Unveiling PET Hydrolase Surface Dynamics through Fluorescence Microscopy.

PET hydrolases are an emerging class of enzymes that are being heavily researched for their use in bioprocessing polyethylene terephthalate (PET). While work has been done in studying the binding of PET oligomers to the active site of these enzymes, the dynamics of PET hydrolases binding to a bulk PET surface is an unexplored area. Here, methods were developed for total internal reflection fluorescence (TIRF) microscopy and fluorescence recovery after photobleaching (FRAP) microscopy to study the adsorption and desorption dynamics of these proteins onto a PET surface. TIRF microscopy was employed to measure both on and off rates of two of the most commonly studied PET hydrolases, PHL7 and LCC, on a PET surface. It was found that these proteins have a much slower off rates on the order of 10-3  s-1 , comparable to non-productive binding in enzymes such as cellulose. In combination with FRAP microscopy, a dynamic model is proposed in which adsorption and desorption dominates over lateral diffusion over the surface. The results of this study could have implications for the future engineering of PET hydrolases, either to target them to a PET surface or to modulate interaction with their substrate.

#ReadyToplay: hamstring injuries in women's football - a two-season prospective cohort study in the Norwegian women's premier league.

In this two-season prospective cohort study (2020-2021), we aimed to describe the characteristics, clinical findings and magnetic resonance imaging (MRI) findings of hamstring injuries in the Norwegian women's premier league. Hamstring injuries were examined by team physiotherapists using a standardised clinical examination and injury form. Injury location and severity (modified Peetrons classification) were graded based on MRI by two independent radiologists. Fifty-three hamstring injuries were clinically examined, 31 of these with MRI. Hamstring injuries caused 8 days (median) lost from football (interquartile range: 3-15 days, range: 0-188 days), most were non-contact and occurred during sprinting. Gradual-onset (53%) and sudden-onset injuries (47%) were evenly distributed. The injuries examined with MRI were classified as grade 0 (52%), grade 1 (16%) or grade 2 (29%). One proximal tendinopathy case was not graded. Grade 2 injuries caused more time loss than grade 0 (19 ± 8 vs. 7 ± 7 days, p = 0.002). Of injuries with MRI changes, 60% were in the m. biceps femoris, mainly the muscle-tendon junction, and 40% in the m. semimembranosus, most in the proximal tendon. Compared to previous findings from men's football, a higher proportion of hamstring injuries in women's football had a gradual onset and involved the m. semimembranosus, particularly its proximal tendon.

Pill or pump? Nitroglycerin 0.5 mg tablet vs 0.8 mg spray: Effect on proximal vessel diameters at Coronary CT Angiography (CCTA).

INTRODUCTION: The administration of sublingual Nitroglycerin (NTG) prior to CT coronary angiography (CCTA) can be perfomed using pump spray or tablets. Choice of method seems to be based on local preference, rather than published guidelines. This retrospective analysis tested whether proximal coronary diameters differed dependent on the sublingual administration of 0.5 mg Nitroglycerin (NTG) tablets or 0.8 mg NTG spray. METHODS: 287 ECG-gated CCTA studies with optimal image quality and Agatston scores<400 were included in this retrospective analysis. 143 of the patients were dosed with NTG tablets at a dose of 0.5 mg prior to CCTA. 144 patients received 2 puffs of 0.4 mg NTG spray for a total dose of 8 mg. All were scanned on a second-generation Dual Source CT. Diameters of proximal segments of Left Main (LM), Right (RCA), Left Anterior (LAD) and circumflex (CX) coronary arteries were measured using semi-automatic electronic callipers by two blinded readers. Results were summarised as the mean of maximum and minimum diameters. Sex-specific analysis of diameters was carried out using repeated-measures ANOVA for each vessel. Agreement between readers was examined with Bland-Altman analysis and intra-class-correlation coefficient (ICC). RESULTS: No significant differences in coronary diameters were found except in the RCA for women and LM for men. In both cases, diameters were smaller in the spray group (11 and 9%, respectively). Reader agreement was excellent, with ICC>0.96 for all vessels, and no significant bias, except in CX (0.03 mm). CONCLUSIONS: We found no evidence for the systematic superiority of either administration method in proximal coronary vessels. IMPLICATIONS FOR PRACTICE: Choosing between tablet or spray NTG prior to CCTA can be guided by practical, economical and hygienic considerations alone.

Excretion kinetics of 1,3-dichlorobenzene and its urinary metabolites after controlled airborne exposure in human volunteers.

The solvent 1,3-dichlorobenzene (1,3-DCB) is formed during thermal decomposition of the initiator 2,4-dichlorobenzoylperoxide in the production of silicone rubber with potential exposure of production workers as shown in previous works. Despite a threshold limit value (MAK value) of 2 ppm in air, there are currently no data about the corresponding internal exposure that would allow for the derivation of a biological limit value. In the present study, we have investigated the absorption of 1,3-DCB and urinary kinetics of its metabolites in 10 human volunteers after controlled inhalative exposure. Due to the strong odour of 1,3-DCB, a subjective evaluation of odour nuisance was also performed. Ten male human volunteers (23-36 yrs.) were exposed 6 h/day to a concentration of 0.7 ppm and 1.5 ppm in the Aachen workplace simulation laboratory (AWSL) with one week between each experiment. In order to investigate potential dermal absorption, the volunteers were exposed to 1.5 ppm wearing a suitable filter mask that prevented inhalative exposure in a third exposure. 1,3-DCB in blood was measured after 3 and 6 h exposure and the urinary metabolites 3,5-dichlorocatechol (3,5-DCC), 2,4-dichlorophenol (2,4-DCP) and 3,5-dichlorophenol (3,5-DCP) were measured over 24 h after exposure via LC/MS/MS. There were clear dose-response relations for all investigated parameters. The maximum excretion of the metabolites was reached at the end of exposure and corresponded to 5.2 ± 0.7 mg/g crea, 1.5 ± 0.35 mg/g crea and 0.07 ± 0.011 mg/g crea at 0.7 ppm and to 12.0 ± 3 mg/g crea, 3.5 ± 1.1 mg/g crea and 0.17 ± 0.05 mg/g crea at 1.5 ppm for 3,5-DCC, 2,4-DCP and 3,5-DCP, respectively. The use of filter masks decreased the internal exposure for about 85-90%, indicating substantial dermal absorption. Odour perception did not show a dose-response, probably due to fast olfactory adaption. The human study presented here provides an excellent basis for deriving a biological limit value for 1,3-DCB.

[Atypical blast injury of the left hand : Multiple trauma with severe injury especially of the left hand]. / Atypische Explosionsverletzung der linken Hand : Polytrauma mit schwerer Verletzung insbesondere der linken Hand.

There is an accumulation of blast injuries on New Year's Eve due to fireworks.During an attempt to manufacture a firework the substances being mixed in a mortar exploded. The left hand of the patient was severely injured.During the operative treatment with radical débridement and generous amputation without osteosynthesis, a basic hand function according to Entin could initially be preserved; however, at a later stage the fourth finger could not be preserved, so that a prosthesis became necessary.This case report shows the importance of expertise in hand surgery in the treatment of such severe injuries. A toe-to-hand transplantation represents an additional treatment option.

Mendelian susceptibility to mycobacterial disease in tuberculosis-hyperendemic South Africa.

BACKGROUND: Severe infections in the absence of secondary immunodeficiency can alert clinicians to single-gene inborn errors of immunity/primary immunodeficiency disorders (PIDDs). Mendelian susceptibility to mycobacterial disease (MSMD) is characterised by selective susceptibility to mycobacterial infections due to inborn errors in the interleukin 12-interferon gamma pathway. The South African (SA) burden of hyperendemic tuberculosis (TB) infection provides an interesting context for the study of MSMD. OBJECTIVES:  To evaluate whether severe, persistent, unusual or recurrent (SPUR) definitions of TB can be applied in the context of MSMD in SA. METHODS: This study is a retrospective review of an SA PIDD cohort. Patients aged 0 - 15 years with SPUR TB infections, assessed between 2013 and 2018, were identified using a proposed algorithm. HIV infection or other secondary causes for immunodeficiency were excluded. Basic investigations, then focused immunophenotyping and next-generation sequencing, were performed. RESULTS:  A total of 20 patients with a clinical diagnosis of MSMD were identified. A further two, forming part of a family cohort, had pathogenic variants but remain asymptomatic. Infection with Mycobacterium tuberculosis complex predominated (64%), while 27% had BCG infection or non-tuberculous mycobacteria (NTM) infection. Molecular analysis revealed pathogenic variants in 41% of patients with SPUR mycobacterial infection, mainly in those with BCG/NTM infection. CONCLUSIONS:  In the SA paediatric population, SPUR TB infections, particularly BCG/NTM, in the absence of secondary immunodeficiency, can alert to possible MSMD. The molecular diagnosis is pivotal, guiding disease classification and influencing clinical approach and management. The diagnosis is complex and requires a multidisciplinary approach with close collaboration between clinical immunologists, bioinformaticians, immunologists, clinical geneticists and genetic counsellors.

The effect of urine storage temperature and boric acid preservation on quantitative bacterial culture for diagnosing canine urinary tract infection.

BACKGROUND: Quantitative bacterial culture (QBC) is the gold standard for diagnosing canine urinary tract infection. Current guidelines recommend QBC within 24 h of urine collection and that unpreserved urine is refrigerated until culture. However, temperature-controlled transport is rarely feasible, indicating a need for alternative storage during transport of urine from primary veterinary practices to the microbiology laboratory. The objective was to investigate the effect of storage temperature and boric acid sponge-preservation on quantitative bacterial culture of canine urine. RESULTS: Significant bacteriuria was detected in 72 out of 179 samples (40%) collected from 141 dogs. Overall accuracy was 94-98% for both storage conditions and time points. Non-inferiority (15% margin) to reference quantitative bacterial culture was evident for sensitivity, specificity and predictive values for both storage methods and time points, except for the negative predictive value for 48 h boric acid preservation (NPV: 89, 95% CI [79;95]). There was no significant difference between the sensitivity and specificity for either of the time-points (p-value = 0.07-1). CONCLUSIONS: Boric acid sponge-preservation using Uriswab™ is a useful alternative to refrigeration of urine samples during transport. Reliable quantitative bacterial culture results can be obtained from canine urine up to 48 h after collection if urine is refrigerated, and for at least 24 h if urine is stored using a boric acid-containing urine transport system.

Crash involvement among unlicensed 17 year old drivers before and after licensing at 17 was allowed.

Unlicensed driving among youth is associated with increased crash risk, and partly motivated by a wish to learn to drive. In this paper we examine whether crash involvement among 17-year-old unlicensed drivers changed after post-licence accompanied driving from the age of 17 was allowed in Denmark in 2017. The study includes police-registered crashes occurring three years before and three years after the change (2014-2019). Results show an increase in crash involvement among 17-year-olds and a small increase in crash involvement among unlicensed 17-year-olds, if population size is taken into account, but no differences in the crash and person characteristics before and after the change. Being male, speeding, and impairment at the time of the crash predicted unlicensed crash involvement. A latent class clustering analysis (LCCA) identified seven clusters of crashes involving an unlicensed 17-year-old. The cluster characteristics reveal different patterns in the associated factors such as females and parked vehicles being more likely to be included in C1, alcohol impaired in C2 and drug impaired in C7. Brief crash descriptions provided by the police indicate that driving with extra motives such as showing-off or pleasure are prevalent in all clusters. Results confirm, that unlicensed crash involvement among 17-year olds is associated with risk-taking behaviours such as speeding, impaired driving, showing-off, and the car being pursued by the police. However, unfortunate manoeuvres and loss of control of the vehicle possibly related to poor driving skills are also associated with the crashes. Crash characteristics such as impairment by alcohol and drugs indicate that unlicensed crash involvement is a distinct safety challenge associated with health risk behaviours rather than a transport related need for a driver's license. Additional studies exploring the motivations and circumstances associated with unlicensed driving among 17-year olds are needed along with measures to prevent car access among unlicensed youth..

Higher vs lower doses of dexamethasone in patients with COVID-19 and severe hypoxia (COVID STEROID 2) trial: Protocol and statistical analysis plan.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has resulted in millions of deaths and overburdened healthcare systems worldwide. Systemic low-dose corticosteroids have proven clinical benefit in patients with severe COVID-19. Higher doses of corticosteroids are used in other inflammatory lung diseases and may offer additional clinical benefits in COVID-19. At present, the balance between benefits and harms of higher vs. lower doses of corticosteroids for patients with COVID-19 is unclear. METHODS: The COVID STEROID 2 trial is an investigator-initiated, international, parallel-grouped, blinded, centrally randomised and stratified clinical trial assessing higher (12 mg) vs. lower (6 mg) doses of dexamethasone for adults with COVID-19 and severe hypoxia. We plan to enrol 1,000 patients in Denmark, Sweden, Switzerland and India. The primary outcome is days alive without life support (invasive mechanical ventilation, circulatory support or renal replacement therapy) at day 28. Secondary outcomes include serious adverse reactions at day 28; all-cause mortality at day 28, 90 and 180; days alive without life support at day 90; days alive and out of hospital at day 90; and health-related quality of life at day 180. The primary outcome will be analysed using the Kryger Jensen and Lange test adjusted for stratification variables and reported as adjusted mean differences and median differences. The full statistical analysis plan is outlined in this protocol. DISCUSSION: The COVID STEROID 2 trial will provide evidence on the optimal dosing of systemic corticosteroids for COVID-19 patients with severe hypoxia with important implications for patients, their relatives and society.

Neuromuscular blockade in patients with ARDS: a rapid practice guideline.

The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) is to formulate an evidence-based guidance for the use of neuromuscular blocking agents (NMBA) in adults with acute respiratory distress syndrome (ARDS). The panel comprised 20 international clinical experts from 12 countries, and 2 patient representatives. We adhered to the methodology for trustworthy clinical practice guidelines and followed a strict conflict of interest policy. We convened panelists through teleconferences and web-based discussions. Guideline experts from the guidelines in intensive care, development, and evaluation Group provided methodological support. Two content experts provided input and shared their expertise with the panel but did not participate in drafting the final recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence and grade recommendations and suggestions. We used the evidence to decision framework to generate recommendations. The panel provided input on guideline implementation and monitoring, and suggested future research priorities. The overall certainty in the evidence was low. The ICM-RPG panel issued one recommendation and two suggestions regarding the use of NMBAs in adults with ARDS. Current evidence does not support the early routine use of an NMBA infusion in adults with ARDS of any severity. It favours avoiding a continuous infusion of NMBA for patients who are ventilated using a lighter sedation strategy. However, for patients who require deep sedation to facilitate lung protective ventilation or prone positioning, and require neuromuscular blockade, an infusion of an NMBA for 48 h is a reasonable option.

Uncarboxylated matrix Gla-protein: A biomarker of vitamin K status and cardiovascular risk.

BACKGROUND: Dephosphorylated uncarboxylated matrix Gla-protein (dp-ucMGP) is a biomarker of functional vitamin K status. High plasma dp-ucMGP concentrations reflect a low vitamin K status and have been related to vascular calcification. Our aims were to assess plasma levels of dp-ucMGP and their association with cardiovascular risk in a general population. METHODS: Plasma dp-ucMGP measurements were performed using the IDS-iSYS InaKtif MGP assay in 491 consecutive participants in a Danish general population study (229 males and 262 females, aged 19-71 years). Multivariable linear and logistic regressions were used to assess the association between dp-ucMGP levels and cardiovascular risk factors. RESULTS: Mean ± standard deviation (SD) for dp-ucMGP was 465 ± 181 pmol/L, and upper 95th percentile was 690 pmol/L. In logistic regression analyses, an increase in dp-ucMGP category (<300, 300-399, 400-499, ≥500 pmol/L) was positively associated with obesity, odds ratio (OR) 2.27 (95% confidence interval (CI) 1.54-3.33), history of cardiovascular disease, OR 1.77 (CI 1.02-3.05), and above-median estimated pulse wave velocity (ePWV), OR 1.54 (CI 1.21-1.96), when adjusted for age, sex, and lifestyle factors. 1 SD increase in diastolic and systolic blood pressure (BP) corresponded to a 5.5% (CI 2.9-8.0%) and 4.7% (CI 2.1-7.4%) increase in dp-ucMGP, respectively, when adjusted for age and sex. CONCLUSION: Plasma dp-ucMGP levels were positively associated with obesity, BP, ePWV, and history of cardiovascular disease. These findings support that dp-ucMGP is a biomarker of cardiovascular risk, and that vitamin K status could play a role in vascular calcification. The strong association with obesity deserves further attention.

Hyperoxia improves autonomic function in individuals with long-duration type 1 diabetes and macroalbuminuria.

AIM: Acute oxygen inhalation and slow deep breathing improve measures of autonomic function transiently in individuals with short-duration type 1 diabetes. Our aims were to examine these interventions and changes in autonomic function in individuals with long-duration type 1 diabetes and to explore interactions with the presence of macroalbuminuria or existing cardiovascular autonomic neuropathy. METHODS: Individuals with type 1 diabetes (n = 54) were exposed to acute oxygen inhalation, slow deep breathing and a combination of both (hereafter 'the combination'). Primary outcomes were change in baroreflex sensitivity and heart rate variability. Associations between changes in outcomes were evaluated using mixed effects models. RESULTS: Mean age ± sd was 60 ± 10 years and diabetes duration was 38 ± 14 years. Changes are presented as per cent difference from baseline with 95% confidence intervals. Acute oxygen inhalation, slow deep breathing and the combination increased baroreflex sensitivity by 21 (10, 34)%, 32 (13, 53)% and 30 (10, 54)%, respectively. Acute oxygen inhalation trended towards increasing heart rate variability 8 (-1, 17)% (P = 0.056), and slow deep breathing and the combination increased heart rate variability by 33 (18, 49)% and 44 (27, 64)% respectively. Macroalbuminuria or cardiovascular autonomic neuropathy did not modify results. CONCLUSION: Autonomic function is improved transiently in individuals with long-duration type 1 diabetes and normoalbuminuria or macroalbuminuria by acute oxygen inhalation and slow deep breathing. There is a risk of survival bias. Autonomic dysfunction might be a reversible condition, and hypoxia might represent a target of intervention.

MiR-219a-5p Enriched Extracellular Vesicles Induce OPC Differentiation and EAE Improvement More Efficiently Than Liposomes and Polymeric Nanoparticles.

Remyelination is a key aspect in multiple sclerosis pathology and a special effort is being made to promote it. However, there is still no available treatment to regenerate myelin and several strategies are being scrutinized. Myelination is naturally performed by oligodendrocytes and microRNAs have been postulated as a promising tool to induce oligodendrocyte precursor cell differentiation and therefore remyelination. Herein, DSPC liposomes and PLGA nanoparticles were studied for miR-219a-5p encapsulation, release and remyelination promotion. In parallel, they were compared with biologically engineered extracellular vesicles overexpressing miR-219a-5p. Interestingly, extracellular vesicles showed the highest oligodendrocyte precursor cell differentiation levels and were more effective than liposomes and polymeric nanoparticles crossing the blood-brain barrier. Finally, extracellular vesicles were able to improve EAE animal model clinical evolution. Our results indicate that the use of extracellular vesicles as miR-219a-5p delivery system can be a feasible and promising strategy to induce remyelination in multiple sclerosis patients.

[Necrotizing esophagitis by stress-cardiomyopathy with right ventricular insufficiency]. / Nekrotisierende Ösophagitis bei Stresskardiomyopathie mit Rechtsherzversagen.

Acute necrotizing esophagitis ("black esophagus") is defined as complete necrosis of the esophageal mucosa, which typically affects the entire circumference. We report a case of a healthy 62-year-old woman, who became hemodynamically unstable due to stress cardiomyopathy with acute right heart failure. Transfusion-dependent anemia occurred 24 h later and an upper gastrointestinal endoscopy revealed a black discoloured mucosa of the distal esophagus. After hemodynamic stabilization and treatment with proton pump inhibitors and sucralfate, complete healing of the esophageal mucosa was achieved.

Acute Neuromuscular Activity in Selected Injury Prevention Exercises with App-Based versus Personal On-Site Instruction: A Randomized Cross-Sectional Study.

INTRODUCTION: A significant step towards sport-related injury prevention is the introduction of easily accessible smartphone applications (apps). However, it is unknown whether this type of app-based instruction facilitates similar acute neuromuscular and biomechanical characteristics of the preventive exercises as achieved when instructed on-site by an expert. Thus, the aim was to evaluate acute neuromuscular characteristics observed during a single bout of selected lower extremity injury preventive exercises instructed by an on-screen app versus on-site individual instruction provided by a physiotherapist. METHODS: In a cross-sectional study design, 47 female football and handball players were randomly assigned to receive app instruction (APP group) or on-site instruction provided by a physiotherapist (PHY group) while performing five lower extremity injury preventive exercises. The exercises performed comprised (1) one-legged balance on Airex, (2) vertical drop jump, (3) one-legged horizontal jump onto floor, (4) one-legged horizontal jump onto Airex, and (5) two-hand Kettlebell Swing. Primary outcome was hamstring (biceps femoris and semitendinosus) muscle activity. Secondary outcomes were quadriceps (vastus lateralis and medialis) muscle activity, as well as hip and knee joint angles. Muscle activity was monitored by surface electromyography (EMG) and normalized to the peak amplitude obtained during a maximal voluntary isometric contraction (MVC). Hip and knee joint angles were recorded by a 3D motion analysis system. A linear mixed model was used to evaluate the differences between experimental conditions for each outcome variable. RESULTS: Medial hamstring (semitendinosus) muscle activity was significantly higher during one-legged jump onto Airex (17 percentage points (95% CI 7 to 27)) and Kettlebell Swing (19 percentage points (95% CI 2 to 36)) in the PHY group than the APP group. Likewise, the PHY group demonstrated 18 percentage points (95% CI 1 to 35) and 19 percentage points (95% CI 0 to 38), greater lateral quadriceps muscle (vastus lateralis) activity during one-legged jump onto floor and one-legged jump onto Airex, respectively, compared with that of the APP group. CONCLUSIONS: Complex exercises, i.e., Kettlebell Swing and one-legged jump onto Airex, are characterized by lower neuromuscular activity when using app-based instructions compared with on-site instruction provided by a physiotherapist. However, the effectiveness of app-based instruction versus on-site individual instruction in injury prevention interventions remains to be investigated in future longitudinally studies.

Polymer-based ammonium-limited fed-batch cultivation in shake flasks improves lipid productivity of the microalga Chlorella vulgaris.

The aim of this work was to study ammonium-limited fed-batch conditions in heterotrophic C. vulgaris shake flask cultivations. Therefore, an innovative polymer-based ammonium release technique (polymer beads) was developed. Using these beads in shake flasks, C. vulgaris cultivations resulted in simultaneous growth and lipid accumulation. Lipid productivity was increased by 43% compared to batch cultivations. Furthermore, by online monitoring of the metabolic activity (RAMOS technique), unlimited growth and depletion of nutrients could be identified. A previously unknown sulfur limitation was detected in the applied Bold's Basal Medium. Combining the ammonium release beads with the RAMOS technique proved to be an efficient method for microalgae process development.

Effects of simulated sample sizes on mortality estimates-Protocol for a study in 3 randomised ICU trials.

BACKGROUND: An increasing number of trials are stopped earlier than originally planned. It has been suggested that trials stopped pre-maturely overestimate the treatment effect. With the outlined observational study, we aim to simulate the results of stopping trials before they reach their planned sample size to assess the effects on mortality estimates. METHODS AND STATISTICS: Based on 3 international, randomised clinical trials (RCTs) in critical care: Scandinavian Starch for Severe Sepsis and Septic Shock (6S) trial, the Transfusion Requirements in Septic Shock (TRISS) trial and the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial, we will estimate relative risks with 95% confidence intervals for the primary outcome 90-day mortality after the inclusion of each individual patient in each RCT. This will be presented graphically with the primary outcome as a function of the number of included patients. DISCUSSION: The outlined study will provide important knowledge about the effects of stopping critical care trials early. This may have important implications for patients, relatives, clinicians, researchers, guideline committee members and policy makers. ETHICS AND DISSEMINATION: We will use data from consenting patients enrolled in RCTs approved by the relevant ethical committees; this study requires no further permissions. We will report the results in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement and submit the final approved manuscript to a peer-reviewed journal.

Road anger expression-Changes over time and attributed reasons.

Based on the results from three independent surveys conducted in Denmark in 2005, 2008 and 2016, this paper provides an overview of the development of road anger expression in general and in demographic sub-groups of road users. In addition, it investigates how people explain own and other people's road anger expression and if attributed reasons are related to demographic factors and level of anger expression measured based on the short form of the driving anger expression inventory (DAX-short). From 2005 to 2016 the percentage of people involved in anger expression incidents increased particularly in the densely populated Capital Region of Denmark. The increase was most pronounced for "yelling" and "threatening". Men were more often involved than women both as aggressor and as victim, but the gender difference decreased from 2008 to 2016. Generally, own anger expression was more often explained with getting frightened (non-hostile attribution), while anger expression by other road users was more often explained by not being able to control own anger or by wanting to show that one made a mistake (hostile attribution). However, people scoring high in aggressive anger expression often explained own anger expression by "not being able to control anger", thereby indicating self-reflection and a potential for behavioural change. Behavioural reactions to being frightened are to some extend mistakenly interpreted as expressions of anger by other road users. Results indicate that cognitive and behavioural interventions, possibly as part of the driver education, are relevant to reduce aggressive anger expression in traffic.

Timing of onset of gastrointestinal bleeding in the ICU: Protocol for a preplanned observational study.

BACKGROUND: Critically ill patients are at risk of gastrointestinal bleeding, but clinically important gastrointestinal bleeding is rare. The majority of intensive care unit (ICU) patients receive stress ulcer prophylaxis (SUP), despite uncertainty concerning the balance between benefit and harm. For approximately half of ICU patients with gastrointestinal bleeding, onset is early, ie within the first two days of the ICU stay. The aetiology of gastrointestinal bleeding and consequently the balance between benefit and harm of SUP may differ between patients with early vs late gastrointestinal bleeding. METHODS: This is a protocol and statistical analysis plan for a preplanned exploratory substudy of the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) randomized clinical trial, comparing intravenous pantoprazole (40 mg once daily) with placebo in 3350 acutely ill adult ICU patients. We will describe baseline characteristics and assess the time to onset of the first clinically important episode of GI bleeding accounting for survival status and allocation to SUP or placebo. In addition, we will describe differences in therapeutic and diagnostic procedures used in patients with clinically important gastrointestinal bleeding according to early vs late bleeding and 90-day vital status. CONCLUSIONS: The study outlined in this protocol will provide detailed information on patient characteristics and the timing of onset of gastrointestinal bleeding in the patients enrolled in the SUP-ICU trial. This may provide additional knowledge and incentives for future studies on which patients benefit from SUP.