Absence of insight as a catch-all extra-legislative factor in Swedish mental health law proceedings.

Previous research indicates that insight is frequently used but rarely defined in mental health proceedings. This article examines how participants in Swedish administrative court proceedings use the concept of insight when discussing decisions regarding involuntary psychiatric care. Open-ended qualitative interviews were conducted with professional mental health court participants. The results show that lack of insight is used by the informants as an argument for all three legal criteria for involuntary psychiatric care in Sweden, as well as the criterion for release from forensic psychiatric care. It is concluded that there are troublesome legal and ethical implications of courts relying on a poorly defined concept such as insight in their rulings.

Anxiety and depression in adults with cystic fibrosis: a comparison between patients and the general population in Sweden and three other European countries.

BACKGROUND: Cystic fibrosis (CF) is the most common autosomal recessive life-shortening disease among Caucasians. Studies exploring the prevalence of anxiety and depression in adult CF patients are few, show inconsistent findings and rarely include comparisons with general populations. Prevalence and degree of anxiety and depression were investigated in adult CF patients in Sweden, Belgium, Germany and the UK, and compared to corresponding general population data. METHODS: Adult non-transplanted CF patients from the three largest CF-centres (out of four) in Sweden (N = 129; Age range 18-70 years; 50 % women) completed the Hospital Anxiety and Depression Scale (HADS). Studies using HADS in adult CF populations in the UK, Germany, and Belgium were included, as well as HADS normative data from the corresponding general populations. RESULTS: No elevated risk for anxiety and depression was found among the CF patients. However, a Country x Group interaction effect emerged; CF patients experienced a higher degree of anxiety than the general population in Sweden, but not in the other countries, though this finding did not remain significant in a logistic regression analysis. In Sweden the effect was limited to women. A Country x Group interaction effect was also found for Depression; CF patients experienced lower degree of depression than the general population in Sweden, Germany and the UK, but not in Belgium/Netherlands. CONCLUSIONS: Contrary to earlier outcomes, the present results do not indicate any general elevated risk for anxiety and depression among CF patients. Anxiety was slightly higher in the Swedish CF population, compared to the general population; this finding was not seen in the other countries. Depression among CF patients was lower than or similar to that in the general populations in the studied countries.

Perinatal conditions related to growth restriction and inflammation are associated with an increased risk of bronchopulmonary dysplasia.

AIM: Bronchopulmonary dysplasia (BPD) is a frequent chronic lung disease in preterm infants, and we aimed to identify factors associated with this condition in infants with respiratory distress syndrome (RDS). METHODS: This case-control study, using national Swedish data, included 2255 preterm infants, born before 33 gestational weeks. The 667 BPD cases were oxygen dependent at 36 weeks' postmenstrual age, and the 1558 controls only had RDS. Comparisons included perinatal conditions and pharmacological treatments. Adjusted odds ratios with 95% confidence intervals were calculated in a conditional logistic regression model, with gestational age as the conditioning term. RESULTS: An increased risk of BPD was associated with prelabour preterm rupture of membranes of more than 1 week (3.35, 2.16-5.19), small for gestational age (2.73, 2.11-3.55), low Apgar score (1.37, 1.05-1.81), patent ductus arteriosus (1.70, 1.33-2.18), persistent pulmonary hypertension (5.80, 3.21-10.50), pulmonary interstitial emphysema (2.78, 1.37-5.64), pneumothorax (2.95, 1.85-4.72), late onset infections (2.69, 1.82-3.98), intubation (1.56, 1.20-2.03), chest compressions (2.05, 1.15-3.66) and mechanical ventilation (2.16, 1.69-2.77), but not antenatal corticosteroids. CONCLUSION: Growth restriction and inflammation increased the risk of BPD in preterm infants and prelabour preterm rupture of membranes, small for gestational age, low Apgar score or need for resuscitation should raise clinical suspicions.

Organizing implementation in healthcare: Balancing orders of worth.

In this paper we direct attention to unavoidable conflicts between disparate value systems co-existing within organizations. Drawing on John Law's concept of ordering and Boltanski and Thévenot's orders of worth, we understand incompatibilities inherent in implementation and governance as competing orders. In extracting and articulating competing orders from our abductive analysis of semi-structured interviews with primary care managers (n = 32) in a Swedish county council, we hope to enable actors to utilise and address them as they engage in implementation work. The potential of such an approach is exemplified by analysing a regional case of health promotion implementation pursued in 2019, in a Swedish county council. Early approaches to implementation and governance have entailed linear models emphasizing program fidelity. Critics have broadened this view by calling for optimization of multiple values and more room for professional judgment. We seek to add to this development by attending to how healthcare practices often entail different and at times conflicting configurations of patients, professionals and priorities. The county council in our case study attempted to steer primary care providers towards health promotion work. To capture the realities of the organization that primary care managers described, we propose that three competing orders can be discerned in primary care: the order of immediate care, focusing on professional judgments of the most pressing needs of patients; the order of accessible care, in which patients themselves define what needs should be cared for; and the order of future health emphasizing prevention of health in the future population. Each order enacts a specific prioritization between patients and a vision of what is or should be primary in primary care. Organizing implementation, we suggest, requires a balancing of orders of worth.

Health consequences of prophylactic exposure to antenatal corticosteroids among children born late preterm or term.

OBJECTIVE: To investigate the duration of effects and health consequences of earlier antenatal corticosteroid exposure in infants born late preterm or term. DESIGN: Observational cohort study. SETTING: Children born after gestational week 34 in Sweden, 1976-1997, whose mothers were hospitalized for imminent preterm delivery. The children were followed to their 11th birthday. SAMPLE: The cohort consisted of 11 873 infants, of whom 8620 were exposed. METHODS: Exposure was estimated at hospital level. Infants born at a hospital practicing antenatal corticosteroid administration were classified as exposed. Estimation of hospital routines was based on questionnaire data, telephone interviews with physicians and pharmacy sales, validated in a random sample of medical records. Logistic regression was used to assess associations with adjustments for pregnancy length, birth year and hospital level. MAIN OUTCOME MEASURES: Rates and odds ratios of mortality, respiratory distress syndrome, bronchopulmonary dysplasia, epilepsy, cerebral palsy, childhood diabetes, birthweight, length and head circumference for all infants, and for preterm and term infants, respectively. RESULTS: Exposed infants had reduced risks of respiratory distress syndrome (odds ratio 0.54, 95% confidence interval 0.35-0.83) and small head circumference (odds ratio 0.47, 95% confidence interval 0.36-0.61), and an increased risk of low Apgar scores (odds ratio 1.40, 95% confidence interval 1.01-1.94), most pronounced in infants born after gestational week 37. CONCLUSIONS: Infants born after gestational week 34 seem to benefit from earlier antenatal corticosteroid administration, with reduced risks of respiratory distress syndrome. However, the treatment was less beneficial for term infants, because they also had increased risk of low Apgar scores.

Short and long-term effects of antenatal corticosteroids assessed in a cohort of 7,827 children born preterm.

OBJECTIVE: To study the benefits of antenatal corticosteroids (ACS) in clinical settings and to evaluate the occurrence of long-term neuro-sensory effects such as epilepsy and cerebral palsy (CP). DESIGN: Observational population-based study including all births between gestational weeks 24 and 34 during 1976-1997 in Sweden. Exposure to ACS was evaluated at hospital level. Children were followed up to their ninth birthday. SAMPLE AND METHODS: Seven thousand eight hundred twenty-seven infants of which 5,632 were exposed to ACS. Data on hospital ACS routines was based on questionnaires and interviews with physicians and pharmacy sales. Outcomes were obtained from the national health registers and assessed according to gender of the child. Logistic regression was used to assess associations. MAIN OUTCOME MEASURES: Neonatal death, low Apgar score, respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), CP, and epilepsy. RESULTS: After adjustment, exposed infants had reduced risks of RDS (OR 0.80, 95% CI 0.70-0.92), late neonatal death (OR 0.86, 95% CI 0.57-1.29), BPD (OR 0.87, 95% CI 0.62-1.22), ROP (OR 0.80, 95% CI 0.48-1.32), IVH (OR 0.93, 95% CI 0.67-1.3), and CP (OR 0.82, 95% CI 0.58-1.15). Males had a higher risk of epilepsy (OR 1.74, 95% CI 0.85-3.55) than females (OR 0.50, 95% CI 0.25-1.03). CONCLUSION: The results confirm the beneficial effect of ACS regarding RDS in clinical settings. Except for a tendency to increased risk of epilepsy among male infants there were no increased risks of neuro-sensory outcomes.

Performance of a 70-mer oligonucleotide microarray for genotyping of Campylobacter jejuni.

BACKGROUND: Campylobacter jejuni is widespread in the environment and is the major cause of bacterial gastroenteritis in humans. In the present study we use microarray-based comparative genomic hybridizations (CGH), pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) to analyze closely related C. jejuni isolates from chicken and human infection. RESULTS: With the exception of one isolate, the microarray data clusters the isolates according to the five groups determined by PFGE. In contrast, MLST defines only three genotypes among the isolates, indicating a lower resolution. All methods show that there is no inherit difference between isolates infecting humans and chicken, suggesting a common underlying population of C. jejuni. We further identify regions that frequently differ between isolates, including both previously described and novel regions. Finally, we show that genes that belong to certain functional groups differ between isolates more often than expected by chance. CONCLUSION: In this study we demonstrated the utility of 70-mer oligonucleotide microarrays for genotyping of Campylobacter jejuni isolates, with resolution outperforming MLST.

Great expectations: The bureaucratic handling of Swedish residential rehabilitation in the 21st century.

BACKGROUND AND AIMS: Increasingly, efforts to counteract perceived problems in drug treatment at residential rehabilitation centres have come to rely on measures drawing on evidence-based practice (EBP). However, the Swedish media, government inquiries, and international research have identified a number of problems regarding both residential rehabilitation and EBP. This suggests that caution should be exercised when placing expectations on EBP. The aim of this study is to investigate how the responsible authorities have handled increasing demands for EBP with administrative control while facing critical evaluations of their steering and implementation efforts. The study examines the maturation of a widespread treatment ideology, which aims to be based on evidence, in a country known for its restrictive drug policy and its goal of becoming a drug-free society. METHODS: Through a qualitative textual analysis of 17 years (2000-2016) of inquiries, directives, and authority archives we have traced the interplay between problem descriptions, intended goals, and implemented solutions. FINDINGS: The analysis shows that the ambition to provide care and welfare based on EBP is still an ambition. Also, the authorities' control over the care actually provided still leaves room for improvement. Recurring criticism and the empirical material indicate that the expectations have not been met. CONCLUSIONS: We would like to suggest that continued frustration can be traced to the misconception that EBP is the opposite of values and ideology, and hence preferable. As drug treatment strives for scientific credibility to give it legitimacy, some types of "evidence" are preferred above others. We would like to suggest that we need to bring ideology to the fore, and openly discuss our restrictive policy goals and choices of "evidence".

Potential for hydrogen-oxidizing chemolithoautotrophic and diazotrophic populations to initiate biofilm formation in oligotrophic, deep terrestrial subsurface waters.

BACKGROUND: Deep terrestrial biosphere waters are separated from the light-driven surface by the time required to percolate to the subsurface. Despite biofilms being the dominant form of microbial life in many natural environments, they have received little attention in the oligotrophic and anaerobic waters found in deep bedrock fractures. This study is the first to use community DNA sequencing to describe biofilm formation under in situ conditions in the deep terrestrial biosphere. RESULTS: In this study, flow cells were attached to boreholes containing either "modern marine" or "old saline" waters of different origin and degree of isolation from the light-driven surface of the earth. Using 16S rRNA gene sequencing, we showed that planktonic and attached populations were dissimilar while gene frequencies in the metagenomes suggested that hydrogen-fed, carbon dioxide- and nitrogen-fixing populations were responsible for biofilm formation across the two aquifers. Metagenome analyses further suggested that only a subset of the populations were able to attach and produce an extracellular polysaccharide matrix. Initial biofilm formation is thus likely to be mediated by a few bacterial populations which were similar to Epsilonproteobacteria, Deltaproteobacteria, Betaproteobacteria, Verrucomicrobia, and unclassified bacteria. CONCLUSIONS: Populations potentially capable of attaching to a surface and to produce extracellular polysaccharide matrix for attachment were identified in the terrestrial deep biosphere. Our results suggest that the biofilm populations were taxonomically distinct from the planktonic community and were enriched in populations with a chemolithoautotrophic and diazotrophic metabolism coupling hydrogen oxidation to energy conservation under oligotrophic conditions.

Associations between genetics, medical status, physical exercise and psychological well-being in adults with cystic fibrosis.

BACKGROUND: Cystic fibrosis (CF) is the most common autosomal recessive, life-shortening disease among people of European origin. Type of genetic mutation and regular physical exercise has an impact on clinical outcome. This cross-sectional study explores the associations between genetics, medical status, physical exercise and psychological well-being in adult patients with CF. METHODS: Adult patients with CF (N=68; mean age: 32.2; range 18-67 years; 46% women) completed the Cystic Fibrosis Questionnaire-Revised and Hospital Anxiety Depression Scale. Measures about lung function/forced expiratory volume in 1 s per cent predicted, body mass index, physical working capacity, immunoglobulin G, CF Transmembrane Conductance Regulator (CFTR) mutations, and physical exercise were obtained. structural equation modelling was used to fit models to data. RESULTS: A cftr gene mutation×age interaction effect indicates a psychological disadvantage increasing with age of having more severe CFTR mutations; >65% of the effect is mediated by medical status. Physical exercise has a positive effect on psychological well-being, but >75% of the effect is mediated by medical status. CONCLUSIONS: Psychological well-being decreases with age in patients with more severe cftr mutations, to a large extent due to a parallel deterioration of medical status. Physical exercise has a positive effect on psychological well-being if resulting in better health only. To manage the complexity of these patients' needs, the CF-care should emphasise a holistic approach and offer individualised exercise/treatment programmes and psychological competence.

Prenatal inflammatory risk factors for development of bronchopulmonary dysplasia.

BACKGROUND: Bronchopulmonary dysplasia (BPD) is a serious, chronic lung disease affecting preterm infants. OBJECTIVE: To identify prenatal risk factors for BPD, focusing on inflammation. METHODS: Observational cohort study including 106,339 preterm infants, live born before gestational week 37 + 0, from 1988 to 2009 in Sweden. A total of 2,115 infants were diagnosed with BPD, of which 1,393 were born extremely preterm, before gestational week 28 + 0. Information on risk factors was obtained from national health registers and included maternal chronic inflammatory diseases, pregnancy related diseases, and drugs related to treatment of inflammation or infection during pregnancy. Adjusted odds ratios (OR) were calculated in multivariable logistic regression models and are presented with 95% confidence intervals [95% CI]. RESULTS: Preeclampsia was the strongest risk factor for BPD [adjusted OR 2.04, 95% CI 1.83, 2.29]. For extremely preterm infants the adjusted OR was 1.33 [95% CI 1.08, 1.64]. Chorioamnionitis was associated with an increased risk of BPD, but only when including all infants in the analyses [OR 1.33, 95% CI 1.19, 1.48]. No apparent associations were found between maternal chronic inflammatory disease or use of anti-inflammatory drugs and the risk of BPD. Maternal diabetes mellitus, gestational diabetes and maternal use of antibiotics were associated with reduced risks of BPD. CONCLUSION: Preeclampsia related disorders increased the risk and maternal diabetes mellitus and gestational diabetes reduced the risk for BPD. As angiogenic factors play a role in preeclampsia and diabetes our findings suggest that an impaired angiogenesis may contribute to BPD development.

The prevalence of the duodenal ulcer promoting gene (dupA) in Helicobacter pylori isolates varies by ethnic group and is not universally associated with disease development: a case-control study.

BACKGROUND: The putative H. pylori pathogenicity-associated factor dupA has been associated with IL-8 induction in vitro, and duodenal ulcer (DU) and gastric cancer (GC) development in certain populations, but this association is inconsistent between studies. We aimed to investigate dupA prevalence in clinical isolates from Sweden, Australia and from ethnic Chinese, Indians and Malays resident in Malaysia and Singapore and to examine the association with DU and GC. In addition we investigated the sequence diversity between isolates from these diverse groups and compared the level of IL-8 secretion in isolates possessing and lacking dupA. METHODS: PCR primers were designed to amplify over the C/T insertion denoting a continuous dupA. PCR products from 29 clinical isolates were sequenced and compared with sequences from three additional strains obtained from GenBank. Clinical isolates from 21 Malaysian patients (8 dupA-positive, 14 dupA-negative) were assessed for their ability to induce IL-8 in AGS cells in vitro. Statistical analysis was performed using Fisher's exact test. RESULTS: The prevalence of dupA in isolates from Swedish functional dyspepsia (FD) control patients (65%, 13/20) was higher and in isolates from Indian FD patients (7.1%, 3/42) was lower as compared with isolates from Chinese (28.9%, 13/49, P = 0.005, P = 0.025), Malay (35.7%, 5/14, P = 0.16, P = 0.018) and Australian (37.8%, 17/45, P = 0.060, P < 0.001) FD patients. dupA was associated with DU and GC development in Chinese with 62.5% (10/16) and 54.6% (12/22) of isolates possessing dupA respectively as compared with FD controls (28.9%) (P = 0.015, P = 0.032). No significant difference in prevalence of dupA between FD controls, DU (63.6%, 7/11) and GC (61.9%, 13/21) cases (P = 1.000) was observed in the Swedish population. Sequence analysis revealed a pairwise variation of 1.9% and all isolates possessed the C/T insertion. The average IL-8 induction was 1330 pg/mL for dupA-positive isolates and 1378 pg/mL for dupA-negative isolates. CONCLUSION: Although dupA is highly conserved when present, we identified no consistent association between dupA and DU or GC development across the ethnic groups investigated, with the dupA prevalence in control groups varying significantly. Our results would suggest that in the clinical isolates investigated dupA is not associated with IL-8 induction in vitro.

Correlation between cag pathogenicity island composition and Helicobacter pylori-associated gastroduodenal disease.

Helicobacter pylori infection is associated with a variety of outcomes ranging from seemingly asymptomatic coexistence to peptic ulcer disease and gastric cancer. The cag pathogenicity island (PAI) contains genes associated with a more aggressive phenotype and has been suggested to be a determinant of severe disease outcome. The cagA gene has served as a marker for the cag PAI. However, the presence of this single gene does not necessarily indicate the presence of a complete set of cag PAI genes. We have analyzed the composition of the cag PAI in 66 clinical isolates obtained from patients with duodenal ulcer, gastric cancer, and nonulcer dyspepsia. Hybridization of DNA to microarrays containing all the genes of the cag PAI showed that 76 and 9% of the strains contained all or none of the cag PAI genes, respectively. Partial deletions of the cag PAI were found in 10 isolates (15%), of which 3 were cagA negative. The ability to induce interleukin-8 (IL-8) production in AGS cells was correlated to the presence of a complete cag PAI. Strains carrying only parts of the island induced IL-8 at levels significantly lower than those induced by cag PAI-positive isolates. The presence of an intact cag PAI correlates with development of more severe pathology, and such strains were found more frequently in patients with severe gastroduodenal disease (odds ratio, 5.13; 95% confidence interval, 1.5 to 17.4). Partial deletions of the cag PAI appear to be sufficient to render the organism less pathogenic.