Cost-effectiveness of cervical length screening and progesterone treatment to prevent spontaneous preterm delivery in Sweden.

OBJECTIVE: To estimate the cost-effectiveness of strategies to prevent spontaneous preterm delivery (PTD) in asymptomatic singleton pregnancies, using prevalence and healthcare cost data from the Swedish healthcare context. METHODS: We designed a decision analytic model based on the Swedish CERVIX study to estimate the cost-effectiveness of strategies to prevent spontaneous PTD in asymptomatic women with a singleton pregnancy. The model was constructed as a combined decision-tree model and Markov model with a time horizon of 100 years. Four preventive strategies, namely 'Universal screening', 'High-risk-based screening' (i.e. screening of high-risk women only), 'Low-risk-based screening' (i.e. treatment of high-risk population and screening of remaining women) and 'Nullipara screening' (i.e. treatment of high-risk population and screening of nulliparous women only), included second-trimester cervical length (CL) screening by transvaginal ultrasound followed by vaginal progesterone treatment in the case of a short cervix. A fifth preventive strategy involved vaginal progesterone treatment of women with previous spontaneous PTD or late miscarriage but no CL screening ('No screening, treat high-risk group'). For comparison, we used a sixth strategy implying no specific intervention to prevent spontaneous PTD, reflecting the current situation in Sweden ('No screening'). Probabilities for a short cervix (CL ≤ 25 mm; base-case) and for spontaneous PTD at < 33 + 0 weeks and at 33 + 0 to 36 + 6 weeks were derived from the CERVIX study, and probabilities for stillbirth, neonatal mortality and long-term morbidity (cerebral palsy) from Swedish health data registers. Costs were based on Swedish data, except costs for cerebral palsy, which were based on Danish data. We assumed that vaginal progesterone reduces spontaneous PTD before 33 weeks by 30% and spontaneous PTD at 33-36 weeks by 10% (based on the literature). All analyses were from a societal perspective. We expressed the effectiveness of each strategy as gained quality-adjusted life years (QALYs) and presented cost-effectiveness as average (ACER; average cost per gained QALY compared with 'No screening') and incremental (ICER; difference in costs divided by the difference in QALYs for each of two strategies being compared) cost-effectiveness ratios. We performed deterministic and probabilistic sensitivity analysis. The results of the latter are shown as cost-effectiveness acceptability curves. Willingness-to-pay was set at a maximum of 500 000 Swedish krona (56 000 US dollars (USD)), as suggested by the Swedish National Board of Health and Welfare. RESULTS: All interventions had better health outcomes than did 'No screening', with fewer screening-year deaths and more lifetime QALYs. The best strategy in terms of improved health outcomes was 'Low-risk-based screening', irrespective of whether screening was performed at 18 + 0 to 20 + 6 weeks (Cx1) or at 21 + 0 to 23 + 6 weeks (Cx2). 'Low-risk-based screening' at Cx1 was cost-effective, while 'Low-risk-based screening' at Cx2 entailed high costs compared with other alternatives. The ACERs were 2200 USD for 'Low-risk-based screening' at Cx1 and 36 800 USD for 'Low-risk-based screening' at Cx2. Cost-effectiveness was particularly sensitive to progesterone effectiveness and to productivity loss due to sick leave during pregnancy. The probability that 'Low-risk-based screening' at Cx1 is cost-effective compared with 'No screening' was 71%. CONCLUSION: Interventions to prevent spontaneous PTD in asymptomatic women with a singleton pregnancy, including CL screening with progesterone treatment of cases with a short cervix, may be cost-effective in Sweden. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

C-CAM (Cell-CAM 105) is a calmodulin binding protein.

C-CAM (Cell-CAM 105) is a transmembrane cell adhesion molecule belonging to the immunoglobulin superfamily. It mediates intercellular adhesion of rat hepatocytes and occurs in various isoforms in several epithelia, vessel endothelia and leukocytes. We now report that purified liver C-CAM interacts specifically with calmodulin. Binding was observed both when 125I-labeled C-CAM was used in a dot-blot assay and when 125I-labeled calmodulin was used in a gel overlay assay. Experiments with protease-generated peptides indicated that calmodulin bound to the cytoplasmic domain of C-CAM. Analyses of whole liver membranes demonstrated that C-CAM is one of five major proteins that bind calmodulin in a calcium-dependent manner.

Leukocyte margination during hemorrhagic shock correlates to preshock margination and is reduced by fucoidin.

Systemic and pulmonary circulation kinetics for 51Cr-erythrocytes and 111In-leukocytes were measured in rats during experimental hemorrhagic shock and normotension with or without pretreatment with the antirolling agent fucoidin. Leukocyte margination was expressed as transit factors (white blood cell transit time/red blood cell transit time) for polymorphonuclear and mononuclear cells. There was an increased pooling of leukocytes in the pulmonary and systemic vascular beds during shock with a maximum after 60 min when the transit factors had increased 2.90-3.72 times in the pulmonary vascular bed and 2.00-3.52 times in the systemic vascular bed for mononuclear and polymorphonuclear cells, respectively. High preshock pooling levels lead to a more pronounced increase in pooling during shock. Pretreatment with fucoidin significantly reduced the pooling increase in the systemic vascular bed. Granulocyte oxidative activity (nitro blue tetrazolium test) invariably increased during shock and was not affected by fucoidin.

Inhibition of human blood aldehyde dehydrogenase activity by cigarette-smoke condensate.

The effect of a cigarette-smoke condensate (CSC) and three CSC subfractions on the aldehyde dehydrogenase (ALDH; EC 1.2.1.3) activity in human blood cells was examined under physiological conditions in vitro. Incubation of intact or sonicated cells with different concentrations of crude CSC resulted in a dose-dependent reduction of the ALDH activity. The inactivation was only restored in part after extensive washing of the cells, indicating that the inhibition observed was mainly irreversible. The nonvolatile (NV) subfraction of the CSC caused a reduction in ALDH activity similar to that obtained with crude CSC, while the semivolatile (SV80) and volatile (SV20) subfractions did not significantly affect ALDH. The present results, showing that the human blood cell ALDH is inactivated by constituents of cigarette smoke in vitro, suggest that the blood ALDH activity reduction found in habitual smokers is also caused by components formed during the combustion of tobacco.

Time course of ethanol-induced changes in serotonin metabolism.

The effect of acute ethanol consumption on serotonin metabolism was examined in healthy volunteers in the fasted and fed state by determination of plasma and urinary levels of the serotonin metabolites 5-hydroxyindole-3-acetic acid (5-HIAA) and 5-hydroxytryptophol (5-HTOL). The plasma and urinary levels of 5-HIAA were reduced by about 40% and 25%, while the 5-HTOL levels were increased on an average 7-fold and 50-fold, respectively, after oral intake of ethanol (0.8 g/kg) over 30 min in a fasted state. The maximal effect on both 5-HIAA and 5-HTOL levels was found 4-6 h after starting drinking. Urinary 5-HTOL and the 5-HTOL/5-HIAA ratio did not return to baseline until 19 h after the start of the administration (i.e., about 10 h after ethanol reached zero level). The mean 24-h excretion of 5-HTOL was increased 15-fold by the ethanol intake, while the 5-HIAA excretion was not significantly different. A clear dose dependent effect was observed in one individual who also ingested a lower amount of ethanol (0.5 g/kg). When ethanol (0.8 g/kg) was ingested over 3 h together with food, the urinary level of 5-HTOL and the 5-HTOL/5-HIAA ratio did not return to baseline until after 20-22 h. In other subjects who had unlimited access to ethanol and ingested between 1.3-2.3 g/kg together with food, the time to reach baseline 5-HTOL/5-HIAA ratio in urine ranged from 20 h to over 26 h.

Urinary excretion of 5-hydroxyindole-3-acetic acid and 5-hydroxytryptophol after oral loading with serotonin.

The urinary excretion patterns of the serotonin (5-hydroxytryptamine; 5-HT) metabolites 5-hydroxyindole-3-acetic acid (5-HIAA) and 5-hydroxytryptophol (5-HTOL) were examined after ingestion of bananas, a food rich in 5-HT. The bananas contained on an average 25 micrograms 5-HT/g pulp. Both urinary 5-HIAA and 5-HTOL increased markedly (15- to 30-fold) shortly after eating 3-4 bananas, with the highest concentrations found in urine specimens collected after 2-4 h, and did not return to normal until after 8-10 h. The excretion of 5-HIAA increased from a control mean value of 3.9 mg/24 h to 12.7 mg/24 h, when conventional diets were supplemented with 3-4 bananas. The corresponding results for 5-HTOL were 16.8 micrograms/24 h and 60.7 micrograms/24 h, respectively. Of the banana-derived 5-HT ingested, 60-80% was recovered in the urine as 5-HIAA and only 0.3-0.5% as 5-HTOL. However, since both the time-course and relative increase in 5-HTOL was similar to that of 5-HIAA, there was no effect on the urinary 5-HTOL to 5-HIAA ratio. By contrast, acute alcohol consumption produced a considerable elevation of this ratio.

Spontaneous nitroblue-tetrazolium (NBT) reduction related to granulocyte priming and activation.

The aim of the present study was to explore the relationship between the increasing level of spontaneous NBT-reduction and the tendency for PMNs to marginate during experimental hemorrhagic shock in rats. Rat PMNs, isolated on Percoll density gradients or suspended in blood, were examined by chemiluminescence (CL), NBT-test and by their CD-18 expression and F-actin formation. The NBT-test generally produced higher numbers of activated PMNs when the cells were suspended in buffer than in whole blood, probably due to the scavenging properties of blood. The level of spontaneous NBT-reduction of PMNs in blood correlated with the magnitude of the NBT-response to f-MLP stimulation in blood and buffer. On the contrary, there were no significant correlations between spontaneous NBT reduction, CD18 expression and F-actin content. Thus, high levels of spontaneous NBT reduction in blood were associated with priming of the separated PMNs rather than increased rigidity (F-actin) or adhesiveness (CD18).

Histochemical studies of hyaluronan and the hyaluronan receptor ICAM-1 in psoriasis.

Histochemical stainings of frozen sections of human normal and psoriatic skin were used to study the localization of hyaluronan (HA) and intercellular adhesion molecule 1 (ICAM-1). HA staining was found in all areas of the skin, with the exception of the stratum corneum, in both normal and psoriatic cases without any apparent quantitative differences between the conditions. The staining for ICAM-1 was detected in vessels in normal skin and at lower levels in normal areas of the skin in patients with psoriasis. However, in these patients the staining increased to about the same level as in normal skin after hyaluronidase treatment of the sections prior to staining. In psoriatic lesions, distinct staining for ICAM-1 was localized mainly to vessels and infiltrating leukocytes. Treatment of the sections with hyaluronidase increased the staining of vessels only slightly, but more strongly around leukocytes. These findings show that ICAM-1 is predominantly free from bound HA on vessel endothelium in psoriasis lesions but not on vessels in normal areas of the skin, and suggests that systematically administered HA, previously shown to reduce chronic inflammation in animal models, might have a beneficial effect in psoriasis via blocking of endothelial ICAM-1 and thereby causing a reduced invasion of leukocytes into the skin.

[A patient with aortic dissection and abdominal aortic aneurysm with fistula]. / Patient hade både aortadissektion och bukaortaaneurysm med fistel.

Aneurysm of the abdominal aorta is not uncommon in later life. The frequency of aneurysm rupture varies with aneurysm diameter. In rare cases, the aneurysm may rupture intra-abdominally into surrounding structures and give rise to a fistula. When blood vessels are involved, the commonest form is aortocaval fistula, the presenting symptoms being those of severe right-ventricular heart failure. Although thoracic aorta dissection may be made manifest in acute intense chest pain, it is asymptomatic in up to 50 per cent of cases. The article consists in a case report of asymptomatic thoracic aorta dissection occurring concomitantly with a ruptured abdominal aneurysm the symptoms of which were severe right ventricular heart failure due to an aortocaval fistula causing increased pressure, and severe bilateral oedema of the legs. If the rare complication of an aortocaval fistula could be detected earlier, it might be possible to prevent progression to refractory cardiac failure. The possibility of a fistula should be borne in mind if haematuria is present in a case of abdominal aneurysm or a pulsatile abdominal mass is present in conjunction with a murmur.

NBT reactivity correlates to the distribution of PMNs between rat pulmonary and systemic circulation.

The rat systemic and pulmonary vascular transit times of radiolabeled polymorphonuclear granulocytes (experimental population referred to as "Polys") and mononuclear leukocytes (experimental population referred to as "Monos") (111In) in relation to those of erythrocytes (51Cr) were measured under physiological conditions. Results were also expressed as "circulating" pool and "marginated" pool of the two leukocyte fractions, and it was investigated whether the degree of spontaneous granulocyte activation, measured with the nitro blue tetrazolium (NBT) reduction test, was of importance for the retention of Polys in the lungs. The measured mean vascular transit was similar for Monos and Polys and several times slower than that of the erythrocytes in the pulmonary (17.4 times) and the systemic (4.1 times) vascular beds. The percentage of NBT-positive cells was < 10% in most animals, indicating a low level of spontaneous granulocyte activation. Increasing levels of NBT-positive cells correlated with a redistribution of granulocytes from the systemic marginated cell pool to the pulmonary marginated cell pool. Microscopic evaluation of sections from embedded lung tissue biopsies, obtained after intravital staining of the leukocytes, confirmed the isotope data on pulmonary transit.

Mediastinal perforation and contralateral hemothorax by a chest tube.

Tube thoracostomy is an invasive and common procedure that is often life-saving, but by no means innocuous. We describe herein a case of chest trauma in which the chest tube crossed through the mediastinum between aorta and esophagus and penetrated the contralateral pleural cavity causing mild hemothorax. A literature search has failed to identify a similar case: the misplacement was detected in a control radiograph which led to early adjustment of the tube and no sequalae.

A simple technique for anchoring chest tubes.

Although some techniques have been described for securing chest tubes, many complications are still reported. A simple method is described for securing chest tubes and closure of the wound, resulting in good fixation of the tube and an airtight closure of the chest wall with a cosmetically satisfactory result.

Nomenclature, classification, and signficance of traumatic extrapleural hematoma.

BACKGROUND: Extrapleural hematoma has been found mostly in single case reports as diagnoses with different names. Although huge extrapleural hematoma can cause ventilatory and circulatory disturbances and even death, it has received almost no attention in the literature. Certain basic and modern facts need to be clarified regarding the definition, classification, and significance of extrapleural hematoma in the practice of chest trauma. METHODS: A 10-year retrospective study was undertaken to analyze the incidence, diagnosis, management, morbidity, and mortality of patients with chest trauma and a documented extrapleural hematoma. RESULTS: The incidence of traumatic extrapleural hematoma was 34 of 477, 7.1%. The incidence of thoracic lesions was 86 of 34 = 2.5 lesions per patient, whereas the incidence of extrathoracic lesions was 30 of 34 = 0.9 lesions per patient. Associated rib fractures were found in 30 of 34, 88.2%. More than half of the patients had an associated hemothorax. A thoracotomy was used successfully to remove a huge hematoma in one patient. CONCLUSION: Extrapleural hematoma has been found to be more common than previously reported. Nomenclature and classification are suggested. One of the common injuries to the chest, particularly rib fracture, hemothorax, lung contusion, or pneumothorax might provide the surgeon with a reliable clinical clue that the patient is at inordinate risk to have associated extrapleural hematoma. A formal or mini-thoracotomy is the recommended procedure in cases of huge hematomas.

Cardiovascular injuries associated with sternal fractures.

OBJECTIVE: To find out if the presence of a sternal fracture indicates cardiac and aortic injuries and to clarify the difference between a retrosternal haematoma and widened mediastinum. DESIGN: Retrospective study. SETTING: Teaching hospital, Sweden. SUBJECTS: 418 patients with blunt chest trauma of whom 29 had a fractured sternum (11 with retrosternal haematoma and 18 without) and 389 did not (7 with widened mediastinum and 382 without). MAIN OUTCOME MEASURES: Definitions, risk factors, morbidity, and mortality. RESULTS: Retrosternal haematomas were found adjacent to many fractures and ranged in size from a few mm to 2 cm. They were more common in fractures of the body of sternum. There was no significant difference in the number of associated lesions between patients with sternal fractures with or without a retrosternal haematoma. Conversely, patients with a widened mediastinum had a higher injury severity score, longer hospital stay (p < 0.0001), and more associated lesions (p < 0.05) than those with retrosternal haematomas. Six patients still had pain 1 month after injury of whom two had injury-related long-term disability because of pain. No serious cardiac or aortic injuries were detected in this series. The early mortality in our study was 2/29 in patients with sternal fractures and 1/7 in patients with widened mediastinum. CONCLUSIONS: Sternal fractures are more common than previously reported. An aggressive approach including early operative reduction is recommended even for a stable fracture to reduce the overhelming pain. Sternal fracture with or without retrosternal heamatoma is not a reliable indicator of cardiac and aortic injuries, while mediastinal widening is still a fairly reliable clue that should indicate further investigation.

Erythrocyte-leukocyte interactions in the vascular bed of isolated perfused rat lungs.

An earlier study of perfused rat lungs showed that leukocytes, given as bolus injections, seemed to become more or less permanently trapped in the pulmonary microvascular bed under erythrocyte-free perfusion. The aim of the present study was, therefore, to investigate the rheologic effects of erythrocytes on the leukocyte microcirculation of perfused rat lungs. Leukocyte and erythrocyte suspensions were given as bolus injections during cell-free, constant pressure perfusion of ventilated rat lungs. Leukocyte numbers were counted in samples of the venous effluent and flow resistance changes were computed from registrations of flow rate, arterial and venous pressures. The preparations showed a continuous efflux of leukocytes which had been trapped in the pulmonary microcirculation before the perfusion was started. A bolus infusion of erythrocytes (3 ml, hematocrit: 30%) caused a transient flow resistance increase during the passage of the erythrocyte bolus through the vascular bed. This initial peak was accompanied by an increased venous efflux of leukocytes and followed by a lower second peak, attributed to a redistribution of trapped leukocytes in the capillary bed. Infusions of mixed cell suspensions (20-30 x 10(6) leukocytes in 30% hematocrit) caused a transient resistance increase similar to that caused by erythrocytes and a sustained resistance increase, less persistent than that caused by leukocytes. The present data suggest that the infusion of erythrocytes caused a re-distribution and an increased efflux of leukocytes, pooled in the pulmonary microcirculation. The rheological effects of erythrocytes could, hypothetically, result from mechanical interactions with the leukocytes in the pulmonary microvessels.

Cardiac injuries: a ten-year experience.

OBJECTIVE: To present our experience of cardiac injuries treated at one Swedish emergency department in the 10 years 1988-97. DESIGN: Retrospective study. SETTING: Teaching hospital. SUBJECTS: 11 patients (9 men and 2 women, mean age 33 years, range 19-54); in 7 they were penetrating injuries and in 4 blunt. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The mechanisms of injury were stab wound (n = 7), and car crash, fall, boat crash, and abuse (n = 1 each); drug or alcohol misuse played a part in all those with penetrating injuries. The penetrating wounds involved the left ventricle (n = 3), the right ventricle (n = 2), and the pericardium (n = 2). All 5 patients with ventricular wounds presented with cardiac tamponade, in 1 of whom it was fatal (he bled to death during emergency thoracotomy). The main complications were anoxic brain damage and postpericardiotomy syndrome (1 each). There was no case of myocardial concussion. CONCLUSION: Our data reflect the Swedish experience of heart trauma: there are few cases, alcohol and drug misuse is the principal risk factor, and there were no gunshot wounds.

Outcome of lung trauma.

OBJECTIVE: To find out whether we could manage critical pulmonary haemorrhages in penetrating injuries, and to report our experience with blunt trauma of the lung. DESIGN: Retrospective study. SETTING: Teaching hospital, Sweden. SUBJECTS: 81 patients who presented with pulmonary injuries during the period January 1988-December 1997; 6 were penetrating and 75 blunt. RESULTS: There was only one patient with an isolated lung contusion. The remaining was divided into 2 groups: those with pulmonary contusion and thoracic lesions (n = 32), and those with pulmonary contusion and extrathoracic lesions (n = 42). Four patients in the penetrating group were shocked and required urgent operations; emergency room thoracotomy (n = 1), urgent thoracotomy (n = 2), and urgent thoracoabdominal exploration (n = 1) were done successfully. We correlated grade of lung injury [American Association for the Surgery of Trauma-Abbreviated Injury Scale (AIS)] with mortality. All patients with penetrating injuries survived without serious consequences. There were a mean (SD), of 6 (2) injuries/patient in those with extrathoracic injuries compared with 3 (1) injuries/patient in the group with thoracic lesions (p < 0.001). The corresponding hospital mortality was 6/42 (19%) mainly as a result of the central nervous system lesions (4/6) compared with 0/32. The mean (SD) Injury Severity Score (ISS) was 9.3 (4.8) in patients with thoracic lesions compared with 24.1 (14.7) in patients with extrathoracic lesions (p < 0.0001), and 14.9 (9.5) in all survivors compared with 49.9 (13.6) among those who died (p < 0.0001). CONCLUSIONS: An excellent outcome can be achieved managing penetrating injuries of the lung by an aggressive approach and urgent surgical intervention even when emergency room thoracotomy is essential. Pulmonary contusion is considered to be a relatively benign lesion that does not add to the morbidity or mortality in patients with blunt chest trauma. These data may help to decrease the obsession with pulmonary contusion in patients with chest trauma, with or without extrathoracic lesions, and avoid many unnecessary computed tomograms of the chest.

Thoracic vascular injuries: a major problem in trauma.

OBJECTIVE: We present a review of our experience in the management of thoracic vascular injuries during the past 10 years in one of Sweden's busiest emergency departments, with morbidity and mortality as the main outcome measures. DESIGN: Of eight patients who sustained chest trauma with thoracic vascular injuries, six presented with shock. Angiography was the gold standard in diagnosing aortic and subclavian injuries. RESULTS: Lesions of the inferior vena cava, left internal mammary artery, and intercostal vessels were detected only at surgery. Two patients died of exsanguination. Managing thoracic vascular injuries is still difficult and challenging for thoracic and trauma surgeons. CONCLUSION: Early thoracotomy is important for salvage of patients with chest-wall vascular injury. Despite our limited experience, which is characteristic for Scandinavian and European countries, our results were satisfactory.

Electroconvulsive therapy in patients on anticoagulants.

Despite studies in the early literature showing that ECT may lead to CNS bleeding, it is unclear whether unmodified ECT increases the risk for hemorrhage in patients taking anticoagulants. The authors report two cases of depressed patients who required ECT while on coumarin derivatives. Both patients were switched to heparin. Heparin's short duration of action allowed temporary discontinuation 6-8 hours prior to each ECT with return of coagulation function close to normal when the stimulus was administered. No complications were observed in any of the patients. The authors believe that this technique minimizes any possible risks from ECT in patients on anticoagulants.