Development of a logic regression-based approach for the discovery of host- and niche-informative biomarkers in Escherichia coli and their application for microbial source tracking.

Microbial source tracking leverages a wide range of approaches designed to trace the origins of fecal contamination in aquatic environments. Although source tracking methods are typically employed within the laboratory setting, computational techniques can be leveraged to advance microbial source tracking methodology. Herein, we present a logic regression-based supervised learning approach for the discovery of source-informative genetic markers within intergenic regions across the Escherichia coli genome that can be used for source tracking. With just single intergenic loci, logic regression was able to identify highly source-specific (i.e., exceeding 97.00%) biomarkers for a wide range of host and niche sources, with sensitivities reaching as high as 30.00%-50.00% for certain source categories, including pig, sheep, mouse, and wastewater, depending on the specific intergenic locus analyzed. Restricting the source range to reflect the most prominent zoonotic sources of E. coli transmission (i.e., bovine, chicken, human, and pig) allowed for the generation of informative biomarkers for all host categories, with specificities of at least 90.00% and sensitivities between 12.50% and 70.00%, using the sequence data from key intergenic regions, including emrKY-evgAS, ibsB-(mdtABCD-baeSR), ompC-rcsDB, and yedS-yedR, that appear to be involved in antibiotic resistance. Remarkably, we were able to use this approach to classify 48 out of 113 river water E. coli isolates collected in Northwestern Sweden as either beaver, human, or reindeer in origin with a high degree of consensus-thus highlighting the potential of logic regression modeling as a novel approach for augmenting current source tracking efforts.IMPORTANCEThe presence of microbial contaminants, particularly from fecal sources, within water poses a serious risk to public health. The health and economic burden of waterborne pathogens can be substantial-as such, the ability to detect and identify the sources of fecal contamination in environmental waters is crucial for the control of waterborne diseases. This can be accomplished through microbial source tracking, which involves the use of various laboratory techniques to trace the origins of microbial pollution in the environment. Building on current source tracking methodology, we describe a novel workflow that uses logic regression, a supervised machine learning method, to discover genetic markers in Escherichia coli, a common fecal indicator bacterium, that can be used for source tracking efforts. Importantly, our research provides an example of how the rise in prominence of machine learning algorithms can be applied to improve upon current microbial source tracking methodology.

Declining calcium concentration drives shifts toward smaller and less nutritious zooplankton in northern lakes.

Zooplankton community composition of northern lakes is changing due to the interactive effects of climate change and recovery from acidification, yet limited data are available to assess these changes combined. Here, we built a database using archives of temperature, water chemistry and zooplankton data from 60 Scandinavian lakes that represent broad spatial and temporal gradients in key parameters: temperature, calcium (Ca), total phosphorus (TP), total organic carbon (TOC), and pH. Using machine learning techniques, we found that Ca was the most important determinant of the relative abundance of all zooplankton groups studied, while pH was second, and TOC third in importance. Further, we found that Ca is declining in almost all lakes, and we detected a critical Ca threshold in lake water of 1.3 mg L-1 , below which the relative abundance of zooplankton shifts toward dominance of Holopedium gibberum and small cladocerans at the expense of Daphnia and copepods. Our findings suggest that low Ca concentrations may shape zooplankton communities, and that current trajectories of Ca decline could promote widespread changes in pelagic food webs as zooplankton are important trophic links from phytoplankton to fish and different zooplankton species play different roles in this context.

Browning affects pelagic productivity in northern lakes by surface water warming and carbon fertilization.

Global change impacts important environmental drivers for pelagic gross primary production (GPP) in northern lakes, such as temperature, light, nutrient, and inorganic carbon availability. Separate and/or synergistic impacts of these environmental drivers on pelagic GPP remain largely unresolved. Here, we assess key drivers of pelagic GPP by combining detailed depth profiles of summer pelagic GPP with environmental and climatic data across 45 small and shallow lakes across northern Sweden (20 boreal, 6 subarctic, and 19 arctic lakes). We found that across lakes summer pelagic GPP was strongest associated with lake water temperatures, lake carbon dioxide (CO2 ) concentrations impacted by lake water pH, and further moderated by dissolved organic carbon (DOC) concentrations influencing light and nutrient conditions. We further used this dataset to assess the extent of additional DOC-induced warming of epilimnia (here named internal warming), which was especially pronounced in shallow lakes (decreasing 0.96°C for every decreasing m in average lake depth) and increased with higher concentrations of DOC. Additionally, the total pools and relative proportion of dissolved inorganic carbon and DOC, further influenced pelagic GPP with drivers differing slightly among the boreal, subarctic and Arctic biomes. Our study provides novel insights in that global change affects pelagic GPP in northern lakes not only by modifying the organic carbon cycle and light and nutrient conditions, but also through modifications of inorganic carbon supply and temperature. Considering the large-scale impacts and similarities of global warming, browning and recovery from acidification of lakes at higher latitudes throughout the northern hemisphere, these changes are likely to operate on a global scale.

Predictors of recurrence after catheter ablation and electrical cardioversion of atrial fibrillation: an umbrella review of meta-analyses.

AIMS: The recurrence rates after catheter ablation (CA) and direct current (DC) cardioversion remain high, although they have been established treatments of rhythm control of atrial fibrillation (AF). This umbrella review systematically appraises published meta-analyses of both observational and randomized controlled trials (RCTs) for the association of risk and protective factors for arrhythmia recurrence after CA and DC cardioversion of AF. METHODS AND RESULTS: Three bibliographic databases were searched up to June 2021. Evidence of association was rated as convincing, highly suggestive, suggestive, weak, or not significant with respect to observational studies and as high, moderate, low, or very low with respect to RCTs, according to established criteria. Thirty-one meta-analyses were included. Of the 28 associations between CA and the risk of arrhythmia recurrence, none presented convincing evidence, and only the time from diagnosis to ablation over 1 year provided highly suggestive evidence. The association between hypertension and metabolic profile provided suggestive evidence. The associations of Class IC and III antiarrhythmic drugs use with the recurrence after DC cardioversion were supported by an intermediate level of evidence. CONCLUSION: Although AF is a major health issue, few risk- and protective factors for AF recurrence have been identified. None of these factors examined were supported by convincing evidence, whereas established factors such as female gender and left atrial volume showed only weak association. An early CA strategy combined with treatment of metabolic syndrome and hypertension prior to CA may reduce the risk of arrhythmia recurrence. The use of antiarrhythmics can increase the success rate of DC cardioversion. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registry number: CRD42021270613.

Cardiac tamponades related to interventional electrophysiology procedures are associated with higher risk of short-term hospitalization for pericarditis but favourable long-term outcome.

AIMS: To investigate the association of iatrogenic cardiac tamponades as a complication of invasive electrophysiology procedures (EPs) and mortality as well as serious cardiovascular events in a nationwide patient cohort during long-term follow-up. METHODS: From the Swedish Catheter Ablation Registry between 2005 and 2019, a total of 58 770 invasive EPs in 44 497 patients were analysed. From this, all patients with periprocedural cardiac tamponades related to invasive EPs were identified (n = 200; tamponade group) and matched (1:2 ratio) to a control group (n = 400). Over a follow-up of 5 years, the composite primary endpoint-death from any cause, acute myocardial infarction, transitory ischaemic attack (TIA)/stroke, and hospitalization for heart failure-revealed no statistically significant association with cardiac tamponade [hazard ratio (HR) 1.22 (95% CI, 0.79-1.88)]. All single components of the primary endpoint as well as cardiovascular death revealed no statistically significant association with cardiac tamponade. Cardiac tamponade was associated with a significantly higher risk with hospitalization for pericarditis [HR 20.67 (95% CI, 6.32-67.60)]. CONCLUSION: In this nationwide cohort of patients undergoing invasive EPs, iatrogenic cardiac tamponade was associated with an increased risk of hospitalization for pericarditis during the first months after the index procedure. In the long-term, however, cardiac tamponade revealed no significant association with mortality or other serious cardiovascular events.

On Scene Injury Severity Prediction (OSISP) model for trauma developed using the Swedish Trauma Registry.

BACKGROUND: Providing optimal care for trauma, the leading cause of death for young adults, remains a challenge e.g., due to field triage limitations in assessing a patient's condition and deciding on transport destination. Data-driven On Scene Injury Severity Prediction (OSISP) models for motor vehicle crashes have shown potential for providing real-time decision support. The objective of this study is therefore to evaluate if an Artificial Intelligence (AI) based clinical decision support system can identify severely injured trauma patients in the prehospital setting. METHODS: The Swedish Trauma Registry was used to train and validate five models - Logistic Regression, Random Forest, XGBoost, Support Vector Machine and Artificial Neural Network - in a stratified 10-fold cross validation setting and hold-out analysis. The models performed binary classification of the New Injury Severity Score and were evaluated using accuracy metrics, area under the receiver operating characteristic curve (AUC) and Precision-Recall curve (AUCPR), and under- and overtriage rates. RESULTS: There were 75,602 registrations between 2013-2020 and 47,357 (62.6%) remained after eligibility criteria were applied. Models were based on 21 predictors, including injury location. From the clinical outcome, about 40% of patients were undertriaged and 46% were overtriaged. Models demonstrated potential for improved triaging and yielded AUC between 0.80-0.89 and AUCPR between 0.43-0.62. CONCLUSIONS: AI based OSISP models have potential to provide support during assessment of injury severity. The findings may be used for developing tools to complement field triage protocols, with potential to improve prehospital trauma care and thereby reduce morbidity and mortality for a large patient population.

Comparing efficacy and safety in catheter ablation strategies for atrial fibrillation: a network meta-analysis.

BACKGROUND: There is no consensus on the most efficient catheter ablation (CA) strategy for patients with atrial fibrillation (AF). The objective of this study was to compare the efficacy and safety of different CA strategies for AF ablation through network meta-analysis (NMA). METHODS: A systematic search of PubMed, Web of Science, and CENTRAL was performed up to October 5th, 2020. Randomized controlled trials (RCT) comparing different CA approaches were included. Efficacy was defined as arrhythmia recurrence after CA and safety as any reported complication related to the procedure during a minimum follow-up time of 6 months. RESULTS: In total, 67 RCTs (n = 9871) comparing 19 different CA strategies were included. The risk of recurrence was significantly decreased compared to pulmonary vein isolation (PVI) alone for PVI with renal denervation (RR: 0.60, CI: 0.38-0.94), PVI with ganglia-plexi ablation (RR: 0.62, CI: 0.41-0.94), PVI with additional ablation lines (RR: 0.8, CI: 0.68-0.95) and PVI in combination with bi-atrial modification (RR: 0.32, CI: 0.11-0.88). Strategies including PVI appeared superior to non-PVI strategies such as electrogram-based approaches. No significant differences in safety were observed. CONCLUSIONS: This NMA showed that PVI in combination with additional CA strategies, such as autonomic modulation and additional lines, seem to increase the efficacy of PVI alone. These strategies can be considered in treating patients with AF, since, additionally, no differences in safety were observed. This study provides decision-makers with comprehensive and comparative evidence about the efficacy and safety of different CA strategies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registry number: CRD42020169494 .

Fecal indicator organisms in northern oligotrophic rivers: An explorative study on Escherichia coli prevalence in a mountain region with intense tourism and reindeer herding.

Increasing pollution levels in waters from remote mountain areas in northern Sweden have been observed. To support a sustainable water quality management, it is necessary to know which environmental and antrophogenic factors influence the water quality. The purpose of this study was to map the Escherichia coli prevalence in the catchment area of the upper part of a large northern Scandinavian river and investigate the controlling factors of microbial contamination. A total of 112 water samples were collected from various locations in the research area between July 2020 and December 2020. These samples were analyzed for microbial and chemical characteristics, and information about tourism and reindeer herding was compiled. Additionally, microbial and physicochemical water characteristics collected by Indalsälven Water Conservation Association (IWCA, 1993-2020) and Swedish Meteorological and Hydrological Institute (SMHI, 2004-2020) were analyzed. The results showed that E. coli enumerations ranged between 0 and 500 CFU/100 ml. There was generally no obvious relation between suspected point sources, e.g., sewage treatment plants at mountain stations, and E. coli levels at downstream sampling points. Principal component analysis showed that E. coli was correlated to coliforms, total heterotrophic count, river discharge, CODMn and river color. Since microbial analyses are time-consuming, expensive and difficult to perform in remote areas, it is important to find more easily extracted water parameters that can serve as a proxy for E. coli. In particular, river color and discharge are promising parameters that may serve as an early indication of bacterial outbreak and fecal contamination in mountain waters.

Lowered nutritional quality of plankton caused by global environmental changes.

Global environmental changes are causing widespread nutrient depletion, declines in the ratio of dissolved inorganic nitrogen (N) to total phosphorus (DIN:TP), and increases in both water temperature and terrestrial colored dissolved organic carbon (DOC) concentration (browning) in high-latitude northern lakes. Declining lake DIN:TP, warming, and browning alter the nutrient limitation regime and biomass of phytoplankton, but how these stressors together affect the nutritional quality in terms of polyunsaturated fatty acid (PUFA) contents of the pelagic food web components remains unknown. We assessed the fatty acid compositions of seston and zooplankton in 33 lakes across south-to-north and boreal-to-subarctic gradients in Sweden. Data showed higher lake DIN:TP in the south than in the north, and that boreal lakes were warmer and browner than subarctic lakes. Lake DIN:TP strongly affected the PUFA contents-especially eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)-in seston, calanoids, and copepods (as a group), but not in cladocerans. The EPA+DHA contents increased by 123% in seston, 197% in calanoids, and 230% in copepods across a lake molar DIN:TP gradient from 0.17 to 14.53, indicating lower seston and copepod nutritional quality in the more N-limited lakes (those with lower DIN:TP). Water temperature affected EPA+DHA contents of zooplankton, especially cladocerans, but not seston. Cladoceran EPA+DHA contents were reduced by ca. 6% for every 1°C increase in surface water. Also, the EPA, DHA, or EPA+DHA contents of Bosmina, cyclopoids, and copepods increased in lakes with higher DOC concentrations or aromaticity. Our findings indicate that zooplankton food quality for higher consumers will decrease with warming alone (for cladocerans) or in combination with declining lake DIN:TP (for copepods), but impacts of these stressors are moderated by lake browning. Global environmental changes that drive northern lakes toward more N-limited, warmer, and browner conditions will reduce PUFA availability and nutritional quality of the pelagic food web components.

Debriding effect of amino acid-buffered hypochlorite on hard-to-heal wounds covered by devitalised tissue: pilot study.

OBJECTIVE: Wounds such as lower extremity ulcers are serious, costly and frequently hard to heal. Guidelines conclude that new dressings and treatments generally fail to show superiority compared with standard of care. Several mechanisms are probably responsible for impaired healing of hard-to-heal wounds, including inflammation and infection. Amino acid-buffered hypochlorite has presumed antiseptic and antibacterial properties and has been shown to be useful in the treatment of diabetic foot ulcers (DFUs). We evaluated the debriding effect of amino acid-buffered hypochlorite (ChloraSolv) on full skin hard-to-heal lower extremity ulcers covered with devitalised tissue (≥50%), with six applications over 5 weeks and follow-up at 12 weeks. METHOD: This was an open-label, single-arm, multicentre, pre-market pilot investigation. We recruited subjects with a lower extremity ulcer, covered with devitalised tissue (≥50%), who were candidates for cleansing and debridement/desloughing. There was a weekly application of the investigational device for five weeks. Follow-up for wound status evaluation was performed at 12 weeks from baseline. RESULTS: We evaluated 57 subjects (33 males, 24 females, median age 73 years, range 51-90 years) (intention-to-treat). Of these, 61.4% had a leg ulcer and 38.6% a foot ulcer. The median wound size at baseline was 7.7cm2 (range 2.1-52cm2) with devitalised tissue coverage of 76.5%. After 5 weeks, a decrease of 72.7% in devitalised tissue was seen, and 71.4% of the subjects showed a decrease in devitalised tissue of ≥50% (evaluated independently using PictZar). At 12 weeks' follow-up the decrease in devitalised tissue was 84.4%. Wound-related pain was reported by ten subjects, resulting in 17 adverse events (AEs). Among these, 12 AEs from eight subjects were recorded as possibly or probably related to the investigational device and one AE was reported to have a causal relationship with the investigational device. CONCLUSION: This clinical study suggests that amino acid-buffered hypochlorite can be effective and well tolerated in the treatment of hard-to-heal lower extremity ulcers to dissolve and remove devitalised tissue.

An upgrade of the Malmö model by implementing case-based teaching and learning, in an undergraduate dental education.

BACKGROUND: At our dental education, the examination failure rate amongst students has increased, resulting in subsequent involuntary dropouts. One of the main problems seems to be that the students struggle with taking the necessary responsibility for their learning, as required by the problem-based learning (PBL) methodology. AIM: To describe the background to, and the transition process from, pure PBL to case-based teaching and learning (CBT) with flipped classroom seminars at the dental programme at [anonymised for peer review]. METHODS: In this position paper, we describe our observed problems with the PBL methodology, as implemented at this faculty, and the potential benefits of a change towards CBT. The current implementation of CBT is presented, along with educational research supporting the choice of activities. RESULTS: Tentative findings are that the flipped classroom seminars and the clearer instructions appear to be successful with higher levels of activity, engagement and attendance amongst the students, and the students have evaluated the seminars as very good learning activities. CONCLUSION: Tentative findings suggest that the current implementation of CBT may be a fruitful way of teaching in dental education today. Most of the teaching staff have been reawakened to teaching, and as a result, the content of the courses are being reviewed and improved. The students appreciate that what is expected of them has been made clearer and that there is a variety of learning activities.

Identifying sociodemographic risk factors associated with residential fire fatalities: a matched case control study.

OBJECTIVES: This study aimed to investigate the association between sociodemographic factors and residential fire fatalities in Sweden. A majority of fatal fires occur in housing. An understanding of risk factors and risk groups is a must for well-founded decisions regarding targeted prevention efforts. There is a lack of consideration of the interrelation between sociodemographic factors and fire fatalities and there is a lack of high quality large-scale studies. METHODS: In this matched case-control study, residential fire fatalities (cases, n=850) (age above 19 years old) were identified in the national register on fatal fires. Four controls per case were randomly matched by gender and age. ORs were calculated to assess the association between different sociodemographic factors with residential fire fatalities using conditional logistic regression. RESULTS: Having low income, receiving social allowance and receiving health-related early retirement pension were associated with an increased risk of dying in residential fires. The results also show clearly that adults dying in residential fires to a significantly lower extent were living together with a partner, were in work, were highly educated and lived in urban areas. However, contrary to previous research, living in rented apartments appeared not to influence the risk of death. CONCLUSIONS: In this study, we show that fatalities due to residential fires in Sweden are associated with some but not all of previously published sociodemographic risk factors. The results provide valuable information that can improve the guiding and targeting of fire mortality prevention strategies in Sweden.

A decade of catheter ablation of cardiac arrhythmias in Sweden: ablation practices and outcomes.

AIMS: Catheter ablation is considered the treatment of choice for many tachyarrhythmias, but convincing 'real-world' data on efficacy and safety are lacking. Using Swedish national registry data, the ablation spectrum, procedural characteristics, as well as ablation efficacy and reported adverse events are reported. METHODS AND RESULTS: Consecutive patients (≥18 years of age) undergoing catheter ablation in Sweden between 01 January 2006 and 31 December 2015 were included in the study. Follow-up (repeat ablation and vital status) was collected through 31 December 2016. A total of 26 642 patients (57 ± 15 years, 62% men), undergoing a total of 34 428 ablation procedures were included in the study. In total, 4034 accessory pathway/Wolff-Parkinson-White syndrome (12%), 7358 AV-nodal re-entrant tachycardia (21%), 1813 atrial tachycardia (5.2%), 5481 typical atrial flutter (16%), 11 916 atrial fibrillation (AF, 35%), 2415 AV-nodal (7.0%), 581 premature ventricular contraction (PVC, 1.7%), and 964 ventricular tachycardia (VT) ablations (2.8%) were performed. Median follow-up time was 4.7 years (interquartile range 2.7-7.0). The spectrum of treated arrhythmias changed over time, with a gradual increase in AF, VT, and PVC ablation (P < 0.001). Decreasing procedural times and utilization of fluoroscopy with time, were seen for all arrhythmia types. The rates of repeat ablation differed between ablation types, with the highest repeat ablation seen in AF (41% within 3 years). The rate of reported adverse events was low (n = 595, 1.7%). Death in the immediate period following ablation was rare (n = 116, 0.34%). CONCLUSION: Catheter ablations have shifted towards more complex procedures over the past decade. Fluoroscopy time has markedly decreased and the efficacy of catheter ablation seems to improve for AF.

Gender and age differences in symptoms and health-related quality of life in patients with atrial fibrillation referred for catheter ablation.

BACKGROUND: Primary indication for catheter ablation of atrial fibrillation (AF) is to reduce symptoms and improve health-related quality of life (HRQoL). There are data showing differences between the genders and between younger and older patients. To evaluate this, we studied a large Scandinavian cohort of patients referred for catheter ablation of AF. METHODS: Consecutive patients filled out the ASTA questionnaire, assessing symptoms, HRQoL, and perception of arrhythmia, prior to ablation. Patients were recruited from four Swedish and one Danish tertiary center. RESULTS: A total of 2493 patients (72% men) filled out the ASTA questionnaire. Women experienced eight of the nine ASTA scale symptoms more often than men. Patients <65 years reported four symptoms more often, only tiredness was more frequent in those ≥65 years (P = .007). Women and patients <65 years experienced more often palpitations and regarding close to fainting and this was more common among women, no age differences were seen. Women and men scored differently in 10 of the 13 HRQoL items. Only negative impact on sexual life was more common in men (P < .001). Older patients reported more negative influence in four of the HRQoL items and the younger in one; ability to concentrate. CONCLUSIONS: Women experienced a more pronounced symptom burden and were more negatively affected in all HRQoL concerns, except for the negative impact on sexual life, where men reported more influence of AF. Differences between age groups were less pronounced. Disease-specific patient-reported outcomes measures (PROMs) add important information where gender differences should be considered in the care.

Investigating the effect of banning non-reduced ignition propensity cigarettes on fatal residential fires in Sweden.

BACKGROUND: Annually, 100 people die as a result of residential fires in Sweden and almost a third of the fatal fires are known to be caused by smoking. In an attempt to reduce the occurrence of these events, reduced ignition propensity (RIP) cigarettes have been developed. They are designed to reduce the risk of fire by preventing the cigarette from burning through the full length when left unattended. In November 2011, a ban was introduced, forbidding the production and sale of all non-RIP cigarettes in all member states of the European Union, including Sweden. METHODS: Monthly data on all recorded residential fires and associated fatalities in Sweden from January 2000 to December 2013 were analyzed using an interrupted time series design. The effect of the intervention [in relative risk (RR)] was quantified using generalised additive models for location, shape and scale. RESULTS: There were no statistically significant intervention effects on residential fires (RR 0.95 [95% CI: 0.89-1.01]), fatal residential fires (RR 0.99 [95% CI: 0.80-1.23]), residential fires where smoking was a known cause (RR 1.10 [95% CI: 0.95-1.28]) or fatal residential fires where smoking was a known cause (RR 0.92 [95% CI: 0.63-1.35]). CONCLUSION: No evidence of an effect of the ban on all non-RIP cigarettes on the risk of residential fires in Sweden was found. The results may not be generalisable to other countries.

The effects of temperature and resource availability on denitrification and relative N2O production in boreal lake sediments.

Anthropogenic environmental stressors (like atmospheric deposition, land use change, and climate warming) are predicted to increase inorganic nitrogen and organic carbon loading to northern boreal lakes, with potential consequences for denitrification in lakes. However, our ability to predict effects of these changes is currently limited as northern boreal lakes have been largely neglected in denitrification studies. The aim of this study was therefore to assess how maximum potential denitrification and N2O production rates, and the relationship between the two (relative N2O production), is controlled by availability of nitrate (NO3(-)), carbon (C), phosphorus (P), and temperature. Experiments were performed using the acetylene inhibition technique on sediments from a small, nutrient poor boreal lake in northern Sweden in 2014. Maximum potential denitrification and N2O production rates at 4°C were reached already at NO3(-) additions of 106-120µg NO3(-)-N/L, and remained unchanged with higher NO3 amendments. Higher incubation temperatures increased maximum potential denitrification and N2O production rates, and Q10 was somewhat higher for N2O production (1.77) than for denitrification (1.69). The relative N2O production ranged between 13% and 64%, and was not related to NO3(-) concentration, but the ratio increased when incubations were amended with C and P (from a median of 16% to 27%). Combined, our results suggests that unproductive northern boreal lakes currently have low potential for denitrification but are susceptible to small changes in NO3 loading especially if these are accompanied by enhanced C and P availability, likely promoting higher N2O production relative to N2.

The effect of a Computerised Decision Support System (CDSS) on compliance with the prehospital assessment process: results of an interrupted time-series study.

BACKGROUND: Errors in the decision-making process are probably the main threat to patient safety in the prehospital setting. The reason can be the change of focus in prehospital care from the traditional "scoop and run" practice to a more complex assessment and this new focus imposes real demands on clinical judgment. The use of Clinical Guidelines (CG) is a common strategy for cognitively supporting the prehospital providers. However, there are studies that suggest that the compliance with CG in some cases is low in the prehospital setting. One possible way to increase compliance with guidelines could be to introduce guidelines in a Computerized Decision Support System (CDSS). There is limited evidence relating to the effect of CDSS in a prehospital setting. The present study aimed to evaluate the effect of CDSS on compliance with the basic assessment process described in the prehospital CG and the effect of On Scene Time (OST). METHODS: In this time-series study, data from prehospital medical records were collected on a weekly basis during the study period. Medical records were rated with the guidance of a rating protocol and data on OST were collected. The difference between baseline and the intervention period was assessed by a segmented regression. RESULTS: In this study, 371 patients were included. Compliance with the assessment process described in the prehospital CG was stable during the baseline period. Following the introduction of the CDSS, compliance rose significantly. The post-intervention slope was stable. The CDSS had no significant effect on OST. CONCLUSIONS: The use of CDSS in prehospital care has the ability to increase compliance with the assessment process of patients with a medical emergency. This study was unable to demonstrate any effects of OST.

Association between catheter ablation of atrial fibrillation and mortality or stroke.

OBJECTIVE: Catheter ablation of atrial fibrillation effectively reduces symptomatic burden. However, its long-term effect on mortality and stroke is unclear. We investigated if patients with atrial fibrillation who undergo catheter ablation have lower risk for all-cause mortality or stroke than patients who are managed medically. METHODS: We retrospectively included 5628 consecutive patients who underwent first-time catheter ablation for atrial fibrillation between 2008 and 2018 at three major Swedish electrophysiology units. Control individuals with an atrial fibrillation diagnosis but without previous stroke were selected from the Swedish National Patient Register, resulting in a control group of 48 676 patients. Propensity score matching was performed to produce two cohorts of equal size (n=3955) with similar baseline characteristics. The primary endpoint was a composite of all-cause mortality or stroke. RESULTS: Patients who underwent catheter ablation were healthier (mean CHA2DS2-VASc score 1.4±1.4 vs 1.6±1.5, p<0.001), had a higher median income (288 vs 212 1000 Swedish krona [KSEK]/year, p<0.001) and had more frequently received university education (45.1% vs 28.9%, p<0.001). Mean follow-up was 4.5±2.8 years. After propensity score matching, catheter ablation was associated with lower risk for the combined primary endpoint (HR 0.58, 95% CI 0.48 to 0.69). The result was mainly driven by a decrease in all-cause mortality (HR 0.51, 95% CI 0.41 to 0.63), with stroke reduction showing a trend in favour of catheter ablation (HR 0.75, 95% CI 0.53 to 1.07). CONCLUSIONS: Catheter ablation of atrial fibrillation was associated with a reduction in the primary endpoint of all-cause mortality or stroke. This result was driven by a marked reduction in all-cause mortality.

Phytoplankton biomass in northern lakes reveals a complex response to global change.

Global change may introduce fundamental alterations in phytoplankton biomass and community structure that can alter the productivity of northern lakes. In this study, we utilized Swedish and Finnish monitoring data from lakes that are spatially (135 lakes) and temporally (1995-2019, 110 lakes) extensive to assess how phytoplankton biomass (PB) of dominant phytoplankton groups related to changes in water temperature, pH and key nutrients [total phosphorus (TP), total nitrogen (TN), total organic carbon (TOC), iron (Fe)] along spatial (Fennoscandia) and temporal (25 years) gradients. Using a machine learning approach, we found that TP was the most important determinant of total PB and biomass of a specific species of Raphidophyceae - Gonyostomum semen - and Cyanobacteria (both typically with adverse impacts on food-webs and water quality) in spatial analyses, while Fe and pH were second in importance for G. semen and TN and pH were second and third in importance for Cyanobacteria. However, in temporal analyses, decreasing Fe and increasing pH and TOC were associated with a decrease in G. semen and an increase in Cyanobacteria. In addition, in many lakes increasing TOC seemed to have generated browning to an extent that significantly reduced PB. The identified discrepancy between the spatial and temporal results suggests that substitutions of data for space-for-time may not be adequate to characterize long-term effects of global change on phytoplankton. Further, we found that total PB exhibited contrasting temporal trends (increasing in northern- and decreasing in southern Fennoscandia), with the decline in total PB being more pronounced than the increase. Among phytoplankton, G. semen biomass showed the strongest decline, while cyanobacterial biomass showed the strongest increase over 25 years. Our findings suggest that progressing browning and changes in Fe and pH promote significant temporal changes in PB and shifts in phytoplankton community structures in northern lakes.