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.

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.

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.

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.

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

Mitochondrial Function of CKS2 Oncoprotein Links Oxidative Phosphorylation with Cell Division in Chemoradioresistant Cervical Cancer

CDK regulatory subunit 2 (CKS2) has a nuclear function that promotes cell division and is a candidate biomarker of chemoradioresistance in cervical cancer. The underlying mechanisms are, however, not completely understood. We investigated whether CKS2 also has a mitochondrial function that augments tumor aggressiveness. Based on global gene expression data of two cervical cancer cohorts of 150 and 135 patients, we identified a set of genes correlated with CKS2 expression. Gene set enrichment analysis showed enrichment of mitochondrial cellular compartments, and the hallmarks oxidative phosphorylation (OXPHOS) and targets of the MYC oncogene in the gene set. By in situ proximity ligation assay, we showed that CKS2 formed complex with the positively correlated MYC target, mitochondrial single-stranded DNA binding protein SSBP1, in the mitochondrion of cervix tumor samples and HeLa and SiHa cervical cancer cell lines, indicating a role in mitochondrial DNA (mtDNA) replication and thereby OXPHOS. CDK1 was found to be part of the complex. Flow cytometry analyses of HeLa cells showed cell cycle regulation of the CKS2-SSBP1 complex consistent with mtDNA replication activity. Moreover, repression of mtDNA replication and OXPHOS by acute hypoxia decreased CKS2-SSBP1 complex abundance and expression of MYC targets. By immunohistochemistry, cytoplasmic CKS2 expression was found to add to the prognostic impact of nuclear CKS2 expression in patients, suggesting that the mitochondrial function promotes tumor aggressiveness. Our study uncovers a novel link between regulation of cell division by nuclear pathways and OXPHOS in the mitochondrion that involves CKS2 and promotes chemoradioresistance of cervical cancer.

Reference MicroRNAs for RT-qPCR Assays in Cervical Cancer Patients and Their Application to Studies of HPV16 and Hypoxia Biomarkers

MicroRNA (miRNA) expressions in tumor biopsies have shown potential as biomarkers in cervical cancer, but suitable reference RNAs for normalization of reverse transcription quantitative polymerase chain reaction (RT-qPCR) assays in patient cohorts with different clinicopathological characteristics are not available. We aimed to identify the optimal reference miRNAs and apply these to investigate the potential of miR-9-5p as human papilloma virus (HPV) 16 biomarker and miR-210-3p as hypoxia biomarker in cervical cancer. Candidate reference miRNAs were preselected in sequencing data of 90 patients and ranked in a stability analysis by RefFinder. A selection of the most stable miRNAs was evaluated by geNorm and NormFinder analyses of RT-qPCR data of 29 patients. U6 small nuclear RNA (RNU6) was also included in the evaluation. MiR-9-5p and miR-210-3p expression was assessed by RT-qPCR in 45 and 65 patients, respectively. Nine candidates were preselected in the sequencing data after excluding those associated with clinical markers, HPV type, hypoxia status, suboptimal expression levels, and low stability. In RT-qPCR assays, the combination of miR-151-5p, miR-152-3p, and miR-423-3p was identified as the most stable normalization factor across clinical markers, HPV type, and hypoxia status. RNU6 showed poor stability. By applying the optimal reference miRNAs, higher miR-9-5p expression in HPV16- than HPV18-positive tumors and higher miR-210-3p expression in more hypoxic than less hypoxic tumors were found in accordance with the sequencing data. MiR-210-3p was associated with poor outcome by both sequencing and RT-qPCR assays. In conclusion, miR-151-5p, miR-152-3p, and miR-423-3p are suitable reference miRNAs in cervical cancer. MiR-9-5p and miR-210-3p are promising HPV16 and hypoxia biomarkers, respectively.

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.

The diverse roles of glutathione-associated cell resistance against hypericin photodynamic therapy

The diverse responses of different cancers to treatments such as photodynamic therapy of cancer (PDT) have fueled a growing need for reliable predictive markers for treatment outcome. In the present work we have studied the differential response of two phenotypically and genotypically different breast adenocarcinoma cell lines, MCF7 and MDA-MB-231, to hypericin PDT (HYP-PDT). MDA-MB-231 cells were 70% more sensitive to HYP PDT than MCF7 cells at LD50. MCF7 were found to express a substantially higher level of glutathione peroxidase (GPX4) than MDA-MB-231, while MDA-MB-231 differentially expressed glutathione-S-transferase (GSTP1), mainly used for xenobiotic detoxification. Eighty % reduction of intracellular glutathione (GSH) by buthionine sulfoximine (BSO), largely enhanced the sensitivity of the GSTP1 expressing MDA-MB-231 cells to HYP-PDT, but not in MCF7 cells. Further inhibition of the GSH reduction however by carmustine (BCNU) resulted in an enhanced sensitivity of MCF7 to HYP-PDT. HYP loading studies suggested that HYP can be a substrate of GSTP for GSH conjugation as BSO enhanced the cellular HYP accumulation by 20% in MDA-MB-231 cells, but not in MCF7 cells. Studies in solutions showed that L-cysteine can bind the GSTP substrate CDNB in the absence of GSTP. This means that the GSTP-lacking MCF7 may use L-cysteine for xenobiotic detoxification, especially during GSH synthesis inhibition, which leads to L-cysteine build-up. This was confirmed by the lowered accumulation of HYP in both cell lines in the presence of BSO and the L-cysteine source NAC. NAC reduced the sensitivity of MCF7, but not MDA-MB-231, cells to HYP PDT which is in accordance with the antioxidant effects of L-cysteine and its potential as a GSTP substrate. As a conclusion we have herein shown that the different GSH based cell defense mechanisms can be utilized as predictive markers for the outcome of PDT and as a guide for selecting optimal combination strategies.

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).

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.

Hypoxia-independent gene expression signature associated with radiosensitisation of prostate cancer cell lines by histone deacetylase inhibition

BACKGROUND

Histone deacetylase inhibitors (HDACis) like vorinostat are promising radiosensitisers in prostate cancer, but their effect under hypoxia is not known. We investigated gene expression associated with radiosensitisation of normoxic and hypoxic prostate cancer cells by vorinostat.

METHODS

Cells were exposed to vorinostat under normoxia or hypoxia and subjected to gene expression profiling before irradiation and clonogenic survival analysis.

RESULTS

Pretreatment with vorinostat led to radiosensitisation of the intrinsically radioresistant DU 145 cells, but not the radiosensitive PC-3 and 22Rv1 cells, and was independent of hypoxia status. Knockdown experiments showed that the sensitisation was not caused by repression of hypoxia-inducible factor HIF1 or tumour protein TP53. Global deregulation of DNA repair and chromatin organisation genes was associated with radiosensitisation under both normoxia and hypoxia. A radiosensitisation signature with expression changes of 56 genes was generated and valid for both conditions. For eight signature genes, baseline expression also correlated with sensitisation, showing potential as pretreatment biomarker. The hypoxia independence of the signature was confirmed in a clinical data set.

CONCLUSIONS

Pretreatment with HDACi may overcome radioresistance of hypoxic prostate tumours by similar mechanisms as under normoxia. We propose a gene signature to predict radiosensitising effects independent of hypoxia status.

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.

Impact of changes to reimbursement of fixed combinations of inhaled corticosteroids and long-acting β₂ -agonists in obstructive lung diseases: a population-based, observational study

BACKGROUND

In 2010, the Icelandic government introduced a new cost-saving policy that limited reimbursement of fixed inhaled corticosteroid/long-acting β₂ -agonist (ICS/LABA) combinations.

METHODS

This population-based, retrospective, observational study assessed the effects of this policy change by linking specialist/primary care medical records with data from the Icelandic Pharmaceutical Database. The policy change took effect on 1 January 2010 (index date); data for the year preceding and following this date were analysed in 8241 patients with controlled/partly controlled asthma and/or chronic obstructive pulmonary disease (COPD) who had been dispensed an ICS/LABA during 2009. Oral corticosteroid (OCS) and short-acting β₂ -agonist (SABA) use, and healthcare visits, were assessed pre- and post-index.

RESULTS

The ICS/LABA reimbursement policy change led to 47.8% fewer fixed ICS/LABA combinations being dispensed during the post-index period among patients whose asthma and/or COPD was controlled/partly controlled during the pre-index period. Fewer ICS monocomponents were also dispensed. A total of 48.6% of patients were no longer receiving any respiratory medications after the policy change. This was associated with reduced disease control, as demonstrated by more healthcare visits (44.0%), and more OCS (76.3%) and SABA (51.2%) dispensations.

CONCLUSIONS

Overall, these findings demonstrate that changes in healthcare policy and medication reimbursement can directly impact medication use and, consequently, clinical outcomes and should, therefore, be made cautiously.

Ecotoxicological evaluation of poly(epsilon-caprolactone) nanocapsules containing triazine herbicides

The triazine class of herbicides includes the compounds ametryn, atrazine, and simazine, which are used to control weeds in plantations of crops such as maize, sorghum, and sugar cane. Despite their acceptance in agriculture, these herbicides can be dangerous to the environment, depending on their toxicity, the degree of contamination, and the duration of exposure. Controlled release systems are increasingly used to mitigate problems of toxicity and minimize environmental impacts, and can also increase herbicide efficiency. The objective of this work was to prepare poly(epsilon-caprolactone) nanocapsules containing ametryn and atrazine, and evaluate their toxicity to aquatic organisms as well as in cytogenetic tests employing human lymphocyte cultures. The PCL nanocapsules were prepared according to the interfacial deposition of pre-formed polymer method. Ecotoxicological assays were performed with the alga Pseudokirchneriella subcapitata and the microcrustacean Daphnia similis. The cytogenetic tests consisted of observing mitotic index alterations after exposing lymphocyte cell cultures to different formulations. Encapsulation of the herbicides in the nanocapsules resulted in lower toxicity to the alga and higher toxicity to the microcrustacean, compared to the herbicides alone. The cytogenetic tests showed that formulations of nanocapsules containing the herbicides were less toxic than the herbicides alone. The findings indicate the potential of the nanocapsule formulations in agricultural applications, where they could help to reduce the quantities of herbicides used as well as impacts on the environment and human health.

Antihistamines and aquatic insects: bioconcentration and impacts on behavior in damselfly larvae (Zygoptera)

Because aquatic insects use histamines as neurotransmitters, adverse impacts on aquatic insects living in aquatic environments that receive antihistamines with wastewater effluent are plausible. In this study, we exposed damselfly larvae to low concentrations of two commonly used antihistamines (Hydroxyzine and Fexofenadine, 360 ± 42 and 2,200 ± 43 ng l(-1), respectively), and recorded damselfly larvae behavior before and after exposure. Further, after the second set of behavioral assays was performed, we quantified bioconcentration of the antihistamines in the damselfly bodies. Our results showed significant changes in damselfly behavior following antihistamine exposure. After Hydroxyzine exposure, the damselfly larvae became less active, and they showed reduced fleeing response (i.e. increased boldness) after being exposed to Fexofenadine, the latter also being significantly different from the non-exposed (control) individuals. Further, we found high levels of bioconcentration in the damselflies; Hydroxyzine showed an average bioconcentration factor (BCF) of 2000. As such, our results indicate that low concentrations of antihistamines can have sub-lethal effects on aquatic insects manifested as behavioral changes, and that bioconcentration of these substances can be high. Therefore, the need to investigate the impact of emergent aquatic contaminants also on aquatic insects, and on behaviors that are of ecological importance, is further highlighted.

Experiences of living with asthma - a focus group study with adolescents and parents of children with asthma

OBJECTIVE

The goal for asthma treatment is that every individual, so far as possible, shall live without symptoms and exacerbations. Patients and health care professionals sometimes have different perceptions of what is important for achieving good quality of life. This work aims to describe the experiences among adolescents as well as those of parents with young children living with asthma.

METHODS

Four focus group interviews were performed, two with parents of young children and two with adolescents. The data were qualitatively analyzed, using Systematic Text Condensation.

RESULT

Three themes relevant to the participants' experiences of living with asthma were presented; strategies, frustrations and expectations. The adolescents wanted to be like their peers and developed their own strategies for self-management of asthma, which included not always taking medication as prescribed. The parents emphasized frustration regarding not being believed, lack of understanding feelings of loneliness, or anxiety. One identified expectation was that the participants wanted to be met with competence and understanding in asthma care from health care professionals. Another expectation expressed among parents was that teachers in nursery and primary schools should have more knowledge and understanding on how to care for children with asthma.

CONCLUSION

Living with asthma leads to developing personal strategies in self-management of asthma. Moreover both parents and adolescents had expectations of being met by competent and understanding health care professionals. Developing a partnership between patients and health care professionals could be a successful way to improve the care of patients with asthma.

Dilute concentrations of a psychiatric drug alter behavior of fish from natural populations

Environmental pollution by pharmaceuticals is increasingly recognized as a major threat to aquatic ecosystems worldwide. A variety of pharmaceuticals enter waterways by way of treated wastewater effluents and remain biochemically active in aquatic systems. Several ecotoxicological studies have been done, but generally, little is known about the ecological effects of pharmaceuticals. Here we show that a benzodiazepine anxiolytic drug (oxazepam) alters behavior and feeding rate of wild European perch (Perca fluviatilis) at concentrations encountered in effluent-influenced surface waters. Individuals exposed to water with dilute drug concentrations (1.8 micrograms liter(-1)) exhibited increased activity, reduced sociality, and higher feeding rate. As such, our results show that anxiolytic drugs in surface waters alter animal behaviors that are known to have ecological and evolutionary consequences.

Seasonal variation in biomarkers in blue mussel (Mytilus edulis), Icelandic scallop (Chlamys islandica) and Atlantic cod (Gadus morhua): implications for environmental monitoring in the Barents Sea

In the Barents Sea, the limited data on biological relevant indicators and their responses to various anthropogenic stressors have hindered the development of a consistent scientific basis for selecting indicator species and developing practical procedures for environmental monitoring. Accordingly, the main aim of the present study was to develop a common set of baseline values for contaminants and biomarkers in three species, and to identify their strengths and limitations in monitoring of the Barents Sea. Blue mussel (Mytilus edulis), Icelandic scallop (Chlamys islandica) and Atlantic cod (Gadus morhua) were sampled from a north Norwegian fjord in March, June, September and December 2010. Digestive glands from the bivalve species and liver from Atlantic cod were analysed for biomarkers of oxidative stress (catalase [CAT], glutathione peroxidase [GPX], glutathione-S-transferase activities [GST], lipid peroxidation as thiobarbituric reactive substances [TBARS] and total oxyradical scavenging capacity [TOSC]), biotransformation (ethoxyresorufine-O-deethylase activity [EROD]) and general stress (lysosomal membrane stability [LMS]). Concentrations of polycyclic aromatic hydrocarbons (PAHs) and metals in the bivalves and PAH metabolites in fish bile were quantified. Finally, energy reserves (total lipids, proteins and carbohydrates) and electron transport system (ETS) activity in the digestive gland of the bivalves and liver of Atlantic cod provided background information for reproductive cycle and general physiological status of the organisms. Blue mussel and Icelandic scallop showed very similar trends in biological cycle, biomarker expression and seasonality. Biomarker baselines in Atlantic cod showed weaker seasonal variability. However, important biological events may have been undetected due to the large time intervals between sampling occasions. Physiological biomarkers such as energy reserves and ETS activity were recommended as complementary parameters to the commonly used stress biomarkers, as they provided valuable information on the physiological status of the studied organisms. Interpretation of the seasonality in oxidative stress biomarkers was in general difficult but TOSC and lipid peroxidation were preferred over the antioxidant enzyme activities. This study is the first reporting seasonal baseline in these three species in a sub-Arctic location. Overall, the Icelandic scallop was considered the most adequate organism for environmental monitoring in the Barents Sea due to the interpretability of the biomarker data as well as its abundance, ease to handle and wide distribution from the southern Barents Sea to Svalbard.