Adverse Events of Peripherally Administered Norepinephrine During Surgery: A Prospective Multicenter Study.

BACKGROUND: Perioperative treatment of hypotension by intravenous administration of norepinephrine in a peripheral vein can lead to adverse events, for example, tissue necrosis. However, the incidence and severity of adverse events during perioperative administration are unknown. METHODS: This was a prospective observational study conducted at 3 Swedish hospitals from 2019 to 2022. A total of 1004 patients undergoing surgery, who met the criteria for perioperative peripheral norepinephrine administration, were included. The infusion site was inspected regularly. If swelling or paleness of skin was detected, the infusion site was changed to a different peripheral line. Systolic blood pressure and pulse frequency were monitored during the infusion time and defined as adverse events at >220 mm Hg and <40 beats•min -1 . In case of adverse events, patients were observed for up to 48 hours. The primary outcome was prevalence of extravasation, defined as swelling around the infusion site. Secondary outcomes were all types of adverse events and associations between predefined clinical variables and risk of adverse events. RESULTS: We observed 2.3% (95% confidence interval [CI], 1.4%-3.2%) extravasation of infusion and 0.9% (95% CI, 0.4%-1.7%) bradycardia. No cases of tissue necrosis or severe hypertension were detected. All adverse events had dissipated spontaneously within 48 hours. Proximal catheter placement was associated with more adverse events. CONCLUSIONS: Extravasation of peripherally administrated norepinephrine in the perioperative period occurred at similar rates as in previous studies in critically ill patients. In our setting, where we regularly inspected the infusion site and shifted site in case of swelling or paleness of skin, we observed no case of severe adverse events. Given that severe adverse events were absent, the potential benefit of this preventive approach requires confirmation in a larger population.

Improved oxygenation in prone positioning of mechanically ventilated patients with COVID-19 acute respiratory distress syndrome is associated with decreased pulmonary shunt fraction: a prospective multicenter study.

BACKGROUND: Prone position is used in acute respiratory distress syndrome and in coronavirus disease 2019 (Covid-19) acute respiratory distress syndrome (ARDS). However, physiological mechanisms remain unclear. The aim of this study was to determine whether improved oxygenation was related to pulmonary shunt fraction (Q's/Q't), alveolar dead space (Vd/Vtalv) and ventilation/perfusion mismatch (V'A/Q'). METHODS: This was an international, prospective, observational, multicenter, cohort study, including six intensive care units in Sweden and Poland and 71 mechanically ventilated adult patients. RESULTS: Prone position increased PaO2:FiO2 after 30 min, by 78% (83-148 mm Hg). The effect persisted 120 min after return to supine (p < 0.001). The oxygenation index decreased 30 min after prone positioning by 43% (21-12 units). Q's/Q't decreased already after 30 min in the prone position by 17% (0.41-0.34). The effect persisted 120 min after return to supine (p < 0.005). Q's/Q't and PaO2:FiO2 were correlated both in prone (Beta -137) (p < 0.001) and in the supine position (Beta -270) (p < 0.001). V'A/Q' was unaffected and did not correlate to PaO2:FiO2 (p = 0.8). Vd/Vtalv increased at 120 min by 11% (0.55-0.61) (p < 0.05) and did not correlate to PaO2:FiO2 (p = 0.3). The ventilatory ratio increased after 30 min in the prone position by 58% (1.9-3.0) (p < 0.001). PaO2:FiO2 at baseline predicted PaO2:FiO2 at 30 min after proning (Beta 1.3) (p < 0.001). CONCLUSIONS: Improved oxygenation by prone positioning in COVID-19 ARDS patients was primarily associated with a decrease in pulmonary shunt fraction. Dead space remained high and the global V'A/Q' measure could not explain the differences in gas exchange.

Surveillance of indeterminate pulmonary nodules detected with CT in a Swedish population-based study (SCAPIS): psychosocial consequences and impact on health-related quality of life-a multicentre prospective cross-sectional study.

OBJECTIVES: To investigate whether surveillance of pulmonary nodules detected with low-dose CT (LDCT) impacted health-related quality of life and psychosocial consequences in the Swedish population-based study, Swedish CArdioPulmonary bioImage Study (SCAPIS). DESIGN: A prospective cross-sectional study. SETTINGS AND PARTICIPANTS: This multicentre (five sites) observational study, which included a cohort from SCAPIS, consisted of 632 participants with indeterminate pulmonary nodules detected with LDCT. These participants continued surveillance for up to 36 months, during which lung cancer was not detected (surveillance group). Additionally, 972 participants with a negative pulmonary LDCT scan were included as a control group. Matching criteria were LDCT date (±2 weeks), gender and site. OUTCOME MEASURES: All participants completed a health-related quality of life questionnaire (RAND-36) and the Consequences of Screening (COS) questionnaire, an average of 3 years after LDCT was conducted at entry into SCAPIS. RESULTS: Participants were 51-70 years old at study commencement. Overall, the two groups did not differ in demographic or psychosocial variables, smoking habits or pulmonary medical history. Individuals from countries other than Sweden and those with low socioeconomic status were less likely to participate (p<0.001). No effects on health-related quality of life were observed via RAND-36. In COS, the surveillance group demonstrated a higher OR for anxiety about lung cancer (OR 3.96, 95% CI 2.35 to 6.66, p<0.001), experiencing a sense of dejection (OR 1.35, 95% CI 1.06 to 1.72, p=0.015) and thoughts about existential values (OR 1.30, 95% CI 1.04 to 1.60, p=0.018). CONCLUSIONS: Lung surveillance with LDCT contributed to significant experiences of sense of dejection, anxiety about lung cancer and development of thoughts about existential values among participants in the surveillance group compared with the controls. The risk of side effects should be communicated for informed decision-making about (non-)attendance in lung cancer screening.

Levels of physical activity before and after stroke in relation to early cognitive function.

Regular physical activity is widely recommended in the primary and secondary prevention of stroke. Physical activity may enhance cognitive performance after stroke, but cognitive impairments could also hinder a person to take part in physical activity. However, a majority of previous studies have not found any association between post-stroke cognitive impairments and a person's subsequent level of activity. In this explorative, longitudinal study, we describe the intraindividual change in physical activity from before to 6 months after stroke, in relation to early screening of post-stroke cognitive impairments. Participants were recruited at 2 to 15 days after stroke, and screened for cognitive impairments using the Montreal Cognitive Assessment tool. Information on pre-stroke physical activity was retrospectively collected at hospital admittance by physiotherapists. Post-stroke physical activity was evaluated after 6 months. Of 49 participants included, 44 were followed up. The level of physical activity changed in more than half of all participants after stroke. Participants who were physically active 6 months after stroke presented with significantly less cognitive impairments. These results highlight that many stroke survivors experience a change in their physical activity level following stroke, and that unimpaired cognition may be important for a stroke survivors' ability to be physically active.

Prone positioning in mechanically ventilated patients with severe acute respiratory distress syndrome and coronavirus disease 2019.

BACKGROUND: The management of COVID-19 ARDS is debated. Although current evidence does not suggest an atypical acute respiratory distress syndrome (ARDS), the physiological response to prone positioning is not fully understood and it is unclear which patients benefit. We aimed to determine whether proning increases oxygenation and to evaluate responders. METHODS: This case series from a single, tertiary university hospital includes all mechanically ventilated patients with COVID-19 and proning between 17 March 2020 and 19 May 2020. The primary measure was change in PaO2 :FiO2 . RESULTS: Forty-four patients, 32 males/12 females, were treated with proning for a total of 138 sessions, with median (range) two (1-8) sessions. Median (IQR) time for the five sessions was 14 (12-17) hours. In the first session, median (IQR) PaO2 :FiO2 increased from 104 (86-122) to 161 (127-207) mm Hg (P < .001). 36/44 patients (82%) improved in PaO2 :FiO2 , with a significant increase in PaO2 :FiO2 in the first three sessions. Median (IQR) FiO2 decreased from 0.7 (0.6-0.8) to 0.5 (0.35-0.6) (<0.001). A significant decrease occurred in the first three sessions. PaO2 , tidal volumes, PEEP, mean arterial pressure (MAP), and norepinephrine infusion did not differ. Primarily, patients with PaO2 :FiO2 approximately < 120 mm Hg before treatment responded to proning. Age, sex, BMI, or SAPS 3 did not predict success in increasing PaO2 :FiO2 . CONCLUSION: Proning increased PaO2 :FiO2 , primarily in patients with PaO2 :FiO2 approximately < 120 mm Hg, with a consistency over three sessions. No characteristic was associated with non-responding, why proning may be considered in most patients. Further study is required to evaluate mortality.

Agreement between participation ratings of children with intellectual disabilities and their primary caregivers.

BACKGROUND: Participation of children with ID it is argued must be understood in relation to the fit with the environment. Since caregivers are a vital factor within the close environment of a child with intellectual disability, their perceptions are unequivocally important. AIMS: The main aim of this study is to describe the self-reported participation of children with ID and the perceptions of their primary caregivers. Both frequency of attendance and perceived importance of activity was measured with self-reported and proxy-reports. METHODS & PROCEDURES: A custom developed Picture my Participation (PmP) survey was utilised in an interview format with children with intellectual disability whilst their primary caregivers completed the survey independently. RESULTS: Overall, the perceptions of children with intellectual disabilities and of primary caregivers showed similarities regarding attendance and activities considered important. On group level, both children and primary caregivers perceived the child to have a high level of attendance ofFormal learning in school, Family mealtime, Interacting with family and Celebrations. An overall poor agreement in perceived frequency of attendance was found. However, in child-primary cargiver-dyads poor agreement in perceived frequency of attendance was found. CONCLUSIONS: While primary caregivers and children's ratings of attendance and selection of the most important activities appeared somewhat similar, there was a noted difference, in that primary caregivers' were uniform in their selection, whilst there was a diversity in the selection of activities amongst children.

Multi-site musculoskeletal pain in Swedish police: associations with discomfort from wearing mandatory equipment and prolonged sitting.

PURPOSE: Musculoskeletal disorders are considered as a major issue affecting the health and well-being of active duty police. Discomfort from wearing mandatory equipment and sitting for long periods of time in fleet vehicles are workload factors linked to musculoskeletal disorders in police. This study aims to determine the prevalence of multi-site musculoskeletal pain among Swedish police and to explore the possible association to discomfort experience when wearing mandatory equipment and sitting for long periods in fleet vehicles. METHODS: In this cross-sectional study responses from 4185 police were collected through a self-administered online survey including questions about physical work environment, mandatory equipment and musculoskeletal pain. Multi-site pain was determined through summing pain sites from four body regions. Binomial logistic regression was performed to explore the association between multi-site musculoskeletal pain: (1) discomfort from wearing mandatory equipment and (2) sitting for long periods in fleet vehicles. RESULTS: The prevalence of multi-site musculoskeletal pain at least 1 day per week within the previous 3 months was 41.3%. A statistically significant association between discomfort from wearing mandatory equipment and multi-site musculoskeletal pain was found; duty belt [OR 5.42 (95% CI 4.56-6.43)] as well as body armour [OR 2.69 (95% CI 2.11-3.42)]. Sitting for long periods in fleet vehicles was not significantly associated to multi-site musculoskeletal pain. CONCLUSION: Multi-site musculoskeletal pain is a considerable problem among Swedish police and modifying mandatory equipment to decrease discomfort is suggested as a potential means of decreasing the musculoskeletal pain experienced by many police officers.

A modified Job Demand, Control, Support model for active duty police.

BACKGROUND: The Job Demand Control Support model (JDCS) is one of the most widely used theoretical models relating job characteristics to health and wellbeing. OBJECTIVE: This study aimed to assess the predictive power of the JDCS model for determining job satisfaction and fatigue in uniformed Swedish police. An additional aim was to determine if predictive power of the model would be improved with the addition of two occupation specific items. METHODS: Questionnaire data, based upon the Swedish Work Environment Survey were collected from Swedish police (n = 4244). A hierarchical multiple regression analysis was run to explore the predictive value of the model and to determine if the additional variables improved predictive power with respect to job satisfaction and fatigue. RESULTS: Regression analysis demonstrated that the JDSC model had high predictive power in relation to job satisfaction and fatigue. Job demands was the strongest predictor of fatigue (14%), while support was the strongest predictor of job satisfaction (12%). The addition of exposure to threats significantly improved predictive power for both job satisfaction and fatigue, while addition of shift work did not significantly affect predictive power of the model. CONCLUSIONS: Workplace interventions to address issues related to job satisfaction and fatigue in police should focus on maintaining a bearable level of job demands and provision of adequate support.

Multidisciplinary Clinics.

More than 400 acquired and genetic diseases are labeled as arthrogryposis. Because of their rarity and complexity coordinated patient management is often lacking. Multidisciplinary clinics are the ideal setting to provide coordinated and comprehensive care to patients with special needs. Two similar experiences of multidisciplinary clinics for the care of patients with arthrogryposis were reported at the Symposium on Arthrogryposis held in Saint Petersburg in September 2014. These clinics are organized to bring together professionals from several disciplines, with the aim to provide patient-centered, comprehensive clinical care, and reduce the burden of multiple medical appointments for the families.

The inter-rater and test-retest reliability of the Self-care and Transfer scales, and intra-rater reliability of all scales of the Swedish Translation of the Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT-S).

OBJECTIVE: The Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT) are used internationally to measure the outcomes of occupational therapy services across diagnoses, ages, and health care settings. This study reports on the inter-rater and test-retest reliability of the Self-care and Transfer scales as well as the intra-rater reliability of all scales of the Swedish (AusTOMs-OT-S) translation. METHODS: Fifteen occupational therapists rated 11 case study clients on two occasions, separated by two weeks. Test-retest reliability and inter-rater reliability were calculated for the Self-care scale and Transfer scales. Moreover, intra-rater reliability was calculated for each of the 15 therapists across all 12 scales. RESULTS: The inter-rater reliability intraclass correlation coefficients (ICCs) were all found to be high to very high, ranging from ICC 0.762 to 0.904; the intra-rater reliability coefficients were also very good with 11 of the 15 therapists achieving ICCs of 0.745 or over, and finally the test-retest ICCs were also found to be high, ranging from 0.705 to 0.920. CONCLUSIONS: Although further research is required to confirm reliability, preliminary reliability of the AusTOMs-OT Swedish translation has been demonstrated and therapists can have confidence when using the scales.

Mild traumatic brain injury: a description of how children and youths between 16 and 18 years of age perform leisure activities after 1 year.

OBJECTIVE: The aim is to describe how children and youths perform leisure activities, 1 year after a mild traumatic brain injury (MTBI). METHODS: Basis is to compile previously collected material; patients were extracted from a prospective randomized controlled trial of MTBI. A retrospective analysis was conducted among 73 children and youths between 16 and 18 years of age. The entire group administrated the Interest Checklist at baseline and at 1-year follow-up. RESULTS: Statistical significant difference was found in 31 of 50 different activities. The result showed that children and youths did not return to perform leisure activities. Fewer returned in the intervention group than in the control group. CONCLUSION: An occupational therapist can help children and youths to have balance in their life and continue a functional life after a MTBI. Continued research is needed, how to prevent MTBI and how to support children and youths to continue with leisure activities.

Mild traumatic brain injuries in children between 0-16 years of age: a survey of activities and places when an accident occurs.

OBJECTIVE: The aim of this study was to identify what activities cause most mild traumatic brain injury (MTBI) among boys and girls between 0-16 years of age. METHODS: Based on a randomized controlled study, a retrospective analysis was conducted among 765 children. RESULT: The most common causes of injury were falls from a height and falls from the same level. The most common place where the accident occurred was at 'home' followed by 'pre-school/school'. The highest incidence was 'play' followed by 'hit by another person', thereafter 'baby nursing'. Boys are more often injured than girls, but with no difference between boys and girls in terms of which activities that cause MTBI. CONCLUSION: Supervision during play at home as well as better designed schoolyards and playgrounds are required to prevent accidents. Furthermore, well-documented medical records are necessary to identify activities causing MTBI among children.

Mild traumatic brain injuries: a 10-year follow-up.

OBJECTIVE AND DESIGN: Long-term consequences of mild traumatic brain injuries were investigated based on a 10-year follow-up of patients from a previously-published randomized controlled study of mild traumatic brain injuries. One aim was to describe changes over time after mild traumatic brain injuries in terms of the extent of persisting post-concussion symptoms, life satisfaction, perceived health, activities of daily living, changes in life roles and sick leave. Another aim was to identify differences between the intervention and control groups. PATIENTS: The intervention group comprised 142 persons and the control group 56 persons. METHODS: Postal questionnaires with a response rate of 56%. RESULTS: No differences over time were found for the intervention and control groups in terms of post-concussion symptoms. In the intervention group some variables in life satisfaction, perceived health and daily life were decreased. Some roles had changed over the years for both groups. No other differences between the intervention and control groups were found. However, in both groups sick leave decreased. CONCLUSION: Early individual intervention by a qualified rehabilitation team does not appear to impact on the long-term outcome for persons with symptoms related to mild traumatic brain injuries. The status after approximately 3 weeks is indicative of the status after 10 years.

Traumatic brain injury in children between 7-12 years of age.

OBJECTIVE: The purpose of this study was to describe the amount of traumatic brain injuries among children in the western part of Sweden. METHODS: Based on a randomized controlled study, a retrospective analysis was conducted of data for children of 257 children 7-12 years of age. The journals were collected from 1997-2000. RESULTS: The results showed that the most common causes were play and sports and that the accidents occurred in the school environment in the afternoon, whilst the least amount of accidents took place in the home. Nearly half of all the children were admitted to the hospital. Most accidents occurred in March and the least number of accidents occurred during the summer months. CONCLUSION: Prevention strategies are needed, especially for play and sport activities in recreation centres and playgrounds. These places are a high risk in causing a TBI for children after a day at school.

Are auricular maps reliable for chronic musculoskeletal pain disorders? A double-blind evaluation.

AIM: To examine the proposed somatotopic relation between the regions in which patients report musculoskeletal pain and tender points located on the external ears according to a map based on commonly used auricular acupuncture maps. METHODS: Twenty-five patients (16 women) from a chronic pain clinic were included. Patients were asked, before examination of the external ears, if they had past or present musculoskeletal pain in any of 11 body regions. An ear map, collapsed into 11 zones representing the musculoskeletal system, was used. The ear examiner was blinded to the patients' pain conditions, medical history and ongoing treatment. Patients communicated with the examiner only to express if tenderness was present in the external ear on palpation using a spring-loaded pressure stylus commonly used for auricular acupuncture. The degree of tenderness was registered on a 5-point scale and dichotomised (no tenderness or tenderness). Agreements between the patients' painful body regions and tenderness in the external ear zones were presented as percentage, kappa values, sensitivity and specificity. RESULTS: The 25 patients reported 116 past or present musculoskeletal pain regions and had 110 tender ear zones. No statistically significant agreements were found between the painful body regions and the corresponding tender ear zones. CONCLUSIONS: Our results did not show agreements between patients' reported musculoskeletal pain regions and tender zones in the external ears assessed according to commonly used maps in auricular acupuncture using a pressure stylus. However, very tender points occur on the external ear in a population with chronic musculoskeletal pain.

The new Swedish Post-Concussion Symptoms questionnaire: a measure of symptoms after mild traumatic brain injury and its concurrent validity and inter-rater reliability.

OBJECTIVE: To study the concurrent validity and the inter-rater reliability of the Post-Concussion Symptoms Questionnaire. DESIGN: The approach was to study the concurrent validity of the Post-Concussion Symptoms Questionnaire when used as an interview questionnaire compared with a self-report questionnaire administered by the patients. The inter-rater reliability was also studied when 2 different raters administered the Post-Concussion Symptoms Questionnaire interview. PATIENTS: Thirty-five patients with mild traumatic brain injury were consecutively contacted by telephone and asked whether they would be willing to participate in a follow-up intervention. METHODS: The Post-Concussion Symptoms Questionnaire was completed by the patients, who answered "Yes" or "No" to the standardized questions. The patients were then interviewed to check the certain "Yes" or "No" answers, 0-10 days after having completed the first Post-Concussion Symptoms Questionnaire. The raters filled in their ratings independently. RESULTS: The concurrent validity of answers in the questionnaire compared with those in the interview ranged from 82% to 100% agreement. The inter-rater reliability results ranged from 93% to 100% agreement between the raters. CONCLUSION: The Post-Concussion Symptoms Questionnaire with answers of "Yes" or "No" is a valid instrument. High reliability was found between the raters.

Vertebrate neurogenesis is counteracted by Sox1-3 activity.

The generation of neurons from stem cells involves the activity of proneural basic helix-loop-helix (bHLH) proteins, but the mechanism by which these proteins irreversibly commit stem cells to neuronal differentiation is not known. Here we report that expression of the transcription factors Sox1, Sox2 and Sox3 (Sox1-3) is a critical determinant of neurogenesis. Using chick in ovo electroporation, we found that Sox1-3 transcription factors keep neural cells undifferentiated by counteracting the activity of proneural proteins. Conversely, the capacity of proneural bHLH proteins to direct neuronal differentiation critically depends on their ability to suppress Sox1-3 expression in CNS progenitors. These data suggest that the generation of neurons from stem cells depends on the inhibition of Sox1-3 expression by proneural proteins.