MyCompass in a Swedish context - lessons learned from the transfer of a self-guided intervention targeting mental health problems.

BACKGROUND: Depression and anxiety is a major public health problem, in Sweden and internationally. Internet-based interventions are increasingly acknowledged as promising approaches for individuals with varying degrees of mental health problems. We present findings from the implementation of myCompass, a fully automated self-guided intervention of Australian origin, in a Swedish context. METHODS: We (i) share our experience of the E-health study platform (i.e., regarding security aspects, functionality) to which the myCompass intervention was linked, and (ii) report findings from the empirical evaluation of myCompass (i.e., prerequisites, execution, study outcomes), in a community sample of individuals (N = 837) reporting mild-to-moderate levels of depression, anxiety and stress. Outcomes were calculated with repeated measures ANOVA and linear mixed models. RESULTS: The E-health study platform proved to be an efficient tool enabling randomization, informed consent and evaluation to be administered in a fully automated manner. The study rendered substantial interest initially with 1207 individuals enrolling, however it failed to maintain engagement of those enrolled with only few participants logging in more than once or twice following registration. A smaller subgroup of "active users" (n = 35) had a markedly higher activity in the program, however their treatment results were not significantly better than those of the control group. CONCLUSION: Based on the large number of dropouts and also modest use of the intervention overall, only tentative speculations can be made regarding its effectiveness in a Swedish context. The number of individuals remaining active in the intervention is much more limited that the number of individuals initially signing up. Moreover, the transportation of interventions across countries and cultures may need more careful consideration, and pilot-trials before attempting large-scale trials are recommended. TRIAL REGISTRATION: MyCompass was retrospectively registered at ClinicalTrials.gov . NCT03659630 September 3rd 2018, and was given the protocol ID 2015/1268-31/2 + 2016/88.

Prospective Evaluation of Health After Breast Reduction Surgery Using the Breast-Q, Short-Form 36, Breast-Related Symptoms Questionnaire, and Modified Breast Evaluation Questionnaire.

INTRODUCTION: Breast hypertrophy is a condition associated with physical, psychological, and psychosocial problems. The primary aims of this study were to determine the impact of breast hypertrophy and the effects of breast reduction, performed on the basis of well-described inclusion criteria, on general and breast-related health, using both general and diagnosis-specific validated questionnaires. We used a prospective, longitudinal paired study design. A secondary aim was to analyze the relationship between preoperative breast volume, body mass index, sternal notch-to-nipple distance and the weight of resected tissue on the one hand and improvements in health on the other. METHODS: Three hundred forty-eight consecutive patients undergoing breast reduction were included and the Short-Form 36 (SF-36), Breast-Related Symptoms Questionnaire (BRSQ), Modified Breast Evaluation Questionnaire (mBEQ) and BREAST-Q were distributed preoperatively and 1 year postoperatively. RESULTS: A total of 284 (83%) patients answered the questionnaires either preoperatively or postoperatively, or both, and 159 (46%) patients answered both. The breast hypertrophy patients had significantly lower scores preoperatively than the matched normal population when it came to all dimensions of the SF-36 and mBEQ. The preoperative scores for both the BRSQ and BREAST-Q were low.After breast reduction, there were significant improvements in all dimensions of the BRSQ, mBEQ, and Breast-Q and in several dimensions of the SF-36. CONCLUSIONS: Breast reduction reduces or removes disease-associated pain. It improves or normalizes perceived health and psychosocial self-esteem in slightly obese women or women of normal weight with preoperative breast volumes around 1000 mL. Women with higher preoperative breast volumes and longer sternal notch-to-nipple distances appear to be more satisfied with the cosmetic result postoperatively.

A randomized prospective study of prophylactic cloxacillin in breast reduction surgery.

BACKGROUND: Postoperative infection after breast reduction surgery is a common complication, with the most commonly involved pathogen being Staphylococcus aureus. Previous studies of antibiotic prophylaxis in breast reduction surgery have been inconclusive. The aim of the present study was to clarify the role of prophylactic antibiotics in breast reduction surgery. METHODS: In total, 325 women were randomized to antibiotic prophylaxis [with 2 g of cloxacillin intravenously (IV) or 600 mg of clindamycin IV] (intervention group) or no antibiotic prophylaxis (control group). Follow-up was conducted at 1 and 2 weeks postoperatively. Patients with signs of infections or other complications were followed up until resolution. Patients who received antibiotic treatment within 30 days from surgery (cloxacillin 750 mg or clindamycin 300 mg orally) were considered having an infection and this was the main outcome variable. All postoperative infections were also judged according to a graded scale. RESULTS: In the intervention group, 26 (16.0%) patients were treated with antibiotic; and in the control group, 32 (19.6%) patients were treated with antibiotics. No difference was found between the groups (relative risk, 0.82; 95% confidence interval, 0.51-1.31; P = 0.49). Twenty-two (14%) patients in the intervention group were classified to have a possible infection according to the scale compared to 27 (17%) in the control group. No statistical difference was found (relative risk, 0.81; 95% confidence interval, 0.48-1.37; P = 0.54). CONCLUSIONS: Prophylactic cloxacillin as a single-dose IV in breast reduction surgery does not reduce the incidence of postoperative infections.

When is the deep inferior epigastric artery flap indicated for breast reconstruction in patients not treated with radiotherapy?

BACKGROUND: It is controversial whether breast reconstruction with a microvascular free flap should be done without restrictions in patients who have not had radiotherapy. Many regard it as too expensive, but some consider it better and more economically advantageous than an implant reconstruction. METHODS: Databases of publications were searched to find out under what conditions is it suitable to offer a deep inferior epigastric perforator (DIEP) or a transverse rectus abdominis myocutaneous flap to normalize the body's appearance in a woman whose breast(s) had been removed for cancer or to prevent the development of breast cancer. The effect of breast reconstruction with DIEP flaps was analyzed, taking account of the following factors: general satisfaction (quality of life), aesthetic satisfaction (cosmesis), and morbidity. To find out which factors were of potential importance, we recorded age, hypertension, whether scars from previous abdominal surgery were present, microcirculation, whether the patient was overweight or obese, and costs of the procedure. RESULTS: Patients planning to have DIEP flaps should be willing to stop smoking at least 4 weeks before and after the procedure and have a body mass index of less than 30 kg/m to avoid a higher risk of complications. Because of the paucity of papers, it is difficult to recommend one approach over the other when considering general satisfaction, aesthetic satisfaction, and health economics. However, economical long-term outcome is highly dependent on the initial costs of each procedure and the cumulative costs of complications for each reconstruction method. CONCLUSIONS: The scientific foundation of assessment of methods of techniques of breast reconstruction is weak. Therefore, it is important that future studies should present more comparable series, highlight the long-term effects in high-quality studies, to provide the patients with optimal results without undue risks and to avoid financial burdens on society.

Establishing conversation spaces in hastily formed networks: the worst fire in modern Swedish history.

In presenting examples from the most extensive and demanding fire in modern Swedish history, this paper describes challenges facing hastily formed networks in exceptional situations. Two concepts that have been used in the analysis of the socio-technical systems that make up a response are conversation space and sensemaking. This paper argues that a framework designed to promote understanding of the sensemaking process must take into consideration the time and the location at which an individual is engaged in an event. In hastily formed networks, location is partly mediated through physical systems that form conversation spaces of players and their interaction practices. This paper identifies and discusses four challenges to the formation of shared conversation spaces. It is based on the case study of the 2006 Bodträskfors forest fire in Sweden and draws on the experiences of organised volunteers and firefighters who participated in a hastily formed network created to combat the fire.

UTM City-Visualization of Unmanned Aerial Vehicles.

In this article, we present a digital platform for unmanned traffic management, UTM City, for research on visualization, simulation, and management of autonomous urban vehicle traffic. Such vehicles orient themselves automatically and provide services ranging from transport to remote presence and surveillance, and new regulations and standards for authorization and monitoring are currently being developed to accommodate for such services. Our system has been developed in close collaboration with domain experts that have contributed with scenarios and participated in numerous workshops to explore the use of visualization in airborne drone traffic monitoring, management, and development of the air space. We share here our experiences with this system and explore the need for visualization in future scenarios to ensure safe, free, and efficient air spaces.

Bilateral prophylactic mastectomy in Swedish women at high risk of breast cancer: a national survey.

BACKGROUND/OBJECTIVE: This study attempted a national inventory of all bilateral prophylactic mastectomies performed in Sweden between 1995 and 2005 in high-risk women without a previous breast malignancy. The primary aim was to investigate the breast cancer incidence after surgery. Secondary aims were to describe the preoperative risk assessment, operation techniques, complications, histopathological findings, and regional differences. METHODS: Geneticists, oncologists and surgeons performing prophylactic breast surgery were asked to identify all women eligible for inclusion in their region. The medical records were reviewed in each region and the data were analyzed centrally. The BOADICEA risk assessment model was used to calculate the number of expected/prevented breast cancers during the follow-up period. RESULTS: A total of 223 women operated on in 8 hospitals were identified. During a mean follow-up of 6.6 years, no primary breast cancer was observed compared with 12 expected cases. However, 1 woman succumbed 9 years post mastectomy to widespread adenocarcinoma of uncertain origin. Median age at operation was 40 years. A total of 58% were BRCA1/2 mutation carriers. All but 3 women underwent breast reconstruction, 208 with implants and 12 with autologous tissue. Four small, unifocal, invasive cancers and 4 ductal carcinoma in situ were found in the mastectomy specimens. The incidence of nonbreast related complications was low (3%). Implant loss due to infection/necrosis occurred in 21 women (10%) but a majority received a new implant later. In total, 64% of the women underwent at least 1unanticipated secondary operation. CONCLUSIONS: Bilateral prophylactic mastectomy is safe and efficacious in reducing future breast cancer in asymptomatic women at high risk. Unanticipated reoperations are common. Given the small number of patients centralization seems justified.

Human Autonomy in Future Drone Traffic: Joint Human-AI Control in Temporal Cognitive Work.

The roles of human operators are changing due to increased intelligence and autonomy of computer systems. Humans will interact with systems at a more overarching level or only in specific situations. This involves learning new practices and changing habitual ways of thinking and acting, including reconsidering human autonomy in relation to autonomous systems. This paper describes a design case of a future autonomous management system for drone traffic in cities in a key scenario we call The Computer in Brussels. Our approach to designing for human collaboration with autonomous systems builds on scenario-based design and cognitive work analysis facilitated by computer simulations. We use a temporal method, called the Joint Control Framework to describe human and automated work in an abstraction hierarchy labeled Levels of Autonomy in Cognitive Control. We use the Score notation to analyze patterns of temporal developments that span levels of the abstraction hierarchy and discuss implications for human-automation communication in traffic management. We discuss how autonomy at a lower level can prevent autonomy on higher levels, and vice versa. We also discuss the temporal nature of autonomy in minute-to-minute operative work. Our conclusion is that human autonomy in relation to autonomous systems is based on fundamental trade-offs between technological opportunities to automate and values of what human actors find meaningful.

Size Matters: Digital Social Networks and Language Change.

Social networks play a role in language variation and change, and the social network theory has offered a powerful tool in modeling innovation diffusion. Networks are characterized by ties of varying strength which influence how novel information is accessed. It is widely held that weak-ties promote change, whereas strong ties lead to norm-enforcing communities that resist change. However, the model is primarily suited to investigate small ego networks, and its predictive power remains to be tested in large digital networks of mobile individuals. This article revisits the social network model in sociolinguistics and investigates network size as a crucial component in the theory. We specifically concentrate on whether the distinction between weak and strong ties levels in large networks over 100 nodes. The article presents two computational methods that can handle large and messy social media data and render them usable for analyzing networks, thus expanding the empirical and methodological basis from small-scale ethnographic observations. The first method aims to uncover broad quantitative patterns in data and utilizes a cohort-based approach to network size. The second is an algorithm-based approach that uses mutual interaction parameters on Twitter. Our results gained from both methods suggest that network size plays a role, and that the distinction between weak ties and slightly stronger ties levels out once the network size grows beyond roughly 120 nodes. This finding is closely similar to the findings in other fields of the study of social networks and calls for new research avenues in computational sociolinguistics.

Extension or combination of an autologous latissimus dorsi flap in breast reconstruction.

The lateral thoracodorsal flap and the pedicled latissimus dorsi flap have been extensively described for breast reconstruction. In search of an alternative, non-microsurgical, autologous method of breast reconstruction we used both flaps combined to achieve adequate volume. The technique was used on three patients who had had a mastectomy at least two years previously. All flaps healed uneventfully with the appearance of an ordinary latissimus dorsi breast reconstruction. The method shows promising initial results and can be used as an alternative when reconstruction with autologous tissue is preferred.

Validation of the breast evaluation questionnaire for breast hypertrophy and breast reduction.

Background: There is a lack of published, validated questionnaires for evaluating psychosocial morbidity in patients with breast hypertrophy undergoing breast reduction surgery. Aim: To validate the breast evaluation questionnaire (BEQ), originally developed for the assessment of breast augmentation patients, for the assessment of psychosocial morbidity in patients with breast hypertrophy undergoing breast reduction surgery. Study design: Validation study Subjects: Women with macromastia Methods: The validation of the BEQ, adapted to breast reduction, was performed in several steps. Content validity, reliability, construct validity and responsiveness were assessed. Results: The original version was adjusted according to the results for content validity and resulted in item reduction and a modified BEQ (mBEQ) that was then assessed for reliability, construct validity and responsiveness. Internal and external validation was performed for the modified BEQ. Convergent validity was tested against Breast-Q (reduction) and discriminate validity was tested against the SF-36. Known-groups validation revealed significant differences between the normal population and patients undergoing breast reduction surgery. The BEQ showed good reliability by test-re-test analysis and high responsiveness. Conclusion: The modified BEQ may be reliable, valid and responsive instrument for assessing women who undergo breast reduction.

Avoidance of complications after the use of deep inferior epigastric perforator flaps for reconstruction of the breast.

We assessed 50 consecutive unilateral deep inferior epigastric perforator (DIEP) flaps for breast reconstruction to find out our morbidity and how to avoid it. We routinely dissected the superficial epigastric vein bilaterally and perforators ipsilaterally. If there were insufficient perforators on the ipsilateral side, we then dissected the contralateral side. We made an additional anastomosis to the superficial epigastric vein in cases of venous congestion after reperfusion that could threaten flap survival. One perforator was used on 31 occasions, and the contralateral side was dissected in 16. A prophylactic anastomosis of superficial epigastric vein was done in 3. No flap was lost completely but 5 partially necrosed. A comparison of the first 25 and the second 25 flaps showed more dissections of the contralateral side and more prophylactic anastomoses of the superficial epigastric vein in the second 25. Partial necrosis was less common in the second 25. We suggest that more liberal dissection of the contralateral side and the prophylactic anastomosis of the superficial epigastric vein to lower morbidity and give better cosmetic results.

A retrospective review of the incidence of various complications in different delayed breast reconstruction methods.

BACKGROUND: Breast reconstruction is a common standard procedure in many centres after breast cancer surgery. The aim of the present study was to investigate and compare the incidence of various complications in different reconstruction methods. METHOD: Six hundred and eighty-five patients were retrospectively classified into five groups: (1) Deep inferior epigastric perforator flap (DIEP), (2) latissimus dorsi flap (LD), (3) lateral thoracodorsal flap (LTDF), (4) expander with secondary implant (EXP), and (5) direct implant (DI). Demographic and perioperative data, the incidence of complications, and follow-up data were collected. RESULTS: There was a significant difference between groups regarding overall early complications (p < 0.001). The DIEP group had the highest incidence of overall complications (50.0%) (p < 0.05). DIEP also had the highest incidence of fat necrosis (18.3%), skin necrosis (22.1%), and incidence of reoperation for complications (26.9%) compared to the other reconstruction methods. In the entire group of patients, the overall incidence of late complications (occurring >30 days after surgery) that needed surgical corrections was 54.7%. The incidence of late complications was 46.2% for DIEP, 66.4% for LD, 74.8% for LTDF, 44.9% for EXP, and 62.9% for DI. The DIEP group had higher incidences of late local complications (fat necrosis, skin necrosis, haematoma, seroma, and wound rupture combined), and scars requiring treatment than the other reconstruction methods. CONCLUSION: Meticulous registration of incidence of different complications in five different breast reconstruction methods revealed high complication rates with all methods. The differences in incidence of complications were related to the operation method used. Based on these results, careful individual planning of a breast reconstruction is mandatory.

The one-person randomized controlled trial.

Currently, the gold standard for collection of clinical evidence is the randomized controlled trial (RCT), preferably with large, multicenter samples of subjects. Although this approach provides valuable information, many clinicians find it difficult to translate RCT results to the individual patient level. In this report, a statistical approach called Design of Experiments (DOE) is described as a method of applying the principles of RCTs one person at a time. An overview of the method, with a simple clinical example, is presented. As shown, DOE is a more efficient method than the sequential approach often taken by clinicians and their patients when evaluating various treatment choices. Further, the effect of multiple interventions can be assessed, alone or in combination with each other. In this way, DOE can be an important addition to the field of evidence-based medicine, although further studies are needed.

Preservation of rat skeletal muscle energy metabolism by illumination.

Skeletal muscle viability is crucially dependent on the tissue levels of its high energy phosphates. In this study we investigated the effect of the preservation medium Perfadex and illumination with Singlet Oxygen Energy (SOE). Singlet oxygen can be produced photochemically by energy transfer from an excited photosensitizer. The energy emitted from singlet oxygen upon relaxation to its triplet state is captured as photons at 634 nm and is here referred to as SOE. Rat hind limb rectus femoris muscles were preserved for five hours at 22 degrees C in Perfadex, saline, SOE illuminated Perfadex or SOE illuminated saline. Extracts of the muscles were analysed by 31P NMR. Data were analysed using two-way analysis of variance and are given as mean values micromol/g dry weight) +/- SEM. The ATP concentration was higher (p = 0.006) in saline groups (4.52) compared with Perfadex groups (2.82). There was no statistically significant difference in PCr between the saline groups (1.25) and Perfadex groups (0.82). However, there were higher (p = 0.003) ATP in the SOE illuminated groups (4.61) compared with the non-illuminated groups (2.73). The PCr was also higher (p < 0.0001) in the SOE illuminated groups (1.89) compared with the non-illuminated groups (0.18). In conclusion, Perfadex in this experimental model was incapable of preserving the high energy phosphates in skeletal muscle during 5 hours of ischemia. Illumination with SOE at 634 nm improved the preservation potential, in terms of a positive effect on the energy status of the muscle cell.

Do women simply complain more? National patient injury claims data show gender and age differences.

The Swedish Counties Mutual Insurance (LOF) owns and operates the Swedish Patient Insurance Company, (PSR) a no-blame insurance system that compensates patients for injuries that result from errors in medical practice. We combined malpractice claims data (from PSR) with national hospital discharge registry data (National Board of Health and Welfare-Socialstyrelsen) and determined Swedish inpatient malpractice claims rates for the years 1996-2000. Women have higher claims rates than men, but their claims are adjudicated as valid more often than men's claims. The data are consistent with other lines of evidence suggesting poorer quality of care for women, e.g., heart disease, kidney disease, and cancer. Middle-aged (40- to 59-year-old) patients file malpractice claims at almost twice the national rate, whereas patients younger than 19 years and older than 80 years of age file at significantly below the average rate. Differences in claims rates have major financial and quality of care implications. Further studies are needed.

Do health care managers know the comparative quality of their care?

Compared with other industries, health care is a high-risk industry. In this study, two national data sets on patient claims and a survey of improvement efforts in Swedish health care were used to investigate the linkage between how health care managers perceive their performance regarding adverse medical events and their performance as reflected in patient malpractice claims rates. The departments' focus on patient safety issues in their improvement efforts was also evaluated. Our results show that Swedish health care department managers underestimate their departments' frequency of adverse medical events relative to that of similar units. Also, there is no correlation between the managers' perception of adverse medical events and their actual frequency of patient malpractice claims. More research is needed on the use of patient-generated malpractice claims and claims rates to promote a higher awareness of the magnitude of the safety problems in health care.

Energy metabolism during microsurgical transfer of human skeletal muscle assessed by high-pressure liquid chromatography and by 31P-nuclear magnetic resonance.

The effect of ischaemia and reperfusion on human skeletal muscle was studied during free vascularised muscle transfer. Muscle biopsy specimens were taken from patients having microsurgical muscle transfer, 18 cases (17 patients; 12 men, 5 women). The biopsies were taken three times: before transfer of the muscle (control), at maximum ischaemic time, and one hour after revascularisation. The biopsy specimens were analysed for purine nucleotides, by high-pressure liquid chromatography (HPLC), and by nuclear magnetic resonance (NMR) at 500 MHz. Phosphocreatine (PCr) recovered only partially (79%) and adenosine triphosphate (ATP) did not differ significantly from normal control after revascularisation and a mean ischaemic time of 114 minutes. NMR measurements showed an accumulation of glucose-6-phosphate (G-6-P) during the ischaemic period, indicating anaerobic metabolism. After three hours of ischaemia and one hour of reperfusion the PCr recovery was less than 60% (r = 0.7). The results confirm those of previous animal studies, which set three hours normothermic ischaemia as a safe limit for tissue preservation when transferring skeletal muscle. Longer ischaemic times may cause serious postoperative healing problems and reduced muscle function.

Risk factors for complications after breast reduction surgery.

Women who suffer from breast hypertrophy commonly have physical symptoms such as back pain and psychosocial problems. Breast reduction surgery is performed to relieve these problems. Side-effects must be kept to a minimum. Risk factors for developing postoperative complications have not clearly been identified so far. The aim of this study was to identify risk factors that lead to complications. The medical records of 512 consecutive women (mean age 40 years) who underwent bilateral breast reduction were retrospectively studied. All complications that occurred during the first 30 days after the operation were retrieved from medical records. Complications occurred in 32% of the patients within 30 days of surgery. The most common complication was infection at the surgical site (16%) followed by delayed wound healing (10%). Fat necrosis occurred in 2.5%, partial areola necrosis in 3.1%, and total areola necrosis in 0.6% of the patients. A longer suprasternal notch to nipple distance gave significantly higher risk of postoperative infection (p < 0.001) and necrosis in the mammilla (p < 0.001). The resected specimen weight during the operation was found to significantly influence the risk of delayed wound healing (p = 0.021) and fat necrosis (p < 0.001). Smokers had twice the risk of getting a postoperative infection, RR = 2.0 (95% CI = 1.3-3.1). Diabetics had a significantly higher risk of necrosis of the areola (p = 0.003). All the above predictors were identified as independent predictors. Complications after breast reduction are common. The study has identified several risk factors for complications, some of them independent, which might be avoidable by performing a careful preoperative evaluation of the patient.

Strategies for dealing with resistance to recommendations from accident investigations.

Accident investigation reports usually lead to a set of recommendations for change. These recommendations are, however, sometimes resisted for reasons such as various aspects of ethics and power. When accident investigators are aware of this, they use several strategies to overcome the resistance. This paper describes strategies for dealing with four different types of resistance to change. The strategies were derived from qualitative analysis of 25 interviews with Swedish accident investigators from seven application domains. The main contribution of the paper is a better understanding of effective strategies for achieving change associated with accident investigation.