no-mild lung disease. Studies evaluating whether increased physical activity and exercise may improve depressive symptoms and aspects of quality of life in patients with moderate-endstage lung disease are needed.

References:

[1]Liem SIE, Meessen JMTA, Wolterbeek R, Ajmone Marsan N, Ninaber MK, Vliet Vlieland TPM, de Vries-Bouwstra JK. Physical activity in patients with systemic sclerosis. Rheumatol Int. 2018;38:443-453

[2]March C, Huscher D, Preis E, Makowka A, Hoeppner J, Buttgereit F, Riemekasten G, Norman K, Siegert E. Prevalence, Risk Factors and Assessment of Depressive Symptoms in Patients With Systemic Sclerosis. Arch Rheumatol. 2019;28;34:253-261

Acknowledgments:

Thanks to the patients involved in the study, patient research partner Monica Holmnér and the staff at the rheumatological clinic, Karolinska University Hospital

Disclosure of Interests:

None declared

Determination of Zearalenone in Barley, Maize and Wheat Flour, Polenta, and Maize-Based Baby Food by Immunoaffinity Column Cleanup with Liquid Chromatography: Interlaboratory Study

An interlaboratory study was performed on behalf of the UK Food Standards Agency to evaluate the effectiveness of an affinity column cleanup liquid chromatography (LC) method for the determination of zearalenone (ZON) in a variety of cereals and cereal products at proposed European regulatory limits. The test portion is extracted with acetonitrile:water. The sample extract is filtered, diluted, and applied to an affinity column. The column is washed, and ZON is eluted with acetonitrile. ZON is quantified by reversed-phase LC with fluorescence detection. Barley, wheat and maize flours, polenta, and a maize-based baby food naturally contaminated, spiked, and blank (very low level) were sent to 28 collaborators in 9 European countries and 1 collaborator in New Zealand. Participants were asked to spike test portions of all samples at a ZON concentration equivalent to 100 μg/kg. Average recoveries ranged from 91–111%. Based on results for 4 artificially contaminated samples (blind duplicates) and 1 naturally contaminated sample (blind duplicate), the relative standard deviation for repeatability (RSDr) ranged from 6.9–35.8%, and the relative standard deviation for reproducibility (RSDR) ranged from 16.4–38.2%. The method showed acceptable within- and between-laboratory precision for all 5 matrixes, as evidenced by HorRat values &lt;1.7.

Prevalence and cumulative incidence of cancer, and mortality in patients with Takotsubo syndrome with focus on the index event

BACKGROUND

It has been suggested that Takotsubo syndrome (TS) is associated with cancer but previous studies have limitations.

AIM

To make a comprehensive analysis of prevalence and cumulative incidence of cancer, and mortality among TS patients with focus on the index event.

DESIGN

A register-based case-control study.

METHODS

The first new cancer occurrences (International Classification of Diseases C00-C75, C81-C96) were compared between 505 patients with TS without obstructive coronary artery disease (CAD) and four age- and gender-matched controls comprising patients with acute coronary syndrome with obstructive CAD (CAD controls), respectively, with chest-pain without obstructive CAD at coronary angiography (controls without CAD).

RESULTS

The prevalence of cancer before the index event was non-significantly (P = 0.052) higher in TS patients (15.8%) than in CAD controls (11.5%), respectively, higher (P = 0.028) than in controls without CAD (11.1%). There were no differences between the groups in cumulative incidence of cancer after the index event but a higher mortality in TS patients who developed cancer when compared with controls without CAD that developed cancer after the index event (P = 0.018).

CONCLUSIONS

There is an increased prevalence of first diagnosed cancer in TS patients before the index event but no increased cumulative incidence of cancer after the index event. The results does not support investigation for the possibility of a malignancy specifically in TS patients but in the event of cancer this patient group might need special care. However, if there is lack of a clear stressor it could be of importance to investigate the possibility of a malignancy.

Can sensation of cold hands predict Raynaud's phenomenon or paraesthesia?

Background

Raynaud’s phenomenon and neurosensory symptoms are common after hand-arm vibration exposure. Knowledge of early signs of vibration injuries is needed.

Aims

To investigate the risk of developing Raynaud’s phenomenon and paraesthesia in relation to sensation of cold hands in a cohort of male employees at an engineering plant.

Methods

We followed a cohort of male manual and office workers at an engineering plant in Sweden for 21 years. At baseline (1987 and 1992) and each follow-up (1992, 1997, 2002, 2008), we assessed sensation of cold, Raynaud’s phenomenon and paraesthesia in the hands using questionnaires and measured vibration exposure. We calculated risk estimates with univariate and multiple logistic regression analyses and adjusted for vibration exposure and tobacco usage.

Results

There were 241 study participants. During the study period, 21 individuals developed Raynaud’s phenomenon and 43 developed paraesthesia. When adjusting the risk of developing Raynaud’s phenomenon for vibration exposure and tobacco use, the odds ratios were between 6.0 and 6.3 (95% CI 2.2–17.0). We observed no increased risk for paraesthesia in relation to a sensation of cold hands.

Conclusions

A sensation of cold hands was a risk factor for Raynaud’s phenomenon. At the individual level, reporting a sensation of cold hands did not appear to be useful information to predict future development of Raynaud’s phenomenon given a weak to moderate predictive value. For paraesthesia, the sensation of cold was not a risk factor and there was no predictive value at the individual level.

COMT genotype and non-recovery after a whiplash injury in a Northern European population

Background

The COMT (Catechol-O-Methyl Transferase) gene may influence a person’s vulnerability to develop long-term pain and some COMT single nucleotide polymorphisms (SNPs) may associate with patterns of acute or chronic pain. Many patients with whiplash-associated disorders (WADs) suffer from long-term pain and other related symptoms, but it is less known if genetic factors play a role in the recovery process. The primary aim of this study was to evaluate whether self-reported non-recovery, including pain, was related to COMT genotype in patients with WAD. The secondary aim was to investigate whether or not background factors, including mental health, were related to genotype and non-recovery.

Methods

A total of 133 patients with neck pain after a whiplash trauma were included. Background factors were collected and blood samples were taken during the acute phase after the accident. DNA was isolated from blood and used to genotype the SNPs rs6269, rs4633, rs4818 and rs4680 in the COMT gene; additionally haplotypes were estimated and haplogenotypes inferred. The patients were followed up after 12 months and asked to rate their recovery including pain, mental health and quality of life.

Results

The overall reported non-recovery rate at 12 months was 44% with no significant differences in distribution of the COMT haplotypes. High levels of self-reported pain (OR 7.2) and anxiety (OR 4.4) after the accident were associated with non-recovery, but not related to the haplotypes. None of the other background factors were related to the haplotypes or non-recovery.

Conclusion

No association between self-reported non-recovery or pain levels and COMT haplotypes in patients with acute whiplash injuries could be detected. Independent replications are necessary to discard the hypothesis that COMT haplotypes do not influence non-recovery or pain levels in patients with acute whiplash injuries. High levels of initial pain and anxiety were associated with non-recovery, thereby confirming previously published reports.

Film-Screen Vs. Digital Radiography in Rheumatoid Arthritis of the Hand

In a prospective investigation the diagnostic accuracy of film-screen and digital radiography in rheumatoid arthritis of hands was compared. Seventy hands of 36 patients with established rheumatoid arthritis were included in the study. Each of 11 joints in every hand was evaluated regarding the following radiologic parameters: soft tissue swelling, joint space narrowing, erosions and periarticular osteopenia. The digital images were obtained with storage phosphor image plates and evaluated in 2 forms; as digital hard-copy on film and on a monitor of an interactive workstation. The digital images had a resolution of either 3.33 or 5.0 lp/mm. ROC curves were constructed and comparing the area under the curves no significant difference was found between the 3 different imaging forms in either resolution group for soft tissue swelling, joint space narrowing and erosions. The film-screen image evaluation of periarticular osteopenia was significantly better than the digital hard-copy one in the 3.33 lp/mm resolution group, but no significant difference was found in the 5.0 lp/mm group. These results support the view that currently available digital systems are capable of adequate diagnostic performance.

Assessment of Digital Chest Radiography Using Stimulable Phosphor

In this pilot study, conventional and digital radiography of the chest was compared in 170 patients. Two digitized radiographs, one frequency modified and one simulating the conventional film-screen combination, and the conventional films were reviewed independently by 5 radiologists with different experience. In spite of the smaller size and lower spatial resolution of the digitized compared with the conventional radiograph, only slight differences were revealed in the observation of different pulmonary and mediastinal changes. Digitized radiography is therefore considered suitable for chest examinations.

Computed VS. Film-Screen Magnification Radiography of Fingers in Hyperparathyroidism

One hundred randomly selected patients with suspected or known hyperparathyroidism were examined in a prospective study of the 2nd and 3rd fingers with film-screen and digital luminescence radiographs using magnification technique. The digital images were displayed on a work-station and printed as hard-copies. Two radiologists evaluated the film-screen images regarding subperiosteal and intracortical resorption and their results were defined as “gold standard” regarding the absence or presence of these changes. Four radiologists evaluated these changes in the 3 image forms and an ROC analysis was performed. Comparing the areas under the ROC curves no significant difference was found between the film-screen images and the 2 digital display forms. These results suggest that currently available digital systems provide adequate diagnostic accuracy for evaluation of subtle skeletal changes.

Gadolinium-DTPA Enhancement of Experimental Soft Tissue Carcinoma and Hemorrhage in Magnetic Resonance Imaging

An experimental series in the rabbit was performed to test gadolinium-DTPA (Gd-DTPA) enhancement of VX-2 carcinoma and hemorrhages induced in the soft tissues. The recognition of both malignant and benign lesions was greatly facilitated on T1 weighted images after intravenous administration of 0.3 mmol Gd-DTPA/kg body weight because of reduced T1 relaxation times. Gd-DTPA enhancement reached its maximum after 10–15 minutes and was most apparent in tumor tissue, connective tissue surrounding the tumor and in the area of fresh hemorrhage.

Comparison of Two- and Three-Dimensional Methods for Assessment of Orientation of the Total Hip Prosthesis

A comparison of two- and three-dimensional methods for the determination of the orientation of total hip prostheses was made in a group of 57 patients. The acetabular inclination and the collum-diaphyseal angle measured on a.p. projections (2-D) were adequate in most cases for assessing how vertically the prosthetic component was inserted, but in individual cases with a high degree of version these measurements could be misleading. Anteversion measured in the transverse plane (2-D) was more sensitive to errors than planar anteversion measured as a rotation around the longest diameter of the ellipsoid projection of the acetabular opening, but it gave a rough estimate of the relation of the prosthetic components. Determination of the spatial (3-D) orientation of the components provides a precise estimate of the component relations.

Trochanteric Fractures

Four hundred and thirty trochanteric fractures operated upon with McLaughlin, Ender or Richard's osteosynthesis were divided into 6 different types based on their radiographic appearance before and immediately after reposition with special reference to the medial cortical support. A significant correlation was found between the fracture type and subseq

Digital Radiography of the Spine, Large Bones and Joints Using Stimulable Phosphor

The value of digital radiography in musculoskeletal disorders was investigated by assessing its ability to depict anatomic structures and common radiologic features as compared with the conventional film-screen combination. The digital image that was frequency modified was superior to conventional films in delineating soft tissue structures and for areas with large attenuation differences. The conventional film-screen system was superior in depicting small anatomic structures and in identifying the zone close to prostheses. This was explained by the high spatial resolution of the conventional film system and the disturbing halo effect around the prosthesis seen with digital images. The halo effect is an overshoot caused by the unsharp masking operator, which was in this series not changed for individual examinations. The exposure (radiation dose) could be reduced to 50 per cent using the digital system, without any loss of information.

Range of Motion Caused by Design of the Total Hip Prosthesis

In a clinical material of total hip prostheses, a study was performed of the range of femoral motion until impingement occurred between the neck of the femoral stem and the rim of the acetabular socket. The results were compared with the physiologic range of motion, and the clinically relevant motion restriction was measured. Restriction was most common in flexion. There was a correlation between the prosthetic design and the restriction due to impingement.

Conventional Radiography in Transient Synovitis of the Hip in Children

Conventional radiography was performed at diagnosis and at follow-up 5 to 9 months later in 70 children with transient synovitis of the hip. Twenty-four of the patients also had CT examination at diagnosis. The cartilaginous and osseous reaction in the conventional antero-posterior radiographs was studied as was the relation between the radiographic and CT findings concerning fat planes, joint effusion, and position of the hip joint. At diagnosis there was significant increase in the medial joint space and at follow-up examination there was significant increase in medial and cranial joint space, metaphyseal width and acetabular roof width. There was a correlation of a bulging lateral ‘capsular fat plane’ to the position of abduction in the affected hip which explains the asymmetry in the lateral fat plane observed in these patients.

Magnetic Resonance Imaging in Hemophilic Arthropathy of the Knee

The MR findings at the examination of 16 knees in 9 hemophilic patients were reviewed. The hemophilic arthropathy was demonstrated in great detail. The state of the joint cartilage, menisci, posterior cruciate ligaments and synovial tissue could be assessed. The presence of intraarticular hemorrhage and cyst fluid in bone cavities was recorded. MRI may become a valuable tool for assessment of early treatment of hemophilic arthropathy.

Computed Tomography of Humeral Head Cup Arthroplasties

Computed tomography (CT) was employed to evaluate resurfacing metal cup arthroplasties, in shoulders affected by rheumatoid arthritis. Reconstruction of the information obtained, with the high frequency filter, resulted in an image of the cement and skeletal structures inside the cup. This new application of CT may prove valuable in assessing the complications and results of cup arthroplasties.

Digital Radiography Using Laser Stimulated Luminescence for Evaluation of Urinary Calcifications

One hundred consecutive patients were investigated with both a conventional film-screen combination and digital radiography using a laser stimulated luminescence technique in order to evaluate differences in detecting urinary tract stones. All patients were referred either for follow-up of previously known stones or for symptoms. The images were reviewed by two radiologists who had the single clinical information that the patients might have urinary stones. Following review, the two techniques were compared and a consensus was obtained. One hundred and eighteen stones were found in 41 patients without any statistical differences in sensitivity between the two imaging systems.

Position, Orientation and Component Interaction in Dislocation of the Total Hip Prosthesis

The position, orientation in space and interaction of prosthetic components was determined in 15 patients with known episodes of dislocation after total hip replacement. The same calculations were performed in a reference group of 44 patients without dislocation. In the group with dislocations, there was a significantly decreased femoral anteversion, and a decreased femoral flexion permitted by the prosthetic components. There were no further significant differences of clinical relevance between the groups concerning all other examined parameters of component position, orientation and interaction. It is concluded that the decreased range of flexion, caused by impingement of the prosthetic components with ensuing leverage effect is one cause of dislocation.

Magnetic Resonance Relaxation Characteristics of Muscle, Fat and Bone Marrow of the Extremities

The T1 and T2 relaxation times were calculated in the bone marrow, subcutaneous fat and muscles in the extremities of 21 volunteers. There were no significant differences in relation to age or sex. In the same individual, the difference in the relaxation time was negligible between different sites in muscle, fat and bone. These and other normal values reported are dependent on examination technique and calculation method which must be compensated for when comparisons between materials from different centers are performed.

Gadolinium-Dtpa Enhancement of Soft Tissue Tumors in Magnetic Resonance Imaging

In a clinical study of 13 patients, gadolinium-DTPA (Gd-DTPA) was used for enhancement of soft tissue tumors at magnetic resonance imaging. Gd-enhanced T1 sequences were found to give additional information concerning tumor vascularity in 11 cases, tumor necrosis in 2 cases and tumor delineation in one case, compared with conventional T1 and T2 weighted spin echo sequences. If Gd-enhanced sequences were to be used as the only source of information, accurate assessment of tissue composition of the tumor would not have been possible. Furthermore, valuable information regarding tumor delineation towards surrounding fat may be lost.

Femoral Anteversion and Restricted Range of Motion in Total Hip Prostheses

Impingement of the neck of the stem on to the rim of the socket may cause dislocation of the total hip prosthesis. The role of femoral anteversion in the occurrence of such impingement was analyzed in a clinical material of total hip prostheses with and without dislocation. A low femoral anteversion was linked to a clinically relevant reduction of the range of motion due to impingement and dominated in the group with dislocations. Impingement is minimized by inserting the femoral component in 10° to 20° of anteversion.

Surgical correction of a rotational deformity of the shoulder in patients with obstetric brachial plexus palsy

We evaluated results at one year after surgical correction of internal rotation deformities in the shoulders of 270 patients with obstetric brachial plexus palsy. The mean age at surgery was 6.2 years (0.6 to 35). Two techniques were used: open subscapularis elongation and latissimus dorsi to infraspinatus transfer. In addition, open relocation was performed or attempted in all patients with subluxed or dislocated joints. A mixed effects model approach was used to evaluate the effects of surgery on internal and external rotation, abduction, flexion and Mallet score. Independent factors included operative status (pre- or post-operative), gender, age, the condition of the joint, and whether or not transfer was performed. The overall mean improvement in external rotation following surgery was 84.6° (95% confidence interval (CI) 80.2 to 89.1) and the mean Mallet score improved by 4.0 (95% CI 3.7 to 4.2). There was a mean decrease in internal rotation of between 27.6° and 34.4° in the relocated joint groups and 8.6° (95% CI 5.2 to 12.0) in the normal joint group. Abduction and flexion were unchanged following surgery. Adding a latissimus dorsi transfer did not result in greater improvement in the mean external rotation compared with elongation of the subscapularis alone.

Cite this article: Bone Joint J 2013;95-B:1432–8.

Plant sterol oxidation products--analogs to cholesterol oxidation products from plant origin?

Cholesterol and plant sterols are lipids which are abundantly present in a western type diet of animal and plant origin, respectively. The daily intake averages 300 mg/day each. Over the past decades, a steadily increasing consumption of plant sterol enriched dairy products (2-3 g/day) took place to lower circulating LDL cholesterol concentrations. Like all unsaturated components, plant sterols can be attacked by reactive oxygen species resulting in plant sterol oxidation products (POPs). The most widespread methods for POP determination are high-performance liquid chromatography and gas-liquid chromatography. Yet, based on the low plasma POP concentrations in normophytosterolemic subjects (POPs: ∼0.3-4.5 ng/mL), a reliable quantification yielding an appropriate limit of detection remains a challenge. While the more abundantly present cholesterol oxidation products (COPs) have elaborately been studied, research on the metabolism and biological effects of POPs is only emerging. In relation to atherogenity, biological effects including modulation of cholesterol homeostasis, membrane functioning, and inflammation are attributed to POPs. Although mostly supra-physiological concentrations are applied in in vitro assays, anti-tumor activity, cytotoxicity and estrogen-competition have been attributed to specific POPs. However, it is not obvious, if and how POPs may exert in vivo adverse or beneficial health effects similar to those attributed to COPs. In the field of nutritional science, standardized methods for the determination of POPs are required to perform relevant biological studies and to assess their presence in complex foods or biological tissues and fluids. The aim of this review is to provide an overview and evaluation of the published methods and an update on the biological effects attributed to POPs.

Enhanced production of 24S-hydroxycholesterol is not sufficient to drive liver X receptor target genes in vivo

BACKGROUND

Oxysterols such as 24S-hydroxycholesterol (OHC) and 27-OHC are intermediates of cholesterol excretion pathways. In addition, they are putative endogenous agonists of the liver X receptor (LXR) class of nuclear hormone receptors and are thought to be important mediators of cholesterol-dependent gene regulation. 24S-OHC is one of the most efficient endogenous LXR agonists known and is present in the brain and in the circulation at relatively high levels.

OBJECTIVES

To explore the regulatory importance of 24S-OHC in vivo.

DESIGN

We developed a transgenic mouse model in which human cholesterol 24-hydroxylase, the enzyme responsible for the formation of 24S-OHC, was expressed under the control of a promoter derived from the β-actin gene.

RESULTS

Both male and female transgenic mice had elevated levels of cerebral, plasma, biliary and faecal 24S-OHC. According to the faecal excretion results, production of 24S-OHC was increased four- to sevenfold. Gene expression profiling revealed that the elevated production of 24S-OHC did not result in the anticipated activation of LXR target genes in the brain or liver.

CONCLUSION

In spite of the fact that 24S-OHC is a highly effective agonist of LXRs in vitro, it is not a critical activator of target genes to this nuclear receptor in vivo, either in the brain or in the liver.

The burden of hepatitis C in Sweden: a national study of inpatient care

The spread of hepatitis C virus (HCV) in Sweden in the 1970s indicated that serious liver complications (SLC) would increase in the 2000s. The aim of this study was to analyse the burden of HCV-associated inpatient care in Sweden, to demonstrate the changes over time and to compare the findings with a noninfected population. The HCV-cohort (n: 43,000) was identified from the national surveillance database 1990-2006, and then linked to national registers to produce an age-, sex-, and region-matched noninfected comparison population (n: 215,000) and to obtain information on demographics, cancers, inpatient care and prescriptions. Cox regression was used to estimate the likelihood (hazard ratios) for admission to hospital in the HCV compared with the noninfected cohort. The hazard ratios were 4.03 (95% CI: 3.98-4.08) for all care, 77.52 (71.02-84.60) for liver-related care and 40.74 (30.58-54.27) for liver cancer care. The admission rate in the HCV-cohort compared with the noninfected cohort, the rate ratio (age- and sex-adjusted) for all inpatient care was 5.91 (95% CI: 5.87-5.94), and the rate ratio for liver-related care was 70.05 (66.06-74.28). In the HCV-cohort, 45% of all episodes were for psychiatric, mostly drug-related, care. Inpatient care for SLC increased in the 2000s. To conclude, drug-related care was common in the HCV-infected cohort, the demand for liver-related care was very high, and SLC increased notably in the 2000s, indicating that the burden of inpatient care from serious liver disease in HCV-infected individuals in Sweden is an increasing problem.

Soft nanostructuring of YBCO Josephson junctions by phase separation

We have developed a new method to fabricate biepitaxial YBa2 Cu3 O7-δ (YBCO) Josephson junctions at the nanoscale, allowing junctions widths down to 100 nm and simultaneously avoiding the typical damage in grain boundary interfaces due to conventional patterning procedures. By using the competition between the superconducting YBCO and the insulating Y2 BaCuO5 phases during film growth, we formed nanometer sized grain boundary junctions in the insulating Y2 BaCuO5 matrix as confirmed by high-resolution transmission electron microscopy. Electrical transport measurements give clear indications that we are close to probing the intrinsic properties of the grain boundaries.

Electron backscattering diffraction and X-ray diffraction studies of interface relationships in Sr3Ru2O7/Sr2RuO4 eutectic crystals

Sr3Ru2O7/Sr2RuO4 eutectic system is investigated by electron backscattering diffraction (EBSD) and X-ray diffraction (XRD). The eutectic growth enables the solidification of the two phases in an ordered lamellar pattern extending along the growth direction, namely the b-axis direction. The eutectic material thus provides in the a-c plane two distinct interfaces having different microstructures with respect to the growth direction. Our analysis shows that, across the inplane c-axis direction (characterized by a poor lattice matching), the b-axis orientation is not constant at the individual interfaces, showing an orientation spread of about 5°. However, across the in-plane a-axis direction (characterized by a good lattice matching), the b-axis orientation does not change within a few tenths of degree (about 0.25°). Such information at nanoscale is also verified on a macroscopic level by standard XRD investigation.

High levels of 15-oxygenated steroids in circulation of patients with multiple sclerosis: fact or fiction?

15-Oxygenated cholesterol species such as 5α-cholest-8(14)ene-3β,15α-diol (15HC) and 3β-hydroxy-5α-cholest-8(14)-en-15-one (15KC) are commercially available synthetic products unlikely to occur in biological systems. Surprisingly, Farez et al. recently reported that these two steroids occur in human circulation at levels considerably higher than those of any other endogenous oxysterol [Farez, M. et al. 2009. Toll-like receptor 2 and poly(ADP-ribose) polymerase 1 promote central nervous system neuroinflammation in progressive EAE. Nat. Immunol. 10: 958-964]. The levels were reported to be increased in patients with multiple sclerosis in a progressive phase and the authors suggested that this could be utilized diagnostically. Based on extensive in vitro experiments exposing cells to the same high levels of 15HC as found in vivo (1000 ng/ml) the authors concluded that 15HC may be an important pathogenetic factor in multiple sclerosis. Using combined gas chromatography-mass spectrometry we fail to detect significant plasma levels of 15HC either in healthy controls or in patients with multiple sclerosis (levels < 2 ng/ml). If 15KC is present in these plasma samples, the concentration of it must be <10 ng/ml. Our failure to detect significant levels of the above steroids could not be due to loss during hydrolysis and work-up because recovery of the added two oxysterols was close to 100%. Autoxidation of lipoprotein-bound cholesterol resulted in extensive conversion of cholesterol into 7-oxygenated but not 15-oxygenated sterols. We conclude that if present there are trace amounts only of the above 15-oxygenated steroids in human circulation and that the role of such oxysterols as pathogenetic factors and biomarkers must be reconsidered.

How often is a low Apgar score the result of substandard care during labour?

Please cite this paper as: Berglund S, Pettersson H, Cnattingius S, Grunewald C. How often is a low Apgar score the result of substandard care during labour? BJOG 2010;117:968-978. Objective To increase our knowledge of the occurrence of substandard care during labour. Design A population-based case-control study. Setting Stockholm County. Population Infants born in the period 2004-2006 in Stockholm County. Methods Cases and controls were identified from the Swedish Medical Birth Register, had a gestational age of >/=33 complete weeks, had planned for a vaginal delivery, and had a normal cardiotocographic (CTG) recording on admission. We compared 313 infants with an Apgar score of <7 at 5 minutes of age with 313 randomly selected controls with a full Apgar score, matched for year of birth. Main outcome measure Substandard care during labour. Results We found that 62% of cases and 36% of controls were subject to some form of substandard care during labour. In half of the cases and in 12% of the controls, CTG was abnormal for >/=45 minutes before birth. Fetal blood sampling was not performed in 79% of both cases and controls, when indicated. Oxytocin was provided without signs of uterine inertia in 20% of both cases and controls. Uterine contractions were hyperstimulated by oxytocin in 29% of cases and in 9% of controls, and the dose of oxytocin was increased despite abnormal CTG in 19% and 6% of cases and controls, respectively. Assuming that substandard care is a risk factor for low Apgar score, we estimate that up to 42% of the cases could be prevented by avoiding substandard care. Conclusions There was substandard care during labour of two-thirds of infants with a low Apgar score. The main reasons for substandard care were related to misinterpretation of CTG, not acting on an abnormal CTG in a timely fashion and incautious use of oxytocin.

How often is a low Apgar score the result of substandard care during labour?

OBJECTIVE

To increase our knowledge of the occurrence of substandard care during labour.

DESIGN

A population-based case-control study.

SETTING

Stockholm County.

POPULATION

Infants born in the period 2004-2006 in Stockholm County.

METHODS

Cases and controls were identified from the Swedish Medical Birth Register, had a gestational age of +/-33 complete weeks, had planned for a vaginal delivery, and had a normal cardiotocographic (CTG) recording on admission. We compared 313 infants with an Apgar score of < 7 at 5 minutes of age with 313 randomly selected controls with a full Apgar score, matched for year of birth.

MAIN OUTCOME MEASURE

Substandard care during labour.

RESULTS

We found that 62% of cases and 36% of controls were subject to some form of substandard care during labour. In half of the cases and in 12% of the controls, CTG was abnormal for > or = 45 minutes before birth. Fetal blood sampling was not performed in 79% of both cases and controls, when indicated.Oxytocin was provided without signs of uterine inertia in 20% of both cases and controls. Uterine contractions were hyperstimulated by oxytocin in 29% of cases and in 9% of controls, and the dose of oxytocin was increased despite abnormal CTG in 19% and 6% of cases and controls, respectively. Assuming that substandard care is a risk factor for low Apgar score, we estimate that up to 42% of the cases could be prevented by avoiding substandard care.

CONCLUSIONS

There was substandard care during labour of two thirds of infants with a low Apgar score. The main reasons for substandard care were related to misinterpretation of CTG, not acting on an abnormal CTG in a timely fashion and incautious use of oxytocin.

Zearalenone in maize: stability testing and matrix characterisation of a certified reference material

Within the certification process of a reference material for the determination of the mycotoxin zearalenone (ZON) in maize, short- and long-time stability tests of naturally contaminated maize have been performed. The short-term stability of ZON in the maize was evaluated under four different conditions (4, 25, 40 and 70 degrees C) in preliminary studies. Four storage times of 0, 1, 2 and 4 weeks were investigated using HPLC. The long-term stability study was conducted with measurements after 0, 3, 6, 12, 24 and 36 months under three storage conditions (4, 25 and 40 degrees C) in preliminary studies using HPLC. Stability data gained under two different conditions (4 and 25 degrees C) with five storage times of 0, 1, 6, 12 and 18 months were further evaluated for the contaminated maize in the certification process. Before the certification, the maize matrix had been characterized with respect to dry residue, ash content, fat content, protein content, ergosterol content and total dietary fibre, and the efficiency of gamma-irradiation on the fungal flora was investigated. The stability of the maize matrix was evaluated by monitoring UV absorption and ergosterol content under four different storage conditions (4, 25, 35 and 70 degrees C) with five storage times of 0, 1, 6, 12 and 24 months. Other possibly occurring mycotoxins (deoxynivalenol, nivalenol, 3-acetyl deoxynivalenol, 15-acetyl deoxynivalenol, fusarenon X and moniliformin) have been quantified. On the basis of the stability measurements, which showed no significant trends for both short- and long-term stabilities, it can be recommended to store the samples at temperatures < 4 degrees C and ship the samples at ambient temperatures.

Real-time PCR detection of Fusarium species in Swedish oats and correlation to T-2 and HT-2 toxin content

Contamination of Fusarium moulds and subsequent production of mycotoxins is a common problem in cereals grown in Northern Europe. Oats is the third most important cereal crop in Sweden and is commonly contaminated by Fusarium. To date there are no published reports on the distribution of trichothecene-producing Fusaria in Swedish oats and correlation to T-2 and HT-2, the two most dominant toxins. Identification of Fusarium species by traditional methods requires specific skill and experience and quantification of specific species is not possible. Using modern molecular methods such as real-time PCR both identification and quantification of specific Fusarium species are possible directly from the food or feed samples. In this study, specific methods for Fusarium langsethiae, Fusarium sporotrichioides, Fusarium graminearum, Fusarium culmorum and Fusarium poae as well as for the total amount of DNA from trichothecene-producing species were evaluated with respect to precision, robustness and efficiency and then used in the analysis of oat samples. Sixty-two oat samples were taken from field trial harvests from 2006-2008 in the central and southern parts of Sweden and analysed for the presence of Fusarium species by using species-specific real-time PCR-based methods with TaqMan or SYBR Green biochemistry. The T-2 and HT-2 toxin content was analysed by gas chromatography with electron capture detection of the toxins' pentafluoropropyl derivatives. The results showed that F. langsethiae and F. poae were the most dominant Fusarium species among those tested in Swedish oats during this period. The DNA level of F. langsethiae correlated well with the level of T-2 and HT-2 toxin (r=0.7), indicating that this species was the most important producer of T-2 and HT-2 toxins in Swedish oats during the sampling period (2006 to 2008). It can also be concluded that real-time PCR is a powerful tool when studying Fusarium species distribution in oats.

Role of surgeon-performed ultrasound on further management of patients with acute abdominal pain: a randomised controlled clinical trial

BACKGROUND

The use of bedside ultrasound performed by the surgeon or emergency physician on duty at the emergency department is increasing. A study was performed which is the first randomised study to evaluate the benefits of surgeon-performed ultrasound for the management of the acute abdomen.

METHODS

800 patients who attended the emergency department at Stockholm South General Hospital, Sweden for abdominal pain were randomised either to receive or not receive surgeon-performed ultrasound as a complement to routine management. Outcome measures included the number of complementary investigations, time spent in the emergency department, admission rate, length of hospital stay if admitted, admission to surgery and timing of surgery if required.

RESULTS

The number of complementary ultrasound examinations was considerably higher in the group who did not receive bedside ultrasound (18.8 percentage points difference, p<0.001). The admission rate was lower in the ultrasound group (7.2 percentage points difference, p = 0.041) and the proportion of patients requiring surgery submitted for surgery directly from the emergency department was higher in the ultrasound group (18.5 percentage points difference, p = 0.013).

CONCLUSION

This study shows benefits in the management of the acute abdomen resulting in fewer further requested examinations, fewer admissions and shorter lead times to surgery. On the basis of these results, it is recommended for implementation in emergency departments.

TRIAL REGISTRATION NUMBER

NCT00550511.

Emerging issues of HT-2 and T-2 toxins in European cereal production

HT-2 and T-2 toxins are two of the most potent trichothecenes; they have a combined (HT-2+T-2) temporary Tolerable Daily Intake (TDI) of 0.06 µg/kg body weight/day. The distribution of HT-2 and T-2 appears to be largely restricted to Europe. Of the cereal species, HT-2 and T-2 usually have higher incidences and concentrations on oats followed by barley and then wheat, however, this can vary between countries. Survey data from Nordic countries have indicated that these mycotoxins have increased in recent years, reaching concentrations of >1000 µg/kg HT-2+T-2 in some samples. HT-2 and T-2 have also been detected in malting barley in France, and in particular in spring sown varieties. A newly identified species, Fusarium langsethiae, has been implicated as a producer of HT-2 and T-2 in European cereals. There is limited data available regarding this species' pathogenicity and mycotoxin production. The impact of agronomy on the concentration of HT-2 and T-2 in cereals has not been clearly identified, but it is evident that it is different to the impact of agronomy on deoxynivalenol. Processing of cereals can have a major impact on the HT-2 and T-2 content of cereals. Oats are de-hulled during processing for human consumption; de-hulling reduces the mycotoxin content of oats by more than 90%. During the malting and brewing of barley the concentration of HT-2 and T-2 increases and decreases within various stages of the processes and the final mycotoxin load of beers will depend on the individual processes used by each maltster and brewer. Whether these mycotoxins are an issue for human health cannot be determined until a full TDI is calculated based on more long-term exposure studies, and human exposure levels are calculated from surveys of retail products using new, highly sensitive assays.

Prediction of time to spontaneous onset of labour with lactate concentration in vaginal fluid in women with suspected preterm prelabour rupture of the membranes

OBJECTIVE

To assess whether lactate determination in vaginal fluid is associated with and can predict onset of labour for women with suspected preterm prelabour rupture of membranes (PPROMs).

DESIGN

Prospective observational study.

SETTING

Labour ward at South General Hospital, Stockholm, Sweden. POPULATION/PARTICIPANTS: Women with suspected PPROMs at 20-36 completed weeks of gestation (n = 81).

METHODS

All women underwent a speculum examination and a test for determining lactate concentration in vaginal fluid. We used logistic regression to estimate the association between lactate concentration in vaginal fluid and time to onset of labour.

MAIN OUTCOME MEASURE

Time from examination to spontaneous onset of labour (cervix > or =4 cm).

RESULTS

The median time between examination and onset of labour was 13.6 hours for those with a high (> or =4.5 mmol/l) lactate concentration and 1152 hours (i.e. 48 days) for those with a low (<4.5 mmol/l) lactate concentration. For a lactate threshold of 4.5 mmol/l, the likelihood ratio for positive test (LR+) was 12.6, and LR- was 0.14 for the outcome of spontaneous onset of labour within 48 hours.

CONCLUSIONS

A high lactate concentration in vaginal fluid is strongly associated with whether a woman with suspected PPROM will commence onset of labour within 48 hours. If confirmed, use of lactate ('LAC test') as a predictive test for onset of preterm labour may be an attractive tool in bedside obstetrics.

Double-pionic fusion of nuclear systems and the "ABC" effect: approaching a puzzle by exclusive and kinematically complete measurements

The ABC effect-a puzzling low-mass enhancement in the pipi invariant mass spectrum, first observed by Abashian, Booth, and Crowe-is well known from inclusive measurements of two-pion production in nuclear fusion reactions. Here we report on the first exclusive and kinematically complete measurements of the most basic double-pionic fusion reaction pn-->dpi;{0}pi;{0} at beam energies of 1.03 and 1.35 GeV. The measurements, which have been carried out at CELSIUS-WASA, reveal the ABC effect to be a (pipi)_{I=L=0} channel phenomenon associated with both a resonancelike energy dependence in the integral cross section and the formation of a DeltaDelta system in the intermediate state. A corresponding simple s-channel resonance ansatz provides a surprisingly good description of the data.

Impact of surgeon-performed ultrasound on diagnosis of abdominal pain

Background:

A randomised study was performed to evaluate the diagnostic accuracy of surgeon-performed ultrasound in the emergency department for patients presenting with abdominal pain.

Methods:

Surgeons responsible for the examination of study patients underwent 4 weeks of ultrasound training. 800 patients who were attending the emergency department for abdominal pain were randomised to undergo or not undergo surgeon-performed ultrasound as a complement to standard examination. The preliminary diagnosis made by the surgeon, with or without ultrasound, was compared with the final diagnosis made by a senior surgeon 6–8 weeks later.

Results:

Diagnostic accuracy was significantly higher in the group examined with ultrasound (64.7% vs 56.8%, p = 0.027). Ultrasound proved to be helpful in making or confirming a correct diagnosis in 24.1% of cases receiving ultrasound and to contribute in 2.9%. In 22.3% of patients the diagnosis of non-specific pain was confirmed by normal findings. Ultrasound was misleading in 10.2% of cases and had no influence on the diagnosis in 40.0%.

Conclusion:

For patients with acute abdominal pain, higher diagnostic accuracy is achieved when surgeons use ultrasound as a diagnostic complement to standard examination. The use of bedside ultrasound should be considered in emergency departments.

Tunneling anisotropic magnetoresistance in Co/AlOx/Au tunnel junctions

We observe spin-valve-like effects in nanoscaled thermally evaporated Co/AlOx/Au tunnel junctions. The tunneling magnetoresistance is anisotropic and depends on the relative orientation of the magnetization direction of the Co electrode with respect to the current direction. We attribute this effect to a two-step magnetization reversal and an anisotropic density of states resulting from spin-orbit interaction. The results of this study points to future applications of novel spintronics devices involving only one ferromagnetic layer.

Severe asphyxia due to delivery-related malpractice in Sweden 1990-2005

Objective

To describe possible causes of delivery-related severe asphyxia due to malpractice.

Design and setting

A nationwide descriptive study in Sweden.

Population

All women asking for financial compensation because of suspected medical malpractice in connection with childbirth during 1990–2005.

Method

We included infants with a gestational age of ≥33 completed gestational weeks, a planned vaginal onset of delivery, reactive cardiotocography at admission for labour and severe asphyxia-related outcomes presumably due to malpractice. As asphyxia-related outcomes, we included cases of neonatal death and infants with diagnosed encephalopathy before the age of 28 days.

Main outcome measure

Severe asphyxia due to malpractice during labour.

Results

A total of 472 case records were scrutinised. One hundred and seventy-seven infants were considered to suffer from severe asphyxia due to malpractice around labour. The most common events of malpractice in connection with delivery were neglecting to supervise fetal wellbeing in 173 cases (98%), neglecting signs of fetal asphyxia in 126 cases (71%), including incautious use of oxytocin in 126 cases (71%) and choosing a nonoptimal mode of delivery in 92 cases (52%).

Conclusion

There is a great need and a challenge to improve cooperation and to create security barriers within our labour units. The most common cause of malpractice is that stated guidelines for fetal surveillance are not followed. Midwives and obstetricians need to improve their shared understanding of how to act in cases of imminent fetal asphyxia and how to choose a timely and optimal mode of delivery.

Please cite this paper as:Berglund S, Grunewald C, Pettersson H, Cnattingius S. Severe asphyxia due to delivery-related malpractice in Sweden 1990–2005. BJOG 2008;115:316–323.

Cluster of Salmonella Enteritidis in Sweden 2005-2006 – suspected source: almonds

Previous outbreaks of Salmonella Enteritidis in Canada and the United States have been associated with the consumption of almonds. From December 2005 to August 2006 a cluster of 15 cases of Salmonella Enteritidis NST 3+ was reported in Sweden. A case-control study was performed to identify the source of transmission. Three controls per case were randomly selected, matched on sex, age and place of residence. Cases and controls were interviewed by telephone and data were analysed with a conditional logistic model. The results showed that eating almonds was a risk factor for infection with Salmonella Enteritidis NST3+ (unmatched odds ratio 45.0, 95% confidence interval: 4.8-421.8). No Salmonella was isolated from almonds tested in the study. In conclusion, almonds could be the source of the outbreak and should be considered when investigating outbreaks as well as sporadic cases of Salmonella Enteritidis.