Risk of preterm birth in relation to history of preterm birth: a population-based registry study of 213 335 women in Norway.

OBJECTIVE: To assess the association between preterm first birth and preterm second birth according to gestational age and to determine the role of placental disorder in recurrent preterm birth. DESIGN: Population-based registry study. SETTING: Medical Birth Registry of Norway and Statistics Norway. POPULATION: Women (n = 213 335) who gave birth to their first and second singleton child during 1999-2014 (total n = 426 670 births). METHODS: Multivariate logistic regression analyses, adjusted for placental disorders, maternal, obstetric and socio-economic factors. MAIN OUTCOME MEASURES: Extremely preterm (<28+0 weeks), very preterm (28+0 -33+6 weeks) and late preterm (34+0 -36+6 weeks) second birth. RESULTS: Preterm birth (<37 weeks) rates were 5.6% for first births and 3.7% for second births. Extremely preterm second births (0.2%) occurred most frequently among women with an extremely preterm first birth (aOR 12.90, 95% CI 7.47-22.29). Very preterm second births (0.7%) occurred most frequently after an extremely preterm birth (aOR 12.98, 95% CI 9.59-17.58). Late preterm second births (2.8%) occurred most frequently after a previous very preterm birth (aOR 6.86, 95% CI 6.11-7.70). Placental disorders contributed 30-40% of recurrent extremely and very preterm births and 10-20% of recurrent late preterm birth. CONCLUSION: A previous preterm first birth was a major risk factor for a preterm second birth. The contribution of placental disorders was more pronounced for recurrent extremely and very preterm birth than for recurrent late preterm birth. Among women with any category of preterm first birth, more than one in six also had a preterm second birth (17.4%). TWEETABLE ABSTRACT: Preterm first birth is a major risk factor for subsequent preterm birth, regardless of maternal, obstetric or fetal risk factors.

Clinical impact of chronic substance abuse in a Norwegian ICU-population.

BACKGROUND: The clinical impact of chronic substance abuse of alcohol and drugs-referred to as substance use disorders (SUD)-is often overlooked in the intensive care (ICU) setting. The aims of the present study were to identify patients with SUD-regardless of cause of admission-in a mixed Norwegian ICU-population, and to compare patients with and without SUD with regard to clinical characteristics and mortality. METHODS: Cross-sectional prospective study of a mixed medical and surgical ICU-population aged ≥18 years in Oslo, Norway. Data were collected consecutively, using a questionnaire including the AUDIT-C test, medical records and toxicology results. Patients classified with SUD were divided into the subgroups alcohol use disorders (AUD) and drug use disorders (DUD). RESULTS: Overall, 222 (26%) of the 861 patients included were classified with SUD; 137 (16%) with AUD and 85 (10%) with DUD. 130/222 (59%) of the SUD-patients had substance abuse-related cause of ICU-admission. Compared to non-SUD patients, DUD-patients were younger (median age 42 vs 65 years) and had lower SAPS II scores (41 vs 46), while AUD-patients had higher SOFA scores (8.0 vs 7.3). Overall, age-adjusted logistic regression analysis showed similar hospital mortality for SUD-patients and non-SUD patients, but AUD was associated with increased mortality among medical patients and in patients with sepsis (OR 1.7 (95% CI 1.0-2.8), and OR 2.6 (95% CI 1.1-6.2)). CONCLUSION: One in four ICU-patients had SUD regardless of cause of admission. Alcohol use disorder was associated with increased mortality in medical patients and in patients with sepsis.

Development of clinical competence - a longitudinal survey of nurse practitioner students.

BACKGROUND: In order to achieve a sustainable standard of advanced clinical competence for nurse practitioners leading to a credible role, it is important to investigate the development of clinical competence among nurse practitioner students. AIM: The aim of the present study is to analyse the development of nurse practitioner students' self-assessed clinical competence from the beginning of their education to after completion of their clinical studies. DESIGN: The study involved the application of a longitudinal survey design adhering to STROBE guidelines. METHODS: The participants consisted of 36 registered nurses from a nurse practitioner programme at a Norwegian university. The Professional Nurse Self-Assessment Scale II was used for data collection during the period August 2015 to May 2020. RESULTS: The students developed their clinical competence the most for direct clinical practice. Our findings are inconclusive in terms of whether the students developed clinical competence regarding consultation, coaching and guidance, and collaboration. However, they do indicate a lack of development in some aspects of clinical leadership. The students with the lowest level of clinical competence developed their clinical competence regarding direct clinical practice significantly more than the students with the highest level of clinical competence. The differences between students with high and low levels of clinical competence were levelled out during their education. Thus, the students as a whole became a more homogenous group after completion of their clinical studies. Previous work experience in primary healthcare was a statistically significant, yet minor, predictor of the development of clinical competence. CONCLUSION: Our findings indicate that the students developed their clinical competence for direct clinical practice in accordance with the intended learning outcomes of the university's Master's programme and international standards for nurse practitioners. It is imperative that the clinical field supports nurse practitioners by facilitating extended work-task fits that are appropriate to their newly developed clinical competence. We refrain from concluding with a recommendation that prior clinical work experience should be an entry requirement for nurse practitioner programmes. However, we recommend an evaluation of the nurse practitioner education programme with the aim of investigating whether the curriculum meets the academic standards of clinical leadership expected in advanced level of nursing.

Multidisciplinary educational programme for caregivers of children with atopic dermatitis- in South East Norway - an observational study.

BACKGROUND: Educational programmes for caregivers of children with atopic dermatitis (AD) are reported to reduce the severity of AD and improve quality of life (QOL). Oslo University Hospital (OUH) in Norway offers a multidisciplinary educational programme for caregivers of children with AD. We aimed to evaluate the AD educational programme by assessing QOL of the family, the severity of the disease and caregiver's fear of topical corticosteroid (TCS) before and after attending the programme. METHODS: This was a small observational prospective cohort study including 41 caregiver-child pairs. The children (mean age 3.4 years) had doctors' diagnosed AD with a difficult to treat eczema. The children's caregivers were referred from physicians to attend the AD educational programme at our hospital. At inclusion and at a 3 months follow-up QOL was assessed by Dermatitis Family Impact (DFI), the eczema severity by Patient-Orientated - SCORing Atopic Dermatitis (PO-SCORAD) and caregivers fear of TCS was recorded by asking a dichotomous "yes" or "no" question: "Are you worried about using TCS on your child?" RESULTS: Three months after caregivers attending the educational programme there was an improvement in QOL by reduced mean DFI from 9.6 (SD 6.3) to 6.8 (SD 5.4), the mean PO-SCORAD was reduced from 38.5 (SD 15.1) to 24.6 (SD13.6), the number of caregivers reporting fear of TCS use was reduced from 33/46 (72%) to 12/41 (29%). All results p < 0.001. CONCLUSION: Our study suggests beneficial effects by improving QOL of the family, the severity of the eczema and in reducing the fear of TCS when caregivers of children with difficult to treat AD attend an AD multidisciplinary educational programme. Lack of control group makes it difficult to draw definite conclusions.

Short- and long-term survival after isolated coronary artery bypass grafting, the impact of gender and age.

Objectives. Assess the short- and long-term survival for patients who underwent isolated coronary artery bypass grafting (CABG) and evaluate the impact of gender and age. Furthermore to assess the long-term survival in the CABG group compared to the general population. Design. This study included 4044 consecutive patients who underwent isolated CABG at Oslo University Hospital, Ullevål, in Oslo, Norway in the time period from 01 January 2003 to 31 December 2015. Patient data was collected retrospectively from the quality register at the department. Information on survival status was obtained from the Norwegian National Registry. Life expectancy data for the general population was gained from Statistics Norway. Results. Female patients were significantly older than male patients at the time of surgery (mean age 67.0 and 63.9 years, respectively, p < .001), and had significantly lower 30-day survival (mortality was 1.4% and 0.6%, respectively, p = .017). Male gender was independently associated with lower long-term survival (p = .0037) in a multivariate analysis. Male patients aged less than 60 years also showed significantly lower long-term survival (SMR = 1.84, 95% CI = 1.49-2.25) compared to the age-matched general population. Among patients older than 60 years, survival was similar to survival in the age-matched general population. Conclusions. Survival was excellent for patients undergoing surgery. Despite increased age and operative mortality, female patients had better adjusted long-time survival than male patients. There was lower long-term survival among male patients aged less than 60 compared to the general population. Our findings may help clinicians in selecting appropriate patients for surgery.

Phosphorylation of intracellular signalling molecules in peripheral blood cells from patients with psoriasis on originator or biosimilar infliximab.

BACKGROUND: Psoriasis vulgaris is a chronic, inflammatory skin disease characterized by a dysregulated immune response and it is associated with substantial systemic comorbidities. Biological drugs such as tumour necrosis factor (TNF)-α inhibitors can ameliorate the disease but are expensive. Biosimilar drugs have the same amino-acid sequence as the originator, but differences in manufacturing can affect biological activity, efficacy and tolerability. OBJECTIVES: To explore potential differences in intracellular phosphorylation of signalling molecules in peripheral blood cells from patients with psoriasis treated with the TNF-α inhibitor infliximab compared with healthy controls, and to investigate if the phosphorylation pattern was influenced by switching from the originator infliximab to the biosimilar CT-P13. METHODS: By flow cytometry, we measured phosphorylation of nuclear factor kappa B, extracellular signal-regulated kinase 1/2, p38 mitogen-activated protein kinase and signal transducer and activator of transcription 3, before and after TNF-α stimulation in monocytes and T, B, natural killer and CD3+  CD56+ cells from 25 patients with psoriasis treated with infliximab and 19 healthy controls. RESULTS: At inclusion, phosphorylation levels of peripheral blood mononuclear cells (PBMCs) were increased in patients with psoriasis compared with healthy controls, even though clinical remission had already been achieved. Phosphorylation levels declined in patients on both originator infliximab and biosimilar during continued treatment. No significant differences were detected between the two medications after 12 months. CONCLUSIONS: Patients with psoriasis on infliximab have higher activation levels of PBMCs than do healthy controls, possibly reflecting systemic inflammation. Switching from the originator infliximab to biosimilar CT-P13 did not affect phosphorylation levels or clinical parameters, suggesting that CT-P13 is a noninferior treatment alternative to the originator infliximab.

Healthcare utilisation, induced labour and caesarean section in the pregnancy after stillbirth: a prospective study.

OBJECTIVE: To investigate healthcare utilisation, induced labour and caesarean section (CS) in the pregnancy after stillbirth and assess anxiety and dread of childbirth as mediators for these outcomes. DESIGN: Population-based pregnancy cohort study. SETTING: The Norwegian Mother and Child Cohort Study. SAMPLE: A total of 901 pregnant women; 174 pregnant after stillbirth, 362 pregnant after live birth and 365 previously nulliparous. METHODS: Data from questionnaires answered in the second and third trimesters of pregnancy and information from the Medical Birth Registry of Norway. MAIN OUTCOME MEASURES: Self-reported assessment of antenatal care, register-based assessment of onset and mode of delivery. RESULTS: Women with a previous stillbirth had more frequent antenatal visits (mean 10.0; 95% CI 9.4-10.7) compared with women with a previous live birth (mean 6.0; 95% CI 5.8-6.2) and previously nulliparous women (mean 6.3; 95% CI 6.1-6.6). Induced labour and CS, elective and emergency, were also more prevalent in the stillbirth group. The adjusted odds ratio for elective CS was 2.5 (95% CI 1.3-5.0) compared with women with previous live birth and 3.7 (1.8-7.6) compared with previously nulliparous women. Anxiety was a minor mediator for the association between stillbirth and frequency of antenatal visits, whereas dread of childbirth was not a significant mediator for elective CS. CONCLUSIONS: Women pregnant after stillbirth were more ample users of healthcare services and more often had induced labour and CS. The higher frequency of antenatal visits and elective CS could not be accounted for by anxiety or dread of childbirth. TWEETABLE ABSTRACT: Women pregnant after stillbirth are ample users of healthcare services and interventions during childbirth.

Metacognitive beliefs mediate the effect of emotional abuse on depressive and psychotic symptoms in severe mental disorders.

BACKGROUND: Early trauma is linked to higher symptom levels in bipolar and psychotic disorders, but the translating mechanisms are not well understood. This study examines whether the relationship between early emotional abuse and depressive symptoms is mediated by metacognitive beliefs about thoughts being uncontrollable/dangerous, and whether this pathway extends to influence positive symptoms. METHOD: Patients (N = 261) with psychotic or bipolar disorders were assessed for early trauma experiences, metacognitive beliefs, and current depression/anxiety and positive symptoms. Mediation path analyses using ordinary least-squares regressions tested if the effect of early emotional abuse on depression/anxiety was mediated by metacognitive beliefs, and if the effect of early emotional abuse on positive symptoms was mediated by metacognitive beliefs and depression/anxiety. RESULTS: Metacognitive beliefs about thoughts being uncontrollable/dangerous significantly mediated the relationship between early emotional abuse and depression/anxiety. Metacognitive beliefs and depression/anxiety significantly mediated the relationship between early emotional abuse and positive symptoms. The models explained a moderate amount of the variance in symptoms (R 2 = 0.21-0.29). CONCLUSION: Our results indicate that early emotional abuse is relevant to depression/anxiety and positive symptoms in bipolar and psychotic disorders, and suggest that metacognitive beliefs could play a role in an affective pathway to psychosis. Metacognitive beliefs could be relevant treatment targets with regards to depression/anxiety and positive symptoms in bipolar and psychotic disorders.

Causes of death in childhood-onset Type 1 diabetes: long-term follow-up.

AIMS: To assess the causes of death and cause-specific standardized mortality ratios in two nationwide, population-based cohorts diagnosed with Type 1 diabetes during the periods 1973-1982 and 1989-2012, and to evaluate changes in causes of death during the follow-up period. METHODS: People with Type 1 diabetes who were aged < 15 years at diagnosis were identified in the Norwegian Childhood Diabetes Registry and followed from diagnosis until death, emigration or September 2013 (n = 7871). We assessed causes of death by linking data to the nationwide Cause of Death Registry and through a review committee that evaluated medical records, autopsy reports and death certificates. RESULTS: During a mean (range) follow-up of 16.8 (0-40.7) years, 241 individuals (3.1%) died, representing 132 143 person-years. The leading cause of death before the age of 30 years was acute complications (41/119, 34.5%). After the age of 30 years cardiovascular disease was predominant (41/122, 33.6%), although death attributable to acute complications was still important in this age group (22/122, 18.0%). A total of 5% of deaths were caused by 'dead-in-bed' syndrome. The standardized mortality ratio was elevated for cardiovascular disease [11.9 (95% CI 8.6-16.4)] and violent death [1.7 (95% CI 1.3-2.1)] in both sexes combined, but was elevated for suicide only in women [2.5 (95% CI 1.2-5.3)]. The risk of death from acute complications was approximately half in women compared with men [hazard ratio 0.43 (95% CI 0.25-0.76)], and did not change with more recent year of diagnosis [hazard ratio 1.02 (0.98-1.05)]. CONCLUSIONS: There was no change in mortality attributable to acute complications during the study period. To reduce premature mortality in people with childhood-onset diabetes focus should be on prevention of acute complications. Male gender implied increased risk.

Do pelvic floor muscle exercises reduce postpartum anal incontinence? A randomised controlled trial.

OBJECTIVE: To evaluate the effect of pelvic floor muscle exercises (PFME) for postpartum anal incontinence (AI). DESIGN: A parallel two-armed randomised controlled trial stratified on obstetrical anal sphincter injury with primary sphincter repair and hospital affinity. SETTING: Ano-rectal specialist out-patient clinics at two hospitals in Norway. POPULATION: One hundred and nine postpartum women with AI at baseline. METHODS: The intervention group received 6 months of individual physiotherapy-led PFME and the control group written information on PFME. Changes in St. Mark's scores and predictors of post-intervention AI were assessed by independent samples t-tests and multiple linear regression analyses, respectively. The study was not blind. MAIN OUTCOME MEASURES: The primary outcome measure was change in AI symptoms on the St. Mark's score from baseline to post-intervention. Secondary outcome measures were manometry measures of anal sphincter length and strength, endoanal ultrasound (EAUS) defect score and voluntary pelvic floor muscle contraction. RESULTS: There was a significant difference in the reduction of St. Mark's scores from baseline to post-intervention in favour of the PFME group (-2.1 versus -0.8 points, P = 0.040). No differences in secondary outcome measures were found between groups. Baseline St. Mark's, PFME group affinity and EAUS defect score predicted post-intervention St. Mark's score in the imputed intention-to-treat analyses. The analysis on un-imputed data showed that women performing weekly PFME improved their AI scores more than women in the control group did. CONCLUSIONS: Our results indicate that individually adapted PFME reduces postpartum AI symptoms. TWEETABLE ABSTRACT: Performing regular pelvic floor muscle exercises may be an effective treatment for postpartum anal incontinence.

Vancomycin levels are frequently subtherapeutic in critically ill patients: a prospective observational study.

BACKGROUND: Appropriate utilization of vancomycin is important to attain therapeutic targets while avoiding clinical failure and the development of antimicrobial resistance. Our aim was to observe the use of vancomycin in an intensive care population, with the main focus on achievement of therapeutic serum concentrations (15-20 mg/l) and to evaluate how this was influenced by dose regimens, use of guidelines and therapeutic drug monitoring. METHODS: A prospective observational study was carried out in the intensive care units at two tertiary hospitals in Norway. Data were collected from 83 patients who received vancomycin therapy, half of these received continuous renal replacement therapy. Patients were followed for 72 h after initiation of therapy. Blood samples were drawn for analysis of trough serum concentrations. Urine was collected for calculations of creatinine clearance. Information was gathered from medical records and electronic health records. RESULTS: Less than 40% of the patients attained therapeutic trough serum concentrations during the first 3 days of therapy. Patients with augmented renal clearance had lower serum trough concentrations despite receiving higher maintenance doses and more loading doses. When trough serum concentrations were outside of therapeutic range, dose adjustments in accordance to therapeutic drug monitoring were made to less than half. CONCLUSION: The present study reveals significant challenges in the utilization of vancomycin in critically ill patients. There is a need for clearer guidelines regarding dosing and therapeutic drug monitoring of vancomycin for patient subgroups.

Vitamin D levels and atopic eczema in infancy and early childhood in Norway: a cohort study.

BACKGROUND: Epidemiological data and the effect of sun exposure on atopic eczema (AE) suggest that vitamin D (vitD) may be involved in the pathogenesis. OBJECTIVES: To investigate if vitD levels were associated with the presence or severity of AE in the first 2 years of life in children living in south-east Norway. METHODS: Infants, recruited to a clinical trial on acute bronchiolitis (n = 404) and from the general population (n = 240), were examined at 1-13 months (first visit) and at 2 years of age (second visit). Caregivers were interviewed using a structured questionnaire. AE was diagnosed clinically, based on well-established criteria. Disease severity was assessed using the SCORing Atopic Dermatitis index. Blood samples were taken for vitD measurements, using liquid chromatography-tandem mass spectrometry and for common filaggrin mutation analyses. Complete data on AE and vitD were available in 596 and 449 children at the first and second visit, respectively. RESULTS: Atopic eczema was diagnosed in 67 children (11%) at the first visit and in 103 children (23%) at the second. Mean vitD levels were 58·2 nmol L(-1) at the first visit and 66·9 nmol L(-1) at the second. Using vitD level tertiles in multivariate regression analysis, there was no association between vitD levels and AE at either visit, regardless of filaggrin mutation. In children without AE at the first visit, vitD levels did not predict AE at the second. CONCLUSIONS: In this cohort of young children in Norway, we found no association between vitD levels and the presence or severity of AE.

Recovery from major depressive disorder episode after non-pharmacological treatment is associated with normalized cytokine levels.

BACKGROUND: Several lines of evidence show that the immune system is implicated in the pathophysiology of major depressive disorder (MDD) and that treatment with antidepressants affects cytokine and C-reactive protein (CRP) levels. Few studies have investigated immune markers during non-pharmacological treatment. In this follow-up study, we investigated whether CRP and elevated plasma cytokine levels observed before treatment of an acute episode of MDD are normalized during non-pharmacological treatment. METHODS: We obtained clinical assessments and blood for CRP and cytokine analysis from 50 unmedicated MDD patients, and cytokine levels from healthy controls. The patients received 'therapy as usual' for 12 weeks, and the assessments were then repeated. Of the 43 completers, 29 patients did not receive medication. RESULTS: In the patients receiving treatment without antidepressants, the depressive symptoms and the plasma levels of eight cytokines (interleukin (IL)-1Ra, IL-5,-6,-8,-10, G-CSF, IFN-γ, and TNF-α) were significantly reduced (P = 0.002-0.048). The cytokine levels were no longer different from the controls. The plasma CRP level did not change. CONCLUSION: Cytokine plasma levels normalized during recovery from an acute depressive episode in MDD without antidepressant treatment. These findings may have implications for the understanding of the role of the immune system in depression and recovery from depression.

No association between multiple sclerosis and periodontitis after adjusting for smoking habits.

BACKGROUND AND PURPOSE: Periodontitis has been reported to be associated with several systemic disorders, and recently a possible relationship with multiple sclerosis (MS) was suggested. The aim of the present study was to investigate the association between periodontitis and MS in a Norwegian cohort. METHODS: A case-control study in 756 MS patients and 1090 controls was conducted, and logistic regression analysis, adjusting for age, gender, place of residence, mononucleosis and smoking, was performed to investigate the association between MS and periodontitis. RESULTS: In the unadjusted analysis a higher prevalence of periodontitis was seen in MS patients, but this difference was not statistically significant after adjusting for the covariates. CONCLUSIONS: The previously suggested association between MS and periodontitis is not supported in this study. Our results underline the importance of adjusting for relevant covariates in epidemiological research.

Structured follow-up by general practitioners after deliberate self-poisoning: a randomised controlled trial.

BACKGROUND: General Practitioners (GPs) play an important role in the follow-up of patients after deliberate self-poisoning (DSP). The aim was to examine whether structured follow-up by GPs increased the content of, adherence to, and satisfaction with treatment after discharge from emergency departments. METHODS: This was a multicentre, randomised trial with blinded assignment. Five emergency departments and general practices in the catchment area participated. 202 patients discharged from emergency departments after DSP were assigned. The intervention was structured follow-up by the GP over a 6-month period with a minimum of five consultations, accompanied by written guidelines for the GPs with suggestions for motivating patients to follow treatment, assessing personal problems and suicidal ideation, and availability in the case of suicidal crisis. Outcome measures were data retrieved from the Register for the control and payment of reimbursements to health service providers (KUHR) and by questionnaires mailed to patients and GPs. After 3 and 6 months, the frequency and content of GP contact, and adherence to GP consultations and treatment in general were registered. Satisfaction with general treatment received and with the GP was measured by the EUROPEP scale. RESULTS: Patients in the intervention group received significantly more consultations than the control group (mean 6.7 vs. 4.5 (p = 0.004)). The intervention group was significantly more satisfied with the time their GP took to listen to their personal problems (93.1% vs. 59.4% (p = 0.002)) and with the fact that the GP included them in medical decisions (87.5% vs. 54. 8% (p = 0.009)). The intervention group was significantly more satisfied with the treatment in general than the control group (79% vs. 51% (p = 0.026)). CONCLUSIONS: Guidelines and structured, enhanced follow-up by the GP after the discharge of the DSP patient increased the number of consultations and satisfaction with aftercare in general practice. Consistently with previous research, there is still a need for interventional studies. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01342809. Registered 18 April 2011.

Prevalence and predictors of persistent post-surgical pain 12 months after thoracotomy.

BACKGROUND: Persistent post-surgical pain is recognised as a major problem. Prevalence after different surgical procedures has been reported to range from 5% up to 85%. Limb amputation and thoracotomy have the highest reported prevalence. Prediction of persistent post-surgical pain has over the last decade caught attention. Several factors have been investigated, but in-depth knowledge is still scarce. The purpose of this study was to investigate the prevalence of persistent post-surgical pain, and predictive factors for persistent post-surgical pain 12 months after thoracotomy. METHODS: A prospective longitudinal study was conducted. One-hundred and seventy patients were recruited before scheduled thoracotomy, and asked to answer a questionnaire. One-hundred and six patients completed the same questionnaire at 12-month follow-up. Regression analysis was performed to explore variables assumed predictive of persistent post-surgical pain. RESULTS: One-hundred and six patients (62%) filled out the questionnaire at both time points. Preoperative, 34% reported muscle-skeletal related chronic pain. At 12-month follow-up, 50% of the patients reported persistent post-surgical pain. Of the variables explored in the logistic regression model, only preoperative pain (P < 0.001) and dispositional optimism (P = 0.04) were statistically significant. In this study, preoperative pain was a predominant predictor for persistent postoperative pain (OR 6.97, CI 2.40-20.21), while dispositional optimism (OR 0.36, CI 0.14-0.96) seem to have protective properties. CONCLUSION: Our results show that preoperative pain is a predominant predictor of future pain. This implies that patients presenting with a chronic pain condition prior to surgery should be assessed thoroughly preoperatively and have an individually tailored analgesic regimen.

Peritumoral dermis of squamous cell carcinomas in renal transplant recipients contains less CD11c+ myeloid dendritic cells and FoxP3+ T cells compared to immunocompetent controls.

BACKGROUND: Renal transplant recipients (RTR) have an increased risk of developing cutaneous squamous cell carcinomas (SCC). These SCC are often more aggressive than SCC in immunocompetent individuals. OBJECTIVES: In this comparative study, we analysed the cell composition in the tissue immediately surrounding invasive SCC in immunosuppressed RTR and immunocompetent controls in an effort to further elucidate the role of the local immune system. METHODS: Morphology and quantity of various dendritic cell (DC) subsets, macrophages and FoxP3+ T cells were analysed by immunohistochemical staining. RESULTS: The number of CD11c+ myeloid DC and FoxP3+ T cells was significantly reduced in RTR, whereas the number of plasmacytoid DC, Langerhans cells and macrophages was similar in RTR and controls. CONCLUSIONS: A reduction in CD11c+ mDC in peritumoral dermis in RTR might contribute to impaired immunosurveillance thus giving rise to an increased risk to develop aggressive SCC in these patients.

Anal incontinence and Quality of Life in late pregnancy: a cross-sectional study.

OBJECTIVE: To evaluate the association between different types of anal incontinence (AI) and Quality of Life (QoL) in late pregnancy. DESIGN: Cross-sectional study. SETTING: Two maternity units in Norway 2009-2010. POPULATION: Primiparae aged 18 or over. METHODS: Participants answered questions about AI during the last 4 weeks of pregnancy on the St. Mark's score and impact of QoL in the Fecal Incontinence QoL score. Socioeconomic data were obtained from hospital records. MAIN OUTCOME MEASURES: Self-reported AI and impact on QoL. RESULTS: 1571 primiparae responded; 573 (37%) had experienced AI during the last 4 weeks of pregnancy. One third of the incontinent women reported reduced QoL in the domain 'Coping'. 'Women experiencing urgency alone reported markedly better QoL compared to any other AI symptoms. AI appeared to have the strongest impact on the domains 'Coping' and 'Embarrassment'. Depression was only associated with experiencing the combination of all three symptoms [odds ratio (OR) 13; 95%confidence interval (CI) 3.2-51]. Experiencing flatus alone weekly or more was associated with the highest impact on 'Embarrassment' (OR 20; 95%CI 6.4-61) compared with all other symptoms or combination of AI symptoms, except the combination of all three AI symptoms. CONCLUSIONS: Between 3 and 10% of the primiparae in this material experienced AI to such a extent that it affected QoL. The greatest impact was seen in the QoL domain 'Coping'. These findings highlight the importance of an increased awareness of AI in late pregnancy among health professionals and the need to implement routine discussions about AI with expectant and new mothers.

Prevalence and predictors of anal incontinence during pregnancy and 1 year after delivery: a prospective cohort study.

OBJECTIVE: To evaluate the prevalence and predictors of anal incontinence (AI) in late pregnancy and 1 year after delivery. DESIGN: Prospective population-based cohort study. SETTING: Two maternity units in Norway 2009-2010. POPULATION: Primiparae aged 18 years or over. METHODS: Primiparae answered questions on the St. Mark's score about AI during the last 4 weeks of pregnancy. One year later, the same questionnaires were distributed by postal mail. Socio-economic and delivery-related data were obtained from hospital records. MAIN OUTCOME MEASURES: Self-reported AI. RESULTS: Answers on AI in late pregnancy were obtained from 1571 women, and 1030 responded 1 year later. Twenty-four per cent experienced one and 4.7% experienced three or more AI symptoms in late pregnancy. One year later, this was reduced to 19% and 2.2%, respectively. Multivariate logistic regression analyses were applied. Formed and loose stool incontinence were strongly associated at both time points. The main predictor of AI 1 year after delivery was AI in late pregnancy. Obstetric anal sphincter injury increased the risk of incontinence of stool and flatus (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.7-9.6) after delivery. Urgency was associated with greater age (OR, 1.8; 95% CI, 1.0-3.3) and operative delivery (OR, 2.0; 95% CI, 1.3-2.9). CONCLUSION: One in four primiparae experienced AI in late pregnancy. One year later, still one in five suffered from incontinence. Sphincter injury predicted incontinence of stool and flatus, whereas greater age and operative delivery predicted urgency. The identification and adequate follow-up of pregnant women with AI may reduce AI after delivery.