Infantile atopic dermatitis - increasing severity predicts negative impacts on maternal and infant sleep: a mixed methods study

BACKGROUND

While the impacts of atopic dermatitis (AD) on maternal and child sleep outcomes have been previously explored, less is known about the associations between infantile AD and sleep quality and quantity.

OBJECTIVE

To describe the perceived causes of AD-associated maternal sleep disturbances and the association between AD severity and infant sleep outcomes.

METHODS

Mothers with infants aged < 19 months old with a diagnosis of AD were recruited from social media and medical clinics in Winnipeg, Canada between October 2021 and May 2022. Infant AD severity was classified using maternal-reported data on the Patient-Oriented Scoring Atopic Dermatitis tool (PO-SCORAD). Quantitative data were collected via a series of questionnaires with a subset of mothers subsequently completing semi-structured interviews. Quantitative and qualitative data were integrated in the discussion.

RESULTS

Mothers of infants with moderate/severe AD (6/12) were more likely to report their infant suffering from a higher degree of sleeplessness (i.e., ≥ 5 on a scale of 0-10) over the past 48 h compared to mothers of infants with mild AD (0/18). This was supported by qualitative findings where mothers described how their infant's sleep quality and quantity worsened with AD severity. Additionally, 7/32 mothers reported that their child's AD, regardless of severity, disturbed their sleep. Maternal sleep loss was most commonly attributed to infant itching (6/7), followed by worry (4/7).

CONCLUSION

Infantile AD severity was associated with worse sleep outcomes for both mothers and infants. We propose that maternal and infantile sleep quality and quantity can be improved by reducing AD severity through adherence to topical treatments.

Reporting standard for describing first responder systems, smartphone alerting systems, and AED networks

Standardized reporting of data is crucial for out-of-hospital cardiac arrest (OHCA) research. While the implementation of first responder systems dispatching volunteers to OHCA is encouraged, there is currently no uniform reporting standard for describing these systems. A steering committee established a literature search to identify experts in smartphone alerting systems. These international experts were invited to a conference held in Hinterzarten, Germany, with 40 researchers from 13 countries in attendance. Prior to the conference, participants submitted proposals for parameters to be included in the reporting standard. The conference comprised five workshops covering different aspects of smartphone alerting systems. Proposed parameters were discussed, clarified, and consensus was achieved using the Nominal Group Technique. Participants voted in a modified Delphi approach on including each category as a core or supplementary element in the reporting standard. Results were presented, and a writing group developed definitions for all categories and items, which were sent to participants for revision and final voting using LimeSurvey web-based software. The resulting reporting standard consists of 68 core items and 21 supplementary items grouped into five topics (first responder system, first responder network, technology/algorithm/strategies, reporting data, and automated external defibrillators (AED)). This proposed reporting standard generated by an expert opinion group fills the gap in describing first responder systems. Its adoption in future research will facilitate comparison of systems and research outcomes, enhancing the transfer of scientific findings to clinical practice.

Infantile atopic dermatitis and maternal-infant bonding: a mixed methods study

BACKGROUND

Childhood atopic dermatitis can have a negative effect on caregivers' quality of life and stress levels due to the burdensome nature of its treatment. Given that the condition often emerges in infancy, atopic dermatitis-related stress also carries the potential to negatively affect the developing mother-infant bond. While it is plausible that atopic dermatitis has a negative impact on maternal-infant bonding, these relationships have not been studied directly. In light of this gap, the current study investigated the association between infantile atopic dermatitis and the maternal-infant bond using a mixed-method design.

METHODS

Mothers of infants (< 19 months) with atopic dermatitis were recruited from social media and medical clinics between October 2021 and May 2022. Mothers with infants unaffected by inflammatory skin conditions were also recruited to serve as a control group. Participants were asked to complete questionnaires related to their demographics, child's health, and mother-infant bond. Multiple linear regression analyses were used to assess bonding quality among cases and controls. A subset of cases were also asked to participate in semi-structured interviews focused on infantile atopic dermatitis and the maternal-infant bond.

RESULTS

The final sample consisted of 32 cases and 65 controls. Scores on the impaired bonding and risk of abuse subscales did not significantly differ between cases and controls. However, mothers of infants with atopic dermatitis did report lower levels of caregiving anxiety (b = - 1.47, p < 0.01) and pathological anger/rejection (b = - 1.74, p = 0.02) relative to controls. Qualitative findings suggest that the topical therapies required to manage atopic dermatitis may strengthen the bond between some mothers and infants.

CONCLUSION

Findings suggest that atopic dermatitis does not have a negative impact on maternal-infant bonding and may actually improve bonds in some cases. In light of this finding, clinicians may leverage the potentially positive impact of atopic dermatitis-related caregiving on the maternal-infant bond to encourage caregivers to remain adherent to their child's topical treatments.

Residential overcrowding in relation to children's health, environment and schooling - a qualitative study

AIM

To explore how overcrowding affects children's health, environment and schooling.

METHODS

A qualitative study was conducted with individual interviews among 20 participants with occupational experience from overcrowded Stockholm areas but diverse in professions, locations and employers. The interviews were recorded, transcribed and analysed with Systematic Text Condensation.

RESULTS

Almost all participants expressed that overcrowding has a negative impact on children's health, environment and schooling - based on perceptions of precarious and different living conditions for children in overcrowded areas, for example, substandard homes, vulnerability, stress, exclusion, limited resources, lack of learning opportunities, gender differences, confinement, shame, insecurity, conflicts, risk of criminality, and bodily impact, both physical and psychological.

CONCLUSIONS

Our qualitative evidence suggest that overcrowding has a negative impact on children's health, environment and schooling.

Childhood atopic dermatitis is associated with cardiovascular risk factors in young adulthood-A population-based cohort study

BACKGROUND

Studies have indicated that atopic dermatitis (AD) is associated with an increased risk of cardiovascular disease (CVD). However, data are conflicting. Furthermore, the longitudinal effect of childhood AD on cardiovascular risk factors in young adulthood is less investigated.

OBJECTIVES

To assess associations between AD in childhood and CVD risk factors in young adulthood.

METHODS

The study encompasses longitudinal data from a population-based birth cohort. Participants with data up to age 24 years were included (n = 2270). The primary outcomes were body mass index (BMI), waist circumference (WC), body fat per cent (BF%) and blood pressure (BP) at 24 years. The secondary outcome was blood lipids. Severe AD was defined as AD in combination with sleep disturbance due to itching.

RESULTS

In total, 18.6% (n = 420) had AD at 24 years. Males with AD had higher BMI (βAdj. 0.81, 95% CI 0.15-1.47), BF% (βAdj. 1.19, 95% CI 0.09-2.29), systolic BP (βAdj. 1.92, 95% CI 0.02-3.82), total cholesterol (βAdj. 0.14, 95% CI 0.00-0.28) and LDL cholesterol (βAdj. 0.15, 95% CI 0.02-0.27) compared with males without AD. No associations were seen in females. Current AD with prepubertal onset was associated with increased BMI in both males (βAdj. 0.89, 95% CI 0.11-1.67) and females (βAdj. 0.72, 95% CI 0.11-1.33). At 24 years, 23.1% (n = 97) of all with AD, had severe disease, which was significantly associated with overweight in both sexes, with BMI (βAdj. 1.83, 95% CI 0.72-2.94), WC (βAdj. 4.03, 95% CI 1.54-6.52) and BF% (βAdj. 2.49, 95% CI 0.60-4.39) in females and with BF% (βAdj. 2.96, 95% CI 0.23-5.69) in males, compared with peers with mild to moderate AD.

CONCLUSION

AD in males appears to be associated with CVD risk factors in young adulthood. The duration and severity of AD seem to be of importance in both sexes.

Termination of resuscitation in out-of-hospital cardiac arrest in women and men: An ESCAPE-NET project

AIM

Women have less favorable resuscitation characteristics than men. We investigated whether the Advanced Life Support Termination of Resuscitation rule (ALS-TOR) performs equally in women and men. Additionally, we studied whether adding or removing criteria from the ALS-TOR improved classification into survivors and non-survivors.

METHODS

We analyzed 6,931 female and 14,548 male out-of-hospital cardiac arrest (OHCA) patients from Dutch and Swedish registries, and validated in 10,772 female and 21,808 male Danish OHCA patients. Performance measures were calculated for ALS-TOR in relation to 30-day survival. Recursive partitioning analysis was performed with the ALS-TOR criteria, as well as age, comorbidities, and additional resuscitation characteristics (e.g. initial rhythm, OHCA location). Finally, we explored if we could reduce the number of ALS-TOR criteria without loss of prognostic value.

RESULTS

The ALS-TOR had a specificity and positive predictive value (PPV) of ≥99% in both women and men (e.g. PPV 99.9 in men). Classification by recursive partitioning analysis showed a high sensitivity but a PPV below 99%, thereby exceeding the acceptable miss rate of 1%. A combination of no return of spontaneous circulation (ROSC) before transport to the hospital and unwitnessed OHCA resulted in nearly equal specificity and PPV, higher sensitivity, and a lower transport rate to the hospital than the ALS-TOR.

CONCLUSION

For both women and men, the ALS-TOR has high specificity and low miss rate for predicting 30-day OHCA survival. We could not improve the classification with additional characteristics. Employing a simplified version may decrease the number of futile transports to the hospital.

Are first responders first? The rally to the suspected out-of-hospital cardiac arrest

BACKGROUND

Time is the crucial factor in the "chain of survival" treatment concept for out-of-hospital cardiac arrest (OHCA). We aimed to measure different response time intervals by comparing emergency medical system (EMS), fire fighters and smartphone aided volunteer responders.

METHODS

In two large Swedish regions, volunteer responders were timed from the alert until they arrived at the scene of the suspected OHCA. The first arriving volunteer responders who tried to fetch an automated external defibrillator (AED-responder) and who ran to perform bystander cardiopulmonary resuscitation (CPR-responder) were compared to both the first arriving EMS and fire fighters. Three-time intervals were measured, from call to dispatch, the unit response time (from dispatch to arrival) and the total response time.

RESULTS

During 22 months, 2631 suspected OHCAs were included. The median time from call to dispatch was in minutes 1.8 (95% CI = 1.7-1.8) for EMS, 2.9 (95% CI = 2.8-3.0) for fire-fighters and 3.0 (95% CI = 2.9-3.1) for volunteer responders. The median unit response time was 8.3 (95% CI = 8.1-8.5) for EMS, 6.8 (95% CI = 6.7-6.9) for fire fighters and 6.0 (95% CI = 5.7-6.2) for AED-responders and 4.6 (95% CI = 4.5-4.8) for CPR-responders. The total response time was 10.4 (95% CI = 10.1-10.6) for EMS, 10.2 (95% CI = 9.9-10.4) for fire fighters, 9.6 (95% CI = 9.1-9.8) for AED-responders and 8.2 (95% CI = 8.0-8.3) for CPR-responders.

CONCLUSION

First arriving volunteer responders had the shortest unit response time when compared to both fire fighters and EMS, however this advantage was reduced by delays introduced at the dispatch center. Earlier automatic dispatch should be considered in further studies.

Living with Atopic Dermatitis as a Young Adult in Relation to Health-related Quality of Life and Healthcare Contacts: A Population-based Study

Most studies of health-related quality of life (HRQoL) and atopic dermatitis are based on data from dermatology clinics. The aim of this study was to determine whether atopic dermatitis affects HRQoL in adolescence and young adulthood, based on data from the population-based cohort BAMSE (Children, Allergy, Environmental, Stockholm, Epidemiology). A further aim was to determine if the use of topical corticosteroids and healthcare contacts affect HRQoL. Participants with data from birth to young adulthood (n=3,064) were included. Two generic instruments were used to measure HRQoL:General Health at age 12, 16 and 24 years and EQ-5D-3L, including EQ-visual analogue scale (EQ-VAS) at age 24 years. In addition, the disease-specific Dermatology Quality Life Index (DLQI) was used at 24 years. Healthcare consultations for atopic dermatitis were obtained from Stockholm Regional Healthcare Data Warehouse (n = 1,944). Participants with atopic dermatitis had an increased odds ratio (OR) of not feeling completely healthy (adjusted OR 1.50; 95% confidence interval (95% CI): 1.30–1.73). Participants with persistent atopic dermatitis, fulfilling atopic dermatitis criteria in the 12- and/or 16- and 24-year follow-ups reported worse EQ-VAS value 70.0 (95% CI 67.3–72.7) in the 25^th percentile, than peers without atopic dermatitis. Over an 8-year period, contact with healthcare was limited (mean number 0.96). In conclusion, atopic dermatitis had a negative impact on HRQoL in young adults from adolescence to adulthood and healthcare consultations were few.

Prevalence and characteristics of atopic dermatitis among young adult females and males - report from the Swedish population-based study BAMSE

BACKGROUND

There is limited knowledge regarding prevalence and characteristics of Atopic Dermatitis (AD) among young adults in the general population.

OBJECTIVES

To study AD among young adults in a Swedish population-based birth cohort, with a particular focus on prevalence, sex differences including risk for AD at different ages, disease course and characteristics of AD at 24 years.

METHODS

The BAMSE cohort includes 4,089 individuals who have been followed regularly from birth to age 24 years regarding AD and atopic diseases. For this study 3,055 individuals who answered questions regarding AD at the 24-year follow-up were included. All were invited to a clinical examination including skin examination, evaluation by Williams criteria and collection of blood for analysis of specific IgE and 2,264 individuals chose to participate.

RESULTS

At 24 years the 12-month prevalence of AD was 17.8% and more females than males had AD (20.5% versus 14.8%), p<0.0001. The point-prevalence of ongoing AD at clinical examination was 8.0%. AD severity as assessed by Patient-Oriented Eczema Measure (POEM) did not differ between sexes. The proportion of adult onset of AD was 16.9% (92 of 543), females 17.3% versus males 16.4%. More females than males with AD at 24 years reported disturbed sleep due to itch (26.1% versus 15.5%, p<0.003). IgE-sensitization was less common among females with AD than males with AD (61.3% versus 79.6%, p<0.0001). In addition, male sex (female sex being the reference) was associated with increased odds for AD the first year of life (OR 1.31, 95% CI; 1.10-1.56), and decreased odds of AD in adolescence and young adulthood (OR 0.66, 95% CI; 0.55-0.80).

CONCLUSIONS

AD is a common disease among young adults and even though more females than males have AD at 24 years, adult onset of AD seems to be equally prevalent among both sexes in young adulthood.

Polycystic ovary syndrome and risk of stillbirth: a nationwide register-based study

OBJECTIVE

To investigate whether polycystic ovary syndrome (PCOS) is associated with increased risk of stillbirth and whether any such association is linked to PCOS with a severe hyperandrogenic profile.

DESIGN

Nationwide register-based cohort study.

SETTING

Sweden.

POPULATION

The cohort consisted of women giving birth to singleton infants in 1997-2015. All women with a diagnosis of PCOS in the period 1997-2017 and a randomly selected reference group of women without PCOS diagnosis were included. PCOS with a severe hyperandrogenic profile was defined as a PCOS diagnosis with at least two dispensations of prescribed anti-androgens during 2005-2017.

METHODS

The risk of stillbirth in women with PCOS was estimated through multiple logistic regression, using women without PCOS as a reference. Risks were expressed as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs), adjusted for maternal age, parity, body mass index, type-1 diabetes, educational level and country of birth.

MAIN OUTCOME MEASURES

Stillbirth, at ≥22 weeks of gestation in 2008-2015 and at ≥28 weeks of gestation in 1997-2007.

RESULTS

Compared with women without PCOS (n = 241 750), women with PCOS (n = 41 851) had a 50% increased risk of stillbirth (aOR 1.50, 95% CI 1.28-1.77). The incidence of stillbirth in women with PCOS was particularly increased at term. Women with PCOS and a severe hyperandrogenic profile (n = 13 713) did not have a stronger association with stillbirth than women with PCOS who did not have such a profile.

CONCLUSIONS

PCOS is associated with stillbirth and should be considered as a possible risk factor in antenatal care. Further research is warranted to investigate possible causal mechanisms.

TWEETABLE ABSTRACT

Women with PCOS have increased risk of stillbirth, and the incidence is particularly increased at term.

Wellbeing, emotional response and stress among lay responders dispatched to suspected out-of-hospital cardiac arrests

Introduction

The recent 2021 European Resuscitation Council guidelines strongly advocate systems for smartphone-aided dispatch of lay volunteers to out-of-hospital cardiac arrests (OHCAs) to perform CPR and bring automated external defibrillators. Systems alike have been implemented in nearly half of all the European countries and are emerging in around the world. This study aimed to investigate the emotional responses, post-traumatic stress reactions and levels of wellbeing among smartphone-alerted lay responders dispatched to cases of suspected OHCAs.

Methods

Participants rated their emotional responses online, at 90 minutes and at 4–6 weeks after an incident. Level of emotional response was measured in two dimensions: “activation” – from deactivation to activation, and “valence” – from unpleasantness to pleasantness. At 4–6 weeks, WHO wellbeing index and level of post-traumatic stress (PTSD) were also rated. Lay responders were stratified by level of exposure: (Un-exp): unexposed, (Exp-1): tried to reach, and (Exp-2): reached the suspected OHCA.

Results

Altogether, 886 (26%) unexposed and 1389 (64%) exposed responders completed the survey. “Activation” was elevated in the exposed groups: Un-exp: 6.7, Exp-1: 7.4 and Exp-2: 7.5, (p&lt;0.001) and “valence” was highest in the Un-exp group: 6.5, vs. Exp-1: 6.3, and Exp-2: 6.1, (p&lt;0.001). Mean scores for PTSD was below clinical cutoff, Un-exp: 10.4, vs. Exp-1: 8.8 and Exp-2: 9.2 (p=0.007). Wellbeing index showed no differences, Un-exp: 77.7, Exp-1: 77.8 and Exp-2: 78.2 (p=0.963).

Conclusion

Laypersons responding to smartphone alerts to suspected OHCAs rated the experience as high-energy and mostly positive. No harm to lay responders was seen. The responding groups had low post-traumatic stress scores, and high-level general wellbeing at follow-up.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Region Stockholm

Who arrives first: EMS, fire-fighter or lay responder? The rally to the suspected out-of-hospital cardiac arrest

Background

Time is the crucial factor for “the chain of survival” in Out-of-Hospital Cardiac Arrest (OHCA). We aimed to compare different response time intervals for dispatched lay responders, fire fighters and emergency medical services (EMS).

Methods

Mobile phone dispatched lay responders in two large Swedish regions (4 million inhabitants) were positioned and timed from alert until arrival to the place of the suspected OHCA. For each suspected OHCA the first arriving lay responder was compared to the first arriving EMS and first fire fighter unit. Time intervals, from witness call-to-dispatch and dispatch-to-arrival was measured.

Results

During 22 months a total of 2631 suspected OHCAs were included. The median time from call-to-dispatch was 1.8 (95% CI: 1.7–1.8) for EMS, 2.9 (95% CI: 2.8–3.0) for fire-fighter units and 3.0 (95% CI: 2.9–3.1) for lay responders. The median time from dispatch-to-arrival was 8.3 (95% CI: 8.1–8.5) for EMS, 6.8 (95% CI: 6.7–6.9) for fire fighters and 6.0 (95% CI: 5.7–6.2) for lay-responders who tried to fetch an AED and 4.6 (95% CI: 4.5–4.8) minutes for lay-responders who ran to perform bystander CPR.

Conclusion

First arriving lay responder have the shortest dispatch-to-arrival time when compared to both fire fighters and EMS. However, this advantage is diminished by a one-minute delay compared to EMS until they are alerted. New solutions are needed for the fully use of mobile dispatched lay responders.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon 2020, For the ESCAPE-NET investigators

Induction of labour at 41 weeks of gestation versus expectant management and induction of labour at 42 weeks of gestation: a cost-effectiveness analysis

OBJECTIVE

To assess the cost-effectiveness of induction of labour (IOL) at 41 weeks of gestation compared with expectant management until 42 weeks of gestation.

DESIGN

A cost-effectiveness analysis alongside the Swedish Post-term Induction Study (SWEPIS), a multicentre, randomised controlled superiority trial.

SETTING

Fourteen Swedish hospitals during 2016-2018.

POPULATION

Women with an uncomplicated singleton pregnancy with a fetus in cephalic position were randomised at 41 weeks of gestation to IOL or to expectant management and induction at 42 weeks of gestation.

METHODS

Health benefits were measured in life years and quality-adjusted life years (QALYs) for mother and child. Total cost per birth was calculated, including healthcare costs from randomisation to discharge after delivery, for mother and child. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in mean cost between the trial arms by the difference in life years and QALYs, respectively. Sampling uncertainty was evaluated using non-parametric bootstrapping.

MAIN OUTCOME MEASURES

The cost per gained life year and per gained QALY.

RESULTS

The differences in life years and QALYs gained were driven by the difference in perinatal mortality alone. The absolute risk reduction in mortality was 0.004 (from 6/1373 to 0/1373). Based on Swedish life tables, this gives a mean gain in discounted life years and QALYs of 0.14 and 0.12 per birth, respectively. The mean cost per birth was €4108 in the IOL group (n = 1373) and €4037 in the expectant management group (n = 1373), with a mean difference of €71 (95% CI -€232 to €379). The ICER for IOL compared with expectant management was €545 per life year gained and €623 per QALY gained. Confidence intervals were relatively wide and included the possibility that IOL had both lower costs and better health outcomes.

CONCLUSIONS

Induction of labour at 41 weeks of gestation results in a better health outcome and no significant difference in costs. IOL is cost-effective compared with expectant management until 42 weeks of gestation using standard threshold values for acceptable cost per life year/QALY.

TWEETABLE ABSTRACT

Induction of labour at 41 weeks of gestation is cost-effective compared with expectant management until 42 weeks of gestation.

Living with Food Hypersensitivity as an Adolescent Impairs Health Related Quality of Life Irrespective of Disease Severity: Results from a Population-Based Birth Cohort

Food hypersensitivity (FHS) refers to food-related symptoms, with or without concurrent Immunoglobulin E (IgE) antibodies related to food(s). It remains unclear how different FHS phenotypes affect health-related quality of life (HRQoL). We examined self-reported HRQoL (with the generic instrument EQ-5D (dimensions and a Visual Analogue Scale (VAS), range 0–100) in association with phenotypes of FHS, and food-specific symptoms among adolescents (n = 2990) from a population-based birth cohort. Overall, 22% of the adolescents had FHS. Compared to adolescents without FHS, those with FHS reported more problems in the dimensions of pain/discomfort (p < 0.001), and anxiety/depression (p = 0.007). Females with FHS reported more problems than males in these dimensions (p < 0.001). Different FHS phenotypes (IgE-sensitization, allergic co-morbidity, and severity of symptoms) were not associated with differences in HRQoL. EQ-VAS scores were lowest for adolescents with symptoms for wheat vs. no wheat, median 80 vs. 89, p = 0.04) and milk vs. no milk (median 85 vs. 90, p = 0.03). Physician-diagnosed lactose intolerance median EQ-VAS was 80 vs. 90, p = 0.03 and also associated with more problems in the dimension of anxious/depression. In conclusion, FHS is associated with lower HRQoL in adolescence, irrespective of phenotypes, but differentially affects females vs. males, and those with vs. without symptoms for milk or wheat.

Young adults' perceptions of living with atopic dermatitis in relation to the concept of self-management: a qualitative study

OBJECTIVES

Learning to take control of one's health is an important part of the transition from adolescence to adulthood. This study aimed to explore young adults' perceptions of living with atopic dermatitis (AD) in relation to the concept of self-management.

DESIGN

A qualitative study with an inductive approach was performed through semistructured interviews (n=15). The interviews were recorded, transcribed verbatim and analysed with systematic text condensation.

PARTICIPANTS

Young adults (mean age 23,4 years) with persistent AD in a longitudinal population-based birth cohort. To capture experience of living with persistent AD (preschool/school-age onset) of different severity (mild to severe/very severe), a purposive selection was performed. In total, 15 young adults were included. Persistent AD (preschool/school-age onset) was defined as dry skin in combination with itchy rash of typical localisation in the 12 months preceding the 16-year and the 24-year follow-ups. Severity was self-assessed using the Patient Oriented Eczema Measure.

RESULTS

Despite having experience of AD since childhood, the respondents expressed uncertainty about treatment and how it affected their bodies. Their uncertainties and feelings affected how they used topical corticosteroids. The respondents emphasised that they perceived availability of healthcare and knowledge about treatment of AD among healthcare providers to be limited. The participants did not state any experiences of support to self-management from healthcare, which affect young adults' possibilities to take full control of their AD care.

CONCLUSIONS

Young adults with preschool/school-age onset of AD are unsure how to treat and manage the disease. One explanation may be insufficient transition process.

Important research outcomes for treatment studies of perinatal depression: systematic overview and development of a core outcome set

OBJECTIVE

To develop a Core Outcome Set (COS) for treatment of perinatal depression.

DESIGN

Systematic overview of outcomes reported in the literature and consensus development study.

SETTING

International.

POPULATION

Two hundred and twenty-two participants, mainly patients, healthcare professionals and researchers, representing 13 countries.

METHODS

A systematic overview of outcomes reported in recently published research, a two-round Delphi survey and a consensus meeting at which the final COS was decided using modified nominal group technique.

MAIN RESULTS

In the literature search, 1772 abstracts were identified and evaluated, and 165 studies were finally included in the review. In all, 106 outcomes were identified and included in the Delphi survey. In all, 222 participants registered for the first round of the Delphi survey and 151 (68%) responded. In the second round, 123 (55%) participants responded. Thirteen participants attended the consensus meeting, where the following nine outcomes were agreed upon for inclusion in the final COS: self-assessed symptoms of depression, diagnosis of depression by a clinician, parent to infant bonding, self-assessed symptoms of anxiety, quality of life, satisfaction with intervention, suicidal thoughts, attempted or committed suicide, thoughts of harming the baby, and adverse events.

CONCLUSIONS

The relevant stakeholders prioritised outcomes and reached consensus on a COS comprising nine outcomes. We expect that this COS will contribute to the consistency and uniformity of outcome selection and reporting in future clinical trials involving treatment of perinatal depression.

TWEETABLE ABSTRACT

Development of a core outcome set regarding treatment for perinatal depression by @SBU_en. TWEETABLE ABSTRACT.

Evaluation of the ATN model in a longitudinal memory clinic sample with different underlying disorders

INTRODUCTION

To evaluate the usefulness of the 2018 NIA-AA (National Institute on Aging and Alzheimer's Association) research framework in a longitudinal memory clinic study with different clinical outcomes and underlying disorders.

METHODS

We included 420 patients with mild cognitive impairment or subjective cognitive impairment. During the follow up, 27% of the patients converted to dementia, with the majority converting to Alzheimer's disease (AD) or mixed dementia. Based on the baseline values of the cerebrospinal fluid biomarkers, the patients were classified into one of the eight possible ATN groups (amyloid beta [Aβ] aggregation [A], tau aggregation reflecting neurofibrillary tangles [T], and neurodegeneration [N]).

RESULTS

The majority of the patients converting to AD and mixed dementia were in ATN groups positive for A (71%). The A+T+N+ group was highly overrepresented among converters to AD and mixed dementia. Patients converting to dementias other than AD or mixed dementia were evenly distributed across the ATN groups.

DISCUSSION

Our findings provide support for the usefulness of the ATN system to detect incipient AD or mixed dementia.

Incidence and characteristics of drowning in Sweden during a 15-year period

AIM

Drowning is a global health problem and deeper knowledge about the extent and causes is of utmost importance for implementing preventative actions. The aim of this study was to describe the incidence and characteristics of drowning in Sweden over time, including both non-fatal and fatal cases.

METHODS

All cases identified as drowning (ICD-10 coding) at a national level in Sweden between 2003-2017 were collected. Three sources of data from the Swedish National Board of Health and Welfare were extracted via the Cause of Death Register and the National Patient Register.

RESULTS

Over 15 years, a total of 6609 cases occurred, resulting in an annual incidence of 4.66 per 100 000. The median age was 49 years (IQR 23-67) and 67% were males. Non-fatal drownings represented 51% (n = 3363), with an overall non-fatal to fatal ratio of 1:1, this being 8:1 for children (0-17 years of age). Non-fatal cases were more often female (36% vs. 30%; p < 0.001), younger 30 (IQR 10-56) vs. 60 (IQR: 45-72) (p < 0.001) and of unintentional nature (81% vs. 55%; p < 0.001). The overall incidence decreased over time from 5.6 to 4.1 per 100 000 (p < 0.001). The highest rate of 30-day survival was found in females 0-17 years (94%, 95% CI 91.1-95.5) and the lowest in males >66 years (28.7%, 95% CI 26.2-31.2). Although the incidence in children 0-4 years increased from 7.4 to 8.1 per 100 000 (p < 0.001), they demonstrated the highest non-fatal to fatal ratio (13:1).

CONCLUSION

Drowning is declining but remains a consistent and underestimated public-health problem. Non-fatal drowning cases represent about half of the burden and characteristics differ from fatal drowning cases, being younger, more often female and of unintentional nature.

Gamma-radiation induced synthesis of freestanding nickel nanoparticles

A versatile method to produce metallic nickel nanoparticles is demonstrated. Metallic Ni nanoparticles have been synthesized from aqueous solution of NiCl₂ using γ-radiation induced reduction. To prevent Ni re-oxidation, post-irradiation treatment was elaborated. Structural and compositional analyses were executed using X-ray diffraction, transmission electron microscopy and X-ray photoelectron spectroscopy. These studies reveal that the synthesized material consists of fcc Ni particles having size of 3.47 ± 0.71 nm. The nanoparticles have a tendency to agglomerate to the larger clusters. The latter are partially oxidized to form thin amorphous/poor-crystalline Ni(OH)₂/NiO layers at the surface. Magnetization measurements demonstrate that the nanomaterial exhibit ferromagnetic-like behaviour with magnetization 30% lower than that in bulk Ni. The large active surface area (ECSA, 39.2 m² g^-1) and good electrochemical reversibility, confirmed by the electrochemical studies, make the synthesized material a potential candidate as an active component for energy storage devices.

Six common behavioral trials and their relevance for perch performance in natural lakes

Behavioral traits measured in laboratory settings are commonly used when predicting ecological effects and evolutionary outcomes in natural systems. However, uncertainties regarding the relevance of simplified lab-based behavioral tests for complex natural environments have created doubts about the use of these tests within aquatic ecology and ecotoxicology. In this study, we scrutinize the assumption that fish performance in six commonly applied behavioral assays has relevance for in situ behavior, by comparing individual behavior tracked in both artificial laboratory settings as well as in two natural lakes. We show that: i) commonly measured behavioral traits of individual fish (Perca fluviatilis) have low predictive power for within-lake behaviors if interpreted alone, but that; ii) composite variables synthesized from several (six) behavioral assays explain important in situ measures such as swimming activity, dispersion, home-range size, and habitat preference. While our findings support recent criticisms against the use of single behavioral tests for predicting environmental effects, we provide empirical evidences suggesting that fish performances in multiple laboratory assays are highly relevant for fish behavior in nature.

Weight of salivary gland ultrasonography compared to other items of the 2016 ACR/EULAR classification criteria for Primary Sjögren's syndrome

OBJECTIVE

Major salivary gland ultrasonography (SGUS) is widely used for the diagnosis of primary Sjögren's syndrome (pSS). Our objective was to assess the contribution of SGUS compared to other items of the 2016 ACR/EULAR pSS classification criteria, based on expert opinion.

METHODS

A secure web-based relational database was used by 24 experts from 14 countries to assess 512 realistic vignettes developed from data of patients with suspected pSS. Each vignette provided classification criteria items and information on history, clinical symptoms and SGUS findings. Each expert assessed 64 vignettes, and each vignette was assessed by 3 experts. A diagnosis of pSS was defined according to at least 2 of 3 experts. Validation was performed in the independent French DiapSS cohort of patients with suspected pSS.

RESULTS

A criteria-based pSS diagnosis and SGUS findings were independently associated with an expert diagnosis of pSS (P < 0.001). The derived diagnostic weights of individual items in the 2016 ACR/EULAR criteria including SGUS were as follows: anti-SSA, 3; focus score ≥ 1, 3; SGUS score ≥ 2, 1; positive Schirmer's test, 1; dry mouth, 1; and salivary flow rate < 0.1 mL/min, 1. The corrected C statistic area under the curve for the new weighted score was 0.96. Adding SGUS improves the sensitivity from 90.2 % to 95.6% with a quite similar specificity 84.1% versus 82.6%. Results were similar in the DiapSS cohort: adding SGUS improves the sensitivity from 87% to 93%.

CONCLUSION

SGUS had similar weight compared to minor items, and its addition improves the performance of the 2016 ACR/EULAR classification criteria.

Living with a Severe Allergy: Lived Perspectives from Swedish Adolescents and their Parents

BACKGROUND

During adolescence, the young person should gradually develop independence from his or her parents. However, having a chronic disease like a severe allergy may add stress and challenges beyond normal development and involves a struggle between adapting socially, feeling healthy, and managing the disease.

OBJECTIVE

To describe experiences of living with a severe allergy from the perspective of adolescents and their parents.

METHOD

A qualitative study with six focus group interviews were performed, two with adolescents and four with their parents (10 adolescents, 10-16 years old and 21 parents). The transcribed data were analyzed using systematic text condensation.

RESULT

Four themes emerged: Feeling different (adolescents and parents), shift in responsibility (adolescents and parents), the importance of parents (only adolescents) and the importance of healthcare providers (only parents). The adolescents relied on their parents, while also taking responsibility for managing their disease. The parents expressed a need to protect their children; but they did not seem to be aware of the responsibility their children took. The parents highlighted the importance of support from healthcare providers but this was not mentioned by the adolescents.

CONCLUSION

This study showed that both the adolescents and their parents stated that they took responsibility for managing the disease, but in different ways. For healthcare providers, this needs to be taken into account in order to support both adolescents and parents for self-management and shift in responsibilities which begins during adolescents.

P4170Survival after dispatcher assisted CPR in out of hospital cardiac arrest compared to CPR without dispatcher assistance and no CPR before emergency medical services arrival – a nationwide study

Background

Cardiopulmonary resuscitation (CPR) before arrival of emergency medical services (EMS) is associated with survival in out-of hospital cardiac arrest. Dispatcher assisted CPR (DA-CPR) has been shown to increase CPR rates. However there are several challenges to successful DA-CPR, such as identification of cardiac arrest, time delays to CPR instructions, time delays to start of chest compression and quality of CPR.

Purpose

The aim of this study is to assess survival in out of hospital cardiac arrest after no CPR, DA-CPR and CPR without dispatcher assistance before EMS arrival in a nationwide cardiac arrest register.

Methods

A register based observational study. All consecutive Out of Hospital Cardiac Arrests reported to the Swedish Register for Cardiopulmonary Resuscitation in 2010–2017 were collected. Patients with cardiac arrest witnessed by EMS, who received CPR by off-duty medical professionals, missing data on CPR, DA-CPR or survival were excluded. Exposure was categorized as either; no CPR before EMS arrival (NO-CPR), dispatcher assisted CPR before EMS arrival (DA-CPR) and CPR before EMS arrival without dispatcher assistance, spontaneous CPR (S-CPR). Propensity score matched cohorts were used for comparison between groups. Primary endpoint was 30-day survival.

Results

Out of 36309, a total of 15471 patients were included, 41.6% received NO-CPR 31.0% received DA-CPR and 27.4% received S-CPR. In propensity score matched cohorts survival to 30-days was 9.0% after NO-CPR, 13.6% after DA-CPR and 15.8% after S-CPR. Using DA-CPR as reference, NO-CPR was associated with lower survival (Conditional OR 0.61, 95% CI 0.52–0.72), absolute difference 4.6% (95% CI 3.0%-6.2%) and S-CPR was associated with higher survival (Conditional OR 1.21 (95% CI 1.05–1.39), absolute difference 2.3% (95% CI 0.5%-4.0%).

30-day survival

Conclusion

In this nationwide study spontaneous CPR was associated with the highest survival. When spontaneous CPR is not initiated DA-CPR is a reasonable option.

Acknowledgement/Funding

Swedish Heart and Lung Foundation

Lost in the transition from pediatric to adult healthcare? Experiences of young adults with severe asthma

Objective: Asthma is a multifaceted disease, and severe asthma is likely to be persistent. Patients with severe asthma have the greatest burden and require more healthcare resources than those with mild-to-moderate asthma. The majority with asthma can be managed in primary care, while some patients with severe asthma warrant referral for expert advice regarding management. In adolescence, this involves a transition from pediatric to adult healthcare. This study aimed to explore how young adults with severe asthma experienced the transition process.Methods: Young adults with severe asthma were recruited from an ongoing Swedish population-based cohort. Qualitative data were obtained through individual interviews (n = 16, mean age 23.4 years), and the transcribed data were analyzed with systematic text condensation.Results: Four categories emerged based on the young adults' experiences: "I have to take responsibility", "A need of being involved", "Feeling left out of the system", and "Lack of engagement". The young adults felt they had to take more responsibility, did not know where to turn, and experienced fewer follow-ups in adult healthcare. Further, they wanted healthcare providers to involve them in self-management during adolescence, and in general, they felt that their asthma received insufficient support from healthcare providers.Conclusions: Based on how the young adults with severe asthma experienced the transition from pediatric to adult healthcare, it is suggested that healthcare providers together with each patient prepare, plan, and communicate in the transition process for continued care in line with transition guidelines.

Influence of contextual factors on quality of primary care in children with asthma

OBJECTIVE

Asthma is a common chronic disease among children, quality assurance is thus important. Adherence to pre-specified quality indicators of practice guidelines could be used to assess the quality of asthma care. The aim was to estimate which contextual factors that had an influence on the primary health care centres (PHCs) adherence to the quality indicators as stated in the practice guidelines.

METHOD

A pragmatic cross-sectional study was performed comprising 14 PHCs in Sweden. Included contextual factors were socio-demographic characteristics, organizational characteristics, and indicators regarding engagement in asthma care. Documentation on adherence to the quality indicators was retrieved from the medical health care records. Quality indicators included documentation of history of allergy and risk factors, diagnostics and patient support performed, and pharmacological treatment. To score adherence, a composite quality indicator (CQI) was computed for each PHC. A multivariable regression analysis was performed by orthogonal projection to latent structures (OPLS). By this analysis, the relationship between the result variable (CQI) and 26 pre-specified contextual factors was assessed.

RESULTS

There was a wide variation of CQI between the PHCs. The OPLS analysis identified that 10 of the contextual factors influenced CQI. The most pronounced influences were found in more time scheduled for asthma care, a lower age-limit for performing spirometry, a lower duty-grade for general practitioners, and a higher activity at asthma educational seminars. We found no influence of socio-demographic contextual factors.

CONCLUSION

We found that some of the contextual factors at the PHCs influenced the quality of performed care. Evidence-based care in paediatric asthma may thus be presumed to be facilitated by allocating time, by improving interprofessional collaboration, and by creating structures and opportunities for commitment to asthma care.

No evidence of increased growth or mortality in fish exposed to oxazepam in semi-natural ecosystems

An increasing number of short-term laboratory studies on fish reports behavioral effects from exposure to aquatic contaminants or raised carbon dioxide levels affecting the GABA_A receptor. However, how such GABAergic behavioral modifications (GBMs) impact populations in more complex natural systems is not known. In this study, we induced GBMs in European perch (Perca fluviatilis) via exposure to a GABA agonist (oxazepam) and followed the effects on growth and survival over one summer (70days) in replicated pond ecosystems. We hypothesized that anticipated GBMs, expressed as anti-anxiety like behaviors (higher activity and boldness levels), that increase feeding rates in laboratory assays, would; i) increase growth and ii) increase mortality from predation. To test our hypotheses, 480 PIT tagged perch of known individual weights, and 12 predators (northern pike, Esox lucius) were evenly distributed in 12 ponds; six control (no oxazepam) and six spiked (15.5±4μgl^-1 oxazepam [mean±1S.E.]) ponds. Contrary to our hypotheses, even though perch grew on average 16% more when exposed to oxazepam, we found no significant difference between exposed and control fish in growth (exposed: 3.9±1.2g, control: 2.9±1g [mean±1S.E.], respectively) or mortality (exposed: 26.5±1.8individuals pond^-1, control: 24.5±2.6individuals pond^-1, respectively). In addition, we show that reduced prey capture efficiency in exposed pike may explain the lack of significant differences in predation. Hence, our results suggest that GBMs, which in laboratory studies impact fish behavior, and subsequently also feeding rates, do not seem to generate strong effects on growth and predation-risk in more complex and resource limited natural environments.

Influences of migration phenology on survival are size-dependent in juvenile Atlantic salmon (Salmo salar)

Long-distance migratory species can reduce mortality risks by synchronizing the migration event and create confusion by swamping predators with high densities. To reduce confusion, predators are known to primarily select aberrant prey. We hypothesized that at the start of their sea sojourn, particularly small and large Atlantic salmon (Salmo salar L., 1758) would spread the risk by also migrating at other times of the year. Based on data from the Norwegian river Imsa between 1976 and 2015, we found that juveniles, 14–19 cm in total length, started their sea sojourn during a short period between late April and early June. However, more than 20% of fish 13 cm or shorter migrated downstream between October and March, whereas 55% of fish 20 cm or longer migrated downstream between July and September. The regular-sized, spring-migrating juveniles had 2–3 times higher survival at sea than similar-sized conspecifics migrating to sea at other times of the year. The survival at sea for smaller juveniles was not improved by migration in spring relative to winter, and the survival of the largest juveniles was similar in spring and summer. Thus, the migration phenology appears adapted to survival in a high-risk environment by changing the timing according to their sizes.

Randomized clinical trial of Appendicitis Inflammatory Response score-based management of patients with suspected appendicitis

BACKGROUND

The role of imaging in the diagnosis of appendicitis is controversial. This prospective interventional study and nested randomized trial analysed the impact of implementing a risk stratification algorithm based on the Appendicitis Inflammatory Response (AIR) score, and compared routine imaging with selective imaging after clinical reassessment.

METHOD

Patients presenting with suspicion of appendicitis between September 2009 and January 2012 from age 10 years were included at 21 emergency surgical centres and from age 5 years at three university paediatric centres. Registration of clinical characteristics, treatments and outcomes started during the baseline period. The AIR score-based algorithm was implemented during the intervention period. Intermediate-risk patients were randomized to routine imaging or selective imaging after clinical reassessment.

RESULTS

The baseline period included 1152 patients, and the intervention period 2639, of whom 1068 intermediate-risk patients were randomized. In low-risk patients, use of the AIR score-based algorithm resulted in less imaging (19·2 versus 34·5 per cent; P < 0·001), fewer admissions (29·5 versus 42·8 per cent; P < 0·001), and fewer negative explorations (1·6 versus 3·2 per cent; P = 0·030) and operations for non-perforated appendicitis (6·8 versus 9·7 per cent; P = 0·034). Intermediate-risk patients randomized to the imaging and observation groups had the same proportion of negative appendicectomies (6·4 versus 6·7 per cent respectively; P = 0·884), number of admissions, number of perforations and length of hospital stay, but routine imaging was associated with an increased proportion of patients treated for appendicitis (53·4 versus 46·3 per cent; P = 0·020).

CONCLUSION

AIR score-based risk classification can safely reduce the use of diagnostic imaging and hospital admissions in patients with suspicion of appendicitis. Registration number: NCT00971438 ( http://www.clinicaltrials.gov).

Experiences of Daily Life Among Adolescents With Asthma - A Struggle With Ambivalence

OBJECTIVE

There is limited knowledge about how adolescents with asthma view their disease in daily life and how these views impact on management. The aim of this study was to describe experiences of daily life, with particular focus on thoughts, feelings and management of adolescents with asthma.

METHODS

In this qualitative study, data were obtained from 10 interviews with adolescents (aged 16-18 years) with asthma recruited from the Swedish population-based prospective birth cohort, BAMSE. Data were analysed through Systematic Text Condensation.

RESULTS

Experiences of daily life among adolescents with asthma were defined in four categories: Insight and understanding; Asthma not the focus of daily life; Being acknowledged and, Being affected by asthma symptoms. The adolescents had developed an insight into and understanding of their disease, but did not want asthma to be the focus of their daily lives. The adolescents wanted their asthma to be acknowledged, but not to the point that they were defined by their asthma. They reported having many asthma symptoms, especially during physical activity, but also described a desire to feel healthy, "normal" and like their peers.

CONCLUSIONS

Having asthma in adolescence involves several struggles with ambivalence between adapting socially, feeling healthy and managing one's asthma.

IMPLICATIONS IN CLINICAL PRACTICE

The provision of person-centred care may be one way to handle the ambivalence among adolescents with asthma and thereby help them to manage their asthma.

Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register study

OBJECTIVE

The aim of the study was to evaluate the association between abdominal adhesions at the time of gynaecologic surgery and a history of caesarean delivery, and to investigate obstetric factors contributing to adhesion formation after caesarean section (CS).

DESIGN

Longitudinal population-based register study.

SETTING

Sweden.

POPULATION

Women undergoing benign hysterectomy and/or adnexal surgery in Sweden, 2000-2014, with a previous delivery during 1973-2013 (n = 15 479).

METHODS

Information about abdominal adhesions during gynaecological surgery, prior medical history, pregnancies and deliveries were retrieved from Swedish National Health and Quality registers.

MAIN OUTCOME MEASURES

Adhesions.

RESULTS

In women with previous CS, adhesions were present in 37%, compared with 10% of women with no previous CS [odds ratio (OR): 5.18, 95% confidence interval (CI): 4.70-5.71]. Adhesions increased with the number of caesarean sections: 32% after one CS; 42% after two CS and 59% after three or more CS (P < 0.001). Regardless of the number of CS, factors at CS such as age ≥35 years (aOR: 1.28, 95% CI: 1.05-1.55), body mass index (BMI) ≥30 [adjusted OR (aOR): 1.91, 95% CI: 1.49-2.45] and postpartum infection (aOR: 1.55, 95% CI: 1.05-2.30) increased the risk of adhesions.

CONCLUSIONS

Presence of adhesions in abdominal gynaecological surgery is associated with women's personal history of caesarean delivery. The number of caesarean sections was the important predictor of adhesions; advanced age, obesity and postpartum infection further increased the incidence.

TWEETABLE ABSTRACT

Repeat caesarean, age, obesity and infection increased the risk of pelvic adhesions after caesarean section.

Biochemical markers in vascular cognitive impairment associated with subcortical small vessel disease - A consensus report

Background

Vascular cognitive impairment (VCI) is a heterogeneous entity with multiple aetiologies, all linked to underlying vascular disease. Among these, VCI related to subcortical small vessel disease (SSVD) is emerging as a major homogeneous subtype. Its progressive course raises the need for biomarker identification and/or development for adequate therapeutic interventions to be tested. In order to shed light in the current status on biochemical markers for VCI-SSVD, experts in field reviewed the recent evidence and literature data.

Method

The group conducted a comprehensive search on Medline, PubMed and Embase databases for studies published until 15.01.2017. The proposal on current status of biochemical markers in VCI-SSVD was reviewed by all co-authors and the draft was repeatedly circulated and discussed before it was finalized.

Results

This review identifies a large number of biochemical markers derived from CSF and blood. There is a considerable overlap of VCI-SSVD clinical symptoms with those of Alzheimer’s disease (AD). Although most of the published studies are small and their findings remain to be replicated in larger cohorts, several biomarkers have shown promise in separating VCI-SSVD from AD. These promising biomarkers are closely linked to underlying SSVD pathophysiology, namely disruption of blood-CSF and blood–brain barriers (BCB-BBB) and breakdown of white matter myelinated fibres and extracellular matrix, as well as blood and brain inflammation. The leading biomarker candidates are: elevated CSF/blood albumin ratio, which reflects BCB/BBB disruption; altered CSF matrix metalloproteinases, reflecting extracellular matrix breakdown; CSF neurofilment as a marker of axonal damage, and possibly blood inflammatory cytokines and adhesion molecules. The suggested SSVD biomarker deviations contrasts the characteristic CSF profile in AD, i.e. depletion of amyloid beta peptide and increased phosphorylated and total tau.

Conclusions

Combining SSVD and AD biomarkers may provide a powerful tool to identify with greater precision appropriate patients for clinical trials of more homogeneous dementia populations. Thereby, biomarkers might promote therapeutic progress not only in VCI-SSVD, but also in AD.

Correlates of Postpartum Depression in First Time Mothers Without Previous Psychiatric Contact

Background

Postpartum depression (PPD) is a common disorder after childbirth. The strongest known predictors are a history of depression and/or a history of PPD. However, for a significant proportion of women, PPD constitutes their first depressive episode. This study aimed to gain further insight into the risk factors for PPD in first time mothers without previous psychiatric contact.

Methods

Women delivering in Uppsala University Hospital, Sweden, from May 2006 to June 2007, were asked to participate and filled out questionnaires five days and six weeks postpartum, containing inter alia the Edinburgh Postnatal Depression Scale (EPDS). Univariate logistic regression models, as well as a path analysis, were performed to unveil the complex interplay between the study variables.

Results

Of the 653 participating primiparas, 10.3% and 6.4% reported depressive symptoms (EPDS ≥ 12 points) five days and six weeks postpartum, respectively. In the path analysis, a positive association between anxiety proneness and depressive symptoms at five days and six weeks postpartum was identified. For depressive symptoms six weeks after delivery, additional risk factors were detected, namely depressive symptoms five days postpartum and subjective experience of problems with the baby. Caesarean section and assisted vaginal delivery were associated with fewer depressive symptoms at 6 six weeks postpartum.

Conclusions

Identification of anxiety proneness, delivery mode and problems with the baby as risk factors for self-reported depressive symptoms postpartum in this group of primiparas can be important in helping health care professionals identify women at increased risk of affective disorders in the perinatal period, and provide a base for early intervention.

Bioaccumulation of five pharmaceuticals at multiple trophic levels in an aquatic food web - Insights from a field experiment

Pharmaceuticals derived from manufacturing and human consumption contaminate surface waters worldwide. To what extent such pharmaceutical contamination accumulates and disperses over time in different compartments of aquatic food webs is not well known. In this study we assess to what extent five pharmaceuticals (diphenhydramine, oxazepam, trimethoprim, diclofenac, and hydroxyzine) are taken up by fish (European perch) and four aquatic invertebrate taxa (damselfly larvae, mayfly larvae, waterlouse, and ramshorn snail), by tracing their bioconcentrations over several months in a semi-natural large-scale (pond) system. The results suggest both significant differences among drugs in their capacity to bioaccumulate and differences among species in uptake. While no support for in situ uptake of diclofenac and trimethoprim was found, oxazepam, diphenhydramine, and hydroxyzine were detected in all analyzed species. Here, the highest bioaccumulation factor (tissue:water ratio) was found for hydroxyzine. In the food web, the highest concentrations were found in the benthic species ramshorn snail and waterlouse, indicating that bottom-living organism at lower trophic positions are the prime receivers of the pharmaceuticals. In general, concentrations in the biota decreased over time in response to decreasing water concentrations. However, two interesting exceptions to this trend were noted. First, mayfly larvae (primarily grazers) showed peak concentrations (a fourfold increase) of oxazepam, diphenhydramine, and hydroxyzine about 30days after initial addition of pharmaceuticals. Second, perch (top-predator) showed an increase in concentrations of oxazepam throughout the study period. Our results show that drugs can remain bioavailable for aquatic organism for long time periods (weeks to months) and even re-enter the food web at a later time. As such, for an understanding of accumulation and dispersion of pharmaceuticals in aquatic food webs, detailed ecological knowledge is required.

Radiation Engineering of Multifunctional Nanogels

Nanogels combine the favourable properties of hydrogels with those of colloids. They can be soft and conformable, stimuli-responsive and highly permeable, and can expose a large surface with functional groups for conjugation to small and large molecules, and even macromolecules. They are among the very few systems that can be generated and used as aqueous dispersions. Nanogels are emerging materials for targeted drug delivery and bio-imaging, but they have also shown potential for water purification and in catalysis. The possibility of manufacturing nanogels with a simple process and at relatively low cost is a key criterion for their continued development and successful application. This paper highlights the most important structural features of nanogels related to their distinctive properties, and briefly presents the most common manufacturing strategies. It then focuses on synthetic approaches that are based on the irradiation of dilute aqueous polymer solutions using high-energy photons or electron beams. The reactions constituting the basis for nanogel formation and the approaches for controlling particle size and functionality are discussed in the context of a qualitative analysis of the kinetics of the various reactions.

Post-traumatic stress symptoms in Swedish obstetricians and midwives after severe obstetric events: a cross-sectional retrospective survey

OBJECTIVE

To examine post-traumatic stress reactions among obstetricians and midwives, experiences of support and professional consequences after severe events in the labour ward.

DESIGN

Cross-sectional online survey from January 7 to March 10, 2014.

POPULATION

Members of the Swedish Society of Obstetrics and Gynaecology and the Swedish Association of Midwives.

METHODS

Potentially traumatic events were defined as: the child died or was severely injured during delivery; maternal near-miss; maternal mortality; and other events such as violence or threat. The validated Screen Questionnaire Posttraumatic Stress Disorder (SQ-PTSD), based on DSM-IV (1994) 4th edition, was used to assess partial post-traumatic stress disorder (PTSD) and probable PTSD.

MAIN OUTCOME MEASURES

Partial or probable PTSD.

RESULTS

The response rate was 47% for obstetricians (n = 706) and 40% (n = 1459) for midwives. Eighty-four percent of the obstetricians and 71% of the midwives reported experiencing at least one severe event on the delivery ward. Fifteen percent of both professions reported symptoms indicative of partial PTSD, whereas 7% of the obstetricians and 5% of the midwives indicated symptoms fulfilling PTSD criteria. Having experienced emotions of guilt or perceived insufficient support from friends predicted a higher risk of suffering from partial or probable PTSD. Obstetricians and midwives with partial PTSD symptoms chose to change their work to outpatient care significantly more often than colleagues without these symptoms.

CONCLUSIONS

A substantial proportion of obstetricians and midwives reported symptoms of partial or probable PTSD after severe traumatic events experienced on the labour ward. Support and resilience training could avoid suffering and consequences for professional carers.

TWEETABLE ABSTRACT

In a survey 15% of Swedish obstetricians and midwives reported PTSD symptoms after their worst obstetric event.

On the origin of functionalization in one-pot radiation synthesis of nanogels from aqueous polymer solutions

E-beam irradiation is a “green”, one-step route for the production of biocompatible nanogels from polymer aqueous solutions. Functional group density is tuned independently from size and molecular weight by a proper choice of irradiation conditions.

Long-Term Persistence of an Anxiolytic Drug (Oxazepam) in a Large Freshwater Lake

Production and human consumption of pharmaceuticals result in contamination of surface waters worldwide. Little is known about the long-term (i.e., over decades) fate of pharmaceuticals in aquatic systems. Here, we show that the most prescribed anxiolytic in Sweden (oxazepam) persists in its therapeutic form for several decades after being deposited in a large freshwater lake. By comparing sediment cores collected in 1995 and 2013, we demonstrate that oxazepam inputs from the early 1970s remained in the sediments until sampling in 2013, despite in situ degradation processes and sediment diagenesis. In laboratory and pond experiments, we further reveal that therapeutic forms of oxazepam can persist over several months in cold (5 °C) lake water free from UV light. We conclude that oxazepam can persist in lakes over a time scale much longer than previously realized and that levels can build up in lakes due to both a legacy of past inputs and a growing urban population.

The risk of uterine rupture is not increased with single- compared with double-layer closure: a Swedish cohort study

OBJECTIVE

To compare single- with double-layer closure of the uterus for the risk of uterine rupture in women attempting vaginal birth after one prior caesarean delivery.

DESIGN

Cohort study.

SETTING

Sweden.

POPULATION

From a total of 19 604 nulliparous women delivered by caesarean section in the years 2001-2007, 7683 women attempting vaginal birth in their second delivery were analysed.

METHODS

Data from population-based registers were linked to hospital-based registers that held data from maternity and delivery records. Logistic regression was used to estimate the risk of uterine rupture after single- or double-layer closure of the uterus. Results are presented as odds ratios (ORs) with 95% confidence intervals (95% CIs).

MAIN OUTCOME MEASURE

Uterine rupture.

RESULTS

Uterine rupture during labour occurred in 103 (1.3%) women. There was no increased risk of uterine rupture when single- was compared with double-layer closure of the uterus (OR 1.17; 95% CI 0.78-1.76). Maternal factors associated with uterine rupture were: age ≥35 years and height ≤160 cm. Factors from the first delivery associated with uterine rupture in a subsequent delivery were: infection and giving birth to an infant large for gestational age. Risk factors from the second delivery were induction of labour, use of epidural analgesia, and a birthweight of ≥4500 g.

CONCLUSIONS

There was no significant difference in the rate of uterine rupture when single-layer closure was compared with double -layer closure of the uterus.